1230-1300 อ.ภควัต Expert Perspectives on Total Nutrition Management in CKD

Nutrition Management in CKD Bhagawat Tangjaturonrasme, MD. Division of Clinical Nutrition, Department of Internal Medicine. Phramongkutklao Hospital. [email protected] Photo by Jodie Morgan on Unsplash

Pre-HD HD/PD Photo by Calum Lewis on Unsplash Photo by Victoria Shes on Unsplash

Disclosure; Thai Otsuka Pharmaceutical Co.,Ltd.











Nutritional intervention for non-RRT CKD patient The aims of nutritional management ✓ Prevent protein energy wasting ✓ Control accumulation of waste product ✓ Slow progression of renal dysfunction ✓ Prevent cardiovascular disease and metabolic bone disorder Basic in Clinical Nutrition. 5th edition.

Energy Protein Route Fluid Micronutrients Formula

Energy ✓ The same as healthy individuals at the same age 35 kcal/IDW/day (age < 60 y) 30-35 kcal/IDW/day (age ≥ 60 y) Height (cm) - 100 Height (cm) - 105 Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Protein ✓ CKD 3b-5 with metabolically stable 0.55-0.8 g/IDW/day 0.4 g/IDW + keto/amino acid analog to meet 0.55-0.8 g/IDW/day ✓ CKD 3b-5 with acute illness ≈ 1-1.2 g/IDW/day ✓ Any stage with PEW ≈ 1.2 g/IDW/d Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Kalantar-Zadeh K, et al. N Engl J Med. 2017 Nov 1;377(18):1765–76. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Protein ✓ High biological value protein (>50% of protein requirement/d) ✓ 2 tbs of meat = 7 g ✓ 1 egg = 7 g ( 2 white eggs =7g ) ✓ 1 ladle of rice = 2 g ✓ 1 ladle of soybean = 14 g *tbs; tablespoon Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67.

Fluid & micronutrients 1 ml : 1 kcal 500-1,000 ml addition to daily urine output 100% recommended daily intake In protein, fruit and vegetable restriction CKD pt. Consider vitamin B supplement in CKD In case of deficiency = supplement Fat-soluble vitamins and vitamin C ; not routinely supplement Adult Nutrition Support Core Curriculum. 3rd edition. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Fluid & micronutrients ✓ Minerals 2 g/d(2-2.3 g/d) Salt 1 tsp Fish sauce 1 tsp Soy sauce 1 tsp MSG 1 tsp Sodium 2000 mg Sodium 500 mg Sodium 500 mg Sodium 500 mg 2 g/d(1.5-2 g/d) Dark green veg 2 ld Red orange 2 ld Starchy veg 2 ld *tsp; teaspoon Potassium 377 mg Potassium 443 mg Potassium 604 mg Bean and peas 2 ld Potassium 739 mg *ld; Ladle Chicken 100 g Tofu 100 g Cowmilk 1 cup Almond 1 cup 1 g/d(0.8-1 g/d) Protein 22 g Protein 6 g Protein 8 g Protein 6 g Phosphorus 148 mg Phosphorus76 mg Phosphorus 227 mg Phosphorus 139 mg www.cnpp.usda.gov/USDAFoodPatterns. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update Kalantar-Zadeh K, et al. N Engl J Med. 2017 Nov 1;377(18):1765–76. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Route ✓ If the gut work, use it Parenteral Nutrition Enteral Nutrition Oral Nutrition supplement/ Intradialytic parenteral nutrition Oral diet

Formula ✓ Oral diet BW 50 kg, Age 60 y, no PEW ≈ Energy 1500 kcal/d, protein 30 g/d Animal meat Carb Protein-free Veg. Fruit Oil Sugar carb 6 tbs 4.5 ld 3 ld 1 serve 10 tsp 6 tsp 3 ld ✓ Challenge in counselling…

Formula Oral Nutrition supplement ✓ Standard polymeric formula is preferred ✓ Contain nonhydrolyzed protein, fat, carbohydrate, and micronutrients ✓ Using among patients without severe malabsorption ✓ Renal specific formula can be considered in some individuals Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67.

