Outlines. Protein Energy Wasting Syndrome. Case presentation. Case presentation. Case presentation. Nutrition in ESRD patients Nutritional management

Transcription

1 Protein Energy Wasting Syndrome Outlines Nutrition in ESRD patients Nutritional management Chutatip Limkunakul, MD Panyananthaphikku Chonpratan Medical Center Srinakarinwirot University Division of Nephrology Nonthaburi,Thailand Case presentation Case presentation A 75 yrs old woman was admitted because of N/V for several weeks. She had CKD from DKD > 10 yrs, HT, HPL Her husband was passed last 9 months. She live on her own but her daughter come to see her weekly. She reported poor appetite some taste change sleepiness decreased physical activity weight loss 7 kg in 6 months. Case presentation Laboratory investigation PE : BW 68.5 kg, BMI 28.5 kg/m 2 BP 115/65 mmhg PR 65/min Her skin and mucosa were dry. She had mild to moderate muscle and fat wasting. Her cardiac and lung are unremarkable. Her leg is 1+ edema. Variable 6 mo before 1 st visit D/C TCO 2 (meq/l) BUN (mg/dl) Creatinine (mg/dl) Glucose (mg/dl) Albumin (g/dl) Calcium (mg/dl) Phosphorus (mg/dl) Hemoglobin A1c ND Urine spot ACR ND Hemoglobin (g/dl) Estimated GFR (ml/min per 1.73 m 2 ) Her kidney function is improved after IV fluid. Her dietary assessment shows daily intake: 1200 kcal, 40 g protein ( 0.6 kg/kg), 80 meq/l potassium 800 mg phosphorus. 1

2 Case presentation ( 4 mo after 1 st visit) PE : BW 68 kg, BMI 28 kg/m 2 BP 115/60 mmhg PR 65/min She came with S O B. Her skin and mucosa were dry. She had mild to moderate muscle &fat wasting. Her cardiac and lung are unremarkable. Her leg is 1+ edema. Variable Laboratory investigation 6 mo before 1 st visit D/C 2 nd visit (4 mo later) TCO 2 (meq/l) BUN (mg/dl) Creatinine (mg/dl) Glucose (mg/dl) Albumin (g/dl) Calcium (mg/dl) Phosphorus (mg/dl) Hemoglobin A1c ND ND Urine spot ACR ND 2.0 Hemoglobin (g/dl) Estimated GFR (ml/min per 1.73 m 2 ) She was initiated HD via tunneled cuff catheter and D/C home for 3 times HD sessions. After MHD 5 months Case presentation HD via catheter ( AVF is not mature yet). U output < 200 cc/day HD prescription was 4 hrs with biocompatible HF membrane, 350 cc/min BF, 800 CC/min DF and Kt/V 1.6. She had very poor appetite. She felt sick toward the end of HD and often singed off early because of cramp. She was admitted because of low grade fever and chills. PE : BW 59 kg, BMI 24.6 kg/m2 (BW 68 kg, BMI 28 kg/m2) She had mild to moderate muscle and fat wasting. Her skin & mucosa were dry. Exit site is clean. H/C were Gram +ve cocci in clusters. Catheter was removed. She was D/C with a new cuffed HD catheter. Laboratory investigation ( 5 mo after 2nd visit) Variable 6 mo before 1 st visit D/C 2 nd visit (HD initiate) 3nd visit (5 mo after HD) TCO 2 (meq/l) BUN (mg/dl) Creatinine (mg/dl) Glucose (mg/dl) Albumin (g/dl) Calcium (mg/dl) Phosphorus (mg/dl) SCREENING AND ASSESSMENT NUTRITIONAL STATUS IN ADVANCED CKD Hemoglobin A1c ND ND ND Urine spot ACR ND 2.0 ND Hemoglobin (g/dl) Estimated GFR (ml/min per 1.73 m 2 ) ND 2

