Nutritional Status in CKD Patients

Syakib Bakri

Division of Nephrology & Hypertension

Department of Internal Medicine
UNHAS-Wahidin Sudirohusodo Hospital Makassar
 INTRODUCTION
The nutritional status of an individual is often
the result of many inter-related factors.

It is influenced by food intake, quantity &

quality, & physical health.

The spectrum of nutritional status spread from

obesity to severe malnutrition
How about CKD patients ??
Factors Impairing Nutritional Status of Patients with Chronic Kidney Disease

Condition Mechanism
Anorexia Inadequate protein or
calorie intake
Metabolic acidosis Stimulation of amino acid
and protein degradation
Infection/inflamatory Stimulation of protein
illness degradation
Diabetes Stimulation of protein
degradation and
suppression of protein
synthesis
 Nutritional profile during CKD

Pre-ESRD Dialysis Transplant* Transplant

Diet LPD SPD HPD LPD
Prot (g/kg/d) 0.6-0.7 1.2-1.4 1.4 0.7
Energy 30-40 30-40 30-40 30-40
(kcal/kg/d)
Malnutrition
1. Malnourished
(Undernutrition) + ++ ++ +/-

2. Obese ++ + + ++

* first 3 months
 Malnutrition in CKD

Metabolic and nutritional abnormalities

arise in CKD
Metabolic and nutritional abnormalities in CKD
Pathophysiology

Uremic toxicity, Altered metabolism, Iatrogenic (e.g.

polypharmacy and the prescription of a low protein diets to
slow disease progression

PROTEIN ENERGY WASTING

(An expert panel from the International Society of Renal Nutrition and
Metabolism proposed the term protein energy wasting (PEW) to
designate malnutrition in kidney diseases)
NDT Plus (20 ) 3: 118124
 PROTEIN ENERGY WASTING

A state of gradual and non-functional loss of muscle

and fat tissue, eventually resulting in cachexia

The described state is not merely caused by an inadequate dietary

intake, but rather the result of disease processes ( acidosis,
inflammation-driven catabolism, nutrient losses in the dialysate,
along with endocrine disturbances

PEW may be seen as a broader concept that includes also

malnutrition; in reality, both PEW and pure malnutrition are
usually present in CKD patients with poor nutritional status
 Types of malnutrition in CKD

Type II

Type I

uremic malnutrition/wasting

Pupim L, Ikizler TA: Uremic malnutrition: New insights into old problem.
Semin Dial 2003; 16: 224-232
 Type of malnutrition in Kidney Disease
Factors Type 1 Type 2
Associated with uremic Associated with MIA
syndrome syndrome

Serum Albumin Normal/low Low

Comorbidity Uncommon Common
Presence of inflamation No Yes
Food intake Decreased Low/Normal
Resting energy Normal Elevated
expenditure Increased Markedly Increased
Oxidative catabolism Decreased Increased
Reversed by dialysis and Yes No
nutritional support

Clinical Queries :Nephrology I (2012) ; 222-235

 Cause of Protein-Energy-Wasting
Inflamation
1. Associated with infected vascular acces sites, systemic infection illness including
tuberculosis, diabetes mellitus, myocardial infarction, stroke, peripherial vascular
ischemia, vasculitis.
2. Unassociated with clinically apparent disease such as, inflammatory reaction to vascular
access catheters, graft, peritoneal dialysis cathehters, dialysis tubing, impure dialysate, old
nonfunctioning transplant kidney, kidney failure per se
Decrease food intake
1. Anorexia caused by uremic toxicity, medication, inflammatory disorders
2. Loss of taste, unpalatable prescribed diets
3. Nonanorexic causes (financial constraints), medical or surgical illness, particularly of
gastrointestinal tract, impaired cognitive function, other mental disability, physical
disability, loss of dentures
Dialysate nutrient losses
1. Losses of amino acid, peptides and protein into dialysate
2. Losses of water soluble vitamins and mineral during dialysis
Metabolic acidemia
Anemia and loss of blood due to
1. Gastrointestinal bleed
2. Frequent blood sampling
Hormonal disorders
1. Resistence to anabolic hormones such as insulin, growth hormones, ILGF-1
2. Increased levels of counter regulatory hormones such as glucagon, parathyroid hormone
Increased fecal excretion of nitrogen
Decrease level of antioxidants such ass vitamin E,C,selenium, reduced glutathione (GSH)
Physical conditioning

Clinical Queries Nephrology I (2012) ; 222-235

 PROTEIN-ENERGY WASTING DIAGNOSTIC CRITERIA
Suggested by the PEW Consensus Conferences

