Nutrition  support  in  hemodialysis  patients

Luisito O.  Llido MD,  FPCS,  DPBCN,  FPSGSClinical  Nutrition  ServiceSt.  Luke’s  Medical  Center,  Quezon  CityPhilippines

Objectives  of  this  presentation

• To  present  an  overview  on  the  nutrition  management  in  renal  disease• To  discuss  the  impact  of  body  composition  changes  in  acute  and  chronic  renal  failure,  nutrition  management  strategies  and  outcome  specially  in  hemodialysis  patients

Factors  affecting  body  composition

• Lean  body  mass  (=  protein  mass)• Protein  intake  – adequate?• Energy  intake  – percent  glucose  and  fatty  acid• Inflammation  state

• Sarcopenia• Cachexia

• Exercise• Adipose  tissue  (=  fat  mass)

• Inflammation  state• Type  of  diet  – fat  (=pro-­‐inflammatory?)• Metabolism• Physical  activity  

What  counts  most  in  management?

• Does  the  amount  of  protein  intake  sustain  maintenance  of  the  lean  body  mass?• Actual  intake  (adequate?,  chronic  poor  intake?  monitoring  frequency?)• Body  protein  losses  (inflammation  status,  energy  spent,  organs  affected)

• Does  the  disease/renal  management  continue  to  allow  protein  losses  or  reduce  protein  losses?• Hemodialysis  losses• Nutritional  intervention

• Reduce  or  counterbalance  gluconeogenesis?• Slows  down  proteolysis  or  enhances  protein  build-­‐up?

Malnutrition  and  survival

Qureshi AR  et  al.  Inflammation,  Malnutrition,  and  Cardiac  Disease  as  Predictors  of  Mortality  in  Hemodialysis  Patients.  J  Am  Soc Nephrol 2002;  13:  S28–S36.  

HGS  =  Hand  Grip  StrengthSGA

What  we  want  to  avoid:  MDRD  study

Kittrawee Kritmetapak et  al.  The  impact  of  macro-­‐ and  micronutrients   on  predicting  outcomes  of  critically   ill  patients  requiring  continuous   renal  replacement  therapy.  PLoS ONE  11(6):  e0156634.  Published:  June  28,  2016. doi:10.1371/  journal.pone.0156634   (Open  Access)  -­‐ Chulalongkorn University,  King  Chulalongkorn Memorial  Hospital,  Bangkok,  Thailand

DPI:  daily  protein  intake;  nPCR;  normalized  protein  catabolic  rate;  CRP:  C-­‐Reactive  protein

Acute  Kidney  Injury:  predictors  of  mortality

PEW:  Protein  Energy  Wasting;  ESRD:  End  Stage  Renal  Disease

Very  Low  Protein  prescription

Mechanisms  of  protein  loss

The  nutrition management  process

The  clinical  nutrition  processAll  admitted  patients  are  nutritionally  screened  

(nurses)

All  nutritionally  at  risk  patients  are  assessed  (dietitians)

All  high   risk  patients  are  given  nutrition  care  plans(clinical  nutrition   physicians)

Monitoring(nurses,  dietitians,  pharmacists,  physicians)

Nutrition  care  plan  modification  /  Discharge

MULTI-­‐DISCIPLINARY  APPROACHNUTRITION  TEAM

STEP  1

Step  1:  Nutrition  assessment/nutrition  care  plan

Determine  the  adequacy  of   the  lean  body  mass What  nutrition   assessment  tool?

Lacuesta-­‐Corro et  al,  http://dpsys120991.com/POJ_0002.htmlBoado et  al.  http://philspenonlinejournal.com/POJ_0018.html

Moderate  malnutrition Severe  malnutrition

Nutrition  care  plan:• Total  energy/day• Total  protein/day• Non-­‐protein  calories• Micronutrients

• Vitamins• Trace  elements

• Pharmaconutrition• Fish  oils• Glutamine  

Nutritional  requirements:  ARF  or  AKIRequirement Value Specifics Dose

Energy 25  – 30   (max: 35)   kcal.kg-­‐1.day-­‐1

Carbohydrates 3  – 5   (max:  7)   g.kg-­‐1.day-­‐1

Lipids   0.8  – 1.2   (max: 1.5) g.kg-­‐1.day-­‐1

Amino  acids Essential  +  non-­‐essential

conservative  therapy 0.6  – 0.8   (max: 1)   g.kg-­‐1.day-­‐1

extracorporeal  therapy 1.0  – 1.5 g.kg-­‐1.day-­‐1

+  hypercatabolism (max: 1.7)   g.kg-­‐1.day-­‐1

Vitamins Multivitamin  preps (Cave: vitamin  C  <200mg.d-­‐1)

water  soluble 1  – 2  amps (2  x  RDA  – recommended  dietary  allowance) Daily  

Fat-­‐soluble 2  – 4  amps Weekly  

Trace  elements 2  – 4  amps Multi-­‐trace  element  preps  (Cave:  toxic  effects) Weekly  

