Nutritional considerations in the dialysis population: from malnutrition to obesity

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Preston Wilkerson
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Jessica Stevenson Senior Renal Dietitian,

University of Sydney Presentation outline:

1 Nutritional considerations in the dialysis population: from malnutrition to obesity Jessica Stevenson Senior Renal Dietitian, St George Hospital PhD Candidate, The University of Sydney Presentation outline: Altered nutritional states in CKD - PEW - Obesity Nutritional requirements in dialysis - energy - protein Management of sarcopenia 1

Malnutrition Increasingly obesity and lifestyle diseases Electrolyte and

2 Dialysis Altered nutritional states in dialysis Protein energy wasting often involving malnutrition - Muscle wasting leading to sarcopenia and frailty - Malnutrition Increasingly obesity and lifestyle diseases Electrolyte and fluid disturbances - potassium - fluid balance - phosphate Protein energy wasting 2

3 Protein Energy Wasting Multiple nutritional and catabolic alterations that occur in chronic kidney disease (CKD) and associate with morbidity and mortality. Malnutrition: under-nutrition and over-nutrition. How do we measure nutritional status? 3

4 Assessment of nutritional status Anthropometry Biochemistry Clinical Dietary An ideal nutrition parameter is: üonly affected by nutritional factors ünormalised with adequate nutritional care üaccurately predicts outcome Very few measures exist; therefore need to rely upon a combination of parameters PEW ISRNM International Society of Renal Nutrition and Metabolism classification of PEW Low body fat and low muscle mass At least 3 of the 4 categories must be satisfied to have a diagnosis of PEW Dietary intake Protein intake <0.8g / kg BW / day Serum chemistry Albumin <38g/L Body Mass Index BMI <23kg/m2 Muscle mass cmamc <90% of expected range Albumin as a nutritional marker Unique conditions in CKD which impact on various control mechanisms of albumin, include: Inflammation Fluid retention / oedema Dialysis losses and proteinuria Rate of synthesis Dilutional effect due to volume expansion Loss of protein and albumin Alb is a well known marker of illness, rather than nutritional state, low levels should be a prompt to investigate a patient s overall health rather than solely focusing on nutrition 4

5 Anthro (change in weight) Physical assessment SGA Dietary intake Functional capacity Nutrition impact symptoms Muscle wasting (Sarcopenia) 5

6 Nutritional deficiencies Physical inactivity Chronic inflammation Muscle loss/ sarcopenia is common with PEW As CKD advances, muscle strength and size reduces Sarcopenia reduces independence and mobility, increases the risk of fractures from falls and reduces QoL Promotion physical activity pivotal Measuring sarcopenia Measuring sarcopenia Functional assessments Upper Body Hand Grip Strength Lower Body 6 minute walk test, sit-to-stand, timed up and go 6

7 Practical issues with measuring nutritional status and sarcopenia - Important to be trained in assessing nutritional status - SGA is the most commonly used in clinical practice but doesn t measure sarcopenia - More accurate body composition measurements to adequately assess and monitor sarcopenia - Who is responsible for conducting functional assessments -? Are some of these measures relevant in obese populations Obesity Who is our population? 1978 Primary Cause of ESKD 18% diabetic nephropathy 5% hypertension 34% glomerulonephritis 22% analgesic nephropathy 1998 Primary Cause of ESKD 21% diabetic nephropathy 12% hypertension 34% glomerulonephritis 5% analgesic nephropathy 2015 Primary Cause of ESKD 41% diabetic nephropathy 14.5% hypertension 18.7% glomerulonephritis 0.8% analgesic nephropathy 1980s 10% adults were obese 60% were a healthy weight Today 66% overweight / obese 35% are a healthy weight 25% malnutrition 7

8 How do we manage the obese patient? Obesity Paradox In earlier, predialysis CKD +ve correlation between obesity and worsening KF 1kg in BMI, probability of CKD progression 1.23 Increased WC associated with higher mortality in dialysis Haemodialysis Higher BMI is associated with increased survival in haemodialysis patients Largely believed that this increase in survival is due to muscle mass Challenges of treating obese dialysis patients Studies are largely epidemiological with no clinical trials looking at outcomes in the obese populations. Difficulty treating obese Less access to renal transplantation Poorer outcomes after renal transplantations More difficult vascular access on dialysis Longer hours on dialysis 8

Challenges of choosing the right assessment Cross-sectional analysis dialysis patients (n=79) Height, weight Skin-folds (biceps, triceps, suprascapular, suprailiac) Waist and hip circumferences Mid

9 Challenges of choosing the right assessment Cross-sectional analysis dialysis patients (n=79) Height, weight Skin-folds (biceps, triceps, suprascapular, suprailiac) Waist and hip circumferences Mid arm muscle circumference Cross-sectional analysis dialysis patients (n=79) Height, weight Skin-folds (biceps, triceps, suprascapular, suprailiac) Waist and hip circumferences MAMC Obesity: BMI >30kg/m2 Fat mass %, >25% men, >35% women Fat mass >90 th percentile Abdominal Obesity: WC >88cm women, >102cm men WHR >0.9 men, 0.85 women Obese sarcopenia: Fat mass >90 th percentile LBM <10 th percentile 9

