Nutrition Assessment in CKD

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1 Nutrition Assessment in CKD Shiaw-Wen Chien, MD, EMBA Division of Nephrology, Department of Medicine, Tungs Taichung MetroHarbor Hospital Taichung, Taiwan September 10, 2017

2 Outline Introduction Composite scores Anthropometrics Biochemical markers Take Home Message

3 Introduction

4 Kovesdy CP. Am J Clin Nutr 2013;97:

5 Potential causes of PEW in CKD

6 Nutrition screening The process of identifying patients at high nutritional risk so that more extensive nutrition assessment can be performed.

7 Nutrition assessment A more detailed evaluation and interpretation of multiple parameters and seeks to define the risk of developing nutrition-related medical complications. Can also be used to monitor the course of nutritional therapy.

8 Ikizler TA. Semin Dial (2014)

9 Considerations for assessment in CKD Considerations Effects on nutritional status Fluid status Inflammation Proteinuria Affects both body composition and biochemical markers. Common in CKD; many biochemical markers are also acute phase reactants. Serum albumin and lipids can be altered. Residual renal function RRT Some biochemical markers are cleared/excreted by kidneys, esp. prealbumin. RRT variously influences biochemical markers.

10 Methods for nutrition assessment in CKD Composite scores Anthropometrics Biochemical markers Dietary intake Functional assessment Physiological assessment

11 Composite scores

12 Widely used composite scores Subjective Global Assessment (SGA) Malnutrition Inflammation Score (MIS)

13 Composite scores Patient interview. Anthropometric measures. Medical charts.

14 Subjective Global Assessment SGA

15 Detsky AS. JPEN 1987;11(1):8-13

16 7-point scale SGA

17 7-point scale SGA

18 7-point scale SGA

19 Steiber AL. J Ren Nutr 2004;14(4): Studies using SGA in CKD 1 st author journal year rating variables n results

20 Steiber AL. J Ren Nutr 2004;14(4): Studies using SGA in CKD 1 st author journal year rating variables n results

21 SGA and survival in PD Paudel K. J Ren Nutr 2015;25(6):

22 Different parameters and survival in PD Paudel K. J Ren Nutr 2015;25(6):

23 Kamyar KZ. Nephrol Dial Transplant 1999;14:

24 Correlation between MQSGA and body fat% by BIA (Chinese HD) Hou Y. Nutr Res 2012;32:

25 Medical history Co-morbidities Medications Functional limitations Residual renal function RRT characteristics Socio-economic and cultural factors

26 Physical examination Peripheral edema Oral problems (dryness, glossitis, candidiasis) Dental problems (toothache, dentures fit poorly) Problems in the GI tract Changes in the skin, eyes, nails, hair

27 Advantages of composite scores Simple. Non-invasive. Inexpensive.

28 Disadvantages of composite scores Subjective. Requires training.

29 Anthropometrics

30 Anthropometry and body composition BMI Waist circumference Mid-arm circumference Mid-arm muscle circumference Skinfold thickness Handgrip strength Bioelectrical impedance analysis Dual-energy X-ray absorptiometry

34 Chumlea WC. J Ren Nutr 2003;13:31-38

35 Chumlea WC. J Ren Nutr 2003;13:31-38

36 Body Mass Index BMI

37 GFR and BMI : solid line : dashed line Kopple JD. Kidney Int 2000;57:

38 Correlations between Age, BMI, and LBM (French HD) Aparicio M. Nephro Dial Transplant 1999;14:

39 IDWG and BMI Yang SC. J Ren Nutr 2008;18(2):

40 Relative IDWG and BMI Yang SC. J Ren Nutr 2008;18(2):

41 Advantages of BMI Simple. Non-invasive. Inexpensive. May be useful in epidemiology or longitudinal studies.

42 Disadvantages of BMI Influenced by hydration status. Does not distinguish between muscle weight and fat weight. No official data for the ideal or optimal BMI of CKD population.

43 Handgrip Strength HGS

44 HGS The subject holds the dynamometer in the hand to be tested, with the arm at right angles and the elbow by the side of the body, and squeezes it with maximum isometric effort, which is maintained for about 5 seconds.

