Prevalence of malnutrition in dialysis

Transcription

1 ESPEN Congress Cannes 2003 Organised by the Israel Society for Clinical Nutrition Education and Clinical Practice Programme Session: Nutrition and the Kidney Malnutrition and Haemodialysis Doctor Noël Cano Marseilles, France Prevalence of malnutrition in dialysis BMI < 20 kg/m 2 24 % Lean body mass < 90 % th. 62 % Albumin < 35 g/l 20 % Transthyretin < 300 mg/l 36 % npcr < 1 g/kg BW/day 35 % French Cooperative study,, n= 7,123 Aparicio M, Cano N, Chauveau P et al. Nephro Dial Transplant 1999;14: ESPEN For personal use only. 1

2 N = 1,620 patients 100 ALBUMIN Cumulative Proportion Surviving (%) Quartiles 36.4 g/l g/l g/l > 43 g/l Survival during hemodialysis 60 p< RR / g/l = % CI Time (days) Cumulative Proportion Surviving (%) C. Combe et al. Am J Kidney Dis, 2001;37:S81-S88 Quartiles 0.27 mg/l mg/l mg/l > 0.39 mg/l p< RR / 0.1 g/l = % CI PREALBUMIN Time (days) Nutritional assessment Parameters body weight BMI diet record (3 days) SGA npcr Albumin, transthyretin (prealbumin) Intervals 1 month 6 months 6 months 1 month 1-3 months 1 - ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : & Clin Nutr, 2000, 19 : Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis, 2000, 35 (suppl 2) ESPEN For personal use only. 2

3 Recommended food intakes in dialysis (g/kg/day) ESPEN consensus (1) DOQIs (2) Protein HD 1,2-1,4 1,2 g/kg/day DP 1,2-1,5 1,2-1,3 Energy 35 < 60 y 35 kcal/kg/day > 60 y ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : & Clin Nutr, 2000, 19 : Kidney Disease Outcomes Quality Initiative. Am J Kidney Dis, 2000, 35 (suppl 2) Vitamin & trace element requirements In hemodialysis patients Pyridoxin, mg Vitamine C, mg Folic Acid, mg (OH) 2 D 3 according to plasma calcium & phosphorus Zinc, mg 15 Selenium,µg ESPEN consensus on nutritional treatment of patients with renal insufficiency Clin Nutr, 2000, 19 : & Clin Nutr, 2000, 19 : ESPEN For personal use only. 3

4 Nutritional support during dialysis - Dietary counselling - Oral supplements - Intradialytic parenteral nutrition - Enteral nutrition Serum albumin changes after 6 months of dietary counselling Randomized controlled trial. Leon JB et al. J Ren Nutr 2001 % Diet (n = 52) Control (n = 31) <2.5 g g >5 g p<0.001 Independent From CRP ESPEN For personal use only. 4

5 Oral supplementation: Metabolic effects Non-diabetic, non malnourished HD patients aged less than 65 y. Test meals composed of 6 portions given every 30 min during 3 h Total intake = 46, 2 g protein, 63 g CHO, 75 g fat Metabolic studies: 1/post absorptive phase 2/ during a dialysis session L- (1-13 C) valine infusion Veeneman JM et al. Am J Physiol Endocrinol Metab 2003;284: Oral supplementation: Nutritional effects - 9 cohort studies Review of 17 Studies Oral supplementation --> improved body weight, AMC, TSF, albumin - 8 controlled studies - 3 cross-over & 5 comparative randomized studies - 6/8 : improvement of nutritional parameters - 2 studies : Oral supplementation --> improved spontaneous food intake [Patel 2000, Hiroshige 2001] - 2 studies: no nutritional gain (non-depleted patients) ESPEN For personal use only. 5

6 Oral supplementation Hiroshige K et al. NDT 2001;16: N=44, cross-over study, BCAA 12 g/j during 6 months vs. placebo ORAL SUPPLEMENTATION: PATIENT COMPLIANCE Eustace JA et al. Kidney int 2000;57: Hemodialysis: : n=29 Perit. Dialysis: : n=18 ESPEN For personal use only. 6

7 Intradialytic Parenteral Nutrition (IDPN) Cyclic parenteral nutrition during HD sessions Nutrient supply: kcal/kg/hd (CHO & fat) g protein/kg/hd Infusion technique - venous way of extracorporeal circulation - constant infusion rate ( 250 ml/hour) - minimum infusion time: 4 hours - controlled ultrafiltration rate - addition of sodium 75 mmol/l - First week: infusion volume/2 IDPN: metabolic effects Pupim LB et al J Clin Invest 2002;110: dialysis patients studied during 2 HD sessions, with and without IDPN. Constant infusion of L- (1-13 C) leucine and L-(ring- 2 H 5 ) phenylalanine: 2 h before, during, 2 h after HD ESPEN For personal use only. 7

