NUTRITION & HD

Mona Tawfik Lecturer of internal Medicine

Nephrology Unit MNDU

What can I eat ?

CASE PRESENTATION-1

Renal Nutrition Forum 2013 • Vol. 32 • No. 4

A 63-year-old male patient who has ESRD secondary to diabetes. He has been on dialysis for three years. Prior to his multiple hospitalizations. He was an active person, had a good appetite and was viewed as a “non-compliant” patient as his phosphorus was always out of control and he usually forgot to take his binders.

He recently had multiple extended hospitalizations.

His first hospitalization was due to altered mental status and hypoglycemia which lasted 9 days. He was then admitted to a rehabilitation facility. His chest x-ray showed a pleural effusion. A MRI of the brain was free. He received dialysis; however, it did not resolve his pleural effusion .

CASE PRESENTATION-2

Renal Nutrition Forum 2013 • Vol. 32 • No. 4

His second admission lasted 26 days and was secondary to confusion after a fall at the rehabilitation facility. A carotid ultrasound detected a bilateral internal carotid arterystenosis and Because of these findings, RS underwent a carotid endarterectomy. He then developed diarrhea postoperatively and was diagnosed with C. difficile colitis which was treated with vancomycin

His total time spent in the sub-acute rehabilitation facility was about three months.

His past medical history included type 2 diabetes mellitus, hypertension, hypothyroidism, and congestive heart failure. is a smoker and does not drink alcohol.

CASE STUDY

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Changes in DW over past 4 months

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1.What is PEW?2.How to screen and assess

patients with PEW?

3.What is the recommendation of PE intake for HD patient?

4.How to treat HD patient with PEM

PEW(protein energy wasting

)

“Is a states of under-nutrition that could

result from decreased nutrient intake and/or increased catabolism”

Seminars in Dialysis. 2012;25(4):423-27.

TERMINOLOGIES

Uremic malnutrition  Protein–energy malnutrition Malnutrition–inflammation atherosclerosis

syndrome Malnutrition–inflammation complex

syndrome Inflammatory wasting

Protein-energy wasting (PEW)

Kidney Int. 2008 Feb;73(4):391-8

PROTEIN-ENERGY WASTING(PEW) Is very common problem among patients

with advanced chronic renal failure (CRF) and those undergoing maintenance dialysis (MD) therapy worldwide.

Different reports suggest that the prevalence of this condition varies from roughly 18-75% of adult MD patients (average 40%).

Seminars in Dialysis. 2012;25(4):423-27

THE MAGNITUDE OF THE PROBLEM In HD patients, the presence of PEW is one of

the strongest predictors of morbidity and mortality.

In addition it was shown that for each one-unit

decrease in BMI the risk for cardiovascular death rose by 6%

Each 1 g/dl fall in serum albumin level was associated with a 39% increase in risk

of cardiovascular deathAm J Kidney Dis (2002)

Inadequate food intake secondary to:

• Anorexia caused by the uremic state• Altered taste sensation• Intercurrent illness• Emotional distress or illness• Impaired ability to procure, prepare, or mechanically ingest foods• Unpalatable prescribed diets

Predialysis patients appeared to have a spontaneous protein intake of <0.6

g/kg/dayAdv Chronic Kidney Dis. 2013 March ; 20(2): 181–189

The catabolic response to superimposed illnesses

The dialysis procedure itself which may promote wasting by removing such

nutrients as amino acids, peptides, protein, glucose, water-soluble vitamins, and other bioactive compounds, and may promote

protein catabolism, due to bioincompatibility

Adv Chronic Kidney Dis. 2013 March ; 20(2): 181–189

Endocrine disorders of uremia (resistance to the actions of insulin and IGF-I,

hyperglucagonemia, and hyperparathyroidism)

Loss of blood due to:• Gastrointestinal bleeding• Frequent blood sampling• Blood sequestered in the hemodialyzer and tubing

Adv Chronic Kidney Dis. 2013 March ; 20(2): 181–189

Screning&

Assessment

SCREENING

Guideline 1.2 – Frequency of screening for undernutrition in CKD

We recommend that screening should be performed (1D)

Weekly for inpatients 2-3 monthly for outpatients with eGFR

<20 but not on dialysis Within one month of starting of dialysis.

ASSESSMENT IN MHD

Nutritional status should be assessed at the start of haemodialysis (Opinion).

In absence of malnutrition, nutritional status should be monitored every 6 months in patients <50 years of age (Opinion).

In patients >50 years of age, and patients undergoing maintenance dialysis for more than 5 years, nutritional status should be monitored every 3 months (Opinion).

