Nutritional Cases with CKD HEMODIALYSIS

Transcription

1 Nutritional Cases with CKD HEMODIALYSIS S. Muge DEGER, MD, FISN Yuksek Ihtisas University Faculty of Medicine, Koru Hospital Department of Nephrology Ankara, TURKEY

2 CASE-1 BC, is a 60- year- old Caucasian female presents to the nephrology clinic complaining of difficult breathing, leg edema, loss of appetite, vomiting

3 CASE-1 PMH Diabetes Mellitus ( 17 years) Hypertension ( 6 years) CKD secondary to diabetes (10 years ago) ESRD-> on HD for 3 years ( thrice weekly) Congestive heart failure ( EF %45) (PCI and stent placement to RCA 2 years ago) Not smoker, not drink alcohol PSH AV fistula placement for 5 times, AV graft placement, hernia repairment MEDICATION Carvedilol 2x 25 mg, Nifedipin 2x 60 mg, EAS 3x5 tb ( can not use due to vomiting) Aspirin 100 mg PPI Insulin glargine 6 unite per night ( not using for one month due to frequent hypoglycemia) EPO

4 CASE-1 She has multiple hospitalizations within last few months prior to clinical visit First, 4 months ago -> due to uncontrolled diabetes ( hypoglycemia and hyperglycemia) Second, 2 months ago-> AV fistula thrombosis-> thrombectomy Third, 20 days ago -> AV fistula failure and AV graft placement She is non-compliant for her meds, frequently skipping hemodialysis sessions and mostly has shortened dialysis

5 CASE-1 PHYSICAL EXAM BP: 190/ 90 mmhg HR:89/min T: 37 C Weight: 53 kg Height: 1.69 m BMI: 18.9 kg/m 2 Chest: Bilateral crepitant rales starting apices Ext: Bilateral pretibial pitting edema (+++/+++)

6 CASE-1 HD records show progressive weight loss DATE WEIGHT 04/ kg 05/ kg 06/ kg 07/ kg Despite the management of weight by ultrafiltration, she still has dyspnea, cough, vomiting, leg edema Kt/V: 0.98

7 Pulmonary edema Pretibial edema High blood pressure Loss of appetite Vomiting Skipping HD CASE-1 Not completing sessions Signs of hypervolemia Progressive weight loss Not effective HD

8 CASE-1 DATE 04/ / / /2013 Weight (kg) HB (g/dl) Creatinine (mg/dl) Adjusted calcium (mg/dl) Phosphorus (mg/dl) Total Chol (mg/dl) 96 PTH (pg/ml) 603 Albumin (g/dl) Potassium (meq/l) hba1c (%) 5

9 CASE-1 Chest Xray: Bilateral alveolar infiltrates

10 CASE-1

11 CASE-1 DATE 04/ / / /2013 Weight (kg) HB (g/dl) Creatinine (mg/dl) Adjusted calcium (mg/dl) Phosphorus (mg/dl) Total Chol (mg/dl) 96 PTH (pg/ml) 603 Albumin (g/dl) Potassium (meq/l) hba1c (%) 5 Weight: 53 kg Height: 1.69 m BMI: 18.9 kg/m 2 BMI< 23 kg/m 2

12 CASE-1 Over 5 % weight loss over 3 months DATE 04/ / / /2013 Weight (kg) HB (g/dl) Creatinine (mg/dl) Adjusted calcium (mg/dl) Phosphorus (mg/dl) Total Chol (mg/dl) 96 PTH (pg/ml) 603 Albumin (g/dl) Potassium (meq/l) hba1c (%) 5 Weight: 53 kg Height: 1.69 m BMI: 18.9 kg/m 2 BMI< 23 kg/m 2

13 CASE-1 DATE 04/ / / /2013 Weight (kg) HB (g/dl) Creatinine (mg/dl) Adjusted calcium (mg/dl) Chol< 100 mg/dl Alb<3.8 gr/dl Phosphorus (mg/dl) Total Chol (mg/dl) 96 PTH (pg/ml) 603 Albumin (g/dl) Potassium (meq/l) hba1c (%) 5 Over 5 % weight loss over 3 months Weight: 53 kg Height: 1.69 m BMI: 18.9 kg/m 2 BMI< 23 kg/m 2

14 CASE-1 Chol< 100 mg/dl Alb<3.8 gr/dl Over 5 % weight loss over 3 months DATE 04/ / / /2013 Weight (kg) HB (g/dl) Creatinine (mg/dl) Adjusted calcium (mg/dl) Phosphorus (mg/dl) Total Chol (mg/dl) 96 PTH (pg/ml) 603 Albumin (g/dl) Potassium (meq/l) hba1c (%) 5 Weight: 53 kg Height: 1.69 m BMI: 18.9 kg/m 2 BMI< 23 kg/m 2 Mid arm muscle circumference: 19 cm Low MAMC

15 CASE-1 PROTEIN ENERGY WASTING

16 Algorithm for Nutritional Intervention Ikizler et al. J Renal Nutrition, Vol 23, No 2, 2013: 77-90

17 Algorithm for Nutritional Intervention NDT Plus (2010) 3: Ikizler et al. J Renal Nutrition, Vol 23, No 2, 2013: 77-90

18 Algorithm for Nutritional Intervention Ikizler et al. J Renal Nutrition, Vol 23, No 2, 2013: 77-90

19 Algorithm for Nutritional Intervention NDT Plus (2010) 3:

20 Algorithm for Nutritional Intervention Ikizler et al. J Renal Nutrition, Vol 23, No 2, 2013: 77-90

21 CASE-1 FOLLOW-UP Increased the dialysis frequency as 4 times per week, tried to complete whole sessions by 4 hours. Continued to decrease weight by ultrafiltration ( until get normal volume examination) RC s nutritional need were 63 gr/d protein and 1855 kcal. We counted and documented her actual calorie intake was 900 kcal and protein was 35 gram/day. Started oral nutritional supplementation ( non-renal diabetic formula) twice daily and started domperidon 10 mg 2x1 ( for to increase intestinal motility)

