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Preliminary Canadian Clinical Guidelines:
IDPN pivotal time for Hemodialysis patient
2017 Spring SOCAND Education Day Presenter
Margaret Avery RD MSc Peterborough Regional Dialysis Program
Friday April 7th
1. Illustrate a pivotal change in genetics
Protein machines
2. Review desired nutrition target for AHD pts.
3. Examine the cost of care for AHD pts
4. Describe the national IDPN recommendations
Bruce Alberts
DNA Polymerase and Leading and Lagging Strand Synthesis
Bruce Alberts
These protein machines function very much like the machine in everyday life that are driven by electricity.
Animal cell biology
“Almost
every process in the cell is now recognized to be driven by a complex of 10 or more proteins.”
“They undergo ordered movements driven by proteins in the set that harness the energy ATP or GTP hydrolysis . “
Look at the future
1)The recognition that feedback loops underline
nearly all cell chemistry, creating complex networks of interactions
2)The recognition that extensive sets of scaffold
proteins produce biochemical sub-compartments
in the cell, without requiring a membrane.
Parathyroid hormone (PTH)-calcium feedback loop that controls calcium homeostasis.
Research Gate
These organelles are dynamic structures whose membrane barriers are continually shaped, remodelled and scaffolded by a rich variety of highly sophisticated protein complexes.
19
Network of supporting fibers. Membranes are structurally supported by intracellular proteins that reinforce the membrane’s shape. For example, a red
blood cell has a characteristic biconcave shape because a scaffold of proteins called spectrin links proteins in the plasma membrane with actin
filaments in the cell’s cytoskeleton.
Peptide bond
Only a single amino acid substitution can give rise to a malfunctioning protein
as in the case of sickle cell anemia
Maybe a piece missing
B12
Folate
Iron
B12
Folate
Iron
Scaffold protein complexes, are constantly moving.
Community Medicine & Health Education Mohammed et al., J Community Med Health Educ 2014, 4:3 http://dx.doi.org/10.4172/2161-0711.1000291 Research Article Open Access Volume 4 • Issue 3 • 1000291 J Community Med Health Educ ISSN: 2161-0711 JCMHE, an open access journal Prediction of Malnutrition Using Modified Subjective Global AssessmentDialysis Malnutrition Score in Patients on Chronic Hemodialysis Fatin Allawi Mohammed1 , Hadeel Fadhil Farhood2 * and Moshtak Abdul-AtheemWtwt3 1 Babylon University, Iraq 2 Department of Community Medicine, College of Medicine, Babylon University, Iraq
.
ESRD 2◦ to DM nephropathy, PVD recurrent issues with foot ulcers, R iliac stenting, PVD resulting gangrene of the left leg, L AKA, smoker, dyslipidemia Hypothyroidism 8 units of insulin 30 mins into IDPN
Date nPNA Edema Appetite weight
February 23, 2016
0.7 2+ pitting ↓↓↓ Diagnoses Severe foot infection 38.5kg
April 5, 2016 May 2, 2016
0.8 Antibiotics IDPN initiated (3weeks prior to AKA)
2+ pitting ↓↓ ↑↑
38.5 Kg 39.6kg
May 19, 2016 1.3 19 days Continues IDPN
1+ pitting ↑↑↑ 34.2 kg (AKA)
Patients who received early and sufficient
nutrition had significantly shorter LOS
(11.9 days) and lower hospital costs ($34,602)
1st Pt on IDPN
Published IDPN
Article IDPN Best Based
Practice
1st Pt on IDPN
8.3 years
IDPN Order Set PICO
Question, Optimal
IDPN
2001 2004 2006 2009 2013 2015
No hospital admissions
Conventional
Aranesp
one-alpha
ferrlecit
venofer
cipro
dalteparin
enoxaparin
heparin
Conventional $320
Aranesp 112.5
one-alpha 19.1
ferrlecit 27.5
venofer 39.38
cipro 30
dalteparin 2.52
enoxaparin 5.75
heparin 2.3
Costs are estimated
Conventional 320
Aranesp 112.5
one-alpha 19.1
ferrlecit 27.5
venofer 39.38
cipro 30
dalteparin 2.52
enoxaparin 5.75
heparin 2.3
sodium thiosulfate 285
Conventional
Aranesp
one-alpha
ferrlecit
venofer
cipro
dalteparin
enoxaparin
heparin
sodium thiosulfate
Conventional
Aranesp
one-alpha
ferrlecit
venofer
cipro
dalteparin
enoxaparin
heparin
Novasource renal
Conventional 320
Aranesp 112.5
one-alpha 19.1
ferrlecit 27.5
venofer 39.38
cipro 30
dalteparin 2.52
enoxaparin 5.75
heparin 2.3
Novasource renal 1.48
Conventional
Aranesp
one-alpha
ferrlecit
venofer
cipro
dalteparin
enoxaparin
heparin
IDPN 3CB
Conventional 320
Aranesp 112.5
one-alpha 19.1
ferrlecit 27.5
venofer 39.38
cipro 30
dalteparin 2.52
enoxaparin 5.75
heparin 2.3
IDPN 3CB 65
Clinical Recommendation Evidence
rating
References
Establishing the Diagnosis of Malnutrition
among Adult Hemodialysis patients and the
need for action.
