”Nutrition in Kidney Disease” -...
Transcript of ”Nutrition in Kidney Disease” -...
”Nutrition in Kidney Disease”
3rd International Conference of
European Renal Nutrition Working Group of ERA-EDTA
T. Alp Ikizler, MD
Vanderbilt University Medical Center
To provide an overview of the relevance of “nutrition”
in kidney disease
To delineate the mechanisms through which wasting
syndrome develops in kidney disease
To outline the available nutritional interventions that
would counteract protein energy wasting and
dysmetabolism of kidney disease
Goals
0%
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0 1 2 3
UnadjustedAdjusted for demographics and
comorbidities
Years Years
NA/EUR HR =1.2
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20%
30%
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100%
0 1 2 3
Eur/Aus/NZ
(HR=2.8)
Japan (ref)
North America
(HR=4.0)
Eur/Aus/NZ
(HR=2.6)
Japan (ref)
North America
(HR=3.1)
NA/EUR HR =1.4
The death rate of chronic dialysis patients is
unacceptably high
2012: 4-year survival is 48% HD vs 87% Tx
Limited Efficacy of Randomized Clinical Trials
in CKD/ESRD
MDRD; BEACON; IDEAL
HEMO; MPO; EGESTUDY
DCOR; EVOLVE; VITAL; PRIMO
4D; AURORA; SHARP
NHct; TREAT; CREATE; CHOIR
FINEs; FAVORIT
FOSIDIAL;OCTOPUS
Current Practices and Challenges
The Need for Paradigm Shift
Treat as many patients as possible
Be cost effective
Minimize testing
Minimize costly treatments
Use simple and applicable treatments
Be pragmatic and practical
Use protocols
Minimize variability
Limit Patient involvement
Limit Physician Involvement
Precision Medicine
Three pillars of Precision Medicine
Right patient,
Right medical care (medicine),
Right time.
Precision Medicine Principles
Personalized care based on molecular, immunologic and
functional endotypes of the disease,
Participation of the patient in the decision making process
Taking into account predictive and preventive aspects of
the treatment
Maintenance Dialysis in 21st Century
Three pillars of Precision Medicine
Right patient
All inclusive
Right medical care (medicine)
One size fits all
Right time
Everything based on numbers
Nutrition, Kidney Disease and Precision Medicine
Personalized care based on molecular, immunologic and
functional endotypes of the disease and treatment.
A long continuum – Stage 1 through 5
Considerations for Nutritional Requirements in Kidney Disease
Protein intake
CKD - Progression
ESRD - Protein wasting
Calorie intake
CKD - Obesity; Insulin Resistance
ESRD - Wasting-Obesity Paradox
CKD and ESRD
Na/K/PO4 (HTN; Hyperkalemia; Bone Mineral Disorders)
Metabolic Disorders (Inflammation; Oxidative Stress)
Nutrient Needs of CKD Patients as Defined by
ESPEN Guidelines*
GFR = glomerular filtration rate; HBV = high biological value; EAA = essential amino acids; KA = ketoanalogues. CAPD=Continuous ambulatory peritoneal dialysis.aAdapted to catabolism levels and to individual needs in case of underweight or obesity.bAdjust as necessary for obese patients.
Cano NJ, et al. Clin Nutr. 2009;28(4):401–414.
Condition
Protein
(Essential and Non-essential
Amino Acids)
Macronutrients
Energy
(non-protein calories)
Non-dialysis CKD patients
GFR = 25-70 mL/min 0.55-0.60b (2/3 HBV)
30-40 kcal/kg/da
GFR < 25 mL/min
0.55-0.60 (2/3 HBV)
or
0.28+EAA or EAA+KA
Hemodialysis 1.2-1.4 (>50% HBV) 35 kcal/kg/day
CAPD 1.2-1.5 (>50% HBV) -
Nutrition, Kidney Disease and Precision Medicine
Personalized care based on molecular, immunologic and
functional endotypes of the disease and treatment.
A long continuum – Stage 1 through 5
Biomarkers – Serum Albumin; hsCRP
Hemodialysis patients, USA,47% (MIS)
Hemodialysis patients, • Sweden: 30 to 43% (SGA)• Netherlands: 28% (SGA)
Peritoneal dialysis patients, Brazil,36 to 65% (SGA)
Peritoneal dialysis patients, China• 29 to 44% (SGA)• 60% (MIS)
Peritoneal dialysis patients, Korea,40% (SGA)
PEW is present in 30 to 65% or more of dialysis patients around the world
Adapted from TNT Renal
Nutritional Markers and Outcomes in ESRD
ALBUMIN PREALBUMIN
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Q1
Q2
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Q4
Months
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Alb
* p-value < .0001
Subjective Global Assessment
Malnutrition-Inflammation Score
Nutrition, Kidney Disease and Precision Medicine
Personalized care based on molecular, immunologic and
functional endotypes of the disease and treatment.
A long continuum – Stage 1 through 5
Biomarkers – Serum Albumin; hsCRP
Multiple phenotypes of “Malnutrition”
Macro- &
Micronutrient
deficiency
Loss of Lean
Body Mass Sarcopenic
Obesity
Metabolic
Syndrome
Obesity
• Obesity > 30 BMI
• Insulin Resistance
Overnutrition•Chronic starvation
without inflammation
Undernutrition
Multiple Phenotypes of “The Malnutrition
Syndrome”
Impaired Utilization
• Acute illness with
inflammation
• Chronic illness with
inflammation
Nutrition, Kidney Disease and Precision Medicine
Personalized care based on molecular, immunologic and
functional endotypes of the disease and treatment.
A long continuum – Stage 1 through 5
Biomarkers – Serum Albumin; hsCRP
Multiple phenotypes of “Malnutrition”
Physiological consequences of dialysis - Catabolism
CVD
Frailty
InfectionCo-Morbid Conditions(Diabetes, CVD, Depression)
Dialysis-Associated Catabolism
Metabolic Derangements(Insulin Resistance, Metabolic Acidosis, IGF-1/GH Resistance)
Dietary Nutrient Intake
Loss of Kidney Function Uremic Toxins
Protein-Energy WastingSarcopenia
Inflammation
Etiology and Consequences of Protein Energy Wasting in CKD
Carrero JJ et al on behalf of ISRNM; JREN 2013
Nutrition, Kidney Disease and Precision Medicine
Personalized care based on molecular, immunologic and
functional endotypes of the disease and treatment.
A long continuum – Stage 1 through 5
Biomarkers – Serum Albumin; hsCRP
Multiple phenotypes of “Malnutrition”
Physiological consequences of dialysis - Catabolism
Participation of the patient in the decision making process
Patients’ dietary preference – Access to nutrients
Considering predictive and preventive aspects of the treatment
Likelihood of success – Improved biomarkers
Only 6.5% of the dieticians did biannual dietary
assessment
Up to 62% “estimated” intake
Median number of patients under care of a dietitian
was 100 (IQR 70-130)
Dedicating dietitian time to development of MNT plan
Prioritize work based on clinical importance and evidence
The regulatory, logistical and administrative requirements
should also be considered as applicable
Nutrition Management: Model for Precision
Medicine in the Kidney Disease
Attempts to manage nutritional aspects of kidney disease
to date have been with limited success primarily due to
lack of consideration of basic characteristics of disease
and patient phenotype and logistics.
Further research is necessary to understand the
mechanisms leading to the lack of beneficial effect and
design more novel approaches.
Involvement of patients in this process will be a key
determinant of future accomplishments