La relation dialyse et nutrition
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1 Nutrition en dialyse : controverses La relation dialyse et nutrition Charles Chazot, MD NephroCare Tassin-Charcot Sainte Foy Les Lyon, France
2 HEMO study lessons (1) Dose Body weight flux Rocco, Kidney Int 2004
3 HEMO study lessons (2) Dose S-Alb flux Rocco, Kidney Int 2004
4 HEMO study lessons (3) Protein intake Rocco, Kidney Int 2004
5 S-Albumin in PD patients Idem for BW and Mid-arm circumference 5 Davies KI 1998
6 Causes of PEW in dialysis patients A multifactorial issue Fouque. Kidney Int 2008
7 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 7
8 Appetite score and HD patients survival Kalantar-Z Am J 8 Clin Nutr 2004
9 Improvement of S Alb level with standard dialysis in incident dialysis patients Retrospective study in 97 incident patients Mehrotra AJKD 2002
10 Improvement of protein intake with standard dialysis in incident dialysis patients Mehrotra, AJKD 2002
11 Survival in incident HD patients Effect of Target Weight change in the 1 year of HD therapy >+2,35% <+2,35% Significant in the Cox analysis Chazot Nephron Clin Pract 2014
12 Blood access and nutritional parameters patients 23% with a permanent catheter Patients with a permanent catheter: significant lower SAlb level after adjustment for blood access type, age, vintage, KT/V, race A native fistula will help the patient even in nutrition (better dialysis delivery, less inflammation, ) Chand, Nephron Clin Pract 2010
13 Relationship between dialysis dose and food intake 50 patients with Urea Monitor and 7-day food records No mathematical flaw. Chauveau NDT 1996
14 npna according to the Processed Blood Volume 364 prevalent patients (75 yo) P=0,0016 Chazot, ICNMRD Okinawa 2016
15 Dialysis parameters and npna npcr>1,0 g/kg/d npcr>1,2 g/kg/d Variable AUC Criterion AUC Criterion Proc. BV 0,624 >203 l/week 0,606 >228 l/week Weekly TT 0,630 >701 min 0,620 >768 min OCM 0,573 >1,49 0,568 >1,62 Chazot ICNMRD 15 Okinawa 2016
16 BNP (ng/l) BNP = 766, ,994 x npna r=-0,43; p=0, ,6,8 1 1,2 1,4 1,6 1,8 2 npna (g/kg/d) Fluid excess may impair appetite and nutritional status Chazot Blood Purif 2009
17 La dose de dialyse L abord vasculaire Le contrôle de l hydratation Préalables à un état nutritionnel correct 17
18 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 18
19 Standard HD versus PD The Chinese-Italian cohort study 509 HD vs 410 PD Shangai and Vicenza Renal Registries Retrospective study Mean data during the 5-year follow-up Switched or Transplanted patients excluded (mg/l) Lu Int J Art 19 Organs 2018
20 Home Short Daily HD versus PD therapy 2x4201 matched incident patients H SD HD vs PD NxStage. Intention to Treat On Treatment Cachexia refers to Nutrition?: Unclear 20 Weinhandl AJKD 2015
21 PD versus Daily Home HD 41 PD vs 47 Home HD patients (Standard Thrice Weekly?) Cross-sectional Bioimpedance study Extracellular fluid excess significantly higher in PD vs Home HD patients (46 vs 21%) No difference on malnutrition criteria in PD vs Home HD patients Title, Subject, Author Copyright Page 21 LI J Renal Care 2018
22 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 22
23 What is longer and/or more frequent hemodialysis? The «Tassin» or «Izmir» model: 6-8 hours x3/week (Charra KI 1992; Ok NDT 2011; Lacson cjasn 2010) The Alternate dialysis model: 8h X 3.5 times/week (Kerr Sem Dial 2011) Daily long nocturnal model : 6-8 h x5-6/week (Pierratos KI 2004; Rocco FHN KI 2011) Short Daily model: 2hx6/week (Galland KI 2004, Chertow FHN NEJM 2010) Extra-session per week: common practice Individualized therapy 23
24 Daily Short HD 24
25 Switch from conventional to daily short hemodialysis (1) Galland KI 2001
26 Switch from conventional to daily short hemodialysis (3) BMI LBM FFM Galland KI 2001
27 Frequent Hemodialysis Network (FHN trial #1) In-Center Daily Trial: Nutritional impact RCT: 120 (standard) versus 125 (frequent short daily) No effect on BW or BIA parameters 27 Kaysen KI 2012
28 Thrice Weekly Long (Nocturnal) (Home) Hemodialysis 28
29 The Long Dialysis Study Prospective case-control study In-Center 3x7-8h versus In-Center 3x h hemodialysis therapy 2x247 patients with matching from 35 criteria Ok NDT 2011
30 Switch from conventional to thrice-weekly In-Center nocturnal HD in FMC North-America IDWG 746 versus 2062 patients (471 vs 226 min) Propensity-score analysis UF rate S-Alb Lacson cjasn 2012
31 g/kg/d Nutritional stability with long-hour HD 5-year follow-up of 53 patients treated with 3x 6-8 hours/week 33 have yearly dietary records - 20 are controls Daily protein intake (g/kg/d) SD 2,00 1,50 1,00 1,34 1,36 1,34 1,36 1,31 1,31 1,30 1,27 1,30 1,32 DPI npcr 0,50 npcr BW, S-Alb, Daily Energy Intake stable ,32 1,29 1,28 1,31 1,24 Controls Chazot HD Int 2006
32 Daily Nocturnal Home Hemodialysis FHN trial #2 32
33 Frequent Hemodialysis Network Daily Home Nocturnal Trial: Nutritional impact RCT: 42 (standard) versus 45 (daily home nocturnal) 33 Kaysen KI 2012
34 Meta-Analysis on nutritional effect of nocturnal HD 34 Ipema PlosOne 2016
35 Nutritional parameters 35 Ipema PlosOne 2016
36 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 36
37 Title, Subject, Author Copyright Page 37 Molina NDT 2017
38 Switch from HF-HD to High Volume OL-HDF Nutrition parameters at one year Lean Tissue Mass Title, Subject, Author Copyright Page 38 Molina NDT 2017
39 Convective Therapies at Home? Not legally possible in France at the moment Title, Subject, Author Copyright Page 39
40 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 40
41 Nutritional supplement during the dialysis session Non-randomized controlled study in 41 HD patients with albuminemia < 38g/L Antioxydant & anti-inflammatory specific oral supplement, 830 Kcal + 33,5 g of protein at each dialysis for 4 weeks 41 Kalantar-Zadeh JRN 2005
42 Title, Subject, Author Copyright Page 42 Pupim JASN 2006
43 With permissions
44 Does Home Dialysis Therapy prevents Protein-Energy Wasting? 1 Never forget the basics! 2 Peritoneal Dialysis versus Hemodialysis 3 Nutritional Effect of Alternative Hemodialysis Strategies 4 Nutritional Effects of HD convective therapies 5 Just a reminder 6 Take Home Message 44
45 Take Home Message Never forget the basics: no good nutrition without good dialysis See the home-treated patients often!!! Home PD or Home HD: no evidence for better nutritional status whatever the method Short daily in-center or home HD (FHN trial #1): no evidence for better nutritional status Nocturnal home HD: Some evidence for better nutritional status Convective therapies: controversial. More stable Lean Body mass to be confirmed Utmost importance for the patient to be fed during dialysis therapy, even at home? 45
46 This presentation is dedicated to Dr Guy Laurent, founder of the Tassin Dialysis Unit 46
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