1. Total Nutrition Management in CKD 2022

Total Nutrition Management in CKD Case-Based Experience Sharing “Nutrition assessment & Intervention” Sirin Jiwakanon, MD. 11th June 2022 Novotel Bangkok Platinum Pratunam & Zoom Webinar



Causes and Mechanisms of PEW in CKD patients Fiaccadori E, Sabatino A, et al. Clinical Nutrition (40): 2021; 1644-1668

Protein Energy Wasting and Cachexia in CKD • PEW prevalence increases when renal function declines. • <2% in CKD stages 1-2 • 11-54% in CKD stages 3-5 • 28-54% in undergoing maintenance dialysis Koppe L, Fouque D, Kalantar-Zadeh K. J Cachexia Sarcopenia Muscle. 2019 Jun;10(3):479-484.

Case scenario Case I : Pre-Dialysis Patients Problem • A 38-Thai male with insulin dependence DM with CKD stage 4 (GFR 20) • Need to slow progression of CKD, so he very strictly on diet intake that make he lose weight 5 kgs in 3 months of FU (from 45 to 40 Kgs) and he eat only 2 times a day with his BP & BS very good controlled, but his serum albumin was 2.8 g/dl with ankle edema 1+ • Problem: • Over restricted diet: inadequate energy & protein intake • Seek for “supplement”: Herbal medicine & dietary supplement

Case I : Pre-Dialysis Patients “Nutrition assessment” https://www.spent.or.th/index.php/publication/category/gl/2020

NAF vs NT 2013



https://www.spent.or.th/index.php/publication/category/gl/2020 ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure, Clinical Nutrition (2006) 25, 295–310 KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE, AJKD, 76, ISSUE 3, SUPPLEMENT 1, S1-S107, SEPTEMBER 01, 2020

Nutritional recommendation in CKD SPENT 2018 KDOQI 2000 ESPEN 2006 KDOQI 2020 Total calories <60 y: 35 < 60 y: 35 35 25-35 (kcal/kg/D) >60 y: 30-35 > 60 y: 30-35 (based on age, gender, level of physical Non-Dialysis activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation) Total calories At least 35 < 60 y.: 35 35 25-35 (kcal/kg IBW/D) (depend on > 60 y.: 30-35 (based on age, gender, level of physical *include energy activities) activity, body composition, weight status from PD fluid > 60 y: at least 30 goals, CKD stage, and concurrent illness or Dialysis presence of inflammation) IBW: male = Height (cm.) – 100 female = Height (cm.) – 105

Nutritional recommendation in CKD SPENT 2018 KDOQI 2000 ESPEN 2006 KDOQI 2020 Total protein CKD 3b-5: GFR<25: GFR 25-70: 0.55-0.6 CKD 3-5 without DM: (g/kg/D) 0.6-0.8 0.6 or 0.75 GFR <25: 0.55-0.6 or 0.55-0.6 or 0.28-0.43 with keto Non-Dialysis If ill: 1-1.2 (intolerance or 0.28+EAA or EAA+KA acid/amino acid analogs to CKD 4-5ND: 0.4+KA inadequate energy 2/3 HBV protein meet protein requirements *not > 1.3 intake) CKD 3-5 with DM: 0.6-0.8 > 50% HBV protein Insufficient evidence to recommend a particular protein type (plant vs animal) in terms of the effects on nutritional status, calcium or phosphorus levels, or the blood lipid profile) Dialysis HD PD HD PD HD PD Total protein 1.1-1.4 1.2-1.3 1.2 1.2-1.3 1.2-1.4 1.2-1.5 1-1.2 (g/kg IBW/D) In In peritonitis: Insufficient evidence to HBV protein peritonitis: In acutely ill: additional recommend a particular >50% 1.5-1.7 0.1-0.2 protein type (plant vs animal) At least 1.3 ESPEN, European Society for Clinical Nutrition and Metabolism; EAA, essential amino acids; IBW: male = Height (cm.) – 100 GFR, glomerular filtration rate; HBV, high biological value; KA, ketoanalogues. female = Height (cm.) – 105

Case scenario Case I : Pre-Dialysis Patients Problem • A 38-Thai male with insulin dependence DM with CKD stage 4 (GFR 20) • Need to slow progression of CKD, so he very strictly on diet intake that make he lose weight 5 kgs in 3 months of FU (from 45 to 40 Kgs) and he eat only 2 times a day with his BP & BS very good controlled, but his serum albumin was 2.8 g/dl with ankle edema 1+ • Problem: • Over restricted diet: inadequate energy & protein intake Goal: total calories 1,125-1,575 kcal/day (25-35 kcal/kg/day) & total protein 27-36 gm/day (0.6-0.8 gm/kg/day)

ชนิดา ปโชติการ, สนุ าฎ เตชางาม . โภชนาการสาหรบั ผเู้ ป็นโรคไตเรอื้ รงั พฤศจิกายน 2560 .