Specific formula – pre RRT CKD 1500 kcal, protein 30 g ✓ Appropriate in protein, sodium, potassium, phosphorus, and micronutrients Nutrients/500 kcal Nutrients Standard formula Improve energy intake Protein 20 g 10 g Sodium 350 mg 185 mg Improve body weight Potassium 650 mg 275 mg Phosphorus 250 mg 200 mg Calcium 250 mg 200 mg Maintain serum Magnesium 100 mg electrolyte concentration Fiber 50 mg Satirapoj et al, International Journal of Nephrology and Renovascular Disease 2016:9 81–86.

Energy Protein Route Fluid Micronutrients Formula

Nutritional intervention for CKD on RRT patient The aims of nutritional management ✓ Prevent protein energy wasting ✓ Control accumulation of waste product ✓ Slow progression of renal dysfunction ✓ Prevent cardiovascular disease and metabolic bone disorder Basic in Clinical Nutrition. 5th edition.

Energy Include energy Peritoneal dialysis from PD fluid !! Hemodialysis Adult Nutrition Support Core Curriculum. 3rd edition. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Protein High biological value protein Renal replacement therapy → protein loss ≈ 10 g/session Hemodialysis Peritoneal dialysis Protein requirement ≈ 1.2 g/IDW/d Protein requirement ≈ 1.2 g/IDW/d ( 1-1.4 g/IDW/d ) ( 1-1.3 g/IDW/d ) [1.5-1.7 g/IDW/d in peritonitis] Adult Nutrition Support Core Curriculum. 3rd edition. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Fluid & micronutrients 1 ml : 1 kcal 500-1,000 ml addition to daily urine output 100% recommended daily intake Fruit and vegetable restriction CKD pt. Consider vitamin B supplement in CKD In case of deficiency = supplement Fat-soluble vitamins and vitamin C ; not routinely supplement Adult Nutrition Support Core Curriculum. 3rd edition. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Fluid & micronutrients ✓ Minerals 2 g/d(2-2.5 g/d) Salt 1 tsp Fish sauce 1 tsp Soy sauce 1 tsp MSG 1 tsp Sodium 2000 mg Sodium 500 mg Sodium 500 mg Sodium 500 mg PD → K loss ↑ Dark green veg 2 ld Red orange 2 ld *tsp; teaspoon Potassium 377 mg Potassium 443 mg 2 g/d(2-2.5 g/d) Starchy veg 2 ld Bean and peas 2 ld Potassium 604 mg Potassium 739 mg *ld; Ladle Chicken 100 g Tofu 100 g Cowmilk 1 cup Almond 1 cup 1 g/d(0.8-1 g/d) Protein 22 g Protein 6 g Protein 8 g Protein 6 g Phosphorus 148 mg Phosphorus76 mg Phosphorus 227 mg Phosphorus 139 mg www.cnpp.usda.gov/USDAFoodPatterns. Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update Kalantar-Zadeh K, et al. N Engl J Med. 2017 Nov 1;377(18):1765–76. Ikizler TA, et al. American Journal of Kidney Diseases. 2020 Sep 1;76(3):S1–107.

Route ✓ If the gut work, use it Parenteral Nutrition Enteral Nutrition Oral Nutrition supplement/ Intradialytic parenteral nutrition Oral diet

Formula Oral Nutrition supplement ✓ Standard polymeric formula is preferred ✓ Contain nonhydrolyzed protein, fat, carbohydrate, and micronutrients ✓ Using among patients without severe malabsorption ✓ Renal specific formula can be considered in some individuals Jiwakanon S, et al. Thai JPEN. 2020 Dec 30;28(2):18–67.

Formula ✓ Oral diet BW 50 kg, Age 60 y, RRT ≈ Energy 1500 kcal/d, protein 60 g/d Animal meat Carb Protein-free Veg. Fruit Oil Sugar carb 1 serve 10 tsp 6 tsp 13 tbs 7 ld - 3 ld ✓ Challenge in counselling…

Specific formula – RRT 1500 kcal, protein 69 g ✓ Appropriate in protein, sodium, potassium, phosphorus, and micronutrients Nutrients/500 kcal Nutrients Protein 10 g 23 g Improve energy intake Sodium 185 mg 208 mg Improve body weight Potassium 275 mg 278 mg Maintain serum electrolyte concentration Phosphorus 200 mg 203 mg Calcium 200 mg 547 mg Magnesium 50 mg 149 mg Fiber Satirapoj B, et al. Int J Nephrol Renovasc Dis. 2017 Jun 13;10:145-151. Limwannata P, et al. International Urology and Nephrology. 53. 10.1007/s11255-020-02768-5.