3/6/17

1

Nutritionalconsiderationsinthedialysispopulation:

frommalnutritiontoobesityJessicaStevenson

SeniorRenalDietitian,StGeorgeHospitalPhDCandidate,TheUniversityofSydney

Presentationoutline:

• AlterednutritionalstatesinCKD- PEW- Obesity

• Nutritionalrequirementsindialysis- energy- protein

• Managementofsarcopenia

3/6/17

2

Dialysis

AlterednutritionalstatesindialysisProteinenergywastingofteninvolvingmalnutrition- Musclewastingleadingtosarcopenia andfrailty- Malnutrition

Increasinglyobesityandlifestylediseases

Electrolyteandfluiddisturbances- potassium- fluidbalance- phosphate

Proteinenergywasting

3/6/17

3

Malnutrition:under-nutritionandover-nutrition.

ProteinEnergyWastingMultiplenutritionalandcatabolicalterationsthatoccurinchronickidneydisease(CKD)andassociatewithmorbidityandmortality.

Howdowemeasurenutritionalstatus?

3/6/17

4

Assessmentofnutritionalstatus

Anthropometry

Biochemistry

Clinical

Dietary

Anidealnutritionparameteris:üOnlyaffectedbynutritionalfactorsüNormalisedwithadequatenutritionalcareüAccuratelypredictsoutcome

Veryfewmeasuresexist;thereforeneedtorelyuponacombinationofparameters

PEWISRNMInternationalSocietyofRenalNutritionandMetabolismclassificationofPEW

Lowbodyfatandlowmusclemass

Atleast3ofthe4categoriesmustbesatisfiedtohaveadiagnosisofPEW

Dietaryintake• Proteinintake<0.8g/

kgBW/day

Serumchemistry• Albumin<38g/L

BodyMassIndex• BMI<23kg/m2

Musclemass• cMAMC <90%of

expectedrange

UniqueconditionsinCKDwhichimpactonvariouscontrolmechanismsofalbumin,include:

Inflammation Rateof synthesis

Fluid retention/oedema Dilutional effect duetovolumeexpansion

Dialysis lossesandproteinuria Lossofproteinandalbumin

Alb isawellknownmarkerofillness,ratherthannutritionalstate,lowlevelsshouldbeaprompttoinvestigateapatient’soverallhealthratherthansolelyfocusingonnutrition

Albuminasanutritionalmarker

3/6/17

5

SGA

Anthro(changeinweight)

Dietaryintake

Nutritionimpact

symptoms

Functionalcapacity

Physicalassessment

Musclewasting(Sarcopenia)

3/6/17

6

Muscleloss/sarcopenia iscommonwithPEW

• Nutritionaldeficiencies• Physicalinactivity• Chronicinflammation

AsCKDadvances,musclestrengthandsizereduces

Sarcopenia reducesindependenceandmobility,increasestheriskoffracturesfromfallsandreducesQoL

Promotionphysicalactivitypivotal

Measuringsarcopenia

Measuringsarcopenia

Functionalassessments

UpperBody– HandGripStrength

LowerBody– 6minutewalktest,sit-to-stand,timedupandgo

3/6/17

7

Practicalissueswithmeasuringnutritionalstatusandsarcopenia

- Importanttobetrainedinassessingnutritionalstatus- SGAisthemostcommonlyusedinclinicalpracticebutdoesn’tmeasuresarcopenia

- Moreaccuratebodycompositionmeasurementstoadequatelyassessandmonitorsarcopenia

- Whoisresponsibleforconductingfunctionalassessments

- ?Aresomeofthesemeasuresrelevantinobesepopulations

Obesity

Whoisourpopulation?1978

PrimaryCauseofESKD• 18%diabeticnephropathy• 5%hypertension• 34%glomerulonephritis• 22%analgesicnephropathy

2015

PrimaryCauseofESKD• 41%diabeticnephropathy• 14.5%hypertension• 18.7%glomerulonephritis• 0.8%analgesicnephropathy

1998

PrimaryCauseofESKD• 21%diabeticnephropathy• 12%hypertension• 34%glomerulonephritis• 5%analgesicnephropathy

1980s

10%adultswereobese60%wereahealthyweight

Today

66%overweight/obese35%areahealthyweight

25%malnutrition

3/6/17

8

Howdowemanagetheobesepatient?

