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© ESPEN 2003. For personal use only. 1

ESPEN Congress Cannes 2003 Organised by the Israel Society for Clinical Nutrition

Session: Nutrition and the Kidney

Malnutrition and Haemodialysis

Doctor Noël CanoMarseilles, France

email [email protected]

Education and Clinical Practice Programme

Prevalence Prevalence of malnutrition in of malnutrition in dialysisdialysis

FrenchFrench Cooperative study Cooperative study, n= 7,123, n= 7,123 Aparicio Aparicio M, Cano N, Chauveau P et al.M, Cano N, Chauveau P et al. Nephro Dial Nephro Dial Transplant 1999;14:1679-1686Transplant 1999;14:1679-1686

BMI < 20 kg/m2 24 %Lean body mass < 90 % th. 62 %Albumin < 35 g/l 20 %Transthyretin < 300 mg/l 36 %nPCR < 1 g/kg BW/day 35 %


Survival during hemodialysis

Time (days)

Cum

ulative Proportion

Surviving (%

)

50

60

70

80

90

100

0 365 730

Quartiles£ 36.4 g/L36.4 - 40 g/L40.0 - 43 g/L> 43 g/L

p< 0.00001RR / g/L = 0.9595% CI 0.93 - 0.97

ALBUMIN

Time (days)

Cum

ulative Proportion

Surviving (%

)50

60

70

80

90

100

0 365 730

PREALBUMIN

Quartiles £ 0.27 mg/L 0.27 - 0.33 mg/L 0.33 - 0.39 mg/L > 0.39 mg/L

p< 0.00001RR / 0.1 g/L = 0.8395% CI 0.73 - 0.96

C. Combe et al.C. Combe et al. Am Am JJ Kidney Kidney Dis , 2001;37:S81-S88Dis , 2001;37:S81-S88

N = 1,620 patients

Nutritional assessment

Parameters Intervalsbody weightBMI 1 monthdiet record (3 days) 6 monthsSGA 6 monthsnPCR 1 monthAlbumin, transthyretin (prealbumin) 1-3 months

1 - ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : 197-207 & Clin Nutr, 2000, 19 : 281-2912 - Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis, 2000, 35 (suppl 2)


1 - ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : 197-207 & Clin Nutr, 2000, 19 : 281-2912 - Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis, 2000, 35 (suppl 2)

ESPEN consensus (1) DOQIs (2)

Protein HD 1,2 - 1,4 1,2g/kg/day DP 1,2 - 1,5 1,2 - 1,3

Energy 35 < 60 y 35kcal/kg/day > 60 y 30

Recommended food intakes in dialysis (g/kg/day)

Vitamin & trace element requirementsIn hemodialysis patients

ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : 197-207 & Clin Nutr, 2000, 19 : 281-291

Pyridoxin, mg 10-15

Vitamine C, mg 30-60

Folic Acid, mg 1

1-25 (OH)2 D3 according to plasma calcium & phosphorus

Zinc, mg 15

Selenium,µg 50-70


- Dietary counselling- Oral supplements- Intradialytic parenteral nutrition- Enteral nutrition

Nutritional support during dialysis

Serum albumin changes Serum albumin changes after 6 months of dietary after 6 months of dietary counsellingcounselling

Randomized controlled trial. Leon JB et al. J Ren Nutr 2001

0

10

20

30

40

50

60

<2.5 g 2.5 - 5 g >5 g

Diet (n = 52)Diet (n = 52)Control (n = 31)Control (n = 31)

%

**

**

**

* * p<0.001

Independent Independent From CRPFrom CRP


Oral supplementation: Metabolic effects

Veeneman Veeneman JM et al.JM et al. Am Am JJ Physiol Endocrinol Metab Physiol Endocrinol Metab 2003;284:954-652003;284:954-65

