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 ??
 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 , Nutritional and Inflammation

( PROTEIN ENERGI WASTING )
 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

Oxidative catabolism Decreased Increased

Reversed by dialysis and

nutritional support Yes No

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

 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
 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
 What are the nutritional
requirement of patients with
CKD ?

American Dietetic Association 2004

Consensus 1: Keto Acid Therapy In CKD Patients

Protein intake and ketoacid dosage recommendation :

0.8/kg/day protein for CKD patients whose GFR 60 ml/min/1.73m2. Ketoacid is

not supplemented.

0.6/kg/day protein for CKD patients whose GFR < 60 ml/min/1.73m2. Ketoacid is
supplemented at the dosage of 0.12/kg/day (1 tablet/5kg/day).

0.3/kg/day protein for CKD patients whose GFR < 30 ml/min/1.73m2. Ketoacid is
supplemented at the dosage of 0.2/kg/day (2 tablet/5kg/day).

Calorie recommendation: 30-35 kcal/kg/day

Dietary supplement of vitamins and trace minerals is also necessary.

Aparicio et al. Consensus statement. J Ren Nutr. 2012.

Obesity Paradox in Patients on
Maintenance Dialysis
Prevalence of obesity among incident dialysis
patients by year of dialysis initiation

Kramer H et al. J Am Soc Neprhol 2006;17:1453-1459

 Temporal trends in mean body mass index (kg/m2) among the incident adult
ESRD patient population by year of first permanent dialysis initiation and in the
total adult US population (Behavioral Risk Factor Surveillance System) for the
corresponding year. Data are age adjusted for the 2000 US census.

Kramer HJ, et al. J Am Soc Nephrol 17; 1455:2002

Reverse epidemiology of obesity in dialysis patients compared with the general
population. Comparison between the effects of BMI on all-cause mortality in the
general population and in the maintenance hemodialysis population. Note that
each population has a different follow-up period: 14 y for the general population
compared with 4 y for the hemodialysis patients

Kalantar-Zadeh K, et al. Kidney Int 2003;63:796.

Paradoxical Association Between Body Mass Index
and Mortality in Men With CKD Not Yet on Dialysis

Distribution of Events by BMI Category

Kovesdy CP, et al. Am J Kidney Dis 2007;49:581-591.

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
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