Nutrition Dilemmas, Controversies & Issues CHRONIC KIDNEY DISEASE (CKD)

Transcription

1 Nutrition Dilemmas, Controversies & Issues CHRONIC KIDNEY DISEASE (CKD)

2 Objectives To discuss the role of nutrition in clinical outcomes of chronic kidney disease (CKD) To discuss and update on the nutrition management of CKD To identify problem areas in nutrition management of CKD

3 PREVALENCE OF MALNUTRITION CONSEQUENCES

4 Prevalence of malnutrition United States: Prevalence of CKD Stage 3-5: 2.6% 1 Philippines: In hemodialysis patients: 2,3 Prevalence of malnutrition: 75% 2 Severe malnutrition: 56.8% 2 ; 36% 3 1. NNHeS Renal Report 2. Divina R et al. Nutritional status of hemodialysis patients in the Philippines: a cross sectional survey in four out- patient dialysis centers. PhilSPEN Online J Paren Ent Nutr Jan Jan 2012: Boado JA et al. Nutritional assessment of patients on maintenance hemodialysis using Dialysis Malnutrition Score (DMS). PhilSPEN Online J Paren Ent Nutr Feb Dec 2014:

5

6

7

8 Morbidity and mortality in CKD Tonelli M et al. Chronic Kidney Disease and Mortality Risk: A Systematic Review. J Am Soc Nephrol 2006; 17:

9 Malnutrition and survival SGA HGS = Hand Grip Strength Qureshi AR et al. Inflammation, Malnutrition, and Cardiac Disease as Predictors of Mortality in Hemodialysis Patients. J Am Soc Nephrol 2002; 13: S28 S36.

10 PATHOPHYSIOLOGY OF PROTEIN ENERGY WASTING (PEW)

11 Pathophysiology of PEW in CKD Very Low Protein prescription PEW: Protein Energy Wasting; ESRD: End Stage Renal Disease

12 LBM = Lean Body Mass/Muscle Mass = PEW PEW = Protein Energy Wasting

13 The MDRD Study* Study period: trial participants with predominantly stage 4 nondiabetic chronic kidney disease Compared results of these diets: Low- protein diet (0.58 g/kg/d) Very low- protein diet (0.28 g/kg/d) supplemented with a mixture of essential ketoacids and amino acids Median time to death = 10.6 years THERE ARE MORE DEATHS IN VERY LOW PROTEIN DIET GRP Outcome Developed kidney failure Died Reached composite outcome Low protein 117 (90.7%) 30 (23.3%) 124 (96.1%) Very low protein 110 (87.3%) 49 (38.9%) 120 (95.2%) Hazard Ratio (*MDRD = Modification of Diet in Renal Disease) Menon V. Effect of a Very Low- Protein Diet on Outcomes: Long- term Follow- up of the Modification of Diet in Renal Disease (MDRD) Study. Am J Kidney Dis, 2009.

14 DIAGNOSIS

15 Malnutrition diagnosis Subjective global assessment Validated in Philippine setting 1,2 Is serum albumin a good marker of nutritional status? 3 Unwarranted; it is a marker of illness Strategy of supplying expensive nutritional supplements as a reflexive first step in managing hypoalbuminemia should be discouraged 1. Lacuesta- Corro et al. PhilSPEN Online Journal Boado JR et al. PhilSPEN Online Journal Friedman, Reassessment of Albumin as a Nutritional Marker in Kidney Disease. Journal of American Society of Nephrology. 2010

16 Nutritional Assessment in CKD Required data: Subjective global assessment Anthropometric measures Pertinent laboratory data (creatinine, serum visceral protein concentrations, inflammatory markers) Diet History Physical Examination Additional data that will help: Cause of CKD and associated complications. Evaluation of medications (nephrotoxic, need for renal adjustment). ASPEN Core Curriculum, p. 497

17 GOALS OF NUTRITION

18 Goals of nutrition in CKD Nutritional status Maintain or further improve lean body mass and function Kidney status and function To sustain what is left of the normal functions of the kidney To slow down the deterioration caused by the disease process

19 Goal: maintain/improve nutrition Strategies: status Adequate calories (=carbohydrate and fat) Adequate protein to maintain protein balance with minimum stress on kidney function Adequate micronutrient balance

