Overlook Nutritional Problems in Dialysis Patients พ.ท.หญิง สิรกานต์ เตชะวณิช, MD, MSc, ABPNS หน่วยโภชนศาสตรค์ ลินิก กองอายรุ กรรม โรงพยาบาลพระมงกฎุ เกล้า 17 มกราคม พ.ศ. 2563 1
Free download at www.spent.or.th 2
OUTLINE ■ Nutrition Support Overview ■ Protein-Energy Wasting (PEW) in CKD/ESRD ■ Nutrition Intervention and Products Used ■ Conclusions 3
OUTLINE ■ Nutrition Support Overview ■ Protein-Energy Wasting (PEW) in CKD/ESRD ■ Nutrition Intervention and Products Used ■ Conclusions 4
Algorithm for Delivery of Nutrition Therapy Nutrition Screen * Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished Rescreen at: Nutrition Assessment Nutrition At-Risk or Malnourished Monitoring • Regularly specified intervals or * Nutrition Therapy • When nutritional/ clinical status changes Reassessment 5 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
Nutrition Screening - -+ Nutrition Assessment (History+ Physical examination + Labs) + Nutrition Monitoring Nutrition Therapy 6
Algorithm for Delivery of Nutrition Therapy General Nutrition Screen SPENT Nutrition admission Screening Tool Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished NAF Nutrition Assessment or Rescreen at: At-Risk or Malnourished NT • Regularly specified Nutrition Therapy Nutrition intervals or Monitoring • When nutritional/ clinical status changes SPENT, Society of Parenteral and Enteral Nutrition Reassessment of Thailand; NAF, Nutrition Alert Form; NT, Nutrition Triage 7 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
Algorithm for Delivery of Nutrition Therapy Nutrition Screen SPENT Nutrition Screening Tool Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished Rescreen at: Nutrition Assessment Nutrition At-Risk or Malnourished Monitoring • Regularly specified intervals or Nutrition Therapy • When nutritional/ clinical status changes SPENT, Society of Parenteral and Enteral Nutrition Reassessment of Thailand; NAF, Nutrition Alert Form; NT, Nutrition Triage 8 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
SPENT Nutrition Screening Tool สมาคมผ้ใู หอ้ าหารทางหลอดเลอื ดดาํ และทางเดนิ อาหารแหง่ ประเทศไทย (SPENT), 29560.
Algorithm for Delivery of Nutrition Therapy Nutrition Screen SPENT Nutrition Screening Tool Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished NAF Nutrition Assessment or Rescreen at: At-Risk or Malnourished NT • Regularly specified Nutrition Therapy Nutrition intervals or Monitoring • When nutritional/ clinical status changes SPENT, Society of Parenteral and Enteral Nutrition Reassessment of Thailand; NAF, Nutrition Alert Form; NT, Nutrition Triage 10 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
Nutrition Screening - -+ Nutrition Assessment (History+ Physical examination + Labs) + Nutrition Monitoring Nutrition Therapy 11
Nutrition Assessment endorsed by SPENT: • NT (Nutrition Triage)-2013 or • NAF (Nutrition Alert Form) SPENT = Society of Parenteral and Enteral Nutrition of Thailand = สมาคมผใู้ หอ้ าหารทางหลอดเลอื ดดาํ และทางเดินอาหารแหง่ ประเทศไทย (www.spent.or.th) 12
NT 2013 (Nutrition Triage) Free download at: www.spen1t3.or.th
พล.อ.ต. วบิ ูลย์ ตระกูลฮนุ 14
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NAF (Nutrition Alert Form) Free download at: www.spent.or.t21h
ศ.นพ. สุรัตน์ โคมนิ ทร์ 22
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“SPENT Nutrition Screening Tool” สมาคมผใู้ หอ้ าหารทางหลอดเลอื ดดาํ และทางเดินอาหารแหง่ ประเทศไทย (SPENT) 28
Algorithm for Delivery of Nutrition Therapy: CKD • SGA Nutrition Screen • MIS • GNRI Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished Rescreen at: Nutrition Assessment Nutrition At-Risk or Malnourished Monitoring • Regularly specified intervals or Nutrition Therapy • When nutritional/ clinical status changes SGA, Subjective Global Assessment; MIS, Malnutrition Inflammation Score; Reassessment GNRI, Geriatric Nutrition Risk Index 29 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
Geriatric Nutrition Risk Index (GNRI) = [1.489 x serum albumin (g/L)] + 41.7 x [(actual BW/ ideal BW*)] * Ideal weight calculated from the Lorentz formula: GNRI Interpretation: nutrition-related complications < 82 Major risk 82 - < 92 Moderate risk 92 - ≤ 98 Low risk No risk > 98 Bouillanne O, et al. Am J Clin Nutr. 2005;82:777-8303.
