1200-1230 อ.ศิรินทร์ Expert Perspectives on nutrition manangement in CKD

Expert Perspectives on Total Nutrition Management in CKD Part I : Pre-dialysis Patients 16th January 2022 Sirin Jiwakanon, MD, Hat Yai Hospital

Nephrologist Perspective • Pathophysiology & Complications • Diagnosis of PEW in CKD • Nutritional recommendation for Non-dialysis

Conceptual model of PEW and Relative contribution of CKD to various physiological factors as Renal disease Progresses Hanna RM, Ghobry L, et al. Blood Purif. 2020;49(1-2):202-211.

Mechanisms of action leading to the development of PEW in CKD Kovesdy CP, Kopple JD, et al. Am J Clin Nutr. 2013 Jun;97(6):1163-77

• The altered homeostasis in CKD negatively affects skeletal muscle mass, strength and quality. • Skeletal muscle dysfunction has significant effects upon overall physical function and activity. Moorthi RN, Avin KG. Curr Opin Nephrol Hypertens. 2017 May;26(3):219-228

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

Interaction of Pathological Factors that Produces a PEW state in CKD CKD-related factors that reinforce the deterioration of nutritional status and overall health. Hanna RM, Ghobry L, et al. Blood Purif. 2020;49(1-2):202-211.

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.

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 ND-CKD SPENT 2018 KDOQI 2000 ESPEN 2006 KDOQI 2020 35 Total calories <60 y: 35 < 60 y: 35 25-35 (based on age, gender, level of physical (kcal/kg/D) >60 y: 30-35 > 60 y: 30-35 activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation) 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 If ill: 1-1.2 0.6 or 0.75 GFR <25: 0.55-0.6 or 0.55-0.6 or 0.28-0.43 with keto acid/amino CKD 4-5ND: 0.4+KA (intolerance or 0.28+EAA or EAA+KA acid analogs to meet protein requirements *not > 1.3 inadequate energy 2/3 HBV protein CKD 3-5 with DM: 0.6-0.8 intake) > 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) ESPEN, European Society for Clinical Nutrition and Metabolism; EAA, essential amino acids; GFR, glomerular filtration rate; HBV, high biological value; KA, ketoanalogues.

Nutritional recommendation in ND-CKD SPENT 2018 ESPEN 2006 KDOQI 2020 Fat :Healthy dietary pattern Mediterranean Diet may improve (% of total :Fish with high omega-3 lipid profiles energy) (100 g x 2-3/wk) :Plant-based oil (unsaturated fat) :Saturated fat <7% CKD 3-5: suggest prescribing :Trans fat <1% ~2 g/d LC n-3 PUFA to lower serum *No omega-3 supplement for triglyceride levels decrease CVD risk Mediterranean style diet

Nutritional recommendation in ND-CKD SPRNT 2018 ESPEN KDOQI 2020 2006 Prescribing folate, vit B12, and/or B-co Vitamin RDA May need vit B co & folic acid supplement to correct for :Water deficiency/insufficiency based on clinical soluble *No vit C supplement if not signs & symptoms. indicated Who are at risk of Vit C deficiency, (may cause hyperoxalemia) supplement to meet RDA at least 90 mg/d (M) and 75 mg/d (W) :Fat soluble Cholecalciferol/ergocalciferal for keep 25(OH)D > 30 ng/ml CKD 1-5: Cholecalciferol/ergocalciferol Vit D analog or calcitriol in CKD 4- to correct 25(OH)D 5ND with 2nd hyperparathyroidism deficiency/insufficiency. CKD 1-5 with nephrotic-range proteinuria: consider supplementation of cholecalciferol, ergocalciferol, or other safe and effective 25(OH)D precursors * Not supplement Vit K in patients receiving anticoagulant

Nutritional recommendation in ND-CKD SPENT 2018 ESPEN 2006 KDOQI 2020 Sodium HT/edema: <2 g/D 1.8-2.5 g/D CKD 3-5: < 2.3 g/D (<100 mmol/day) to Potassium No HT/edema: <4 g/D Depends on degree of renal reduce BP, proteinuria, BW, and improve Calcium insufficiency, dietary habits, volume control. Keep normal energy intake, rate of progression Phosphorous 1.5-2 g/D in hyper K or renal failure, etc. Keep normal in GFR < 1.5-2 g/D CKD 3-5: Keep normal range with dietary or 45 800-1000 mg/D in Individual requirements can differ supplemental potassium intake be based on hyper P considerably. a patient’s individual needs and clinician judgment. CKD 3-4: not taking active vitamin D analogs, a total elemental calcium intake of 800- 1,000 mg/d (including dietary calcium, calcium supplementation, and calcium- based phosphate binders) be prescribed to maintain a neutral calcium balance 600-1000 mg/D CKD 3-5: Keep normal range Depending on physical activity, CKD 1-5: when making decisions about LBM, age, gender, degree of phosphorus restriction treatment to with malnutrition, etc. consider the bioavailability of phosphorus sources (e.g. animal, vegetable, additives)

Nutritional recommendation in ND-CKD SPENT 2018 ESPEN 2006 KDOQI 2020 Acid load CKD 1-4: reducing net acid production (NEAP) Water through increased dietary intake of fruits and vegetables CKD 3-5: reducing net acid production (NEAP) through increased bicarbonate or a citric acid/sodium citrate solution supplementation to maintain serum HCO3 at 24-26 mmol/L Not limited * depends on degree of renal insufficiency, dietary habits, energy intake, rate of progression or renal failure, etc. Fiber CKD 1-4: increased fruit and vegetable intake may decrease BW, BP, and Trace NEAP element CKD 1-5: Not routinely supplement selenium or Zinc ( little evidence that it improves nutritional, inflammatory or micronutrient status )

