Definition: Nutrition Therapy • “Nutrition Support”1 : Orally modified formulas or intravenous nutrition necessitated by inability to consume a general diet; administered to malnourished individuals who cannot consume food in its original form. • “Nutrition Therapy”2 : A component of medical treatment that includes oral, enteral, and parenteral nutrition. • “Nutrition Support Therapy”2 : Enteral and/or parenteral nutrition. 1Mosby's Dictionary of Complementary and Alternative Medicine. (c) 2005, E5ls1evier. 2 A.S.P.E.N. http://www.nutritioncare.org/lcontent.aspx?id=546
Core Concept of Nutritional Intervention ◦ How much? Calories ? Protein ? Fluids ? Micronutrients ◦ Route of Administration Oral diet ONS EN PN + SPN ONS, oral nutririon supplement; EN, enteral nutrition; PN, parenteral nutrition; SPN, supplemental PN 52
Daily Requirements in General Daily Goals Stable Critical Care Energy (Kcal/kg) 30-35 (20-25) 25*-30* • Risk for • 5(10)-20 Kcal/kg/day Refeeding • 80% BEE • Obesity • BMI 30-50* 11-14 (actual BW) • BMI > 50* 22-25 (IBW) Protein (g/kg) 1.2*-1.5 (2* – 2.5) • Obesity • BMI 30-40: ≥ 2 (IBW)* • BMI > 40: 2-2.5 (IBW)* Fluids (mL/kg) 30-35 mL (depending on comorbidities) + loss JPEN. 2009;33(3):277-316. Clinical Nutrition. 2009; 28:387–400. Nutr Clin Pract. 2005;20:468-73. Heimburger DC, Ard JD (eds): Handbook of clinical nutrition, 4th ed, 2006. 53 *ASPEN ICU guideline: Crit Care Med. 2016;44(2):390-438. (JPEN. 2016;40(2):159–211.)
Nutrition Recommendations for Adult with Kidney Disease General Non-dialysis PD HD CRRT AKI Population CKD 30-35 + 30-35 Energy from Energy* • 30-35 dialysate 30-35 • All: ≥ 35 ⴕ Age <60: 35 • Age>60: ≥ 30 carbon but that • 20-30 may be offset • 25-35 (Kcal/kg/ Age >60: (PD:+ Energy from by CRRT- day) 30-35 dialysate) induced hypothermia • CKD3b-5: Protein* 0.6-0.8 (g/kg/ • [CKD 4-5: • 1.2 • Non- day) <0.4 + 1.2-1.3 >1.2 catabolic [50% = 0.8-1 keto- • Peritoni • 1.1-1.4 • ≥2.5 AKI: 0.8-1 HBV] analogue] • tis: 1.5- • • 1.5-2.5 • AKI on RRT • All: < 1.3 1.7 1-1.5 • + illness: 1-1.2 Not restricted • Anuric: 1- unless CHF or hypoNa 1.2L Fluid Not • HD: 500-800 mL + urine output Monitor closely • Oliguric: Not (mL/kg/ restricted • PD: 30-35 mL/kg IBW/day for fluid restricted balance unless CHF day) or hypoNa Restrict ⴕK*Bignai=stiekadgl noIBenWepdhs[Sy; NsPiEceaNeldTascgatuirveiditieynlcilnereeva:esMl.eIadnlewse=itdhHetnd-ti1aa0lry0ys;iasFd/esumtlrteass,lesr/:ehHcyotpm–erm1c0ae5tn]adbeodlicensetargteysi;nHtSaBPkVeE, ihsNig3T0h KbGcioaullo/ikdggiec/dalilanvyaelu2e0•18 Paleysky PM, et al. Am J Kidney Dis. 2013;61(5):649-672. Brown RO, et al. J Parenter Enteral. 2010;34(4):366-377. – red5f4ont Ikizler TA, et al. Kidney. 2013;84(6):1096-1107. KDIGO2012. Kidney Int Suppl. 2013;3:1-163.
Nutrition Recommendations for Adult with Kidney Disease: Micronutrients General Non-dialysis PD HD CRRT AKI (Thai DRI) CKD Vitamins DRI (Dietary Recommended Intakes) Standard DRI and trace additive elements 2,000-2,333 DRI DRI DRI Vitamin A IU/day DRI Vitamin C 75-90 • 75-100 mg/day N/A DRI (mg/day) mg/day DRI • กนิ น้อย + 100 DRI DRI Pyridoxine 1.3-1.7 DRI DRI (mg/day) mg/day mg/day Folic acid 400 •5 mcg/day • กินน้อย: DRI + 10 DRI mg DRI 1 mg/day Vitamin D 5-10 Aim for levels similar to general population mcg/day Iron 10.4-24.7 Supplement as needed mg/day KBDroIwGOn R20O1,2e.tKaidl.nJePyaIrnetnSteurpEpnl.t2e0ra13l.;23:011-016;334.(4):366-377S. PENT 55 2018 Paleysky PM, et al. Am J Kidney Dis. 2013;61(5):649-672. Ikizler TA, et al. Kidney. 2013;84(6):1096-1107. Guideline
Nutrition Recommendations for Adult with Kidney Disease: Electrolytes General Non-dialysis PD HD CRRT AKI (Thai DRI) CKD Sodium 400-1,450 • 2-2.3 g/day, as tolerated As tolerated (g /day) mg/day • Non-dialysis: < 2 g if + HT or edema • HD: 1.8-2.5 g/day/ PD: < 2 g/day 2,050- • < 40 No < 40 4,100 mg/day mg/kg/day restriction mg/kg/day Potassium if hyperK as hyperK is if hyperK Monitor As tolerated (mg/kg/day) closely and - • < 1,500- not usually • 2,000- replete as an issue 2,000 2,500 needed mg/day mg/day Calcium 800-1,00 1.5 g/day <2 g/day (g/day) mg/day • PD: 1.5-2 g Phosphate 700 • 800-1,000 mg; use binders if elevated No restriction; - (mg/day) mg/day • PD: 5-10 mg/kgIBW/day but < 800 mg monitor for hypoP Magnesium 260-320 Initially as DRI; Monitor DRI; adjust mg/day adjust based on serum levels closely and based on serum replete as levels needed Paleysky PM, et al. Am J Kidney Dis. 2013;61(5):649-672. Brown RO, et al. J Parenter SPENT guideline – red fon5t6 Enteral. 2010;34(4):366-377. Ikizler TA, et al. Kidney. 2013;84(6):1096-1107. KDIGO2012. Kidney Int Suppl. 2013;3:1-163.
