TERAPIJA PODHRANJENOSTI PRI PD Bojan Knap Klinični oddelek za nefrologijo Univerzitetni Klinični center Ljubljana
Renal Patient Medical Challenges Renal diet compliance Anorexia (lack of appetite) Nutritional status Hyperglycemia / diabetes Cardiovascular risk / mortality Hyperphosphetemia Infection / immune status PEW weight loss, anorexia, inflammation, etc Multiple medications Bone mineral disorders Edema Anemia High potassium levels Frequent hospitalizations Life-style issues Quality of life Delaying CKD progression Longevity of dialysis or transplantation
RX Transplant Dialysis Nutrition Cardiovascular and diabetic prescriptions may help No proof of improved survival Long waiting time Risky, costly Repeat kidney failure Maintenance therapy Catabolic Nutrition is the only low-cost, effective, available treatment 3
Lakota in sitost?
Realnost bolnika s KLB
Johansen K L JASN 2007;18:1845-1854.
. Importance of physical activity Johansen K L JASN 2007;18:1845-1854
DEBELEJŠI DIALIZNI BOLNIKI ŽIVIJO DLJE
DIALIZNI BOLNIKI Z ALBUMINI MANJ KOT 30G/L UMIRAJO PREJ DIA
OMEJEN VNOS ZDRAVE HRANE PRI KLB
Better nutritional status is associated with improved long term survival in dialysis patients Source: Chan et al., (2012). J Ren Nutr. 2012 Nov;22(6):547-57
LEDVIČNI BOLNIKI IMAJO SLAB APETIT Izguba apetita in želje za hrano Izguba vonja in okusa Prezgodnja sitost Motnje v delovanju hipotalamusa Vpliv zvišane koncentracije citokinov Omenjeno olajša nastanek kaheksije s nezadostnim vnosom energije in proteinov
DIETA LEDVIČNEGA BOLNIKA
Phosphorus balance
ŠTEVILNI VZROKI PODHRANJENOSTI PRI LEDVIČNI BOLEZNI Zmanjšan vnos hrane Omejevalne diete: proteini Uremični toksini* Metabolna acidoza Endokrini dejavniki Gastrointestinalni dejavniki MIA sindrom
UREMIČNI SINDROM Vodi k podhranjenosti tudi zaradi: Insulinske rezistence Motenega klirensa lipidov Metabolične acidoze Sekundarnega hiperparatireoidizma, uremične kostne bolezni
DEBELOST OGROŽA TUDI LEDVIČNE BOLNIKE METABOLIČNI SINDROM SLADKORNA BOLEZEN II MAŠČOBNE CELICE KOT ENDOKRINI ORGAN TUDI PRI KLB VPLIVAJO NA KVS PROBLEM MOTENJ HRANJENJA IN MALNUTRICIJA Z OHRANJENO TELESNO MASO, OB ZMANJŠANJU PUSTE TELESNE MASE pomen določanja puste telesne mase z bioimpedanco: lean tissue index, fat mass index
VLOGA LEPTINA PRI KAHEKSIJI KLB Zvišan pri KLB Deluje podobno kot citokinski receptorji tipa IL6(vnetje) Preko receptorjev za melanocortin v hipotalamusu deluje na apetit in metabolizem Antagonisti MC-R4 receptorja nov terapevtski obet
VELIK POMEN PREHRANSKE DIAGNOSTIKE ZA DIALIZNE PACIENTE Klinična presoja pacienta in kvalitete življenja, oziroma uspeha zdravljenja Biokemija:vrednosti albuminov, prealbumina in vnosa proteinov: (35g/l, 300mg/l, 1g/kg/dan) Nadzor: telesna teža, BMI, SGA, BCM(bioimpedanca), serumski albumin, kreatinin.