Electrolytes Requirements  must  be  calculated  individually (Cave:  refeeding – low  K  or  P  at  start  of  PN/EN

Druml W,  Cano  N,  Teplan V.  8.7.2.3.  Patients  with  acute  renal  failure  (ARF)  and  HD/CAPD  patients  with  acute  metabolic  disease.  Basics  in  Clinical  Nutrition,  4th ed.  Sobotka L,  ed-­‐in-­‐chief.  Galen.  2011

SCCM and ASPEN guidelines 2016

Requirements:  stable  CKDRequirement Conservative  Therapy Hemodialysis   Peritoneal  Dialysis

Energy  (kcal.kg-­‐1) >35 30-­‐35 >35  *

Protein  (g/kg-­‐1) 0.6  -­‐ 0.8 1.1  – 1.4 1.2  – 1.5

Phosphorus   (mg)(mmol)

600 – 100019  – 31  

800  – 100025  – 32  

800  – 100025  – 32  

Potassium  (mg)(mmol)

1500 – 2000  **38  – 40  

2000  – 250040  – 63  

2000  – 250040  – 63  

Sodium  (g)(mmol)

1.8  – 2.5  **77  – 106  

1.8  – 2.577  – 106  

1.8  – 2.577  – 106  

Fluid  (ml) Not restricted 1000  +  DO 1000  +  UF  +  DO

DO  =  daily  urine  output;   UF  =  ultrafiltrate*  Includes  energy  (glucose)  from  the  dialysate**  individual  requirements  differ  considerably  

Druml W,  Cano  N,  Teplan V.  8.7.2.1.  Non-­‐catabolic  patients  with  stable  chronic  kidney  disease.  Basics  in  Clinical  Nutrition,  4th ed.  Sobotka L,  ed-­‐in-­‐chief.  Galen.  2011

STEP  1

STEP  2

Step  2:  Reach  adequacy  of  intake  /  fluid  balance

Evaluate  deficiencies:  macronutrients  and  micronutrients

Oral  nutrition Supplement   some  nutrients  by  IV

Monitor   intake• Nutrients• Losses  in  hemodialysis

If  deficient  by  the  oral  route• Oral  supplementation• Tube  feeding

Parenteral    nutrition

50%  intake

Losses

Cano  NJM  et  al.  ESPEN  Guidelines   on  Parenteral  Nutrition:  Adult  Renal  Failure.  Clinical  Nutrition  28  (2009)  401–414.

Targets

Targets

Pharmaconutrition

STEP  1

STEP  2

STEP  3

Enteral  nutrition:  Disease  specific  formulas

(n=68)Enteral  Nutrition  

preferredSCCM and ASPEN guidelines 2016

Parenteral  nutrition:  Points  to  remember

• All  three  macronutrients  should  be  supplied  daily• If  oral  or  tube  feeding  and  there  is  an  insufficient  macronutrient  – give  by  PN

• Micronutrients  should  be  given  daily• Note  the  deficiencies  and  the  retained  micronutrients  to  avoid  complications  – these  do  not  happen  overnight,  they  accumulate

• Pharmaconutrients like  glutamine  or  fish  oil  have  better  results  with  parenteral  nutrition• IDPN  helps  in  reducing  deficiency  states,  but  volume  overload  concerns  require  regular  and  strict  fluid  balance  assessments

Glutamine

Parenteral  nutrition:  Indications

• Supplemental  parenteral  nutrition:• When  oral/enteral  nutrition  is  inadequate

• Total  parenteral  nutrition:• Intestinal  obstruction• Severe  ileus• Initial  phase  of  short  bowel  syndrome

Patients  in  the  late-­‐initiation  group,  as  compared  with  the  early-­‐initiation  group,   had  • fewer  ICU  infections  (22.8%  vs.  26.2%,  P  =  0.008)• lower  incidence  of  cholestasis  (P<0.001)• relative  reduction  of  9.7%  in  the  proportion   of  patients  requiring  more  than  2  days  of  

mechanical  ventilation  (P=0.006)• median  reduction  of  3  days  in  the  duration  of   renal-­‐replacement  therapy  (P=0.008)  • mean  reduction   in  health  care  costs  of  €1,110   (about  $1,600)   (P=0.04)  • Conclusion:  Late  initiation  of  parenteral  nutrition  was  associated  with  faster  recovery  and  

fewer  complications,   as  compared  with  early  initiation.  