Plant-based Diet in Chronic Kidney Disease • Plant-based diets, despite containing low amounts of protein, are also rich in potassium and phosphorus, and therefore they are believed to be unsuitable for CKD patients. • Nowadays, there are numerous types of vegetarianism, including lacto- ovo-vegetarianism, lacto-vegetarianism, ovo-vegetarianism, veganism, vitarianism, fruitarianism, liquidarianism, etc. • Some of these diets combine plant-based diets with animal products such as eggs, milk, and honey, other are based on fruits or sprouts or juices. • A number of reports suggest that plant-based foods may be associated with favorable effects on CKD patients that can delay the progression of CKD, protect endothelium, decrease proteinuria, control high BP, phosphorus burden, acid load, uremic toxins, inflammation, and oxidative stress. Brzózka A.G, Franczyk B, et al. Nutrients 2017, 9, 374 Ban-Hock Khor, Dina A. Tallman, et al. Nutrients. 2021 Oct; 13(10): 3341

Plant-based Diet in Chronic Kidney Disease

Plant-dominant diet (PLADO) K Kalantar-Zadeh, S Joshi, R Schlueter, et al. Nutrients 2020, 12, 1931

Ban-Hock Khor, Dina A. Tallman, Joel D. Kopple, et al. Nutrients. 2021 Oct; 13(10): 3341.

0.5 g/kg/d 0.6 g/kg/d Ban-Hock Khor, Dina A. Tallman, Joel D. Kopple, et al. Nutrients. 2021 Oct; 13(10): 3341.

Plant-based Diet in Chronic Kidney Disease • With 0.5 g protein/kg/day, all diets were below the Recommended Dietary Allowances (RDA) for at least one essential amino acid (EAA). • At a protein prescription of 0.6 g/kg/day, only the conventional low protein diets (LPDs) met the RDA for all EAAs. • With a protein prescription ≥0.7 g/kg/day, all the plant-based and vegetarian LPDs provided the RDA for all EAA. • The plant-based and vegetarian diets also contained relatively greater potassium, phosphorus, and calcium content but lower long-chain n-3 polyunsaturated fatty acids and vitamin B-12 than the conventional diet. • Other essential micronutrients were commonly below the RDA even at higher protein intakes. • Prescription of all LPDs for CKD patients, especially plant-based and vegetarian LPDs, requires careful planning to ensure the adequacy of all nutrients, particularly essential amino acids. • Consideration should be given to supplementing all animal-based and plant-based LPDs and moderately high protein diets (MHPDs) with multivitamins and certain trace elements. Ban-Hock Khor, Dina A. Tallman, et al. Nutrients. 2021 Oct; 13(10): 3341



Case scenario Case I : Pre-Dialysis Patients Problem • A 38-Thai male with insulin dependence DM with CKD stage 4 (GFR 20) • Need to slow progression of CKD, so he very strictly on diet intake that make he lose weight 5 kgs in 3 months of FU (from 45 to 40 Kgs) and he eat only 2 times a day with his BP & BS very good controlled, but his serum albumin was 2.8 g/dl with ankle edema 1+ • Problem: • Seek for “supplement”: Herbal medicine & dietary supplement

Factors influencing toxicity of herbal medicines Science 347(6219 Suppl):S47-S49 · January 2015





สมนุ ไพร....ดตี ่อไตจรงิ เหรอ ?????