3 Variable Screening Threshold for Detailed Assessment/Intervention Relevant to Case? Body weight Continuous decline or <85% IBW Yes(7kg in 6 mo,13%) Dietary nutrient intake DEI (kcal/kg IBW/d) <25 Yes(17.5) DPI (g/kg IBW/d) <0.8 Yes(0.6) Serum albumin (g/dl) <4.0 Yes(2.9) Serum creatinine Relatively low value Yes but subtle MST(malnutrition screening tool) >2 Yes(3) Assessment prealbumin (mg/dl) <28 ND hscrp (mg/dl) >10 ND Anthropometrics Deviation from norms ND SGA B or C (moderately or severely malnourished) ND (presumed score B or C) MIS >5 ND IBW, ideal body weight; DEI, dietary energy intake; DPI, dietary protein intake; MST, Malnutrition Screening Tool; hscrp, high sensitivity C reactive protein; SGA, subjective global assessment; MIS: malnutrition inflammation score; MAMC, mid arm muscle circumference; ND, not done. a Influenced by kidney function. 1-6 kg =1 7-11kg= kg=3 >17=4 Unsure =2 น าหน กลดไหม? เบ ออาหารไหม? MST 2 AT RISK Ferguson, M et al. Nutrition : Variable Threshold for Detailed Assessment/Intervention Diagnosis PEW (3 of 4) Relevant to Case? Serum chemistry Albumin (g/dl) <3.8 Yes(2.9) Prealbumin (mg/dl) <28 a ND Cholesterol (mg/dl) <100 ND Body mass BMI (kg/m 2 ) <23 No Weight loss >5% over 3 mo or 10% over 6 mo Yes( 68.5 >59 kg,13%) Total body fat (%) <10 ND Muscle mass Muscle wasting >5% over 3 mo or 10% over 6 mo ND Reduced MAMC >10% reduction compared with norms ND Cr appearance (g/kg IBW) <1 ND Dietary intake Low DPI (g/kg IBW per d) <0.8 Yes(0.6g/kg) What do we find? This case demonstrated several factors related to PEW such as decreased nutritional intake, catabolic effects of RRT, systemic inflammation,comorbid conditions:dm and depression. Low DEI (kcal/kg IBW per d) <25 Yes(1200kcal,17.5kcal/d) Malnutrition in ESRD Malnutrition definition Anorexia is an important cause of malnutrition in ESRD Decline of protein and calorie intake will be manifested when GFR approximately <25 38 ml/min. 1 CKD spontaneous restrict protein to less0.6g/kg/d when GFR < 15 cc/min 2 Measurement of chronic inflammation can be useful clues for protein energy wasting but do not define protein energy wasting. 3 A poor nutritional status caused by poor nutrient intake or improper diet. 1. Kopple JD et al, KI 1989 Nov 27; S Ikizler TA et al; J Am Soc Nephrol 6: , Fouque D et al, Kidney Int 2008 Feb;73(4):

4 Uremic malnutrition Protein energy wasting,pew Malnutrition may not suitable for CKDassociated wasting patient which has many factors other than poor intake. Also, there are multiple metabolic findings among dialysis CKD patients eg. high protein catabolic state and loss of LM mass in CKD population Protein energy wasting' is defined for loss of body protein mass and fuel reserves. Protein energy wasting,pew A proposed nomenclature and diagnostic criteria for protein energy wasting disease Kidney International (2008) 73, If 3 characteristics are presented 1. Low serum levels of albumin, transthyretin(prealbumin), or cholesterol 2. Reduced body mass (low or reduced body or fat mass or weight loss with reduced intake of protein and energy) 3. Reduced muscle mass (muscle wasting or sarcopenia, reduced mid arm muscle circumference). 3 of 4 Fouque d et al. Kidney Int Feb;73(4):391-8 Malnutrition affect clinical outcomes Factors affect nutritional status in advanced CKD 130,052 dialysis patients (PD, 12,171; HD, 117,851) Serum albumin predicts all cause, cardiovascular, and infection related mortality in both PD and HD patients Fouque D et al: KI(2008)73:

5 Causes of PEW in advanced CKD Dialytics factors Biocompatibilities Inadequate dialysis dose Nutrient losses Inadequate intake Protein Energy wasting Other factors Co morbidities Inflammation Insulin resistance/deprivation Metabolic and hormonal derangement DEI in CKD patients was lower than recommendation. Studies on REE showed mixed results depend on differences in population characteristics, clinical conditions, and stage of the disease. ESRD patients, esp. HD are in general less active than sedentary healthy individuals. Increase energy expenditure Frequent hospitalization From Ikizler T A, Current Opinion in Nephrology and Hypertension 2008, 17: Energy balance in advanced chronic kidney disease and end stage renal disease. Cuppari L, Ikizler TA, Semin Dial July 1, 2010; 23 (4); Inflammation and advanced CKD Chronic inflammation are important comorbid that predict poor clinical outcome in advanced CKD with PEW. Higher pro inflammatory cytokines are associated with mortality in CHD patients.1 Both low protein intake and high inflammation are associated with low Alb in MHD patients. 2 S.albumin associated with mortality risk in dialysis pts was partly explained by inflammation not only malnutrition 3. 1 Kimmel PL et al, KI 1998 Jul;54(1): Kim Y et al, Int Urol Nephrol De Mutsert,J Ren Nutr 2009 Mar(2);19; Dialysis catheter utilization and inflammation HD catheter is an independent determinant of an exaggerated inflammation in CHD patients. RRT had catabolic stimulation Dialytic factors Hung A,et al. Hemodial Int

