Board Review: Nutrition Ouppatham Supasyndh, M.D. Nephrology Division Phramongkuyklao Hospital & College of Medicine
2020 2020 2021
Nutrition Care Process *Screening (1) Assessment (4) Monitoring (2) Diagnosis And Evaluation (3) Intervention
Case Study (1) An 80 Y/O chronic HD male patient presents with catheter-related infection. He complains loss of appetite for 5 days. His weight in the past year was decreased for 1 kg. PE: Weight 40 kg, BMI 18 kg/m2, BP 160/70 mmHg, PR 80 bpm. BT 38 C. Leg edema 2+ Lab: CBC: WBC 9,800 cell/mm2, P 85, L 15, Creatinine 4 mg/dL , Serum K 3.0 mEq/L and Albumin 3.4 g/dL
Which one indicates that patient has the risk of malnutrition? A. Old age, sepsis B. Appetite loss 5 days, weight loss within 1 yr C. BMI 18 kg/m2, sepsis D. BMI 18 kg/m2, albumin 3.4 g/dL
Nutrition Care Process *Screening (1) Assessment (4) Monitoring (2) Diagnosis And Evaluation (3) Intervention
Nutrition Risk Screening Tool
SPENT/NST 2020 • Screening tool นํ้าหนักตวั ลดลงโดยไมต่ ัง้ ใจ ใน 6 เดอื น กินไดน้ อ้ ยกว่าเดมิ เกนิ กว่า 7 วัน BMI < 18.5 อาการวิกฤติ หรือ กึ่งวิกฤติ ต้ังแต่ 2 ข้อ ข้ึนไป มี risk of malnutrition
Which one indicates that patient has the risk of malnutrition? A. Old age, sepsis B. Appetite loss 5 days, weight loss within 1 yr C. BMI 18 kg/m2, sepsis D. BMI 18 kg/m2, albumin 3.4 g/dL
Nutrition Care Process *Screening (1) Assessment (4) Monitoring (2) Diagnosis And Evaluation (3) Intervention
Which one of the followings is the tool or parameter using to identify malnutrition? A. Serum albumin B. Protein Nitrogen Appearance (PNA) C. Subjective global assessment (SGA) D. Body Mass Index (BMI)
(1) Nutrition Assessment 1. History taking: Dietary Interview & Food Record
(1) Nutrition Assessment 1. History taking: Dietary Interview & Food Record 2. Physical examination; Anthropometry (BW, BMI etc.)
(1) Nutrition Assessment 1. History taking: Dietary Interview & Food Record 2. Physical examination; Anthropometry (BW, BMI etc.) 3. Laboratory investigation; Albumin, prealbumin Creatinine nPCR
(1) Nutrition Assessment 1. History taking: Dietary Interview & Food Record 2. Physical examination; Anthropometry (BW, BMI etc.) 3. Laboratory investigation; Albumin, prealbumin Creatinine nPCR 4. Assessment tool; 7-point SGA, MIS
1. History: Dietary Interview 70 Kcal 70 Kcal 70 Kcal 7g 25 Kcal protein 1g 2g protein 0.5 g protein protein
เนือ้ สัตว์ 1 ส่วน พพโโปปลลรรังังตตงงนนีี าานน77 77กก00รรมัมั กกิโิโลลแแคคลลออรรีี เช่น • เนื้อสัตว์ 2 ชอ้ นโตะ๊ • ลูกช้นิ 4 ลกู • ไขท่ ้งั ฟอง 1 ฟอง • ไข่ขาว 2 ฟอง
ข้าวและแปง้ 1 ส่วน โโปปรรตตีนีน 22กกรรัมมั พพลลงั งั งงาานน7700กกิโลโิ แลคแลคอลรอี รี ไดแ้ ก่ • ขา้ วสวย 1 ทพั พี • ข้าวตม้ 2 ทพั พี • ก๋วยเตีย๋ ว 1 ทัพพี • ขนมปงั 1 แผ่น • ขา้ วเหนยี ว 3 ป้ นั
2. Anthropometric measurement 1. Waist circumference (2C) 2C 2. Bioelectrical impedance (30 minutes after end of dialysis) Opinion 2. Dual nergy absorptiometry (DXA – gold standard) 3. Body weight & BMI 4. Skinfold thickness
Body Mass Index (BMI) 2C P•DP: DUn: dUenrwderigwheti(gbhatse(dbaosnedBMoI)ncBanMIb)ecuasnedbeasuased preadsicatopr roefdhicigthoerromf ohritgalhiteyr. mortality (2C). 2B HD: Overweight or obesity status (based on BMI) can be used as a predictor of lower mortality, whereas, underweight status and morbid obesity can be used as a predictor of higher mortality.
Mortality & BMI (Reverse Epidemiology) Undernutrition Overweight to Obese Morbid Obese N = 54,535 Follow up to 2 years Kalantar-Zadeh K, Am J Kidney Dis. 2005 Sep;46(3):489-500.