SUBJEKTIVNA GLOBALNA NUTRICIJSKA OCENA-SGA SGA ocena prehranjenosti zajema anamnezo (o spremembi telesne teže, o vnosu hrane, simptomih s strani GIT, funkcionalne zmogljivosti) in telesni pregled (atrofija mišic, zmanjšanje podkožne maščobe in pojav oteklin). zlati standard ocene bolnika,(keith: Nutrition in Clinical Practice, 2008)
Malnutrition Inflammation Score (MIS) Fully quantitative Uses the 7 original SGA components Adds 3 new components Body mass index Serum albumin Serum total iron binding capacity
PEM - PROTEINSKO ENERGETSKA MALNUTRICIJA PEM je pogost v KLB Je povezan s povečano obolevnostjo in umrljivostjo 40% PEM na začetku nadomestnega zdravljenja KOL 10-70% HD pacientov 18-51% CAPD pacientov
Nutritional Recommendations:Dialysis/Stage 5 CKD K/DOQI 1 ESPEN 2 EBPG 3 Energy/Calories < 60 years: 35 kcal/kg/d 60 years or obese: 30-35 kcal/kg/d Protein 1.2 g/kg/d 50% HBV 35 kcal/kg/d 30-40 kcal/kg/d 1.2-1.4 g/kg IBW/d 1.1 g/kg/d Sodium 1.8-2.5 g/d 2000-3000 mg/d Fluid 1000 ml + urine volume Potassium 2000-2500 mg/d 1950-2730 mg/d Phosphorus 800-1000 mg/d < 17 mg/kg IBW or SBW/d 800-1000 mg/d 800-1000 mg/d Calcium 2 g/d 2000 mg/d 1. NKF K/DOQI Clinical practice guidelines for nutrition in chronic renal failure. AJKD, 2000; 35:S1-S140. 2. Cano N, et al. Clin Nutr, 2006; 25:295-310. 3. Fouque D, et al. NDT 2007; 22(suppl 2):ii45-ii87.
Ocena prehranskih potreb V akutni fazi 20-25 nebeljakovinskih kkal/kg/dan, v anabolni fazi in podhranjeni 25-30 kkal/kg/dan. Maščobe: 0.3 g/kg t.t./dan do 2 g/kg t.t./dan (30 do 70%). Ogljikovi hidrati: 2-5g /kg/dan (30 do 70%) Beljakovine: povprečno 1.5 g /kg t.t./ dan (15-20 %) Mikrohranila-dnevne priporočene potrebe individualno glede na obolenje. Opečenci več Cu, Se in Zn.
AA V PARENTERALNI PREHRANI Povečana izguba AA Neravnovesje med izgubo in porabo Esencielne AA z dodatkom histidina ter arginina niso optimum Nadomeščanje tirozina problem, zaradi slabe topnosti Acetil-tirozin je rešitev, vendar ne pri KLB Rešitev predstavlja dipeptid: glicil-tirozin, ki je dobro topen in idealno nadomešča večje potrebe po tirozinu pri KLB (AminoMel nephro)
PREHRANSKI DODATKI Enteralni: Nepro, Nepro HP, Nepro LP, Ensure, Ensure Plus Advance, Prosure, Fresubin enkrat na dan per os Glutamin 5-10g na dan per os Carenal 1 tableto po dializi L-karnitin? Parenteralni: Aminomel Nephro aminokisline (500ml med HD) Kabiven Glamin 500ml Dipeptiven 100ml Soluvit N(vodotopni vitamini) Vitalipid N(maščobotopni vitamini) Addamel N(mikroelementi) Omegaven (ribje olje )
Why Renal Specific ONS? Component Renal Specific ONS Standard ONS Protein Optimum* Medium Glycemic Index (Carbohydrates) MUFA / Omega-3 (Fats/Lipids) Electrolytes: Phosphorus, Potassium, Sodium Low High Low High Low High Fluid volume Low High Caloric density High Standard Fiber High Low Prebiotics / scfos Present None CKD-specific vitamin & mineral profile Optimized None
1. NKF K/DOQI Clinical practice guidelines for nutrition in chronic renal failure. AJKD, 2000; 35:S1-S140. 2. Cano N, et al. Clin Nutr, 2006; 25:295-310. 3. Fouque D, et al. NDT, 2007; 22(suppl 2):ii45-ii87. Why Standard versus Renal Specific ONS? Nutrition Intervention in CKD Patients Expert recommendations: Nutrition Support KDOQI 1 ESPEN 2 EBPG 3 Individuals undergoing maintenance dialysis who are unable to meet their protein and energy requirements with food intake for an extended period of time should receive nutritional support Special formula products for HD treatment can be useful, especially in malnourished patients who are not able to increase their nutrient intake Oral nutritional supplements should be prescribed if nutritional counseling does not achieve an increase in nutrient intake to a level that covers minimum recommendations. Products specifically designed for dialysis patients should be prescribed
Recomm-S ESPEN KDOQI EBPG Proteini (g/kg/dan) 1.2-1.4 1.0-1.2 1.1 Energija (kcal/kg/dan) 35 <60 g 35 >60 g 30 30-35 >50 % intke <1 g/kg/dan Actual ntake 20-25 kcal/kg 0.8-1 g proteina/kg
Renal Specific Nutritional Therapy Clinical studies have shown that renal-specific nutrition offers advantages over standard nutrition Phosphorus levels were lower with the renal-specific nutrition than with the standard nutrition 1 Less fluid and potassium in renal-specific nutrition offers advantages over standard nutrition 2 1. Cockram DB et al. J Ren Nutr. 1998;8:25-33. 2. Williams RF, Summers AM. J Ren Nutr. 2009;19:183-188.