6 HD stimulates muscle &whole body protein loss Protein loss during HD Dialytic removal of AA ~ g per HD session as well as low amounts of protein(<1 3 g per session) 1 Losses increase with glucose free dialysate. PD patients lose ~9 12 g of total protein and 6 8 g of albumin daily. 2,3 (may increased if infected CAPD) Ikizler T A et al, 2001 Dialytic factors 1.Ikizler TA et al. Amino acids and albumin losses during heemodialysis. KI 1994;46: Dukkipati, R. & Kopple, J. D. Causes and prevention of protein-energy wasting in chronic kidney failure. Semin. Nephrol. 29, (2009). 3.Blumenkrantz, M. J. et al. Protein losses during peritoneal dialysis. Kidney Int. 19, (1981). RRT had effect on nutrition?? Comorbid conditions effect nutrition? Adequate dialysis dose recommended in various guidelines are sufficient to preserve nutritional status. Increase dialysis dose dos not further improve nutritional status. ( PD;ADEMEX,HD;HEMO study) High flux HD membrane(mpo study) does not show difference in nutritional marker. 1 Nutritional marker is not differ between in center 6 times/week and 3 times/week. (FHN trial) 2 Higher incidence of PEW among diabetes CKD. 1 Depressive symptom which linked to fatigue and loss appetite among CKD. 2 There was association between depression, inflammation, albumin in MHD patients 3 1.Locataellt et al. J Am Soc Nephrol 20:645-54, Chertow GM et al; N Eng J Med , Cano N J et al : KI 62: , Carrero JJ et al : J Ren Nutr 19: Hung K-C et al: NDT26: ,2011 Protein breakdown in T2DM MHD Insulin resistance and CKD LBM LOSS IR is detectable in dialysis patients 1. In animal, insulin deficiency and IR appear to decrease in PI3K activity and lead to enhance activation of UUP. 2 Muscle protein synthesis is sensitive to both insulin and concomitant increase in amino acid infusion. 3 4 Pupim et al, KI 2005 Oct;68(4): Comorbidity UUP =ubiquitin-proteasome system PI3K activity= phosphatidylinositide 3 kinases 1.DeFronzo RA et al; Kidney Int Suppl 16:S102 S114, Lee Sw etal;j Am Soc Nephrol 15: , Bohe J,Renne MJ;J Ren Nutr 16:3-16, Lim Vs etal; J Am Soc Nephrol 14: ,2003 6

7 Insulin resistance and CKD related factors leading to IR Metabolic acidosis role in PEW Uremic toxins Metabolic acidosis Inflammation Cachexia/wasting Physical activity Cortisol EPO deficiency 1,25 dihydroxy vitamin D Insulin resistance CKD Metabolic acidosis 1,25 dihydroxyvitamin D parathyroid hormone Insulin secretion Increased protein degradation from the activation of ATP dependent ubiquitin proteasome system and the enzyme branched chain keto acid dehydrogenase in acidosis. 1 3 Administering of sodium bicarbonate and raising ph is presumably reduced activity of branched acid dehydrogenase. 1 2 Impaired glucose tolerance hyperglycemia 1.Bailey JL et al; J Clin Invest 97: , Bailey JL et al; J Am Soc Nephrol 17: , May RC et al; Am J Physiol 252(6 Pt 1): E , 1987 Metabolic acidosis role in PEW Nutrition Assessment Correcting metabolic acidosis decreases whole body protein degradation in PD 1 and HD 2 patients. Oral NaHCO3 ( among pts with HCO3 <25 meq l) was associated with fewer hospitalizations and increased Npna in PD patients. 3 To avoid alkalosis after HD which had adverse outcome, suggest pre dialysis goal HCO meq/l. 1.Graham KA et al; Kidney Int 49: , Graham KA et al; J Am Soc Nephrol 8: , Szeto CC et al; J Am Soc Nephrol 14: , WU DY et al : Clin J Am Soc Nephrol 2006:1;70-78 Anthropometry Biceps fold 1. Mid arm circumference(mac),waist Circumference(WC) 2. Waist Hip Circumference(WHR) 3. Body mass Index (BMI) 4. Subcutaneous skin fold Monthly Albumin: 4.0g /dl Potassium: meq/l Phosphorus: mg/dl Calcium: mg/dl Blood glucose <200 (nonfasting) Ca phosphate product: < 55 URR: >65% Hb: g/dl Biochemistry Quarterly Hemoglobin A1C: < 7% PTH: pg/ml Lipid Panel Chol < 200 mg/dl HDL > 40mg/dL LDL <100mg/dL Triglycerides <200 mg/dl Physical Assessment workshop Nov McCann L. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4 th ed. National Kidney Foundation;

