MANAJEMEN NUTRISI PASIEN DIALISIS

Ria Bandiara
FK UNPAD/ RS Hasan Sadikin Bandung
PENDAHULUAN
• Keadaan status nutrisi pasien hemodialisis (HD) rutin sangat
menentukan kualitas hidup pasien tersebut
• Status nutrisi yang buruk pada populasi ini menyebabkan angka
morbiditas dan mortalitas kardiovaskular menjadi tinggi
• Mengenal secara dini keadaan nutrisi pasien hemodialisis rutin akan
dapat mencegah atau memperbaiki keadaan gangguan nutrisi pasien
hemodialisis tersebut
 Mengapa nutrisi penting untuk pasien dialisis rutin?

• Akibat dari tindakan dialisis dan akibat penyakitnya dapat

timbul keadaan :
– anoreksia (nafsu makan menurun)
– uremia (penumpukan ureum di darah)
– gangguan metabolisme
– kehilangan protein serta vitamin yang larut dalam air

gangguan status gizi  karena proses dialisis ini adalah proses

yang berulang dalam jangka waktu panjang

MALNUTRISI
• Gangguan nutrisi/malnutrisi pada pasien HD
 Protein Energy Wasting syndrome (PEW)

• Prevalensi PEW pada pasien HD rutin cukup

tinggi : 20 – 70 % (ESPEN)
MODEL KONSEPTUAL ETIOLOGI DAN KONSEKUENSI PASIEN PENYAKIT
GINJAL KRONIK DENGAN PEW

Ikizler et al, Kideny Int 2013; May: 1-12

 Diagnosis PEW
pada PGK
Diagnosis of PEW
when at least
one parameter is
found below
recommendation
in three of the
four nutritional
variable groups
 Bagaimana mengetahuinya ?
Menilai status nutrisi secara berkala

 ESPEN dan NKF K/DOQI :

• Konseling diet tiap 6 bulan
• BMI tiap bulan
• Serum albumin tiap 3bulan
• SGA/MIS tiap 3 bulan (sistem skoring nutrisi)
 Penilaian Status Nutrisi
• Penilaian asupan makanan
• Kehilangan massa otot
• Kebutuhan tercukupi (lingkar lengan atas)
– Kualitas
• Hilangnya lemak subkutan
– Kuantitas
(lipatan kulit triceps)
• Makanan dan minuman yang
dikonsumsi
• Berat badan
• Tinggi badan
• Indeks Massa Tubuh (IMT)

IMT : < 23kg/m2  risiko malnutrisi

Ideal : 22 – 26 kg/m2
 MALNUTRITION INFLAMMATION
SCORE (MIS)
• Merupakan suatu penilaian komprehensif dari status nutrisi
• Merupakan pengembangan dari alat sebelumnya : SGA konvensional ,
Dialysis Malnutrition Score (DMS)
• 10 komponen penilaian :
– 7 komponen SGA
– 3 komponen baru : IMT, albumin serum dan TIBC
• MIS terdiri dari 4 bagian :
– Riwayat gizi
– Pemeriksaan fisik
– IMT
– Parameter laboratorium
 MIS : > 6
MALNUTRISI

MEMERLUKAN INTERVENSI NUTRISI

 STEPS

DIETARY DIETARY MONITORING

TERAPI EVALUASI
RECALL PLAN

JANGAN MEMBUAT
RENCANA TERAPI TANPA Ahli Gizi /Nutrisionist/Dietician harus
TAHU MASALAH masuk dalam tim
SEBENARNYA
 Kebutuhan Nutrisi Pasien Dialisis

Nutrien NKF ESPEN

Asupan Protein (g/kgbb/hr)

- HD 1,2 (>50% HBV) 1,2-1,4(>50%HBV)
- CAPD 1,2-1,3 (>50% HBV) 1,2-1,5(>50%HBV)