8 IDPN: nutritional effects 30 retrospective series & one controlled study showed, after 3 to 9 months of IDPN: body weight, arm muscle circumference albumin, transthyretin npcr, creatinine production response to hypersensitivity skin tests spontaneous intakes Perdialytic parenteral nutrition with lipids and amino acids Cano N et al. Am J Clin Nutr 1990;52: Prospective, controlled, randomized study IDPN 16 kcal/kg/hd & 0.08 g N/kg/HD, n = 12, vs. Controls,, n = 14 BW % days days TTR % AMC % Albumin % ESPEN For personal use only. 8

9 IDPN: effect on survival Retrospective study: National Medical Care Hemodialysis Centers Chertow GM et al. Am J Kidney Dis 1994;24: /1/1991: IDPN (n=1679) vs controls (n=22517) Evaluation: Intention to treat, one-year follow-up Data adjusted for: age, gender, race, diabetes, URR Improved survival: Albumin 33 g/l (p<0,01) Reinforced efficacy: creatinine < 8 mg/dl Enteral nutrition Polymeric EN, administered via naso-gastric tube or gastrostomy Necessary during severe undernutrition, particularly when spontaneous intakes are < 20 kcal/kg/day: - IDPN cannot reach recommended supplies - daily nutritional support is needed - enteral nutrition should be prefered to parenteral nutrition Poorly investigated ESPEN For personal use only. 9

10 A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients Nondiabetic adult MHD patients with BMI <20 and serum albumin <4.0 g/dl: - Control group: appropriate monitoring, dietary counselling - Supplement group: post-hd enteral nutrition, 500 kcal, 15 g protein for 1 month - Both groups : baseline food intake, dry weight and BMI - Supplement group: serum albumin and functional scoring. Sharma M. J Ren Nutr 2002:12: Nutritional Support in Dialysis patients moderate malnutrition Food intake < 35 kcal/kg/day < 1.2 g protein /kg/day Diet counselling + oral supplements (if necessary) Severe malnutrition SGA npcr < 1g prot/kg/day Albumin < 35 g/l, Transthyretin < 300 mg/l Food intake kcal/kg/d < 20 kcal/kg/d g/kg/d < 0.8g/kg/d IDPN ± oral suppl. Enteral Nutrition (if necessary) ESPEN For personal use only. 10

11 Conclusion & Perspectives 1 - Nutritional support in hemodialysis patients - appears to be able to improve nutritional status - remains to be evaluated concerning its effects on - quality of life - healthcare requirements - survival 2 - Multidisciplinary approaches for the treatment of malnutrition during dialysis need to be evaluated, combining nutritional support with - Anabolic factors - Rehabilitation Références (1) 1. Combe C, Chauveau P, Laville M et al. Influence of nutritional factors and hemodialysis adequacy on the survival of 1,610 French patients. Am J Kidney Dis 2001; 37: S Aparicio M, Cano N, Chauveau P et al. Nutritional status of hemodialysis patients: a French National Cooperative Study. Nephrol Dial Transplant 1999; 14: Toigo G, Aparicio M, Attman P-O et al. ESPEN consensus on nutritional treatment of patients with renal insufficiency (Part 2 of 2). Clin Nutr 2000; 19: National Kidney Foundation. Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. I. Adult guidelines. A. Maintenance dialysis. Am J Kidney Dis 2000; 35 (suppl 2): S17-S Veeneman JM, Kingma HA, Boer TS et al. Protein intake during hemodialysis maintains a positive whole body protein balance in chronic hemodialysis patients. Am J Physiol 2003; 284: E ESPEN For personal use only. 11

12 References (2) 6. Pupim LB, Flakoll PJ, Brouillette JR et al. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 2002; 110: Cano N, Labastie-Coeyrehourcq J, Lacombe P et al. Perdialytic parenteral nutrition with lipids and amino-acids in malnourished hemodialysis patients. Am J Clin Nutr 1990; 52: Chertow GM, Ling J, Lew N et al. The association of intradialytic parenteral nutrition administration with survival in hemodialysis patients. Am J Kidney Dis 1994; 24: Sharma M, Rao M, Jacob S, Jacob CK. A controlled trial of intermittent enteral nutrient supplementation in maintenance hemodialysis patients. J Ren Nutr 2002; 12: Mitch WE. Mechanisms causing loss of lean body mass in kidney disease. Am J Clin Nutr 1999;67: ESPEN For personal use only. 12