8 Clinical observation Diet History atrophy Wasted clavicle Hand wasting Prominent bony part subcutaneous fat White band Shopping and Cooking Abilities Facilities Medication Side Effects Compliance Physical limitations Psychosocial problems Emotional support Economic limitations Depression Adjustment to disease Treatment Compliance How to assess diet history? Category I Measure Minimum frequency Predialysis or stabilized serum albumin Monthly Food Records 24 Hour Recall 3 Day Food Record 3 Day Calorie Count Food Frequency Questionnaire Diet Assessment Calories Protein Carbohydrates Fat/Cholesterol Sodium Potassium Phosphorus Fluid Vitamins Minerals KDOQI 2000 Percent of ususal postdialysis body weight(mhd) or post drain body weight (CPD) Percent of standard (NHANES II) body weight Subjective global assessment (SGA) Dietary interview and / or diary Normalized protein nitrogen appearance (npna) Measurements that should be performed routinely in all patients Monthly Every 4 months Every 6 months Every 6 months Monthly for MHD Every 3 4 months forcpd Category II Measure Minimum frequency Category III Measure Minimum frequency KDOQI 2000 Predialysis or stabilized serum prealbumin Skin fold thickness Mid arm muscle area, circumference, or diameter Dual energy x ray absorptometry As needed As needed As needed As needed KDOQI 2000 Pre dialysis serum Creatinine As needed Urea nitrogen As needed Cholesterol As needed Creatinine Index Measures that can be useful to confirm of extend data obtained from the measure in the category I Clinically useful measures,which if low,might suggest the need for a more rigorous examination of PEW status 8

9 SGA msga Nutritional scores Dialysis Malnutrition Score MIS PEW Journal of Renal Nutrition, Vol 23, No 3 (May), 2013: pp Subjective Global Assessment,SGA Detsky AS, et al.jpen 1987;11:8 15 Modified Subjective Global Assessment, msga Kalantar Zadeh K et al.ndt Jul1999,14(7) Malnutrition Inflammation Score,MIS Kalantar Zadeh K et al.am J Kidney Dis Dec 2001,38(67) Geriatric Nutritional Risk Index,GNRI Bouillane O et al : Am j clin Nutri2005Oct ;82(4); Protein energy wasting,pew Fouque et al: Kidney Int 2008 Feb;73(4):391 8 Subjective Global Assessment,SGA Weight change: A= ต ากว า 5 %, B= ลดลง5-10 %, C= ลดลงมากกว า 10% Dietary intake: A= ไม ลดลงช ดเจน, B= แย แต ด ข นบ าง หร อก าก งแต เลวลง C= ก นแทบไม ได GI symptoms: A= ไม ม อาการ, B= ม บางอาการ C= ม หลายอาการ Functional capacity: A= ปกต B= ลดลงเล กน อย C = ลดลงมาก Metabolic demand (stress): A= ไม ม stress, B= mild-moderate stress C= severe stress Modified SGA 7 = normal 35 = severest malnutrition Malnutrition Inflammation Score (MIS) C,D (A) Patients related medical history : 1. Change in end dialysis dry weight (overall change in past 3 6 months) : No decrease in dry Wt or Minor Wt loss Wt loss > 1 kg but < 5% Wt loss > 5% Wt loss< 0.5 kg (>0.5 kg but < 1kg) 2. Dietary intake Good appetite and no Somewhat sub optimal Moderate overall decrease to Hypo caloric liquid to deterioration of the dietary solid diet intake full liquid diet starvation pattem 3. Gastrointestinal (GI) symptoms: No symptoms with good Mild symptoms, Occasional vomiting diarrhea poor appetite or Frequent or vomiting appetite or nauseated occasionally moderate GI symptoms or severe anorexia 4. Functional capacity(nutritionally related functional impairment): Normal to improved Occasional difficulty with Difficulty with otherwise Bed/chair ridden, or little to functional capacity, feeling baseline ambulation, or independent activities (eg. no physical activity fine feeling tired frequently Going to bathroom) 5. Co morbidity (including number of years on Dialysis) On dialysis < 1 yr and healthy Dialyzed for 1 4 yr, or mild Dialyzed > 4 yr, or moderate Any severe, multiple comorbidity otherwise co morbidity (excluding MCC*) co morbidity (including I MCC*) (> 2 MCC*) (B) Physical Exam (according to SGA criteria): 6. Decreased fat stores or loss of subcutaneous fat (below eyes, triceps, chest) : Normal (no change) mild moderate severe 7. Signs of muscle wasting (temple, clavicle, scapula, ribs, quadriceps, knee, interosseous): Normal (no change) mild moderate severe (C) Body mass index (BMI) 8.Body mass index : BMI = Wt (kg)/ht 2 (m) BMI >20 BMI BMI BMI < 16 (D) Laboratory parameters 9. Serum albumin : Albumin > 4.0 g/dl Albumin g/dl Albumin g/dl Albumin < 3.0 g/dl 10.Serum TIBC (total iron binding capacity) : TIBC > 250 mg/dl TIBC mg/dl TIBC mg/dl TIBC mg/dl Total Score = sum of above 10 components (0 30) Criteria for malnutrition treatment Aims of nutritional support Dietary recall, npna BMI Serum Albumin Body weight loss or IDW loss The ultimate goal in management PEW is to preserve muscle mass, stabilize whole body homeostasis. 2 out of 4 9