10 Koeford et al ISRNM PEW PEW 4% 29% Low lean body mass 32% Obese sarcopenia 10% PEW + Obese 0% 20% Abdo obesity Waist Circ 58% Abdo obesity WHR 98% Underweight 2% Nutritional management energy Diet quality protein Vitamins and minerals Nutritional counseling potassium Sodium & fluid phosphorus 10

11 Prioritising nutritional issues Dietary quality Co-morbid m ment Energy and Protein Potassium Sodium Fluid *Phosphate CKD stage 1-2 xx xx x CKD stage 3 xx xx x x CKD stage 4 xx xx x x CKD stage 5 x x xx xx x xx x Haemodialysis x x xx xx xx xx x Peritoneal dialysis xx x xx x xx xx x *Dietary phosphate: the evidence is weak. However if you are reducing sodium, moderating protein and focusing on dietary quality this will often be better controlled energy Diet quality protein Vitamins and minerals Nutritional counseling potassium Sodium & fluid phosphorus Energy requirements Haemodialysis 11

People with CKD and those on dialysis have similar REE to age and gender matched controls Energy requirements in haemodialysis Australian guidelines: Caring for Australasians with Renal Impairment

12 People with CKD and those on dialysis have similar REE to age and gender matched controls Energy requirements in haemodialysis Australian guidelines: Caring for Australasians with Renal Impairment (CARI) - NONE available DAA Reference KDOQI and CARI International guidelines: Kidney Disease Outcomes Quality Initiative (KDOQI) 2000 KDOQI (2000) The recommended daily energy intake for both MHD and CPD patients with light to moderate physical activity is 35 kcal/kg/d for those less than 60 years of age and 30 to 35 kcal/kg/d for those 60 years of age or older (Guideline 17). EE is similar to that of normal, healthy individuals More sedentary individuals may need less calories to maintain nitrogen balance and anthropometric indices. 12

13 Considerations for energy prescription Nutritious Olive oils Unsalted nuts or nut butters (if able) Cranberry juice Canned fish Non-nutritive Biscuits or cakes jams Cordials Ham Considerations for energy prescription For our obese population: - consider level of physical activity - minimise non-nutritive energy sources - under stable conditions use lower end energy requirements -?? consider trialling other weight loss strategies under supervision liaise with medical team Weight loss strategies Meal replacement Surgery Popular diets (e.g. 5:2, paleo) no literature 13

14 Dietary counselling Dietary Assessment: Overall caloric intake (including sources of calories) Diet quality - source and amount of protein - adequate fibre Controlling for electrolytes and fluid **consider physical activity level and age when determining nutritional requirements Meal replacements Effective at inducing rapid and significant weight loss in general population People with CKD stage 3 onwards contraindicated due to electrolyte and fluid concerns Meal replacements Effective at inducing rapid and significant weight loss in general population People with CKD stage 3 onwards contraindicated due to electrolyte and fluid concerns Optifast 850kJ 18g protein 20mmol K 340mg PO4 220mg Na standard meal 120g pork chop with ½ cup mash and 1cup veg 1850kJ 45g protein 35mmol K 500mg PO4 150mg Na 14

Renal dietitian prescribed modified low calorie diet: - 1.1-1.

15 Renal dietitian prescribed modified low calorie diet: g prot/kg/day - 1mmol K/kg/d mg PO4 - fluid as per patient prescription Prescribed: - 2 meal replacement shakes + 1 bar - 150g lean protein - 15g CHO - 2 serves low K fruit - 1cup low K low calorie veg Renal dietitian prescribed modified low calorie diet: g prot/kg/day - 1mmol K/kg/d mg PO4 - fluid as per patient prescription Used: 2 meal replacement shakes and 1 bar, 150g lean protein, 15g CHO, 2 serves low K fruit, 1cup low K low calorie veg Results N=5 maintenance HD patients N=1 ceased due to hyperkalemia (due to non-compliance with HD treatment) Weight loss: median 7% ( %) Limited adherence in all patients across 12/12 and no ax body composition Renal dietitian prescribed modified low calorie diet: g prot/kg/day - 1mmol K/kg/d mg PO4 - fluid as per patient prescription Used: 2 meal replacement shakes and 1 bar, 150g lean protein, 15g CHO, 2 serves low K fruit, 1cup low K low calorie veg Results N=5 maintenance HD patients N=1 ceased due to hyperkalemia (due to non-compliance with HD treatment) Weight loss: median 7% ( %) Limited adherence in all patients across 12/12 and no ax of body composition Safe and effective but should be utilised in motivated and supported patients 15