Emphasis  points:  for  acute  renal  problems

Acute  Phase  (usually   in-­‐patient,  critical  care)• Goal:  Adequate  intake

• Enteral• Parenteral• Pharmaconutrition

• Mindful   of  the  specific  deficiencies  or  overdosing

• Strict  nutrient  audit• Strict  fluid  management

Fiaccadori E  et  al.  Prevalence  and  Clinical  Outcome  Associated  with  Preexisting  Malnutrition  in  Acute  Renal  Failure:  A  Prospective  Cohort  Study.  J  Am  Soc Nephrol

10:  581–593,  1999.

• High   inflammation  status• Insulin  resistance• Multi-­‐organ  dysfunction• More  utilization  of  PN  for  immediate  

correction  of  deficiency/losses• Nutrient  doses  are  highly  variable  

depending   on  severity/complexity

Emphasis  points:  for  chronic  renal  problems

Acute  Phase  (usually  critical  care)• Adequate  intake

• Enteral• Parenteral• Pharmaconutrition

• Mindful   of  the  specific  deficiencies  or  overdosing

• Strict  nutrient  audit• Strict  fluid  management

Chronic  Phase  (outpatient)• Regular  assessment  of  nutritional   status• Diligent,   regular,   frequent  nutrient   intake  audit• Usually  oral  nutrition• Others  may  be  on  tube  feeding• May  give  parenteral  nutrition  when  audit  reveals  

deficiencies  • Intermittent  PN• IDPN

TargetsConservative  Therapy Hemodialysis   Peritoneal  Dialysis

Energy  (kcal.kg-­‐1) >35 30-­‐35 >35  *

Protein  (g/kg-­‐1) 0.6  -­‐ 0.8 1.1  – 1.4 1.2  – 1.5

Phosphorus   (mg)(mmol)

600 – 100019  – 31  

800  – 100025  – 32  

800  – 100025  – 32  

Potassium  (mg)(mmol)

1500 – 2000  **38  – 40  

2000  – 250040  – 63  

2000  – 250040  – 63  

Sodium  (g)(mmol)

1.8  – 2.5  **77  – 106  

1.8  – 2.577  – 106  

1.8  – 2.577  – 106  

Fluid   (ml) Not restricted 1000  +  DO 1000  +  UF  +  DO

DO  =  daily  urine  output;   UF  =  ultrafiltrate*  Includes  energy  (glucose)  from  the  dialysate**  individual  requirements  differ  considerably  

Druml W,  Cano  N,  Teplan V.  8.7.2.1  Non-­‐catabolic  patients  with  stable  chronic  kidney  disease.  Basics  in  Clinical  Nutrition,  4th ed.  Sobotka L,  ed-­‐in-­‐chief.  Galen.  2011

Targets

Issues:  CKD  statistics,  outcomes

Issues:  CKD  statistics,  outcomes

Body  composition  changes:  CKD

Keane  D  et  al.  Changes   in  Body  Composition   in  the  Two  Years  after  Initiation  of  Haemodialysis:  A  Retrospective Cohort  Study.  Nutrients 2016,  8,  702;  doi:10.3390/nu8110702

• Used  BIA  (Bioelectric  Impedance  Analysis)• Changes  occur  in  all  age  groups  – two  (2)  year  follow  up• Implications  on  lean  body  mass  enhancement  and  life  expectancy  – NUTRITION  HAS  A  ROLE

Lean  body  mass  enhancers

• High  protein  intake  (preferably  BCAA)• Fish  oils  and  HMB  (hydroxymethyl butyrate)• Early  mobilization  and  exercise• Arginine  and  glutamine• Adequate  energy  intake

Monitor  body  composition  changes:  CKD

Massy-­‐WestroppNM  et  al.  Hand  Grip  Strength:  age  and  gender  stratified  normative  data  in  a  population-­‐based  study   .  BMC  Research  Notes  2011,  4:127  http://www.biomedcentral.com/1756-­‐0500/4/127

MEN

WOMEN

• Hand  grip  dynamometer

Monitor  body  composition  changes:  CKD

Recommendations

• Need  for  regular  nutritional  assessment• Need  for  good  monitoring  data  (nutrient  audit  and  fluid  balance)• Need  for  regular  assessment  of  body  composition  data• Need  for  local  protocols  and  guidelines  in  the  nutrition  assessment,  nutrition  therapy  and  monitoring  of  renal  disease  patient  management• Need  for  you  to  please  report  your  data

Thank  You