Geriatric Nutrition Risk Index (GNRI) ■ Simple: utilizes only serum albumin and actual/ideal body ratio. ■ Objective ■ It was developed for assessing PEW and nutritional risk in geriatric patients. ■ It was validated in Asian ESRD patients. ■ Higher interobserver agreement in prevalent hemodialysis patients than the MIS Obi Y, et al. Curr Opin Clin Nutr Metab Care. 2015;18(3):254-62. Riella MC. J Ren Nutr. 2013; 23(3): 195–8. Kang SH, et al. Perit Dial Int. 2013; 33(4): 405–10. JungYS, et al. Hemodial Int. 2014; 18(1): 104–12. Tsai MT, et al. Am J Nephrol. 2014; 40(3): 191–9. Beberashvili I, et al. Clin J Am Soc Nephrol. 20133;18(3): 443–51.
Component Variables Screening Tools Assessment Tools NUTRIC NRS- SPENT SGA NAF NT- MIS GNRI 2002 2013 Recent food intake - √ √ √√ √ √ - Nutrition Hx GI symptoms -- - √√ - √ - DICaUys in hospital before √- Anthropo- Current BW/ BMI -√ - -- - - - metry -√ Weight change √- √ -√ - √√ Inflammation (ILse-6ruomr CaRlbPuomrin) -- Subcutaneous fat √ √√ √ √ - - - (√) - √√ - √- √ √ - Muscle loss - - - √- √ √ - Fluid status Physical Muscle strength - - - √√ √ - - Examination - - - -- √ - - Functional capacity - - - √√ - √ - Client Hx No. of chronic diseases √- - - (√) (√) √ - Age √ √ - - - - - - Clinical A(dPisAeCaHseEsIeI verity) √- √ - (√) (√) - 32- SOFA (organ dysfunction) √ - - -- - - -
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OUTLINE ■ Nutrition Support Overview ■ Protein-Energy Wasting (PEW) in CKD/ESRD ■ Nutrition Intervention and Products Used ■ Conclusions 34
“Malnutrition”: Definition ■ “A state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” ESPEN, The European Society for Clinical Nutrition and Metabolism Sobotka L, et al. Basics in clinical nutrition. 4th ed. GALÉN; 2011. Pirlich M, et al. Nutrition 2005;21:295-300. Cederholm T, et al. Clin Nutr. 20173;536:49-64.
Protein-Energy Wasting (PEW) Definition: ■ “A state of disordered catabolism resulting from metabolic and nutritional derangements in chronic disease states including CKD”. Characteristics: ■ Simultaneous loss of systemic body protein and energy stores loss of muscle and fat mass and cachexia Hana RM, et al. Blood Purif. 2019:1-10. Fouque D, et al. Kidney Int. 2008;73(4):336 91-398.