16 Surgical options Restrictive bariatric options: gastric banding or sleeve gastrectomy Malabsorptive procedures: gastric bypass, Roux-en-Y Small study populations reporting short term (12 month) outcomes have shown positive results re: substantial weight loss 43-70% Pros: Enable transplantation Vs Cons: Increased risk of post operative complications Protein requirements Haemodialysis Protein metabolism in HD Changes to utilisation of protein: Metabolic acidosis Inflammation and pro-inflammatory cytokines Dialysis (causing decreased protein synthesis in muscle) Excess protein loss: 6-12g amino acids lost through dialysis 16

17 Protein requirements in HD KDOQI (2000) 1.2g protein / kg IBW / day with >50% from HBV proteins BDA (2013) 1.1g protein / kg IBW / day with sufficient calories (30-40kcal / day) with >50% HBV proteins Goals of treatment is to reduce muscle wasting and sarcopenia. Considerations for dietary prescription High Biological Value Meat, chicken, fish Eggs Milk and milk products Low Biological Value Nuts Beans and lentils Breads and cereals Considerations for dietary prescription High Biological Value Meat, chicken, fish Eggs Milk and milk products Low Biological Value Nuts Beans and lentils Breads and cereals Timing and amount of protein Ingestion of approximately 25 30g of protein per meal maximally stimulates muscle protein synthesis in both young and older individuals Eating during dialysis treatment may be more beneficial aim for 20g protein. 17

18 Vegetarian diets Beneficial on phosphate homeostasis May improve metabolic acidosis No deleterious affect on body composition or nutritional status Can provide adequate protein and calories National Kidney Foundation (USA) With careful planning, vegetarianism, or even part-time vegetarian eating, is not only safe, but also beneficial to kidney disease patients Post menopausal women reduced rates of femoral neck (hip) bone loss Safety Concerns WRT potassium Vegetable proteins and potassium Animal protein 100g Chicken, beef, lamb =9mmol 100g Fish (e.g. salmon) = 11 mmol 65g canned tuna = 4mmol 100ml Cows milk = 4mmol Vegetable protein 100g tofu = 3mmol ½ c (90g) Canned chickpeas = 3mmol ½ c (90g) canned Red Kidney beans = 6.5mmol ½ c (90g) canned brown lentils = 4.5mmol 100ml soy milk = 5.5mmol 30g almonds = 5.5mmol 30g macadamia nuts = 3mmol 1 tablespoon peanut butter = 4mmol Physical activity 18

19 Physical activity in HD Anemia and abnormal muscle catabolism contribute to reduce PA and functioning. 35% less physically active and this increases with age HD patients spend less time participating in physical activity (-54 mins/day) Lower average daily METs 1.3 vs 1.5 *<1.4 METs considered to be sedentary Predictive equations may over-estimate TEE in sedentary HD patients. Strategies to prevent or treat sarcopenia 1. Adequate protein and energy intake. - non-ckd sarcopenia guidelines recommend g protein/kg IBW/day >50% HBV protein with Eating on dialysis >20g protein per meal Strategies to prevent or treat sarcopenia 2. Physical activity 1 year mortality rate 1.62 fold higher in sedentary than physically active HD patients Benefits of exercise training include: - Improve muscle function and strength - Improvements in glucose and lipid metabolism - Reduced inflammation and oxidative stress - Inhibition of catabolism - Improved mental state 12 weeks of exercise training effective in reducing skeletal muscle loss even when patients following low protein diet (0.6g/kg/day) 19

3/6/17 Guideline Recommendations Aerobic exercise at mild-moderate intensity for 20-60 mins 3-5/7 KDOQI 30 mins moderate intensity exercise most

routine assessment of physical function and encouragement of regular physical activity Cochrane 30 mins exercise 3/7 Exercise should not be done

Housework Working at a standing workstation.

20 3/6/17 Guideline Recommendations Aerobic exercise at mild-moderate intensity for mins 3-5/7 KDOQI 30 mins moderate intensity exercise most days of the week. routine assessment of physical function and encouragement of regular physical activity Cochrane 30 mins exercise 3/7 Exercise should not be done immediately post HD session due to fluid and electrolyte shifts Few recommendations on specific exercises What type of physical activity Light: Housework Working at a standing workstation. Moderate: Brisk walking Recreational swimming Social tennis Exercise on dialysis Benefits of exercise on dialysis are well known Number of resources: - KHA Exercise on Dialysis - Life Options (Ex Physio, PhD, USA) - Choose Health Brochure (Aust Govt) - Heartmoves Barriers: - who is responsible for this - scope of practice - confidence and comfort in recommendations 20

21 Summary Nutritional management Should be advocating for controlled weight loss in obese patients Continue exploring safe weight loss strategies for obese patients incorporating both physical activity and dietary management Promote nutrient-dense diets for both under and over nutrition Consider sources and timing of protein intake Physical activity Monitoring physical function (e.g. HGS, sit to stand) and when possible sarcopenia We should be promoting physical activity use available resources Questions 21

Malnutrition in advanced CKD

Malnutrition in advanced CKD Malnutrition Lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things or being unable to use the food that one does eat Jessica Stevenson