22 CASE-1 Diagnosed AV graft infection and started antibiotics. Although graft infection healed by antibiotics, high CRP levels and hypoalbuminemia sustained. Couldn t determine any other infection IDPN has been started. FOLLOW-UP

23 63 years old, AA, female CASE-2 Under hemodialysis for 6 years (secondary to FSGS) Hypertension for 7 years No other comorbidity Meds: Amlodipin 10 mg, cinacalcet 60 mg 1x1 ( prescribed for CC, but not using) Under follow-up by her dialysis facility. She has no complaint. Her physical exam and laboratory assessment records obtained for research purposes.

24 CASE-2 Physical Exam ( 24/09/2015) BP: 138/90 mmhg HR: 77/min Height:1.58 cm Weight: 111 kg BMI: 44.5 kg/m 2 HB: 10.5 AST: 21 P:6 TKOL: 213 Kt/V: 1.4 Glucose: 92 ALT: 26 TPRO:7.1 HDL: 32 HBA1C: 5.1 ALP:302 ALB:4 LDL: 134 Chest Xray: No infiltration BUN:36 NA: 140 UA: 6.7 TG: 70 Creatinine: 5.76 K: 4.5 CRP:10.2 anuric FERRITIN: 455 CA +2 : 8.6 HCO3: 23 PTH:1103 Prealbumin: 25

25 CASE-2 DEXA: Dietary Recall Fat Mass: 57 kg Lean Mass: 50.5 kg Trunc Fat (%) : 53 Calorie: 900 kcal/day Protein: 33 gram (%17) CH: 103 gram (%50) Fat: 30 gram (% 33)

26 Physical Exam ( 17/12/2017) BP: 120/60 mm Hg HR:80/ min Height:1.58 Weight: 115 BMI: 46.1 kg/m 2 No hypervolemia sign. HB: 9.9 AST: 18 P:4.8 CHOL: 172 KT/V: 1.1 Glucose: 90 CASE-2 ALT: 17 TPRO:6.1 HDL: 66 HBA1C: 5.3 ALP:197 ALB:3.6 LDL:95 BUN:29 NA: 135 UA: 5 TG: 59 CREA: 4.8 K: 4.6 CRP: 29 anuric FERRITIN: 367 CA +2 : 8.1 HCO3:23 PTH:1071 Prealbumin:27

27 CASE-2 DEXA: Dietary Recall Fat mass: 66.9 kg Lean Mass: 46.5 kg Trunc Fat(%) : % 55 Calorie: 1032 kcal/day Protein : 37 gram (%17) CH : 135 gram (%50) Fat: 39 gram (% 33)

28 CASE-2 Weight: 111 -> 114 (no weight loss) BMI: > 46.1 kg/m2 Serum alb: 3.6 Prealbumin: 27 Lean mass: 50.5-> 46.5 kg (% 9 decrease) 0.32 gram/kg/day protein intake 8.9 kcal/kg/day energy intake

29 CASE-2 Obesity paradox in MHD patients is known since Obesity is associated with better stem cell mobilization, more efficient disposal uremic toxins, better bone strength and improved hemodynamic tolerance Although obesity can be associated with muscle wasting and catabolism, increased fat stores usually reflect well preserved energy stores and preserved appetite. Stenvinkel et al, J Am Soc Nephrol 24: , 2013

30 CASE-2 However, abdominal obesity has direct relation with increased inflammation. It has been reported that coexistence of overt diabetes and obesity increases mortality risk which might be mediated by adipocytokine imbalances A disproportionally lower muscle mass in relation to increased metabolically active visceral fat mass is associated with poor outcome in ESRD. Deger et al. Renal Fail 2014; 36 (4): Cordeiro et al. Nephrol dial transp 2010; 25: Beddhu et al, JASN 2003; 14: Stenvinkel et al, J Am Soc Nephrol 24: , 2013

31 CASE-2 We have to focus on to the interventions that increase muscle mass and decrease visceral fat mass for the treatment of obesity (obese sarcopenia). A multidisciplinary approach with other health care providers (i.e., dietitians and physiotherapists) is important to control those patients. Stenvinkel et al, J Am Soc Nephrol 24: , 2013

32 CASE-2 FOLLOW-UP Dietary protein intake was increased to 1.3 gr/kg/day ( adjusted CH intake) Couldn t demonstrate any infection ( high CRP due to ESRD?) Consulted to physiotherapists and recommended exercise ( patient couldn t tolerate) Couple of months later her body weight decreased to 110 kg but lean mass did not change ( DEXA).

33 NOTES MHD patients are at high risk for PEW and may present with different clinical manifestations. Regular assessment of nutritional status essential for early diagnosis of PEW. Multidisciplinary approaches and more alternatives are needed to control nutritional disorders in MHD patients.

34 ACKNOWLEDGEMENT Sukru Sindel, MD, Prof. Turgay Arinsoy, MD, Prof Alp Ikizler, MD, Prof Ulver Derici, MD, Prof Adriana Hung, MD, Assoc Prof Cindy Mambungu, RN

35 NDT Plus (2010) 3:

36 After the first hemodialysis therapy in 1960 s, several questions have been solved, except PEW!