4. ช่วยบารุงคนเป็นโรคไตไดท้ กุ ระยะ : ถ้าไตปกตดิ นี ่ันไมใ่ ชป่ ญั หาในการทานถง่ั เช่า แตส่ าหรับคนเปน็ โรคไตต้งั แตร่ ะยะท่ี 3 ไมค่ วรทานถัง่ เชา่ ... กรณไี ตเสอ่ื มในระยะ 1-2 ยังสามารถทานถง่ั เช่าเพ่ือบารุงรา่ งกาย และบารุงไตได้ แต่ ถา้ หากค่าไตอยใู่ นระดบั 3 ไปแล้ว ไมแ่ นะนาให้ทานอาหารเสรมิ หรืออาหารใดๆ ได้ตามปกตคิ รับ ตอ้ งมีการ ควบคุมชั่ง ตวง วดั ในอาหารแตล่ ะมอ้ื เลยทีเดยี ว แม้แตน่ า้ เปล่า ก็ตอ้ งควบคมุ อยา่ งเคร่งครดั เพ่ือไม่ใหไ้ ตทางานหนกั หากเปน็ โรคไตระยะทีส่ ามขึ้นไป ควรปรึกษาแพทย์แผนปจั จบุ ัน จะเหมาะสมกวา่ ครับ https://www.cordyfarmacy.com/



Ho C, Martinusen D, et al. Can J Kidney Health Dis. 2019; 6

Ho C, Martinusen D, et al. Can J Kidney Health Dis. 2019; 6

Mitragyna speciosa (Kratom) and CKD • Mitragyna speciose (Kratom) is a herbal supplement with potential abuse due to its opioid-like properties. • Kratom as a supplement has been used for fatigue, pain, mood, and euphoria because it interacts with the serotonergic (5-HT) and µ-opioid receptors to produce favorable psychotropic and antinociceptive effects, respectively. • Subchronic effect of standardized methanolic extract of Kratom (SMEMS) produced toxic effect to liver, kidney, and lung in rats. • Long-term (>20 years with a daily intake of ≥87.54mg of mitragynine) brewed kratom decoction consumption did not cause any significant alterations in haematological, kidney, liver, thyroid, inflammatory and gastrointestinal analytes in a cohort of kratom users who had no history of substance misuse, although prolonged and heavy use (>3 glasses daily) may result in cardiovascular risks. • There are some case report of kratom induced hyperkalemia, intrahepatic cholestasis, and multiorgan dysfunction in the setting of prolonged kratom ingestion (acute liver injury (ALI) associated with simultaneous renal failure and pancolitis). Ilmie MU, Jaafar H, et al. Front Neurosci. 2015; 9: 189. Singh D, Narayanan S. et al., Mal J Med Health Sci 16(4) Dec 2020 : 64-72, https://www.asn-online.org/education/kidneyweek/2020/program-abstract.aspx?controlId=3449018 Kapp FG, Maurer HH, et al., J Med Toxicol. 2011 Sep;7(3):227-31 Khan MZ, Saleh MA. et al., ACG Case Rep J. 2021 Aug 25;8(8):e00647







Satirapoj B, Prapakorn J, et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86



Inclusion criteria Screening (N = 40) Exclusion criteria • Diabetes Mellitus • 18 years up with CKD stage III-IV • Active malignancy • Severe heart, lung, or liver disease, • Stable renal function or stroke, chronic infection within 1 year <10% change in GFR within 3 months • Malnourished conditions • No change in any medical treatment (loss of ≥5% BW over the past 3 months within 3 months before starting the study and albumin < 3.5 g/dL Enrollment N = 29 • Lab / Nutrition assessment Record dietary intake 3 days Lab / Nutrition assessment (within study) (End) (Baseline) • Record dietary intake 3 days Take ONCE Renal 76 g (370 kcal) supplement (before start study) as meal replacement for 7 days Satirapoj B, Prapakorn J, et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86

* Satirapoj B, Prapakorn J, et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86

* * Satirapoj B, Prapakorn J, et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86

Conclusion • In patients with CKD, ingestion of ORF was well tolerated and had a positive effect with an increase in dietary energy, fat, and fiber intake, as well as a decreased dietary protein intake. • No mineral or electrolyte abnormalities were observed during the study. • During the study period, no major complications and GI adverse effects were observed. • The rate of adverse events with hyperkalemia (potassium > 5.5 mEq/L), hypercalcemia (calcium >10.5 mg/dL), hyperphosphatemia (phosphorus > 5.5 mg/dL), and elevated liver enzymes among patients given dietary supplement was not detected. Satirapoj B, Prapakorn J, et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86