Non-diabetic, non malnourished HD patients aged less than 65 y.Test meals composed of 6 portions given every 30 min during 3 h Total intake = 46, 2 g protein, 63 g CHO, 75 g fat

Metabolic studies:1/post absorptive phase2/ during a dialysis session

L- (1-13C) valine infusion

Review of 17 Studies

- 9 cohort studies

Oral supplementation --> improved body weight,AMC, TSF, albumin

- 8 controlled studies- 3 cross-over & 5 comparative randomized studies- 6/8 : improvement of nutritional parameters- 2 studies : Oral supplementation --> improved spontaneous

food intake [Patel 2000, Hiroshige 2001]- 2 studies: no nutritional gain (non-depleted patients)

Oral supplementation: Nutritional effects


OralOral supplementation supplementation Hiroshige K et al . NDT 2001;16:1856-62N=44, cross-over study , BCAA 12 g/j during 6 months vs. placebo

ORAL SUPPLEMENTATION: PATIENT COMPLIANCEORAL SUPPLEMENTATION: PATIENT COMPLIANCEEustace Eustace JA et al.JA et al. Kidney int Kidney int 2000;57:2527-382000;57:2527-38

HemodialysisHemodialysis: n=29: n=29PeritPerit. . DialysisDialysis: n=18: n=18


Cyclic parenteral nutrition during HD sessions

Nutrient supply: 15-20 kcal/kg/HD (CHO & fat)0.5-1 g protein/kg/HD

Infusion technique- venous way of extracorporeal circulation- constant infusion rate (≤ 250 ml/hour)- minimum infusion time: 4 hours- controlled ultrafiltration rate- addition of sodium 75 mmol/l- First week: infusion volume/2

Intradialytic Parenteral Nutrition (IDPN)

7 dialysis patients studied during 2 HD sessions, with and without IDPN.Constant infusion of L- (1-13C) leucine and L-(ring-2H5) phenylalanine: 2 hbefore, during, 2 h after HD

IDPN: metabolic effectsPupim Pupim LB et al LB et al J ClinJ Clin Invest Invest 2002;110:483-4922002;110:483-492


30 retrospective series & one controlled studyshowed, after 3 to 9 months of IDPN:

↑ body weight, arm muscle circumference↑ albumin, transthyretin↑ nPCR, creatinine production↑ response to hypersensitivity skin tests↑ spontaneous intakes

IDPN: nutritional effects

Prospective, Prospective, controlledcontrolled, , randomized studyrandomized studyIDPN 16 kcal/kg/HD & 0.08 g N/kg/HD, n = 12, vs. IDPN 16 kcal/kg/HD & 0.08 g N/kg/HD, n = 12, vs. ControlsControls, n = 14, n = 14

Perdialytic parenteral Perdialytic parenteral nutritionnutrition with lipids and amino acids with lipids and amino acidsCano N et al.Cano N et al. Am Am J ClinJ Clin Nutr Nutr 1990;52:726-7301990;52:726-730

∆ B

W %

∆ A

MC

%

∆ T

TR

%∆

Alb

umin

%

2

1

0

43210-1

40

20

0

-20-1

2

1

0

-1

days 0 42 84 days 21 42 84

**

**

*

*

*

*


1/1/1991: IDPN (n=1679) vs controls (n=22517)Evaluation: Intention to treat, one-year follow-up

Data adjusted for:age, gender, race,diabetes, URR

Improved survival:Albumin ≤ 33 g/l(p<0,01)

Reinforced efficacy:creatinine < 8 mg/dl

IDPN: effect on survivalRetrospective study: National Medical Care Hemodialysis Centers

Chertow GM et al. Am J Kidney Dis 1994;24:912-920

Polymeric EN, administered via naso-gastric tube or gastrostomy

Necessary during severe undernutrition, particularlywhen spontaneous intakes are < 20 kcal/kg/day:

- IDPN cannot reach recommended supplies- daily nutritional support is needed- enteral nutrition should be prefered to parenteral nutrition