Expert Perspectives on Total Nutrition Management in CKD Part II : Dialysis Patients 16th January 2022 Sirin Jiwakanon, MD, Hat Yai Hospital

Nephrologist Perspective • Assessment tools • Nutritional recommendation for dialysis patients

Proposed monitoring schedule for nutritional parameters dialysis patients Nutritional SPENT 2018 ESPEN KDOQI parameter (Adult) Interval 2020 (months) BMI* 3-6 1 1 Dietary interview 3-6 6-12 Routine Nutrition Screening at least biannually nPNA 3-6 1 1 Routine Nutrition Assessment Midweek predialysis at least within the first 90 days creatinine 1-3 of starting dialysis, annually, or 1-3 when indicated Serum albumin* 3-6 SGA, MIS Serum prealbumin 3-6 Assessment form* NAF, NT 2013, MIS, SGA European best practice guidelines for peritoneal dialysis. NDT 2005 ESPEN LLL programme 2013 https://www.nephrothai.org/wp-content/uploads/2020/08/Clinical_Practice_Recommendation_for_Nutritional_Management_in_Adult_Kidney_Patients_2.pdf KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE, AJKD, 76, ISSUE 3, SUPPLEMENT 1, S1-S107, SEPTEMBER 01, 2020

New in KDOQI 2020 Mifflin-St.Jeor Equation (MSJE) Maintenance Hemodialysis Equation (MHDE) KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE, AJKD, 76, ISSUE 3, SUPPLEMENT 1, S1-S107, SEPTEMBER 01, 2020 Byham-Gray L, Parrott JS, et al., J Ren Nutr, 2014 Jan;24(1):32-41



MIS vs NAF vs NT 2013



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https://www.spent.or.th/index.php/publication/category/gl/2020 https://www.nephrothai.org/wp-content/uploads/2020/08/Clinical_Practice_Recommendation_for_Nutritional_Management_in_Adult_Kidney_Patients_2.pdf 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 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 ESPEN 2006 KDOQI 2020 Nutrition HD PD HD PD HD PD Fat As healthy Therapeutic lifestyle Not routinely prescribing LC n-3 PUFA, (% of total energy) people changes including those derived from fish or :Saturated fat <7% flaxseed and other oils, to lower risk of :Polyunsaturated fat <10% mortality or CVD events. :Trans fat <1% Not routinely prescribing fish oil to improve primary patency rates in patients with AV grafts or fistulas. 1.3-4 g/d long-chain n-3 PUFA may be prescribed to improve the lipid profile.

Nutritional recommendation SPRNT 2018 ESPEN 2006 KDOQI 2020 Nutrition HD PD HD PD HD PD Vitamin No vitamin If indicated -Vit B6 10-20 mg/d -Vit B6 10 mg/d Prescribing folate, vit B12, RDA supplement if and/or B-co supplement to :Water not indicated :Vit B6 10 mg/d -Vit C 30-60 mg/d -Vit C 100 mg/d correct for soluble deficiency/insufficiency based May need fat- :Vit C 100 mg/d -folic acid 1 mg/d on clinical signs & symptoms. :Fat soluble vitamin Who are at risk of Vit C soluble such as No Vitamin A, E, :Vit D depend on deficiency, supplement to meet :Vit D depend RDA at least on Ca, P, and and K Ca, P, and iPTH 90 mg/d (M) and 75 mg/d (W) iPTH :Vit E 800 IU/D supplement Cholecalciferol/ergocalciferol in CVD to correct 25(OH)D deficiency/insufficiency. Not routinely supplement Vit A or E because of the potential for vitamin toxicity. Not supplement Vit K in patients receiving anticoagulant

Nutritional recommendation SPENT 2018 ESPEN 2006 KDOQI 2020 Nutrition HD PD HD PD HD PD Sodium (g/d) 1.8-2.5 <2 1.8-2.5 < 2.3 (<100 mmol/day) Potassium 2000-2500 Keep normal 2000-2500 Keep normal range with dietary or (mg/d) supplemental potassium intake be based on a patient’s individual Calcium Keep normal needs and clinician judgment. :1.5-2 g/D include all source (PD, Adjust calcium intake (dietary foods, drugs) calcium, calcium supplements/calcium- based binders) with consideration of Phosphorous 800-1000 Keep normal 800-1000 concurrent use of vit D analogs & (mg/d) calcimimetics in order to avoid :5-10 mg/kgIBW/D hypercalcemia (<800 mg/D) Keep normal range with consider the bioavailability of phosphorus Trace element In deficiency In deficiency sources (e.g. animal, vegetable, :Zinc 15 mg/D :Zinc 15 mg/D additives) :Se 50-70 mcg/D :Se 50-70 mcg/D Not routinely supplement selenium or Zinc ( little evidence that it improves nutritional, inflammatory or micronutrient status )

Nutritional recommendation SPENT 2018 K/DOQI 2000 ESPEN 2006 KDOQI 2020 Nutrition HD PD HD PD HD PD HD PD Acid load Serum HCO3 Maintain serum Water should be HCO3 at 24-26 Fiber maintained mmol/L at or > 22 mmol/L. 1000 ml + Urine volume 30-35 ml/kgIBW/D depend on urine output, UF, volume status 25-30 g/D 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.