ASSESSMENT TOOLS OF NUTRITION Predict the outcome Inexpensive Easily performed Reproducible

Not affected by

o Inflamation

o Gender

o Age

o Systemic disease

There is No Single IDEAL Nutritional marker is available

EPBG 2007

DIATARY ASSESSMENT 24 h diatary recall 3 day recall

7 day recall

(K/DOQI) 2000 Recommendations for Nutritional Management

Diet Assessment Calories Protein CarbohydratesFat/Cholesterol Sodium Potassium PhosphorusFluid Vitamins Minerals

BMI

EBPG,2007

USRDS DIALYSIS, MORBIDITY AND MORTALITYWAVE II STUDY (DMMS).

Kidney International, 2004 ·

P<0.01

SUBJECTIVE GLOBAL ASSESSMENT (SGA) EBPG 2007

DOPPS studyThe investigators concluded that in

haemodialysis patients malnutrition, as indicated by low values obtained with the SGA, was associated with higher mortality

risk Kidney Int 2002; 62: 2238–2245

EBPG2007

MAC (MID-ARM CIRCUMFERENCE)

MAMC( mid-arm muscle circumference)=MAC in cm __TSF×

Weight 55 kg     ID Hours  44 h    

ID BUN Rise   45 mg/dl   

Urine Urea Nitrogen   0 gm   

nPCR = 1.1   g/kg/day

Results : 

Example:

SERUM ALBUMIN AS A TOOL OF NUTRITIONAL ASSESSMENT

Strong predictor of morbidity and mortality ,

HoweverAlbumin is affected by non-nutritional factors

Infection Inflammation Co-morbidities Fluid overload Inadequate dialysis Blood loss Metabolic acidosis

J Bras Nefrol 2015;37(2):198-205

SERUM PREALBUMIN

Prealbumin half life is approximately 2 days instead of 20 days for albumin

Serum prealbumin is a more sensitive indicator for the nutrition status than albumin due to its shorter half life and not strongly affected by inflamation like albumin

The patients 2-year survival rate was 50% with a serum prealbumin level <0.3 g/l and 90% in patients with a prealbumin level >0.3 g/l.

Kidney Int 2000; 58: 2512–2517

TECHNICAL INVESTIGATIONS BIT

It might be the preferred method, as BIA is not operator dependent and requires minimal training to assess fluid status.

Clin Nephrol 1998; 49: 180–185

DXA FAT SCAN

PHYSICAL EXAMINATION

Include General physical

appearance Oral , skin health & Signs of

vitamin deficiencyHandgrip strength

(Heimburger et al 2000) Subjective visual assessment

of subcutaneous tissue and muscle mass (Enia1993)

Kidney International (2008) 73, 391–398

As there is no single IDEAL ‘gold standard’ measure of

nutritional state

DIAGNOSIS OF PEW IN HD

Kidney Int. 2008;73:391-98 ISRNM

CASE STUDY: DIETETIC HISTORY

Renal Nutrition Forum 2013 • Vol. 32 • No. 4

Before hospitalization; the patient was following the clinic’s standard HD diet (80gm protein, 2gm sodium, 2gm potassium, <900mg phosphorus and 1000mL fluid restriction). His diets during hospitalizations has interrupted frequently from NPO to clear liquids, to the hospital’s diabetic diet.

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CASE STUDY: DIETETIC HISTORY

Renal Nutrition Forum 2013 • Vol. 32 • No. 4

His meal completion during 1st admission recorded by the hospital’s dietitians for this admission was 0-50%.

2nd admission 25-75%( 3 day average intake of 55%)

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Recieved Recommended

1116 kcal/kg/d Calories (35 kcal/kg/d)2030 kcal

35gm/d Protein (1.2 – 1.3g/kg/day) 70-75 gm/d

CASE STUDY

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Back to the case

CASE STUDY: INTERPRETATION

Renal Nutrition Forum 2013 • Vol. 32 • No. 4

Patient’s albumin levels dropped.He had a decrease in weight of >15% over one month (58 to 49)nPCR has decreased (1.43 to 0.58,0.59)Decreasing serum cholesterol (150-117-106)BMI was 15.5 based on his height and most recent weight (58kg)His intake had decreased considerably from his usual intake following his first hospitalization.

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PEW

Prevention and treatment of PEW

Multidisciplinary team Nephrologist Nurse pharmacist Social Worker patient's best

friend renal specialist

dietitian psychotherapist

Ideally worsening nutrition should be identified early and proactively managed as correcting established malnutrition is difficult. All reversible factors (including inflammation and occult sepsis) should be identified and corrected.

Initiation of dialysis may be required in pre-dialysis patients (2B) KDOQI 2012.

Increased dialysis dose ,the use of biocompatible membranes and ultrapure water have been associated with improved nutritional state.