Asupan Energi (kkal/kg/hr) < 60 thn: 35 35

HD dan CAPD > 60 thn: 30

Air (ml) 750-1000 + vol urine 1000 + vol urine

 Kebutuhan Nutrisi Pasien Dialisis

Nutrien NKF ESPEN

Natrium (gr/hari) 2-3 1,8-2,5

Kalium (mg/gr) 2000-3000 2000-2500

Fosfor (mg/hari) 800-1200 800-1000

Kalsium (mg/hari) 1000

Zat besi (mg/hari) 600

 Kebutuhan Nutrisi Pasien Dialisis

Nutrien NKF ESPEN

Asam folat (mg/hari) 1

Piridoksin (mg/hari) 10-20

Vitamin C (mg/hari) 30-60

Zinc (mg/hari) 15

Selenium (μg/hari) 50-70

Healthy person: HD patients:
1. Increased nutrient require-
ments due to
 AA losses in dialysate
Intake = Requirements
 Hemodialysis as a catabolic
and inflammatory event
HD patient: losses 
needs 
Intake 
inflammation 
2. Limited nutrient intake
 Caused by many factors

Intake  < Requirements 

Resulting in:
Nutrient deficit – PEW
Desired state:
HD patient
Solution:
Increased nutrient intake
Intake  = Requirements 
Nutrition Support in CKD
No Total
Functional GIT Parenteral
Nutrition
(TPN)
Yes
Enteral
Nutrition
(EN)
HDx
1st Intradialytic PN
(IDPN)
Tube Oral (+edn & counseling):
• Food fortification
feeding +/- • Oral nutrition
+/-
(TF) supplementations (ONS) PDx
Intra- Peritoneal
MO: Nutrition
• Control co-morbidities/ Exercise
inflammation Nursing training
• Medications / Appetite stimulant Psychosocial support

Multi-disciplinary
Approach
 Indication for nutrition support

Nutritional support is indicated in maintenance dialysis patients

with

severe malnutrition:
 BMI less than 20 kg/m2
 body weight loss >10% over 6 months
 serum albumin <35 g/l
 serum transthyretin <300 mg/l

Moderate malnutrition will be managed with dietary counselling

as a fist step.

1. Cano NJM et al. Clin Nutr 2009; 28:401-414

ALGORITMA DUKUNGAN NUTRISI PADA PASIEN HD PEW

Dietary intakes and nutritional status evaluation

Moderate undernutrition Severe undernutrition

Spontaneous intakes BMI < 20 kg/m2
≤ 30 kcal/kg/day Body weight loss > 10% within 6 months
< 1 g protein/kg/ day Albumin < 35 g/l
Transthyrein (Prealbumin) < 300 mg/l

Clinical experience
Spontaneous Lack of Spontaneous intakes
intakes compliance < 20 kcal/kg/day shows:
> 20 kcal/kg/day or stress conditions Poor compliance
is a limiting factor
for oral nutritional
Enteral Nutrition
Dietary Oral
IDPN if EN is not possible:
supplements
counselling supplements
Central venous PN (ONS)2

1. Adapted from Cano NJM et al.

Clin Nutr 2009;28:401-414
No improvement No improvement 2. Bossola et al. Am J Kidney Dis
2005; 46: 371-386
Intradialytic parenteral nutrition (IDPN)
Rules for administration
1. IDPN should be infused at a constant rate during a typical 4 h dialysis session,
3 times per week.*
2. Slow and continuous infusion from start to end of dialysis.
As to clinical experience, a lower infusion rate during the first 30 min
improves individual tolerability in rare cases.
3. IDPN should be performed during controlled ultrafiltration to prevent over-
hydration; here the infused volume should be added to the total ultrafiltration
(UF) calculation.
Based on clinical experience, UF might be limited to only 50% of the volume
infused with IDPN to avoid hypotension. Careful monitoring is mandatory.
4. 75 mmol Na (~4 g sodium chloride) should be added per liter of IDPN solution
(consisting of amino acids, glucose and lipids) in order to compensate Na losses
due to ultrafiltration.#