10 HOW?? Only diet,meal Planning?? How to order diet?? Individualize diet for patient s lifestyle Other adjuvant treatment and procedure?? Criteria's for management of malnourish dialysis pt I.Dietary intake HD PD Unintentional low dietary Energy intake Unintentional low dietary Protein intake 3 days diet dairy preferred to 24 hr dietary recall. < 25 kcal/kgibw/d at least 2 months < 1.0 g/kgibw/d at least 2 months Valid & clinically useful for measuring dietary protein and energy intake. Symptoms of anorexia, nausea,vomiting, weight loss,dietary habits and pattern, quantity & quality of food ingested and fluid balance should be properly and carefully evaluated and compared with the recommended intake. KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104. Suggested Energy Intake for Dialysis Patients HD DOQI 35 kcal/kg BW/day 35 kcal/kg BW/day kcal/kg BW/day if age 60 years PD kcal/kg BW/day if age 60 years Consider energy provided by dialysate ESPEN 35 kcal/kg IBW/day 35 kcal/kg IBW/day Fats 30 40% of total energy supply; complex carbohydrates 25 40%; simple sugars restricted Glucose absorption must be taken into account EBPG kcal/kg IBW/day Adjusted to age, gender and physical activity level EDTNA/ERCA 35 kcal/kg IBW/day 35 kcal/kg IBW/day 30 kcal/kg IBW/day in the elderly and patients with reduced activity 30 kcal/kg IBW/day in the elderly and patients with reduced activity Including calories from peritoneal absorption of glucose Adapted from: NKF 2000 (DOQI); Toigo et al. (2000) (ESPEN); EDTNA/ERCA 2002; Fouque et al. (2007) (EPBG) Suggested Protein Intake for Dialysis Patients HD PD DOQI 1.2 g/kg IBW/day, 50% HBV g/kg IBW/day, 50% HBV ESPEN 1.2 g/kg IBW/day, 50% HBV g/kg IBW/day, 50% HBV Greater intake if peritonitis EBPG At least 1.1 g/kg IBW/day Balanced intake of high quality animal protein and vegetable protein source EDTNA/ERCA g/kg IBW/day, 50% HBV g/kg IBW/day, 50% HBV 1.5 g/kg IBW/day if peritonitis Adapted from: NKF 2000 (DOQI); Toigo et al. (2000) (ESPEN); EDTNA/ERCA 2002; Fouque et al. (2007) (EPBG) Recommended minimal protein, energy, and mineral intakes for CKD and maintenance dialysis patients Nondialysis CKD Hemodialysis Peritoneal dialysis Enteral Nutrition Support Protein* g/kg/day Illness 1.0 g/kg >1.2 g/kg/day >1.2 g/kg/day Peritonitis 41.5 g/kg Energy kcal/kg/day kcal/kg/day kcal/kg/day including kcal from dialysate Sodium mmol/day mmol/day mmol/day Potassium Phosphorus <1mmol/kg if elevated mg and binders if elevated <1mmol/kg if elevated mg and binders if elevated Not usually an issue mg and binders if elevated Oral Supplements Barriers: compliance, fluid, palatability, cost Tube feeding Barriers: acceptance, intolerance, tube placement, fluid intake, reimbursements, assistance * 50% high biological value protein( with EEA) ** Base on ideal body weight Ikizler et al:kidney Int (2013) 84,