NEPHROLOGIST FROM OPC TO DIALYSIS UNIT

o Improve appetite & food intakeo General feeling of well being, ↑ed physical

activityo Fewer dietetic restrictionso Decrease dose of medications → Phosphate & K

binders, antihypertensive drugso Increase clearance of potential anorexic factorso Improve metabolic acidosis

DIALYSIS

DIALYSIS Removal of : Amino acids (about 10 to 12 g per HD) Some peptides low amounts of protein (< 1 to 3 g per dialysis,

including blood loss) Small quantities of glucose (about 12 to 25 g per

dialysis if glucose-free dialysate is used)

Inflamatory Cytokine release due to membrane contact.

UK RENAL ASSOCIATION GUIDLINE 2010 Guideline 2.1 – Dose of small solute

removal to prevent undernutrition

We recommend that dialysis dose meets recommended solute clearance index

guidelines (e.g. Kt/V) (1C)

Our results showed that nPCR has increased significantly with increasing the dialysis dose

(target Kt/V), also serum albumin was significantly higher at the end of the study. The Kt/V had a

beneficial effect on neuromuscular and cardiac functions. Also it had a positive impact on the

patients well-being at the end of our study.

DITEITIANS :

Dietitians

are qualified professionals and

experts in the application of

science in nutrition and metabolism.

.

NUTRITIONAL CARE ……

HD DIETS AIMS TO Limit the build up of waste

product (urea, phosphate, K, Na & salt)

Prevent metabolic complication (renal bone disease, hyperkalemia )

Replace nutrient losses associated with the dialysis process

Optimize and maintain nutritional state

Adequate energy intake essential to optimize nutritional status

Present in (Carbohydrates – Fats - Protein) Calculated based on

Current weight,Age and genderPhysical activity and metabolic stress

30-35 kcal/kg/d 1B

CALORIES

UK Renal Association 2010,EBPG, 2007AND KDOQI 2000

WEIGHT AND HD ABW: actual body weight—the patient’s presentbody weight at the time of the observation.

IBW: Ideal body weight—normal weight ofhealthy individuals of similar sex, age, height andskeletal frame size.

USB: usual body weight—the patient’s weightobtained through history or previous

measurements,considered to be stable over time.

efBW: oedema free body weight, corresponding to

‘dry weight’—obtained post-dialysis in HD patients

based on clinical judgement wether the patient still

presents clinical oedema.

AefBW: adjusted oedema-free body weight—should be used in order to calculate the optimal dietary intake of protein and energy.

Nephrol Dial Transplant (2007) 22 [Suppl 2]: ii45–ii87

FEMALE 40 YS, ACTUAL BW=80 KG , HEIGHT 170CM

Ideal Body Weight (IBW)

For men = [ (height(cm) – 154) x 0.9) ] + 50

For women= [ (height(cm) – 154) x 0.9) ] + 45.5

IBW={(170-154) x 0.9} +45.5= 59.9

kg

Adjusted BW = (actual weight- IBw) x 0.38) + IBw =( 80 – 59.9 ) x (0.38) + 59.9 =

67.5Kg

Energy = 35 x 67.5 = 2363 k cal.

FoodCarbohydrate

4 kcal/gProtein4 kcal/g

Fat9 kcal/g

1 cup milk 12 8 0 –101 oz meat 0 7 1 – 12 1 oz bread 15 3 01 cup veg. 5 2 01 fruit 15 0 01 teaspoon fat/ oil 0 0 5

Caloric content of different food composition

PROTEIN

There are two kinds of proteins (HBV) or animal protein-meat, fish, poultry, eggs and dairy (LBV) or plant protein – breads, grains, vegetables, dried

beans and peas and fruits

50 -70% should be of HBV. Protein Alternatives

protein bars, protein powders, supplement drinks

PROTEIN INTAKE

Guideline 2.3 – Minimum daily dietary protein intake

o 0.75 g/kg IBW/day for patients with stage 4-5 CKD not on dialysis

o 1.2 g/kg IBW/day for patients treated with dialysis (2B)

No Protein Restriction for Dialysis Patients

EXAMPLE 1 PROTEIN intake for male patient whose weight is 68 kg, on maintenance HD

• 82 grams•½ cup milk•2 eggs or 4 egg whites

•5-6 oz meat•3 vegetables•8 servings of grains

1.2 (protein per kg BW)×68 (BW)

=81.6 gm of protein

50-70% of HBV

TIPS FOR COOKING

SODIUM

Plays vital role in regulation of fluid balance and blood

pressure

In CKD& HD:- May result in :-

High blood pressure, Fluid retention/swelling (edema)Excessive thirstCHF

SODIUM CONTENT OF BREAKFAST

Cook At home with low-sodium ingredients 2ooo mg/d

(4-5 gm Na Cl)

for HD patient EBPG 2007

• Salt• High-sodium condiments• Processed, cured foods

• Herbs• Spices

• Lemon• Vinegar

No Added Salt (NAS)

Avoid

Add

Eat out less (especially Fast Food)

TIPS FOR SALT REDUCTION

FLUIDS

Excess fluid :

Edema, HTN, CHF and Breathlessness

any food that is liquid at room temp”

Soup, gelatin, ice cream, popsicles, tea, coffee, ice

INTERDIALYTIC WEIGHT GAIN (IDWG)

General recommendation 4-4.5% of DBW (EBPG 2007)

PHOSPHORUS

Dietary intake ~800 to 1000 mg/day ( EBPG 2007)

Dietary education improves phosphate control. Dietary phosphate control should not compromise

protein intake.