20 Energy requirements Energy recommendations ESPEN ASPEN Conservative/Predialy sis state > 35 kcal/kg kcal/kg Hemodialysis state Peritoneal dialysis state > x ( )* ESPEN: European Society of Parenteral and Enteral Nutrition ASPEN: American Society of Parenteral and Enteral Nutrition * Stress factor added when using the Harris- Benedict formula

21 Protein requirements Energy recommendations ESPEN ASPEN Conservative/Predialy sis state g/kg g/kg Hemodialysis (HD) CRRT >1-2.5 Peritoneal dialysis to (PD) ESPEN: European Society of Parenteral and Enteral Nutrition ASPEN: American Society of Parenteral and Enteral Nutrition

22 CKD specific recommendations 1,2,3 CKD Stage 1-3 CKD G4 (severe) CKD G5 (failure) Energy Variable kcal/kg kcal/kg Protein DM = Diabetes Mellitus HD = Hemodialysis PD = Peritoneal dialysis DM: g/kg/d, 50% high biologic value Non- DM: 0.8 g/kg DM: g/kg Non- DM: g/kg 1.2 g/kg (HD) kg.kg (PD) 1. Kopple, 2001; Mitch 2010; National Kidney Disease Education Program (NKDEP), 2010; 2. American Dietetic Association, 2010; Uhlig, 2010; Byham- Gray and Wiesen, 2004); 3. National Kidney Foundation, 2009

23 FEEDING PATHWAYS

24 Feeding pathways: CKD

25 Micronutrient losses

26 Issues/dilemmas/controversies CKD patients are at risk of malnutrition, however the amount of protein needed to upbuild might be in excess of the amount that the diseased kidney can handle which may lead to uremia. In the hospital setting, it is common that a low albumin level is attributed with malnutrition hence Clinical Nutrition physicians are expected to give the maximum protein level allowable in cases of hypoalbuminemia even in renal patients.

27 Issues/dilemmas/controversies How low should the protein intake be? The MDRD study review showed very low protein intake is harmful (=death) Are there indications for increasing protein intake? When the serum albumin is low, do I have to correct it immediately with albumin infusion? Can eggs provide all protein needs? What is meant by high biological value protein?

28 PROTEIN INTAKE

29 What is the value of achieving adequate protein intake? Anabolic resistance requires more amino acids to achieve adequate muscular synthesis rate. The inflammatory status and its effects on the rest of the organ systems require more amino acids for the synthesis of acute phase response proteins. The need for cysteine, the rate limiting step of glutathione synthesis, in order to limit oxidative stress. Prevention in glutamine depletion in muscle and plasma. Increased utilization in both increased metabolic rate and requirements. Preiser et. Al. Critical Care (2015) 19:35

30 What is the value of achieving adequate protein intake? Effects of achieving a zero protein balance: Efficient use of non- protein calories for both metabolic and inflammatory requirements When the amino acid mix (in both EN or PN) is close to requirements: Urea synthesis is reduced Nitrogen balance improves Amino acid catabolism is minimized and whole- body protein turnover decreases. EN: Enteral Nutrition PN: Parenteral Nutrition Preiser et. Al. Critical Care (2015) 19:35

31 What are the factors causing protein loss in CKD? Kidney disease Reduced oral intake of nutrients (anorexia, depression, restrictive diets, low social status) most important Effects on gastric motility and rest of the gut Endocrine factors (growth factor abnormalities, deficiency in erythropoietin and male hormones, insulin resistance, hyperparathyroidism) Inadequate blood purification Uremia; metabolic acidosis Dialysis associated factors Loss of macro and micro nutrients, inflammatory response Others: Diabetes mellitus and inflammatory state Reduced physical activity

32 PROTEIN RESTRICTION

33 What is the role of protein restriction in CKD? Preserve renal function by reducing: intraglomerular pressure solute load mesangial stretch toxic products of metabolism overall nephron activity Dietary protein restriction decreases the severity of uremic symptoms can delay the onset of dialysis need and preserves GFR ASPEN Core Curriculum Chapter 29, p 495

34 What do the evidence(s) say for low protein restriction? Studies exploring the long term risks and benefits of an LPD (=Low Protein Diet) have yielded mixed results. Mean follow- up ranged from 4.5 months to 4 years; in all studies, compliance with a low DPI (=Dietary Protein Intake) was poor; there was no convincing or conclusive evidence that long- term protein restriction delayed the progression of CKD. (Kidney International Supplements 2013; 3(1): 73 90) Shortfalls in many of the studies include: Poor assessment of adherence to prescribed protein intake levels Limited long term follow- up Exclusion of diabetics Nutrition therapy in Chronic Kidney Disease p. 125

35 What do the evidence(s) say for low protein restriction? Comment from Nutrition therapy in Chronic Kidney Disease Given that restricting protein intake has the potential to preserve renal function and reduce the symptoms of uremia with minimal impact on nutritional status, many feel that this recommendation should be utilized more frequently with close monitoring by a dietitian.