5. IDPN should not be started at a blood flow rate less than 200 ml/ minute.
* If only amino acids will be infused, the infusion rate will be lower and limited by the maximum infusion rate
as indicated in the SmPC
# Needs to be reduced appropriately if only amino acids are administered. Cano NJM et al. : Clin Nutr 2009,28:401-414
 Intradialytic parenteral nutrition (IDPN)
Clinical effects of IDPN and intradialytic AA supplementation

Net amino acid balance with and without AA supplementation

Author AA Calorie Net AA balance

infusion carrier(s)
Without AA infusion With AA infusion

Wolfson et al. 1982 1 39.5 g Glucose (200 g) - 8.2 g + 26.9 g

(Cellulose-based membranes)

Berneis et al. 1999 2 48 g Glucose (150 g) - 7.6 g + 29.5 g

(Polysulfone membranes) Lipids (50 g)

Navarro et al. 2000 3 25.7 g None - 12.5 g - 2.6 g

(Polyacrylonitrile membranes) [only 1 g/L glucose in dialysate
to prevent losses]

AA: amino acid

 Infusion of amino acids during haemodialysis can prevent dialysis-

induced
losses or even achieve a positive net AA balance
(depending on administered AA dose, membrane type and simultaneous administration of calorie
carriers)
Intradialytic parenteral nutrition (IDPN)
Clinical effects of intradialytic AA supplementation

Intradialytic amino acid supplementation resulted in:

 Increase in visceral proteins 1-3

 Improved protein catabolic rate 1
 Reduction of net amino acid losses 1
 Increase in subjective global assessment
(SGA) score 2
 Increase in anthropometrics 2
 Improved cellular immunity 3

1. Navarro et al. Am J Clin Nutr 2000;71:765-773

2. Czekalski S et al., J Ren Nutr 2004: 14, 82-88
3. Smolle et al. Nephrol Dial Transplant 1995; 10: 1411-1416
Nephrosteril® Memenuhi kebutuhan nutrisi parenteral pasien
penyakit ginjal akut & kronik
larutan asam amino 7%

Content per 1000 ml Gram  Asam amino seimbang dengan rasio EAA : NEAA = 60 : 40
 mengoptimalkan sintesa protein dan meminimalkan
L- isoleucine 5,10
produk buangan (waste products)
L- leucine 10,30
L- lysine monoacetate 10,01
L- methionine 2,80
Acetylcysteine 0,50  Kadar BCAA tinggi (30%) : membantu sintesa protein
L- phenylalanine 3,80
L- threonine 4,80
L- tryptophan 1,90  Formula disesuaikan dengan gangguan metabolisme
L- valine 6,20
asam amino
L- arginine 4,90
L- histidine 4,30
Glycine 3,20
L- alanine 6,30  Bebas elektrolit : fleksibel menambahkan elektrolit sesuai
L- proline 4,30 kebutuhan
L- serine 4,50
L- malic acid 1,50
Glacial acetic acid 1,38  Osmolaritas rendah (645 mosm/l) : mengurangi resiko
Total amino acids 70 phlebitis
Total energy 280 kcal

Essential amino acids 60%  Bebas sulfit : tidak menimbulkan reaksi alergi
Non essential amino acids 40%
Ratio E/N 1,5
BCAA 30%  Premium quality : shelf life 3 tahun
Total Nitrogen 10,80
Osmolarity 645 mosm/l
 RINGKASAN
• Prevalensi PEW cukup tinggi dengan konsekuensi peningkatan
morbiditas dan mortalitas
• Skrining dan assessment merupakan dua parameter yang wajib
dilakukan untuk perencanaan terapi nutrisi.
• Assessment yang dianjurkan digunakan adalah MIS karena sudah
meliputi anamnesis, pemeriksaan fisik , IMT dan pemeriksaaan
laboratorium.
• Manajemen terapi nutrisi harus dilakukan oleh tim yang lengkap
termasuk ahli gizi
• Terapi nutrisi disesuaikan dengan kebutuhan masing-masing pasien
22 – 24 MARET 2019
TERIMA KASIH