ObesityParadoxInearlier,predialysis CKD+ve correlationbetweenobesityandworseningKF• 1kginBMI,probabilityofCKDprogression1.23• IncreasedWCassociatedwithhighermortalityindialysis

HaemodialysisHigherBMIisassociatedwithincreasedsurvivalinhaemodialysispatients

Largelybelievedthatthisincreaseinsurvivalisduetomusclemass

Challengesoftreatingobesedialysispatients

Studiesarelargelyepidemiologicalwithnoclinicaltrialslookingatoutcomesintheobesepopulations.

Difficultytreatingobese• Lessaccesstorenaltransplantation• Pooreroutcomesafterrenaltransplantations• Moredifficultvascularaccessondialysis• Longerhoursondialysis

3/6/17

9

Challengesofchoosingtherightassessment

Cross-sectionalanalysisdialysispatients(n=79)• Height,weight• Skin-folds(biceps,triceps,suprascapular,suprailiac)• Waistandhipcircumferences• Midarmmusclecircumference

Cross-sectionalanalysisdialysispatients(n=79)• Height,weight• Skin-folds(biceps,triceps,suprascapular,suprailiac)• Waistandhipcircumferences• MAMC

Obesity:• BMI>30kg/m2• Fatmass%,>25%men,>35%women• Fatmass>90thpercentile

AbdominalObesity:• WC>88cmwomen,>102cmmen• WHR>0.9men,0.85women

Obesesarcopenia:• Fatmass>90thpercentile• LBM<10th percentile

3/6/17

10

Koeford etal ISRNM PEW

PEW 4% 29%

Lowleanbodymass 32%

Obesesarcopenia 10%

PEW+Obese 0% 20%

Abdo obesityWaistCirc 58%

Abdo obesityWHR 98%

Underweight 2%

Nutritionalmanagement

Nutritionalcounseling

energy

protein

potassium

phosphorusSodium&fluid

Vitaminsand

minerals

Dietquality

3/6/17

11

PrioritisingnutritionalissuesDietaryquality

Co-morbidm’ment

EnergyandProtein

Potassium Sodium Fluid *Phosphate

CKDstage1-2 xx xx x

CKDstage3 xx xx x x

CKDstage4 xx xx x x

CKDstage5 x x xx xx x xx x

Haemodialysis x x xx xx xx xx x

Peritonealdialysis xx x xx x xx xx x

*Dietaryphosphate:theevidenceisweak.Howeverifyouarereducingsodium,moderatingproteinandfocusingondietaryqualitythiswilloftenbebettercontrolled

Nutritionalcounseling

energy

protein

potassium

phosphorusSodium&fluid

Vitaminsand

minerals

Dietquality

EnergyrequirementsHaemodialysis

3/6/17

12

PeoplewithCKDandthoseondialysishavesimilarREEtoageandgendermatchedcontrols

Energyrequirementsinhaemodialysis

Australianguidelines:CaringforAustralasianswithRenalImpairment (CARI)- NONEavailable

DAA– 2006- ReferenceKDOQIandCARI

Internationalguidelines:KidneyDiseaseOutcomesQualityInitiative(KDOQI)2000

KDOQI(2000)

TherecommendeddailyenergyintakeforbothMHDandCPDpatientswithlighttomoderatephysicalactivity is35kcal/kg/dforthoselessthan60yearsofageand30to35kcal/kg/dforthose60yearsofageorolder(Guideline17).

• EEissimilartothatofnormal,healthyindividuals• Moresedentaryindividualsmayneedlesscaloriestomaintainnitrogenbalanceand

anthropometricindices.