45 HGS and age in PD Wang YM. Am J Clin Nutr 2005;81:79-86

46 HGS and residual RFT in PD Wang YM. Am J Clin Nutr 2005;81:79-86

47 Reduced HGS is associated with : Sarcopenia and PEW CV complications. Increased length of hospital stay. Decreased survival in CKD.

48 HGS and FFM in HD Broers N JH. J Ren Nutr 2015;25(2):

49 HGS and LBM in PD Wang YM. Am J Clin Nutr 2005;81:79-86

50 HGS, appetite, and hscrp in HD Carrero JJ. Am J Clin Nutr 2007;85:

51 HGS and Salb in PD Wang YM. Am J Clin Nutr 2005;81:79-86

52 HGS and survival in dialysis Vogt BP. Clin Nutr 2016;3:1-5

53 Simple. Inexpensive. Non-invasive. Advantages of HGS

54 Disadvantages of HGS Lack of reference population. Rest periods between tests must always be the same to ensure accuracy. Must be adjusted to the hand size of the individual. Does not isolate hand strength alone as it requires the use of forearm strength as well.

55 Biochemical markers

56 Albumin Pre-albumin Transferrin Cr Total protein Biochemical markers

57 Albumin

58 GFR and Salb : solid line : dashed line Kopple JD. Kidney Int 2000;57:

59 Salb is widely used as a nutritional marker in CKD Most abundant serum protein (300 g); half-life is 20 days Primary functions are to maintain osmotic pressure and act as transport proteins. Concentration determined by: 1.exchanges between intra-and extravascular compartments. 2.volume status. 3.synthesis/degradation. 4.losses. < 3.8 g/dl is considered the threshold for PEW

60 Correlation between Salb and death risk in HD Owen WF Jr. N Engl J Med 1993;329:1001

61 Correlations between Salb and 3 factors in HD George A. AJKD 1997;29(5):

62 Relationship between Salb and npcr and log(crp) in HD George A. AJKD 1997;29(5):

63 Relationship between Salb and npcr and log(saa) in HD George A. AJKD 1997;29(5):

64 Age, albumin, and prealbumin in HD Aparicio M. Nephrol Dial Transplant 1999;14:

65 HD months, albumin, and prealbumin in HD Aparicio M. Nephrol Dial Transplant 1999;14:

66 IDWG and Salb Yang SC. J Ren Nutr 2008;18(2):

67 Relative IDWG and Salb Yang SC. J Ren Nutr 2008;18(2):

68 Kubrusly M. J Bras Nefrol 2012;34(1):27-35

69 Kubrusly M. J Bras Nefrol 2012;34(1):27-35

70 Starting dialysis Dalrymple L. J Ren Nutr 2013;23(2):91-97

71 Advantages of Salb Simple. Moderate cost. Reproducible. Sensitive as a screening tool. Prognostic marker for risk of hospitalizations and mortality.

72 Disadvantages of Salb Affected by multiple factors of CKD. Limited diagnostic power (low specificity).

73 Prealbumin

74 Prealbumin Half-life is 2 days. Response to changes in nutrition. Low values indicate PEW. Normal ranges for ESRD are not established.

75 Starting dialysis Dalrymple L. J Ren Nutr 2013;23(2):91-97

76 Transferrin

77 GFR and transferrin : solid line : dashed line Kopple JD. Kidney Int 2000;57:

78 GFR and Urine Cr amount : solid line : dashed line Kopple JD. Kidney Int 2000;57:

79 GFR and TCHO : solid line : dashed line Kopple JD. Kidney Int 2000;57:

80 Limitations of the use of plasma proteins to estimate nutritional status in ESRD Plasma albumin concentration may be reduced by dilution if the patient is fluid overloaded Plasma transferrin may be reduced independent of nutritional status due in part to fluctuations in iron stores Plasma prealbumin and retinol-binding protein levels may be increased due to reduced renal catabolism and excretion Plasma levels of nonessential amino acids may be increased Body weight will be elevated by fluid retention independent of muscle mass

81 Wolfson M. Am J Clin Nutr 1984;39:547 Estimates of biochemical markers in HD Parameter Normal Patients P value Albumin, g/dl Transferrin, mg/dl IgG, mg/dl 4.5± ±0.4 < ±41 208±57 < ± ±345 <0.05

82 Take Home Message SGA BMI HGS (pre)albumin Transferrin

83 83

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