Control = Binders + Diet + Adequate dialysis

HIGH PHOSPHORUS FOOD

HIGH PHOSPHOROUS FOODS

DAIRYCheeseMilk

1 oz½ cup

150 mg120 mg

PROTEIN Egg Liver Peanut butter Salmon or tuna Nuts

1 large1 oz

2 Tbsp1 oz1 oz

100 mg150 mg120 mg 75 mg100 mg

VEGETABLESBaked beansSoybeans

½ cup½ cup

130 mg160 mg

BREADSBranCornbreadWhole-grain bread

½ cup2 inch square

1 slice

350 mg200 mg 60 mg

BEVERAGESBeerCola

12 oz can12 oz can

50 mg 50 mg

AVOID PHOSPHORUS ADDITIVES

Inorganic Phosphorus absorbed easilyPhosphorus binders ineffective with many

additives READ THE INGREDENTS LABEL!!

Phosphoric acid Sodium hexametaphosphate Calcium phosphate Disodium phosphate Trisodium triphosphate Monosodium phosphate Sodium tripolyphosphate Tetrasodium pyrophosphate Potassium tripolyphosphate

PHOSPHORUS ADDITIVES

POTASSIUM

CKD Stages 4 and 5 and HD

Dietary Goal is usually 2 - 3 gm/day . Fruits & Vegetables

Low: 20-150 mg High: 250-550 mg

Avoid Salt Substitutes Dairy

1 cup 380-400 mg High phosphorus foods

HIGH POTASSIUM FOODS

LOW POTASSIUM FOOD

HOW TO REDUCE K POTATO

VITAMIN SUPPLEMENTATIONمخطط إلضافة الرمز فوق انقر

Guideline 2.5 – Vitamin supplementation in

dialysis patientsWe recommend that

haemodialysis patients should be prescribed

supplements ofwater soluble vitamins

(1C).

METABOLIC ACIDOSIS…UK RENAL ASSOCIATION GUIDELINE 2010

Mid-week predialysis serum bicarbonate levels should be maintained at 20–22 mmol/l (Evidence level III).

In patients with venous predialysis bicarbonate persistently <20 mmol/l, oral supplementation with sodium bicarbonate and/or increasing dialysate concentration to 40 mmol/l should be used to correct metabolic acidosis (Evidence level III).

EXERCISE

Guideline 2.6 – Exercise programs in dialysis patients (EBPG 2007)

We recommend that haemodialysis patients should be given the opportunity to participate in regular exercise programmes (1C).

ANABOLIC AGENTS

Guideline 3.5 – Anabolic agents in established undernutrition

We recommend that anabolic agents such as androgens, growth hormone or IGF-1 are not indicated in the treatment of undernutrition in adults (1D).

Androgens and growth hormone have demonstrated improvement in serum albumin levels and lean body mass but not mortality and these medications have significant side effects.

ORAL NUTRITIONAL SUPPLEMENTS

Guideline 3.2 – Oral nutritional supplements in established undernutrition

We recommend the use of oral nutritional supplements if oral intake is below the levels indicated above and food intake cannot be improved following dietetic intervention (1C)

CASE STUDY: MANAGEMENT

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Nepro was ordered for RS, which he did not consume at first. By the end of the admission, he was consuming some of the supplement.

He was only receiving Nepro once daily (K/DOQI guidelines, when a patient is unable to consume enough nutrients, use of oral supplements is indicated).

This quantity was not enough, in view of his low oral intake at meals. Therefore, RS’s Nepro dose was increased to three times daily.

liberalize the diet and monitor labs.

CASE STUDY

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ENTERAL AND PARENTAL NUTRITION

Guideline 3.3 – Enteral nutritional supplements in established undernutrition

(1C)

Guideline 3.4 – Parenteral nutritional supplements in established undernutrition

(1C)

AKNOWELGEMENT

Dr. Noha Mahmoud Abdelsalam Lecturer of internal medicine (Rheumatology and

immunology unit) Clinical nutritionist at National Nutrition Institute

Dr. Doaa Hamed Clinical Nutrition AssociateNational Nutrition Institute