PRIMARY CRITERIA SUPORTIVE CRITERIA

1. Appetite, food intake, and energy expenditure

1. Biochemical markers
Appetite assessment
Albumin < 3.8g/dl (BCG)
Food frequency questionnaires
Prealbumin (transthyretin) < 30mg/dl (dyalisis pts)
2. Body Mass and composition
Total cholesterol < 100mg/dl
Total body nitrogen or potassium
2. Body composition indices
Energy-beam based methods
Body Mass Index <22 kg/m2 (<65 years) or <23
Dual-emmision X-ray absorptiometry
kg/m2 (>65 years)
Bioelectric Impedance Analysis
Unintentional weight loss > 5% over 3 mo or 10%
Near Infrared Reactance
over 6 mo
3. Other laboratory biomarkers
Total body fat percentage < 10%
Serum biochemistry : transferin, urea,
3. Muscle mass
triglyceride, bicarbonate
Muscle wasting 5% over 3 mo or 10% over 6 mo
Hormones : leptin, ghrelin, growth hormones
Reduced mid-arm muscle circumference area
Inflammatory markers : CRP,IL-6, TNF-, IL-1,SAA
Creatinin appearence
Peripheral blood cell count lymphocyte count or
4. Dietary intake
percentage
Unintentional dietary protein intake (DPI) < 0,80
4. Nutritional scoring systems
g/kg/day (Evidence indicates that 1.0 g
Subjective Global Assessment
protein/kg/day may engender protein wasting in
Malnutrition-Inflamation Sore (MIS [87]
some patients)
5. Other novel markers
Unintentional dietary energy intake (DEI) < 25
14kD Actin fragment [82,97]
Kcal/kg/day (Data indicate that some patient may
Gelsoiln [98]
need 30 kg/day)

Nutritional Management of Renal Disease

 A Variety tools and technique to asses nutritional status in patients with CKD

(1) Biochemical parameters

- Serum albumin concentrations < 4.0 g/dl
- Serum transferrin concentrations < 200 mg/dl
- Serum IGF-1 concentrations < 200 ng/ml
- Serum prealbumin concentrations < 30 mg/dl or an apparent decreasing trend
- Abnormally low plasma and muscle essential amino acid concentrations
- Low serum creatinine concentrations with other signs of uremia or low
creatinine
kinetics
(2) Anthropometric measures
- Continuous decline in body weight or low % ideal body weight (< 85%
- Abnormal skinfold thickness, midarm muscle circumference and/or sclestrength
(3) Body composition analysis
- Abnormally low % of lean body mass by bioelectrical impedance analysis and/or
DEXA
- Low total body nitrogen and/or nitrogen index (observed nitrogen/predicted
nitrogen)
(4) Dietary assessment
- Low spontaneous dietary protein intake by 24-hr urea nitrogen excretion in
chronic renal failure patients (< 0.7 g/kg/day) and by protein catabolic rate in
chronic dialysis patients (< 1.0 g/kg/day)
) Nutritional Assesment in CKD ( >> dialysis patients)
MIS SGA
Malnutrition Inflammation Score Subjective Global Assessment
Variable for routine nutritional assessment during maintenance hemodialysis and peritoneal dialysis,
as recommended by the National Kidney Foundation and ERA-EDTA
NKF-DOQI clinical practice guidelines for HD
adequacy ( HD and DP) [71]
EGPG Giudeline on nutrition (HD)
- Predialysis stabilized serum albumin : monthly.
Serum albumin be 40g/L by the bromocresol
green methode
- BW : percentage of ususal postdialysis (HD) or
post-drain (DP) BW, monthly : percentage of
standard (NANHESII) BW, every 4 mo
- SGA every 6 mo
- Dietary interview and/or diary nPNA, every 6 mo
- Dietary interview : every 6-12 mo or every 3 mo
in patients > 50 years of age or on HD for more
than 5 years
- BW and BMI : Average postdialysis BW over the
month and percentage change in the average
BW, BMI should be > 23.0
- nPNA : 1 mo after beginning of HD and three mo
thereafter. Serum albumin should be > 40 g/L by
bromocresol green methode
- Serum transthyretin should be > 300 mg/dl
- Serum cholesterol should be less than minimal
laboratory threshold value
NDT Plus (2010) 3 : 118-124
 Algorithm for nutritional management and support in patient with CKD
(Clinical Journal of the American Society of Nephrology)
Nutritional Assessment (as indicated)
*Periodic Nutritional Screening
Sprealb, SGA, Anthropometrics
Salb, Weight, BMI, MIS, DPI, DEI

Continuous Preventive Measures :

Continuous Nutritional Counseling
Optimize RRT-Rx and Dietary Nutrient Intake
Manage co-morbidites (Acidosis,DM,Inflamation,CHF,Depression)

Indication for Nutritional Interventions Despite Preventive Measure :