Protein-Energy Wasting (PEW) in CKD ■ Definition by ISRNM (2008): “the state of decreased body stores of protein and energy fuels (that is, body protein and fat masses)”1 ■ Pathogenesis: complex and multifactorial ISRNM, The International Society of Renal Nutrition and Metabolism 1Fouque D, et al. Kidney Int. (2008) 73:391–8. 2Dai L, et al. PLoS One. 2017;12(12):e0186659. 3Kang SS, et al. Nutrients. 2017;9:E399. 4Wong CS, et al. Kidney Int. 2002;61:630–7. 5Canpolat N, et al. Pediatr Nephrol. 2013;28:2149–56. 6Obi Y, et al. Curr Opin Clin Nutr Metab Care. 2015;183(73):254-62.
Pathophysiology of PEW in CKD Velasquez MT, et al. Chronic renal disease (2nd edition). 2020;328 25-248.
Protein-Energy Wasting (PEW) in CKD ■ Definition by ISRNM (2008): “the state of decreased body stores of protein and energy fuels (that is, body protein and fat masses)”1 ■ Pathogenesis: complex and multifactorial ■ SGA: prevalence of PEW ~30% adults with CKD (dialysis and non-dialysis patients).2 ■ ↑ risk of morbidity (cardiovascular disease and infection) and mortality in both adult and pediatric patients with CKD particularly in those with CKD stage G3b, G4 and G5 (eGFR<45 ml/min/1.73 m2 BSA) and ESRD requiring maintenance dialysis treatment. 3-5 ISRNM, The International Society of Renal Nutrition and Metabolism 1Fouque D, et al. Kidney Int. (2008) 73:391–8. 2Dai L, et al. PLoS One. 2017;12(12):e0186659. 3Kang SS, et al. Nutrients. 2017;9:E399. 4Wong CS, et al. Kidney Int. 2002;61:630–7. 5Canpolat N, et al. Pediatr Nephrol. 2013;28:2149–56. 6Obi Y, et al. Curr Opin Clin Nutr Metab Care. 2015;183(93):254-62.
Criteria for the Clinical Diagnosis of Kidney Disease-related PEW” • ≥3/4 of listed categories along with at least 1 test in each of the selected category • Each criterion should be documented on at least 3 occasions, preferably 2–4 wks apart. 1. Dietary intake • Unintentional low dietary protein intake for at least 2 months Dialysis patients: < 0.8 g/kg/day Patients with CKD stages 2–5: < 0.6 g/kg/day • Unintentional low dietary energy intake <25 kcal/kg/day for at least 2 months 2. Body mass • BMI (edema free) <23 kg/m2 (A lower BMI might be favorable in Asian populations) • Unintentional weight loss over time: 5% over 3 months or 10% over 6 months • Total body fat percentage <10% 3. Muscle mass • Reduced muscle mass 5% over 3 months or 10% over 6 months • Reduced mid-arm muscle circumference area (reduction >10% in relation to 50th percentile of reference population) • Creatinine appearance 4. Serum • Serum albumin <3.8 g/dL chemistry • Serum prealbumin (transthyretin) <30 mg/dL (for maintenance dialysis patients only) • Serum cholesterol <100 mg/dL Fouque D, et al. Kidney Int. 2008;73(44)0:391-398.
Dialysis is a cause of PEW due to: ■ Nutrient losses into dialysate ■ Dialysis-related inflammation ■ Dialysis-related hypermetabolism ■ Loss of residual renal function Kovesdy CP, et al. Am J Clin Nutr. 2013; 97(6):1163–1177. Carrero JJ, et al. J Ren Nutr. 2013; 23(24)1:77–90.
During Dialysis: ■ REE ↑~ 12-20% ↑need for protein and energy intake in dialysis1 ■ ↑ Protein losses (mostly amino acids) through dialysis techniques (both hemodialysis and peritoneal dialysis) ■ ↑ Peritoneal loss of protein during episodes of peritonitis ■ ↓ Synthesis of albumin a state of negative nitrogen balance and muscle wasting Kaysen GA, et al. Am J Kidney Dis.2003; 42:1200–11. ZhaY, and Qian Q. Nutrients. 2017;9:E208. Utaka S, et al. Am J Clin Nutr. 2005;82:801–5. Canepa A, et al. Perit Dial Int. 1996;16(Suppl.1)4:2S526–31.