36 INCREASED PROTEIN INTAKE

37 Is there evidence for increasing the protein dose for CKD?

38 How to achieve adequate to high protein dose in CKD Formulation: Oral supplementation EN (Enteral Nutrition) like tube feeding PN (Parenteral Nutrition) IDPN (IntradialyticParenteral Nutrition) Combinations Micronutrients should be given daily Close monitoring Calorie and protein counting Dietitian or a nutrition team

39 THE EGG ISSUE

40 Biological value of protein source HIGH contains the essential amino acids in a proportion similar to that required by humans animal sources of protein, such as meat, poultry, fish, eggs, milk, cheese and yogurt LOW one or more essential amino acids are scarce Plant sources of protein like legumes, grains, nuts, seeds and vegetables European Food Information Council.

41 Egg white 70 gm protein/day = 23 pieces of eggs/day (that s a lot of leche flan)

42 SERUM ALBUMIN

43 If serum albumin is low Low serum albumin History, PE, laboratory Extreme dietary protein deficiency (< g/kg/day Muscle mass loss noted YES Hypoalbuminemia may reflect malnutrition NO Hypoalbuminemia does not reflect malnutrition Initiate protein and calorie supplementation NO Evaluate for non- dietary causes Are serum albumin and body composition improving? YES Continue nutritional supplementation

44 If serum albumin is low Factors causing low serum albumin Reduced hepatic synthesis and secretion due to inflammation, malnutrition or poor intake Exchanges between the intra- and extravascular compartments Increased lymphatic uptake Alterations in volume of distribution (including hemodilution) Body losses Friedman AN, Fadem SZ. Reassessment of albumin as a nutritional marker in kidney disease. J Am Soc Nephrol 2010; 21:

45 KIDNEY INJURY

46 Mechanism of kidney injury Increased workload of remaining nephrons. Increased GFR results in intraglomerular hypertension, stretching of the mesangial supporting cells, and an increase in oxygen- free radicals and other inflammatory metabolic products progressive scarring of the remaining glomeruli. ASPEN Core Curriculum Chapter 29, p 494

47 Goal: improve kidney status and/or function Special nutrition that intervene in the kidney disease process Anti- inflammatory nutrition Fish oils Glutamine Keto- analogs

48 Fish Oils (ω3 Fatty Acids)

49 Glutamine

50 Ketoanalogs Background: CKD > endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) are elevated and may contribute to vascular complications Methodology: prospective randomized; obese patients; 36 mos ff- up Diet: 0.6 g/kg protein; kcal/kg Study group: keto- amino acids at 100 mg/kg Results: Study group > significant changes ê BMI ê in the plasma level of ADMA ê in pentosidine (marker for AGEs = advanced glycation end products), proteinuria, glycated Hb and LDL- cholesterol Teplan V et al. Reduction of plasma asymmetric dimethylarginine in obese patients with chronic kidney disease after three years of a low- protein diet supplemented with keto- amino acids: a randomized controlled trial. Wien Klin Wochenschr. 2008;120(15-16):478-85

51 PHILSPEN

52 What are PhilSPEN members doing? Institution: Nutrition Screening and Assessment Practice: Evidence- based guidelines and clinical pathways* For patients not on dialysis: g/kg/day For patients on dialysis: g/kg/day Request for serum prealbumin and CRP to rule out inflammation (if available) If inflammation is ruled out, upper protein limit may be used. *Once you have logged in as PhilSPEN member:.../clinicalnutriguidelines.php

53 What are PhilSPEN members doing? Recommendation: Always coordinate with attending nephrologist Refer to available evidence based clinical guidelines* Evaluate the cause of hypoalbuminemia (inflammatory status/critical illness?) Clinical experience/judgment *Once you have logged in as PhilSPEN member:.../clinicalnutriguidelines.php

54 THANK YOU