All cause mortality Kalantar-Zadeh K, Am J Kidney Dis. 2005 Sep;46(3):489-500.
Cardiovascular mortality Kalantar-Zadeh K, Am J Kidney Dis. 2005 Sep;46(3):489-500.
3. Laboratory measurement KDOQI 2020 Biomarkers such as normalized protein catabolic rate (nPCR), serum albumin, and/or serum prealbumin may be considered complementary tools to assess nutritional status. However, they should not be interpreted in isolation. (Opinion) Serum albumin - predicts mortality (16 studies) (1A) Serum prealbumin- complementary test (4 studies) Creatinine kinetics - may be used to estimate muscle mass (2C)
(1) Serum albumin SGA; Subjective global assessment, HGS; Hand grip strength, LBM; Axelsson, T.G. Clin J Am Soc Nephrol 2012. 7(9):1446-53. Lean body mass, Anthro; Anthropometry
Albumin and Mortality PD = 1,522 HD = 16,404 Lowrie EG. Am J Kid Dis. 1995;26(1)220-8
(2) Creatinine kinetics Association between serum creatinine and all-cause mortality in 10,896 PD patients Park J. NDT. 2013,28(8):2146-55.
(3) PCR v.s. PNA PCR (Protein Catabolic Rate) - misnomer • Require isotopically-labelled amino acids • Protein/ amino acids loss in dialysate PNA (Protein Nitrogen Appearance) • Metabolically stable: 24-hr urinary nitrogen = protein intake Kidney Dialysis Outcome Quality Initiative. Am J Kid Dis. 2000.
Rationale; PCR PCR overestimated protein intake when • daily protein intake was <1 g/kg PCR underestimated protein intake when • daily protein intake was >1 g/kg Kidney Dialysis Outcome Quality Initiative. Am J Kid Dis. 2000.
เครือ่ งมือที่ใช้ นํา้ หนกั คุณภาพหลักฐาน ความสําคัญ คาํ แนะนาํ Albumin ควรทํา ความเช่อื ม่นั สูง อาจใช้เปน็ เพียงตวั ชว่ ยประกอบการประเมินภาวะ (1A) โภชนาการ “ไมค่ วรใช้”เปน็ ตวั บง่ ชภ้ี าวะโภชนาการ ต้อง ใช้รว่ มกบั การประเมินแบบอ่นื ร่วม แตใ่ ชเ้ ป็นตัวทาํ นาย Creatinine การเสียชวี ติ ของผูป้ ว่ ยและการนอนในโรงพยาบาลได้ (2C) PCR แนะให้ทาํ ความเชือ่ ม่นั มีจํากดั อาจใชเ้ ปน็ ตวั ประเมนิ มวลกลา้ มเน้อื (2D) แนะใหท้ ํา ความเชือ่ มน่ั น้อย ใชเ้ ป็นตัวเลือกช่วยประกอบการประเมินการบรโิ ภค Prealbumin โปรตีน (Opinion) ความเหน็ อาจใชเ้ ป็นเพียงตัวชว่ ยประกอบการประเมนิ ภาวะ ผู้เชย่ี วชาญ โภชนาการ “ไมค่ วรใช้”เปน็ ตัวบง่ ชภ้ี าวะโภชนาการ ตอ้ ง ใช้ร่วมกบั การประเมนิ แบบอ่นื รว่ ม Kidney Dialysis Outcome Quality Initiative. Am J Kid Dis. 2020; 76 (3) suppl 3.
