1. Total Nutrition Management in CKD 2022

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MIS vs NAF vs NT 2013



Nutritional recommendation Nutrition SPENT 2018 K/DOQI 2000 ESPEN 2006 KDOQI 2020 HD PD HD PD HD PD 35 HD PD Total calories At least 35 < 60 y.: 35 (kcal/kg IBW/D) (depend on activities) > 60 y.: 30-35 25-35 *include energy > 60 y: at least 30 (based on age, from PD fluid gender, level of physical activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation) 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 In acutely ill: In peritonitis: Insufficient evidence (g/kg IBW/D) In peritonitis: At least 1.3 additional to recommend a 0.1-0.2 particular protein HBV protein >50% 1.5-1.7 type (plant vs animal) IBW: male = Height (cm.) – 100 female = Height (cm.) – 105

Nutritional recommendation SPENT 2018 K/DOQI 2000 ESPEN 2006 KDOQI 2020 Nutrition HD PD HD PD HD PD HD PD ONS Should apply ONS/EN If oral nutrition Use standard ONS in conscious Minimum 3-months before IDPN or PN (including patients. trial of ONS nutritional For TF prefer HD- Formulae with a Consider EN before supplements) is specific formulae. higher protein but IDPN, TPN, IPPN inadequate, TF The formula lower should be offered if content in P & K carbohydrate medically should be content are to be appropriate. checked preferred.

Recommendation 3 “In malnourished non-critically ill hospitalized patients with AKI/AKD or CKD with or without KF and those patients at risk for malnutrition who can safely feed orally but cannot reach their nutritional requirements with a regular diet alone, ONS shall be offered.” Grade of recommendation A - Strong consensus (100% agreement) • ONS, and especially those with higher energy and protein content, can add up to 10-12 kcal/kg and 0.3-0.5 g of protein/kg daily over the spontaneous intake in a 70 kg patient if provided 2 times a day at least 1 h after a meal, thus facilitating the achievement of nutritional targets. Fiaccadori E, Sabatino A, et al. Clinical Nutrition (40): 2021; 1644-1668

Guideline 4: Nutritional Supplementation • ONS should be prescribed 2 - 3 times daily and patients should be advised to take ONS preferably 1 hour after meals rather than as a meal replacement to maximize benefit. • Monitored in-center provision of high-protein meals/ONS during MHD may be a useful strategy to increase total protein and energy intake. • Many of the perceived negative effects of intradialytic feeding such as postprandial hypotension, aspiration risk, infection control, and hygiene, as well as diabetes and phosphorus control, can be avoided with careful monitoring. • ONS prescription should take into account patient preference. • The acceptability of ONS in terms of appearance, smell, taste, texture, and type of preparation (milkshake type, juice type, pudding type, protein/energy bar, or fortification powder) should be carefully considered. • The tolerability of ONS should also be carefully monitored because some patients may develop GI symptoms with ONS. • Energy-dense and low-electrolyte renal-specific ONS may be necessary to increase protein and energy intake and avoid fluid overload and electrolyte derangements. KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE, AJKD, 76, ISSUE 3, SUPPLEMENT 1, S1-S107, SEPTEMBER 01, 2020

Decisional Algorithm for Management of PEW in HD N.J.M. Cano et al. Clinical Nutrition 28 (2009) 401–414

Recommended IDPN formulations Dextrose (infusion rates) Lipid (infusion rates) Protein Moderate to high dextrose 4 mg/kg/min or AA 0.6-0.8 g/kg/HD Carbohydrate controlled; 4-6 mg d-glucose/kg/min 12-12.5 g/hr or IDPN bag Noncarbohydrate controlled; 6-8 mg d-glucose/kg/min Low dextrose; < 3 mg/kg/min 4 mg/kg/min or AA 0.6-0.8 g/kg/HD 12-12.5 g/hr or IDPN bag Low dextrose, no lipids; < 3 mg/kg/min No lipids AA 0.6-0.8 g/kg/HD or IDPN bag Glucose 50-100 g/HD Lipid 50 g/HD AA 30-40 g/HD (200-400 kcal/HD) (450 kcal/HD) (120-160 kcal/HD) 400-900 kcal/HD Dukkipati R, Nutritional management of renal disease, 3rd edition, 2013

Inclusion criteria Exclusion criteria • Age 18-75 years • Inadequate dialysis • Regular HD 4 hrs, 3 times/wk > 3 months • Life expectancy < 6 months • Serum albumin level < 3.8 g/dl • Non-adherence to dialysis • Dietary protein intake < 1 g/kg/day • Dietary energy intake < 25 kcal/kg/day regimen • Active infection, malignancy Record dietary intake 3 days (before start study) and severe heart, lung or liver disease 370 kcal/Day for 30 days Lab / Nutrition assessment MIS, SF-36 (Baseline) Record dietary intake 3 days (within study) Lab / Nutrition assessment MIS, SF-36 (End of study) Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

* Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

* * Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

* Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

Conclusion • Short-term ONS were associated with increased energy, protein, fat, fiber and magnesium intake. • ONCE dialyze supplement significantly improved nutritional status score and serum albumin level in malnourished patients with kidney failure undergoing maintenance hemodialysis without abnormal electrolyte disturbance. • Compliance of patients in our study was extremely good; 96% of patients complied with the ONS supplement for 30 days Limwannata P, Satirapoj B, et aI. Int Urol Nephrol.2021 Aug;53(8):1675-1687

ONCE Dialyze • 400 g Powder • Nutrition following dialysis guideline • Caloric distribution 18 : 42 : 40 (High protein formula) • Preserve lean body mass • Control blood sugar • Control lipid profile • Suitable minerals for both PD/HD dialysis patients • Suitable total fiber (13.52 g/1000 kcal) • Use for meal supplement