The Conceptual Model for CKD Progression, PEW, and Its Consequences ObiY, et al. Curr Opin Clin Nutr Metab Care. 2015;18(3):43254-62.
The Conceptual Model for Etiology of PEW in CKD and Direct Clinical Implications ObiY, et al. Curr Opin Clin Nutr Metab Care. 2015;18(3):24454-62.
Criteria for Diagnosis: “Frailty” : ≥ 3/5 1. Weight loss 2. Fatigue 3. Low physical activity 4. Slowness: by gait speed 5. Weakness: by handgrip strength Nixon AC, et al. Clinical kidney journal. 2018;11(2):2435 6-45.
Frailty and Muscle Wasting ■ Prevalence: ~ 30% of incident HD patients ■ Muscle loss and frailty, as with PEW, may develop and progress during the course of CKD. ■ Strong relationship between muscle wasting, PEW, and morbidity and mortality in CKD, maintenance dialysis, and even post-transplant patients Obi Y, et al. Curr Opin Clin Nutr Metab Care. 2015;18(3):254-62. Walker SR, et al. BMC Nephrol. 2013; 14(1): 228. Kim JC, et al. J Am Soc Nephrol. 2013 Feb; 24(3): 337–51. Bao Y, et al. Arch Intern Med. 2012; 172(14): 1071–7. McAdams-DeMarco MA, et al. J Am Geriatr Soc. 2013; 61(6): 896–901. Matsuzawa R, et al. Phys Ther. 2014; 94(7):947–56. Johansen KL, et al. J Am Soc Nephrol. 2014; 254(62): 381–9.
Muscle Mass Evaluation ■ Dual-energy X-ray absorptiometry (DXA) and MRI are the current gold standard methods for assessing lean body mass and muscle mass, respectively. ■ Bioelectrical impedance spectroscopy (BIS)1 ■ Non-dialysis patients: 24-hour creatinine clearance2 • The decline in urine creatinine > 16 mg/year suggesting more rapidly progressive muscle wasting, was associated with death and initiating dialysis independent of BMI and estimated GFR ■ HD patients: serum creatinine3-4 1Onofriescu M, et al. Am J Kidney Dis. 2014; 64(1):111–118. 2Di Micco L, et al. Clin J Am Soc Nephrol. 2013; 8(11):1877–1883. 3Patel SS, et al. Sarcopenia and Muscle. 2013; 4(1):19–29. 4Canaud B, et al. PLoS ONE. 2014; 9(3):e93286. 47
A combination of changes in dry weight and serum creatinine concentrations during the first 6 months of the cohort as a predictor of mortality in 50,831 patients receiving HD. Kalantar-Zadeh K, et al. Mayo Clin Proc. 2010; 85(11):991–1001. 48
OUTLINE ■ Nutrition Support Overview ■ Protein-Energy Wasting (PEW) in CKD/ESRD ■ Nutrition Intervention and Products Used ■ Conclusions 49
Algorithm for Delivery of Nutrition Therapy Nutrition Screen Risk or Presence of Malnutrition?? Not-at-Risk At-Risk or Malnourished Rescreen at: Nutrition Assessment Nutrition At-Risk or Malnourished Monitoring • Regularly specified intervals or Nutrition Therapy • When nutritional/ clinical status changes SPENT, Society of Parenteral and Enteral Nutrition Reassessment of Thailand; NAF, Nutrition Alert Form; NT, Nutrition Triage 50 Adapted from Clinical Pathways and Algorithms for Delivery of Parenteral and Enteral Nutrition Support in Adults. ASPEN; 1984:4.
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