Inclusion criteria Screening (N = 62) Exclusion criteria • 18 -75 years with CKD stage IV • Active malignancy • GFR = 15-29 mL/min/1.73 m2 • Severe heart, lung, or liver disease, • <10% change in GFR within 3 months • Well nourished subjects chronic HIV, hepatitis B virus, hepatitis C (SGA A/B and albumin ≥ 3.5 g/dL) virus infection • Malnourished conditions Enrollment N = 32 (loss of ≥5% BW over the past 3 months and albumin < 3.5 g/dL) • Lab / Nutrition assessment Record dietary intake 3 days Lab / Nutrition assessment (within study) (End) (Baseline) • Record dietary intake 3 days Take ONCE Renal 76 g (370 kcal) supplement (before start study) as meal replacement for 30 days Satirapoj B, Varothai N, et al., J Southeast Asian Med Res 2020; 2:7-15

* * * * Satirapoj B, Varothai N, et al., J Southeast Asian Med Res 2020; 2:7-15

Satirapoj B, Varothai N, et al., J Southeast Asian Med Res 2020; 2:7-15

Conclusion • Renal specific oral diet supplement can improve energy intake, body weight and maintain serum electrolyte concentrations among patients with stage IV CKD. • The ONCE Renal diet improved energy, fiber and magnesium intake without significant short term abnormal electrolyte disturbance. • This intervention might require larger studies in other groups of patients with CKD with longer duration of the ONCE Renal supplement. Satirapoj B, Varothai N, et al., J Southeast Asian Med Res 2020; 2:7-15

• 400 g Powder • Nutrition following Pre-dialysis guideline • Caloric distribution 8 : 52 : 40 (Low protein formula) • Protein 7.2 g/360 kcal • Preserve lean body mass? • Control blood sugar • Control lipid profile • Suitable minerals for pre-dialysis CKD patients • Total fiber 8.3 g/1000 kcal • Use for meal replacement 46



Case scenario Case II : PD Patients Problem • Then he developed CKD stage 5 and started peritoneal dialysis with 1.5% CAPD 1.5 L x 4 Ex/day with UF 200-300 ml/day and urine output 1500 ml/day. After 2 months of dialysis treatment, he became enjoyed eating, so his BP & BS is not good controlled at this situation, his BP is 170/100 mmHg with BS 180 mg/dl with his serum albumin 2.7 g/dl, TG 350 mg/dl, with pitting edema 3+ • Problem: • Hypertension: Salt & water retention • Hyperglycemia & Hypertriglyceridemia • Hypoalbuminemia: kwashiorkor-like protein malnutrition

Fluid Retention in PD • Fluid overload is a common complication of PD, which is closely related to HT, cardiac dysfunction, inflammation, and mortality. • 25% incidence of symptomatic fluid retention among patients treated with CAPD. • Peripheral edema, pulmonary congestion, pleural effusions, and systolic and diastolic HT were the most common manifestations of symptomatic fluid retention. • The hospitalization rate for fluid retention was 4.1+5.8 days/patient/year, significantly higher than that observed for the total PD population. • Patient noncompliance with dietary restrictions and with the prescribed PD prescription was identified as the major predictor of fluid retention. Guo Q, et al.PLoS One. 2013;8(1):e53294 Abu-Alfa AK, et al. Kidney Int Suppl. 2002 Oct;(81):S8-16 Tzamaloukas AH, et al J Am Soc Nephrol. 1995 Aug;6(2):198-206

Other nutritional problems in PD • Because peritoneal solutions with a high glucose content are standard, CAPD is associated with a high glucose uptake. • PD leads to the absorption of glucose, the calorific value of which can range from 300-450 kcals/day (approximately 8 kcal/kg/day) or mean daily glucose absorption 27.98 to 110.35 grams depending on the type of PD undertaken, dwell time, and peritoneal membrane transport status. • An excess of energy over protein net intake can ensue, and obesity can develop that can conceal a dangerous kwashiorkor-like protein malnutrition. • The high glucose intake can cause: – Obesity – Hypertriglyceridemia – Increased LDL and VLDL cholesterols – Hyperglycemia – Induction or aggravation of diabetes N Cano, E Fiaccadori, et al. Clinical Nutrition, 2006; 25: 295–310 NJM Cano et al. Clinical Nutrition, 2009; 28: 401–414 Johansson L. PDI, 2015; 35(6): 655–658 G Toigo, M Aparicio, et al. Clinical Nutrition, 2000; 19(4): 281-291 Kotla SK, Saxena A, Saxena Kidney360. 2020 Dec 31; 1(12): 1373–1379