Core Concept of Nutritional Intervention ◦ How much? Calories ? Protein ? Fluids ? Micronutrients ◦ Route of Administration Oral diet ONS EN PN 57 + SPN ONS, oral nutririon supplement; EN, enteral nutrition; PN, parenteral nutrition; SPN, supplemental PN
Feeding Approaches Oral Peripheral vein Parenteral Enteral Central vein Tube “ If the gut works, use it ” 58
Route: Oral diet * Oral Nutritional Supplements (ONS) Enteral Tube Feeding (ETF) “Enteral formula” SPN, Supplemental PN 59
Lack of Proteins and Calories Intake ??? ONS ONS, Oral Nutritional Supplement 60 Reproduction from a slide courtesy of Abbott
Oral Nutritional Supplements (ONS) Multi-nutrient liquid, semi-solid or powder products that provide macronutrients and micronutrients with the aim of increasing oral nutritional intake. Clin Nutr 2006; 25:180–186. 61
อาหารทาง การแพทย์ สูตร มาตรฐาน 230 230 8.5 (15%) ครบถว้ น ครบถว้ น ONS = complete balanced diet 62 Proprietary and confidential — do not distribute
Polymeric Formula 63
Polymeric Formula 64
Polymeric Formula 65
Polymeric Formula 66
Polymeric Formula 67
Modified Enteral Formulas Composition Clinical Indication ↑ Caloric density: 1.5-2 Kcal/ml Fluid restriction e.g. advanced CKD Lower CHO content, fructose, CARBOHYDRATE added fiber High protein Glucose intolerance PROTEIN Critically ill patients Hydrolyzed protein to small peptides Impaired absorption Arg, Glu, nucleotides, (+/- ω3 fat) Immune-enhancing formula BCAAs, AAAs Liver failure patients intolerant of 0.8 g prot/kg FAT Low fat, partial MCT substitution Fat > 40% Fat malabsorption Fat from MUFA Pfourlmmuolnaary failure with CO2 retention on standard Improvement of GI control in diabetes Fat from ω3 and ω6 Improve ventilation in ARDS FIBER e.g. soy polysaccharide Improve laxation 68
Disease-Specific Formulas Diabetic formula Diabetic formula Renal formula Hepatic formula 69
Disease-Specific Formulas Diabetic formula 70
Disease-Specific Formulas Diabetic formula Renal formula Hepatic formula 71
Modular Products 72
Route: Oral diet * Oral Nutritional Supplements (ONS) Enteral Tube Feeding (ETF) “Enteral SPN formula” Parenteral nutrition (PN) SPN, Supplemental PN 73
Dietary Intakes and Nutrition Status Evaluation Moderate Severe undernutrition undernutrition • BMI < 20 Spontaneous intakes: • BW loss > 10% in 6 mo • Serum albumin < 3.5 g/dL • ≤ 30 Kcal/kg/day • Serum pre-albumin < 30 mg/dL • Protein ≤ 1.1 g/kg/day Spontaneous intakes Spontaneous intakes > 20 Kcal/kg/day < 20 Kcal/kg/day or + stress condition Lack of compliance EN Diet counseling ONS IDPN No improvement No improvement 74 IDPN, Intradialytic parenteral nutrition Basic Clinical Nutrition. 4th ed. ESPEN, 2011.
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All-in-1 Commercial Peripheral PN
All-in-1 CommercialCentral PN
OUTLINE ■ Nutrition Support Overview ■ Protein-Energy Wasting (PEW) in CKD/ESRD ■ Nutrition Intervention and Products Used ■ Conclusions 78
Conclusions ■ In dialysis patients, PEW is associated with increased morbidity and mortality. ■ In addition, most of CKD/ESRD patient are older adults who are more vulnerable to malnutrition. ■ Nutritional status indicators (from nutrition screening and assessment) should be thought of as vital signs. ■ Prevention and treatment of PEW should involve individualized and integrated approaches to modulate identified risk factors and contributing comorbidities. 79
Multiple treatment strategies against those etiologies may be required to prevent or reverse PEW. ■ Individualized, continuous nutritional counseling ■ Nutrition therapy may be needed ■ Optimizing the dialysis regimen ■ Preventing or correcting muscle wasting ■ Management of comorbidities (e.g. metabolic acidosis, diabetes, infection, congestive heart failure, and depression) are the most essential preventive measures. Ikizler TA, et al. Kidney Int. 2013; 84(6):10890 6–1107.
THANK YOU 81
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