Poorly investigated

Enteral nutrition


AA controlled controlled trial of intermittenttrial of intermittent enteral nutrient enteral nutrient supplementation supplementation in maintenancein maintenance hemodialysis hemodialysis patientspatients

Sharma Sharma M. J M. J Ren Nutr Ren Nutr 2002:12:229-372002:12:229-37

Nondiabetic adult MHD patients with BMI <20 and serum

albumin <4.0 g/dL:

- Control group: appropriate monitoring, dietary counselling

- Supplement group: post-HD enteral nutrition,

500 kcal, 15 g protein for 1 month

- Both groups : baseline food intake , dry weight and BMI

- Supplement group: serum albumin and functional scoring.

Nutritional Nutritional Support inSupport in Dialysis Dialysis patientspatients

(if necessary)

moderate malnutritionFood intake< 35 kcal/kg/day< 1.2 g protein /kg/day

Severe malnutritionSGAnPCR < 1g prot/kg/dayAlbumin < 35 g/l, Transthyretin < 300 mg/l

Dietcounselling

+oral

supplementsIDPN ±

oral suppl.EnteralNutrition

Food intakeFood intake20-30 kcal/kg/d < 20 kcal/kg/d20-30 kcal/kg/d < 20 kcal/kg/d

0.8-1 g/kg/d0.8-1 g/kg/d < 0.8g/kg/d < 0.8g/kg/d

(if necessary)


1 - Nutritional support in hemodialysis patients- appears to be able to improve nutritional status- remains to be evaluated concerning its effects on

- quality of life- healthcare requirements- survival

2 - Multidisciplinary approaches for the treatment ofmalnutrition during dialysis need to be evaluated, combiningnutritional support with

- Anabolic factors- Rehabilitation

Conclusion & Perspectives

Références (1)

1. Combe C, Chauveau P, Laville M et al. Influence of nutritional factors andhemodialysis adequacy on the survival of 1,610 French patients. Am J Kidney Dis2001; 37: S81-8.2. Aparicio M, Cano N, Chauveau P et al. Nutritional status of hemodialysispatients: a French National Cooperative Study. Nephrol Dial Transplant 1999; 14:1679-1686.3. Toigo G, Aparicio M, Attman P-O et al. ESPEN consensus on nutritionaltreatment of patients with renal insufficiency (Part 2 of 2). Clin Nutr 2000; 19: 281-291.4. National Kidney Foundation. Kidney Disease Outcomes Quality Initiative. ClinicalPractice Guidelines for Nutrition in Chronic Renal Failure. I. Adult guidelines. A.Maintenance dialysis. Am J Kidney Dis 2000; 35 (suppl 2): S17-S55.5. Veeneman JM, Kingma HA, Boer TS et al. Protein intake during hemodialysismaintains a positive whole body protein balance in chronic hemodialysis patients.Am J Physiol 2003; 284: E954-65.


References (2)

6. Pupim LB, Flakoll PJ, Brouillette JR et al. Intradialytic parenteral nutritionimproves protein and energy homeostasis in chronic hemodialysis patients. JClin Invest 2002; 110: 483-492.7. Cano N, Labastie-Coeyrehourcq J, Lacombe P et al. Perdialytic parenteralnutrition with lipids and amino-acids in malnourished hemodialysis patients.Am J Clin Nutr 1990; 52: 726-730.8. Chertow GM, Ling J, Lew N et al. The association of intradialytic parenteralnutrition administration with survival in hemodialysis patients. Am J Kidney Dis1994; 24: 912-20.9. Sharma M, Rao M, Jacob S, Jacob CK. A controlled trial of intermittententeral nutrient supplementation in maintenance hemodialysis patients. J RenNutr 2002; 12: 229-37.10. Mitch WE. Mechanisms causing loss of lean body mass in kidney disease.Am J Clin Nutr 1999;67:359-366

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