11 Oral nutrition It should be given 2 3 times a day, preferable after main meal and /or during dialysis for MHD. This can provide additional energy 7 10 kcal/kg/day and protein g/kg/d. (pt should had energy intake minimally 20 kcal/kg/d, g/kg/d of protein which will meet recommended requirement. Parenteral Nutrition Support IDPN Barriers Oral intake is maximized without improvement Usually requires documented malabsorption diagnosis Cost Benefits Supplemented during treatment No additional tube/access needed ONS VS IDPN Similar improvement of nutritional marker and rate hospitalization, or death between them.** not head to head study*** 186 malnourish MHD with ONS with or without IDPN. Both groups improve BMI albumin and prealbumin. FINE:French study group for nutrition in dialysis But IDPN(add) did not improved 2 yr mortality. J Am Soc Nephrol 18: , J Am Soc Nephrol 18: , Implementation from RCT(ONS and IDPN) among PEW maintenance dialysis patients Nutritional response is correlated with severity of PEW at baseline and amount of nutrients delivered. Underlying SIR does not hinder beneficial effects of nutrition supplement. DM patients had differ response and may require individualized prescription. Route of administration (ONS,IDPN) does not have significant effect on the response.(as long as equal and adequate amounts of protein and calories are provided.) Optimal targets DPI is >1.2 g/kg/d,dei >35 kcal/kg/d among MHD patients Serum albumin and prealbumin used as surrogate markers not only of nutritional status but also possibly of hospitalization, CVS outcome and survival. Ikizler et al; Kidney Int(2013) 84, Other treatment Anabolic hormone: recommbinant human growth hormone(rhgh) Number studies show convincing direct and indirect evidence for anabolics response and biomarker, LBM in MHD. Large RCT is premature terminate to prove effect rhgh on hospitalization and mortality. 1. Ziegler TR et al. J AmSoc Nephrol 1991; 2: Johannsson G,et al Am J Kidney Dis 1999; 33: Kopple JDet al. Nephrol Dial Transplant 2005; 20: Hansen TB, et al. Clin Nephrol 2000; 53: Ikizler TA et al. Kidney Int 1994; 46: Feldt-Rasmussen B et al. J Am Soc Nephrol 2007; 18: Garibotto G et al. J Clin Invest 1997; 99: Pupim LB, et al. Am J Clin Nutr 2005; 82: Iglesias P, et al. J Kidney Dis 1998; 32: Guebre-Egziabher F et al. J Clin Endocrinol Metab 2009; 94:

12 Other treatment Other treatment Testosterone: It improved in anthropometric and biochemistries indices. 12 High dose nandrolone decanoate (100mg/week,IM) had side effect for woman and not use more than 6 month. Exercise: There were collectively data indicate beneficial effects of exercise in muscle quality and quantity strength and physical function. 1. Macdonald Jh et al:nephron Clin Prect106:c125-c135, Johansen KL et al ;JAMA 281: ,1999 ONS Increase forearm Muscle balance IDPN Increase forearm Muscle balance Emerging treatment for PEW in CKD Appetite stimulant: megestrol acetate It has S/E: hypogonadism, impotence, and increased risk of thromboembolism. It can stimulate appetite and increases BW&FFM. But it needs large scale of study to assess whether it will provide adjuvant nutritional treatment in MHD. Algorithm for nutritional management &support in patients with CKD. 1.Yeh S-S, et al. J Ren Nutr 2010; 20: *Minimum every 3 months, monthly screening recommended. Only for patients with ESRD who do not have residual renal function. 12

13 Conclusions Inadequate intake is highly prevalent among ESRD patients. Multiple factors associated with PEW. Routine nutrition marker monitoring should be considered to prevent PEW. T. Alp Ikizler CJASN 2013;8: Suggest reading Kidney International (2013) 84, Kidney International (2008) 73,