PREHRANSKE ZAHTEVE DIALIZE PRAKSA: ENERGIJA 35KCAL/KG TT NA DAN PROTEINI 1,2G/KG TT NA DAN VNOS TEKOČINE: 1000ML + IZLOČEN URIN NATRIJ: 2-3G NA DAN KALIJ 2-3G NA DAN FOSFOR 0,8-1,2G/DAN NKF:KDOQI 2000, ADA 2002, WILKENS, 2004
BIOIMPEDANCE PRINCIPLES
Phase angle Phase angle is an indicator based on reactance and resistance obtained from bioelectrical impedance analysis (BIA). PA depends on cell membrane integrity and on body cell mass. Although its biological meaning is still not clear, phase angle appears to have an important prognostic role. Phase angle differs across categories of sex, age, BMI, and percentage fat. Maria Cristina G Barbosa-Silva, Aluísio JD Barros, Jack Wang, Steven B Heymsfield, and Richard N Pierson Jr. Am J Clin Nutr July 2005 vol. 82 no. 1 49-52 Satish Kumar, *,1 Aswini Dutt, 1 Sandhya Hemraj, 2 Shankar Bhat, 1 and Bhat Manipadybhima. Iran J Basic Med Sci. 2012 Nov-Dec; 15(6): 1180 1184.
PHASE ANGLE AND LEAN TISSUE INDEX ARE SLIGHTLY HIGHER IN HEMODIALYSIS THAN IN PERITONEAL DIALYSIS GROUP OF PATIENTS B.Knap, Z.Veceric Haler, J.Buturovic-Ponikvar, R.Ponikvar, A.F. Bren University Clinical Center Ljubljana, Department of Nephrology, Slovenia
Ideal nutrition CKD patients Prevents musle loss Prevent and/or treat PEW Correct metabolic derrangements Decrease morbidity and mortlity Improve QoL Does not promote progression of CKD Or, ideally, slow down progression of CKD
ZAKLJUČEK Podhranjenost je pomembna in pogosto ključna za preživetje Sodobne metode detekcije in zdravljenja podhranjenosti omogočajo zgodnejšo nutricijsko intervencijo Prehranski dodatki tako enteralni kot parenteralni so pogosto nujna in včasih edina možnost.
Kaj je dobro vedeti LEDVIČNI BOLNIKI JEDO SLABO V ZAČETNI FAZI KLB TERAPIJA Z OMEJEVANJEM VNOSA PROTEINOV LAHKO PRIPELJE DO MALNUTRICIJE IN KAHEKSIJE POMEMBNA OCENA HRANJENOSTI IN PRAVOČASNA NUTRICIJSKA INTERVENCIJA V VSEH FAZAH KLB USPEH ZDRAVLJENJA MALNUTRICIJE JE POVEZAN Z DOBRIM ZDRAVLJENJEM OSNOVNE LEDVIČNE BOLEZNI IN CELOSTNEGA ZDRAVLJENJA KLB POLEG HRANE VELIKO PRISPEVAJO K KVALITETI ŽIVLJENJA TUDI PREHRANSKI DODATKI IN TELESNA VADBA ANABOLNI AGENSI IN STIMULATORJI APETITA NA NIVOJU HIPOTALAMUSA SO OBET BLIŽNJE PRIHODNOSTI