3/6/17

13

Considerationsforenergyprescription

Nutritious Non-nutritiveOlive oils BiscuitsorcakesUnsaltednutsornut butters(ifable) jamsCranberryjuice CordialsCannedfish Ham

Considerationsforenergyprescription

Forourobesepopulation:

- considerlevelofphysicalactivity

- minimisenon-nutritiveenergysources

- understableconditionsuselowerendenergyrequirements

- ??considertriallingotherweightlossstrategiesundersupervision–liaisewithmedicalteam

Weightlossstrategies

MealreplacementSurgery

Populardiets(e.g.5:2,paleo)– noliterature

3/6/17

14

Dietarycounselling

DietaryAssessment:• Overallcaloricintake(includingsourcesofcalories)• Dietquality- sourceandamountofprotein- adequatefibre

• Controllingforelectrolytesandfluid

**considerphysicalactivitylevelandagewhendeterminingnutritionalrequirements

Mealreplacements• Effectiveatinducingrapidandsignificantweightlossingeneralpopulation• PeoplewithCKDstage3onwardscontraindicatedduetoelectrolyteandfluidconcerns

Mealreplacements• Effectiveatinducingrapidandsignificantweightlossingeneralpopulation• PeoplewithCKDstage3onwardscontraindicatedduetoelectrolyteandfluidconcerns

Optifast “standardmeal”120gporkchopwith½cupmashand1cupveg

850kJ 1850kJ

18gprotein 45gprotein

20mmolK 35mmolK

340mg PO4 500mgPO4

220mgNa 150mgNa

3/6/17

15

Renaldietitian prescribedmodifiedlowcaloriediet:- 1.1-1.2gprot/kg/day- 1mmolK/kg/d- 800-1000mgPO4- fluidasperpatientprescription

Prescribed:- 2mealreplacementshakes+1bar- 150gleanprotein- 15gCHO- 2serveslowKfruit- 1cuplowKlowcalorieveg

Renaldietitian prescribedmodifiedlowcaloriediet:- 1.1-1.2gprot/kg/day- 1mmolK/kg/d- 800-1000mgPO4- fluidasperpatientprescription

Used:2mealreplacementshakesand1bar,150gleanprotein,15gCHO,2serveslowKfruit,1cuplowKlowcalorieveg

ResultsN=5maintenanceHDpatientsN=1ceasedduetohyperkalemia (duetonon-compliancewithHDtreatment)

Weightloss:median7%(5.2-11.4%)

Limitedadherenceinallpatientsacross12/12andnoax bodycomposition

Renaldietitian prescribedmodifiedlowcaloriediet:- 1.1-1.2gprot/kg/day- 1mmolK/kg/d- 800-1000mgPO4- fluidasperpatientprescription

Used:2mealreplacementshakesand1bar,150gleanprotein,15gCHO,2serveslowKfruit,1cuplowKlowcalorieveg

ResultsN=5maintenanceHDpatientsN=1ceasedduetohyperkalemia (duetonon-compliancewithHDtreatment)Weightloss:median7%(5.2-11.4%)Limitedadherenceinallpatientsacross12/12andnoax ofbodycomposition

Safeandeffectivebutshouldbeutilisedinmotivatedandsupportedpatients

3/6/17

16

Surgicaloptions

• Restrictivebariatricoptions:gastricbandingorsleevegastrectomy• Malabsorptive procedures:gastricbypass,Roux-en-Y

• Smallstudypopulationsreportingshortterm(12month)outcomeshaveshownpositiveresultsre:substantialweightloss43-70%

Pros:Enabletransplantation

Cons:Increasedriskofpostoperativecomplications

Vs

ProteinrequirementsHaemodialysis

ProteinmetabolisminHD

Changestoutilisation ofprotein:• Metabolicacidosis• Inflammationandpro-inflammatorycytokines• Dialysis(causingdecreasedproteinsynthesisinmuscle)

Excessproteinloss:• 6-12gaminoacidslostthroughdialysis

3/6/17

17

ProteinrequirementsinHD

KDOQI (2000)• 1.2gprotein/kgIBW/daywith>50%fromHBVproteins

BDA (2013)• 1.1gprotein/kgIBW/daywithsufficientcalories(30-40kcal/day)with>50%HBVproteins

Goalsoftreatmentistoreducemusclewastingandsarcopenia.

Considerationsfordietaryprescription

HighBiologicalValue LowBiologicalValueMeat,chicken,fishEggsMilkandmilkproducts

NutsBeansandlentilsBreadsandcereals

Considerationsfordietaryprescription

HighBiologicalValue LowBiologicalValueMeat,chicken,fishEggsMilkandmilkproducts

NutsBeansandlentilsBreadsandcereals

Timingandamountofprotein

Ingestionofapproximately25–30gofproteinpermealmaximallystimulatesmuscleproteinsynthesisinbothyoungandolderindividuals

Eatingduringdialysistreatmentmaybemorebeneficial– aimfor20gprotein.