4. Nutrition Assessment Tool Tool Guideline Evidence Advantage (1) 7-point SGA KDOQI 2020 1B Reliable (2) MIS KDOQI 2020 2C (3) NAF SPENT 2020 Opinion Reimbursement (4) NT SPENT 2020 Opinion Reimbursement SGA: Subjective Global Assessment, MIS: Malnutrition Inflammation Score, NAF: Nutrition Alert Form, NT: Nutrition Triage, KDOQI: Kidney Diseases Outcome and Quality Initiative, SPENT: Society of Parenteral and Enteral Nutrition
7-point scale SGA
NAF
2. Which one of the followings is the tool or parameter using to identify malnutrition? A. Serum albumin B. Protein Nitrogen Appearance (PNA) C. Subjective global assessment (SGA) D. Body Mass Index (BMI)
Nutrition Care Process *Screening (1) Assessment (4) Monitoring (2) Diagnosis And Evaluation (3) Intervention
Terminology: Protein Energy Wasting Disease related malnutrition with inflammation (acute or chronic); 1. Biochemical markers: serum albumin or cholesterol 2. Decreased body cell mass* 3. Decreased muscle mass * measured by bioelectrical impedance analyzer (BIA)
ISRNM Criteria 2008 PEW: 3 out of 4 categories (one-test in selected categories) Serum chemistry: Serum albumin < 3.8 g/dL Serum prealbumin < 30 mg/dL Serum cholesterol < 100 mg/mL PEW; Protein energy wasting Fouque D. Kidney Int. 2008; 73(4):391-398
ISRNM Criteria 2008 PEW: 3 out of 4 categories (one-test in selected categories) Serum chemistry: Serum albumin < 3.8 g/dL Serum prealbumin < 30 mg/dL Serum cholesterol < 100 mg/mL Body mass: BMI<23 Weight loss 5% oevr 3 months/ 10% over 6 months Total body fat <10% PEW; Protein energy wasting Fouque D. Kidney Int. 2008; 73(4):391-398
ISRNM Criteria 2008 PEW: 3 out of 4 categories (one-test in selected categories) Serum chemistry: Serum albumin < 3.8 g/dL Serum prealbumin < 30 mg/dL Serum cholesterol < 100 mg/mL Body mass: BMI<23 Weight loss 5% oevr 3 months/ 10% over 6 months Total body fat <10% Muscle mass Reduced 5% over 3 months or 10% over 6 months Reduced mid-arm muscle circunference area Reduced creatinine appearance PEW; Protein energy wasting Fouque D. Kidney Int. 2008; 73(4):391-398
ISRNM Criteria 2008 PEW: 3 out of 4 categories (one-test in selected categories) Serum chemistry: Serum albumin < 3.8 g/dL Serum prealbumin < 30 mg/dL Serum cholesterol < 100 mg/mL Body mass: BMI<23 Weight loss 5% oevr 3 months/ 10% over 6 months Total body fat <10% Muscle mass Reduced 5% over 3 months or 10% over 6 months Reduced mid-arm muscle circunference area Reduced creatinine appearance Dietary intake Low DPI < 0.8 g/kg/day for at least 2 months-dialysis patient or < 0.6 g/kg/day for at least 2 months-CKDG2-5 patient PEW; Protein energy wasting Low DEI < 25 kacl/kg/day for at least 2 months Fouque D. Kidney Int. 2008; 73(4):391-398
E44.0 Moderate malnutrition: E43 BMI 16-16.99 Kg/m2 หรอื NAF B Severe malnutrition: BMI < 16 Kg/m2 หรอื NAF C
Nutrition Care Process *Screening (1) Assessment (4) Monitoring (2) Diagnosis And Evaluation (3) Intervention
Basic Principle of Management 1. Protein requirement 2. Energy requirement 3. Water requirement 4. Route of administration
Case Stydy (2) A 55 year old patient weight 60 kg. Ht 170 cm. MHD x 3/week What is your daily dietary prescription to the patient according to Thai guideline? A. 2,100 kcal, 72 g protein B. 2,450 kcal, 84 g protein C. 1,800 kcal, 70 g protein D. 2,100 kcal, 60 g protein
Protein - Dialysis SPENT 2020 1.2 g/Kg. IBW./d in HD & 1.2 -1.3 g/Kg. IBW./d in PD > 50% high biological value protein KDOQI 2020 1-1.2 g/Kg.BW./d in HD & PD and higher in diabetes (1C) Insufficient evidence for particular protein type (1B)
Energy - Dialysis SPENT 2020 35 kcal/Kg. IBW. in age < 60 yrs 30-35 kcal/Kg. IBW. in age > 60 yrs KDOQI 2020 25-35 kcal/Kg.BW. Depends on age, activity (1A)
คาํ แนะนาํ ที่ 5 โภชนบาํ บัดสําหรบั ผูป้ ่วยโรคไตเรอ้ื รงั ที่ ได้รับการบําบดั ทดแทนไตในผใู้ หญ่ (Renal Replacement Therapy) Daily Intake Hemodialysis CAPD Energy (Kcal/ IBW.kg) 30-35 30-35 (-hidden calories) Protein (g/IBW.kg) 1.1-1.4 Sodium (mg) 1.2-1.3 Potassium (mg) 1,800 - 2,500 < 2,000 Phosphorus (mg) 2,000 - 2,500 Depends on serum Water soluble vitamin 5-10 mg/IBW.Kg 800 - 1,000 Vit B6 10 mg, RDI Vit C 100 mg/day * IBW: Male = Hight(cm.)-100, Female = Hight(cm.)-105
Case Stydy (2) A 55 year old patient weight 60 kg. Ht 170 cm. MHD x 3/week What is your daily dietary prescription to the patient according to Thai guideline? A. 2,100 kcal, 72 g protein B. 2,450 kcal (35), 84 g protein (1.1-1.4) (IBW = 70) C. 1,800 kcal, 70 g protein D. 2,100 kcal, 60 g protein
KDOQI 2020 - Calcium CKD 3-4 without vit D supplement, suggest prescribe elemental calcium 800-1,000 mg/d (2B) • *CaCO3 (1,000 mg) provide elemental calcium 400 (40%)
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