Poor appetite and/or poor oral intake
DPI<1,2(CKD 5D) or <0.7(CKD 3-4:DEI<30Kcal/kg/d
Unintentional weight loss >5% of IBW or EDW over mo
Salb < 3,8 g/dl or Sprealb < 28 mg/dl
Worsening Nutritional Markers Over Time
SGA in PEW range

Start CKD-Specific Oral Nutritional Supplementation :

CKD 3-4 : DPI target of > 0.8g/kg (AA/KA or ONS)
Salb > 3,8 ; Sprealb >28 CKD 5D : DPI target >1.2g/kg/d (ONS at home or during dialysis No Improvement
Weight or LBM gain treatment ; in-centre meals) or Deterioration

Maintenance Nutritional Therapy Intensified Therapy : Adjuvant Therapies :

Goals : Dialysis prescription alterations Anabolic hormones
Salb > 4.0g/dl Increase quantity of oral therapy Androgen,GH
Sprealb > 30 mg/dl Tube, feeding or PEG if indicated Appetite stimulants
DPI > 1,2 (CKD-5D) & >0.7 g/kg/d Parenteral interventions : Antiinflamatory interventions
(CKD 3-4) IDPN (esp.if salts <3.0g/dl) Omega 3; IL-1ra
DEI 30-35 Kcal/kg/d TPN Exercise (as tolerated)
 Decisional algorithm for the management of PEW
Dietary intakes and nutritional status evaluation

Moderate undernutrition Severe undernutrition

Spontaneous intakes BMI < 20
30 kcal/kg/day Body weight loss > 10% within 6 mo
1.1 g protein/kg/day Albumin < 35 g/l
Transthyretin < 300 mg/l

Spontaneous intakes Spontaneous intakes < 20 kcal/kg/d

or
> 20 kcal/kg/d Stress conditions

Lack of compliance

Enteral Nutrition
Dietary Oral
IDPN If EN is not possible:
counselling supplements Central venous PN

No improvement No improvement
Clinical Nutrition.2009;28:401-414
Interventions to prevent and/or treat PEW in CKD patients
(1) Pre-dialysis patients
- Optimal dietary protein and calorie intake
- Optimal timing for initiation of dialysis, before onset of indices of malnutrition
(2) Dialysis patients
- Appropriate amount of dietary protein intake (> 1.2 g/kg/day) along with nutritional counseling to
encourage increased intake
- Optimal dose of dialysis (Kt/V > 1.4 or URR > 65%)
- Use of biocompatible dialysis membranes
- Enteral or intradialytic parenteral nutritional supplements (hemodialysis) and amino acid dialysate
(peritoneal dialysis) if oral intake is not sufficient
- Growth factors (experimental):
Recombinant human growth hormone
Recombinant human insulin-like growth factor-I
(3) Transplant patients:
- Appropriate amount of dietary protein intake
- Avoidance of excessive use of immunosuppressives
- Early reinitiation of dialytic therapy with proper steroid tapering in patients with chronic rejection
Kidney Int. 1996;50:343-357
Summary of Clinical Practice Guideline for Nutrition in CKD

Frequency of screening for PEW in CKD

Weekly for inpatient

2-3 mo for outpatients with eGFR < 20

but not on dialysis

Within one mo of commencement of

dialysis then 6-8 weeks later

4-6 mo for stable haemodialysis patients

4-6 mo for stable peritoneal dialysis

patients

Nephron Clin Pract 2011; 118 (suppl):c153-c164

Screening for Undernutrition in CKD

Actual Body Weight (ABW) (<85% of Ideal Body

Weight (IBW))

Reduction in oedema free body weight (of

5% or more in 3 mo or 10% or more in 6 mo

BMI (<20 kg/m2)

Subjective Global Assessment (SGA) (B/C on 3

point scale or 1-5 on 7 point scale)

Nephron Clin Pract 2011; 118 (suppl):c153-

c164
Centra role of cytokines in the pathphysiology of PEW in CKD
 Differences between malnutrition and PEW
Malnutrition : Occurs when insufficient dietary intake results from an
inadequate diet, leading to a scarcity of one or more nutrients.
Associated with the degree of uremic symptoms. Food intake low.
Energy expenditure low-normal. Preferential loss of fat over lean body
mass. Normal or low s-albumin . Reversed by adequate dialysis and
nutritional support

PEW : A state of loss of muscle and fat tissues together with metabolic
changes not amenable to dietary intervention in the context of CKD.
Associated with degree of co-morbidities and inflammation. Increased
energy expenditure. Fat is underutilized - muscle is wasted Markedly low
s-albumin, pre-albumin, s-creatinine , High CRP . Correction of acidosis,
inflammation, nutritional interventions, adequate, dialysis doses
Etiology PEW in CKD