3/6/17

18

Vegetariandiets• Beneficialonphosphatehomeostasis• Mayimprovemetabolicacidosis• Nodeleteriousaffectonbodycompositionornutritionalstatus• Canprovideadequateproteinandcalories

NationalKidneyFoundation(USA)Withcarefulplanning,vegetarianism,orevenpart-timevegetarianeating,isnotonlysafe,butalsobeneficialtokidneydiseasepatients

• Postmenopausalwomenreducedratesoffemoralneck(hip)boneloss

SafetyConcernsWRTpotassium

Vegetableproteinsandpotassium

Animalprotein Vegetableprotein100gChicken,beef,lamb=9mmol 100gtofu =3mmol100gFish(e.g.salmon)=11mmol65gcannedtuna=4mmol

½ c (90g) Cannedchickpeas=3mmol½c(90g)canned RedKidneybeans=6.5mmol½c (90g)cannedbrownlentils=4.5mmol

100mlCowsmilk=4mmol 100mlsoymilk=5.5mmol30galmonds=5.5mmol30g macadamianuts=3mmol1 tablespoonpeanutbutter=4mmol

Physicalactivity

3/6/17

19

PhysicalactivityinHD

AnemiaandabnormalmusclecatabolismcontributetoreducePAandfunctioning.

• 35%lessphysicallyactiveandthisincreaseswithage• HDpatientsspendlesstimeparticipatinginphysicalactivity(-54mins/day)• LoweraveragedailyMETs1.3vs 1.5

*<1.4METsconsideredtobesedentary

Predictiveequationsmayover-estimateTEEinsedentaryHDpatients.

Strategiestopreventortreatsarcopenia

1. Adequateproteinandenergyintake.- non-CKDsarcopenia guidelinesrecommend1.2-1.5gprotein/kgIBW/day

• >50%HBVproteinwith• Eatingondialysis• >20gproteinpermeal

Strategiestopreventortreatsarcopenia2.Physicalactivity

1yearmortalityrate1.62foldhigherinsedentarythanphysicallyactiveHDpatients

• Benefitsofexercisetraininginclude:- Improvemusclefunctionandstrength- Improvementsinglucoseandlipidmetabolism- Reducedinflammationandoxidativestress- Inhibitionofcatabolism- Improvedmentalstate

12weeksofexercisetrainingeffectiveinreducingskeletalmusclelossevenwhenpatientsfollowinglowproteindiet(0.6g/kg/day)

3/6/17

20

GuidelineRecommendations

• Aerobicexerciseatmild-moderateintensityfor20-60mins3-5/7• KDOQI– 30minsmoderateintensityexercisemostdaysoftheweek.routineassessmentofphysicalfunctionandencouragementofregularphysicalactivity• Cochrane– 30minsexercise3/7

ExerciseshouldnotbedoneimmediatelypostHDsessionduetofluidandelectrolyteshifts

Fewrecommendationsonspecificexercises

Whattypeofphysicalactivity

Light:• Housework• Workingatastandingworkstation.

Moderate:• Briskwalking• Recreationalswimming• Socialtennis

ExerciseondialysisBenefitsofexerciseondialysisarewellknown

Numberofresources:- KHA“ExerciseonDialysis”- LifeOptions(ExPhysio,PhD,USA)- ChooseHealthBrochure(Aust Govt)- Heartmoves

Barriers:- whoisresponsibleforthis- scopeofpractice- confidenceandcomfortinrecommendations

3/6/17

21

Summary

Nutritionalmanagement• Shouldbeadvocatingforcontrolledweightlossinobesepatients• Continueexploringsafeweightlossstrategiesforobesepatientsincorporatingbothphysicalactivityanddietarymanagement• Promotenutrient-densedietsforbothunderandovernutrition• Considersourcesandtimingofproteinintake

Physicalactivity• Monitoringphysicalfunction(e.g.HGS,sittostand)andwhenpossiblesarcopenia• Weshouldbepromotingphysicalactivity– useavailableresources

Questions