What is the desired Nutritional Target in
Chronic Kidney Disease Patients receiving
dialysis?
• There is no single measurement that can predict the risk of malnutrition.
SGA is a clinical technique which can assess nutritional status. SGA is a reliable and valid method of assessing nutritional status of hospitalized surgical patients.
A A and B
1 1 ,8
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.
1. The authors recommend well-nourished AHD
patients with a SGA score of A.
A SGA score of B or C it will indicate
malnutrition.
What is Malnutrition? Malnutrition includes both the deficiency and excess (or imbalance) of energy, protein and other nutrients.
Clinical Recommendation Evidence
rating
References
Establishing the Diagnosis of Malnutrition
among Adult Hemodialysis patients.
What are the clinical and biochemical features
in the diagnoses of malnutrition Chronic
Kidney Disease Patients receiving dialysis?
Protein energy wasting (PEW) is highly prevalent in patients
undergoing maintenance hemodialysis (MHD) patients.
B B
1, 18 1,18
2. The authors identify clinical features such as
co-morbidities and acute conditions in the
diagnosis of malnutrition. The biochemical
methods: nPNA, and decline in serum urea,
phosphate, cholesterol and transferrin can
contribute to malnutrition diagnosis.
Clinical Recommendation Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What is the desired patient selection criteria
for IDPN?
Most references suggest that IDPN is most appropriate in HD
patients with moderate to severe malnutrition who cannot be
supplemented via enteric routes.
Selection criteria not withstanding, guidelines can never
replace clinical expertise when making treatment decisions for
individual patients
B and C
1,8,13
3. The authors recommend at least three of the
following criteria :intake <50% of caloric
requirement, weight loss >10% within 6 months,
BMI <18.5, nPNA <0.8, SGA score B or C, GI
documented disorder, and/or nutrition
supplements have failed to meet patient’s
nutrition requirements.
Clinical Recommendation Evidenc
e rating
References
When establishing nutrition support IDPN
should contain enough protein to ameliorated
the AHD patient’s protein losses and
synthesis.
What is the common pathway for all
derangements in the etiology of PEW among
Chronic Kidney Disease Patients receiving
dialysis?
Oral intake including supplements are suggested in the latter part of
dialysis when urea is the lowest. It has been suggested that at 150
minutes, where the lowest amount of urea is present is the best time for
protein synthesis to occur.
A
B and C
7,8
7,8
4. The authors identify the common pathway for
all derangements in the etiology of PEW is
exaggerated protein degradation along with
decreased protein synthesis. The HD procedure
per se is an important contributor to this
process. Therefore AHD patients receiving
IDPN may also have an oral supplement.
Rate of IDPN
maybe higher here
When is a good time to feed on HD to promote protein synthesis?
The fundamental issue underlying the malnutrition that is seen in the ESRD population is that these patients are catabolic. Rates of protein breakdown outstrip production of new body protein.
Clinical Recommendation Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What is the initial rate of IDPN?
What is the desired lipid composition?
IDPN can afford the opportunity to use fish oil as part of the lipid composition. Current research by Gurzell , Fenton et al found fish oil may have immune enhancing properties that could benefit immunocompromised individuals. In the dialysis population endogenous L-Carnitine (LC) has been shown to be deficient, although the benefit of carnitine supplementation remains unproven. HD patients may benefit from a lipid composition that contains medium chain triacylglycerols from coconut and or olive oil (long chain fatty acid beneficial for the acute septic patient) These medium chain fatty acids enter the mitochondria by a carnitine-independent mechanism.
B B and C
9 10
5. The authors recommend to start at half the
required volume of IDPN and titrate to goal
rate. IDPN should contain a combination lipid
profile.
Clinical Recommendation
Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What is the required type of insulin and the
frequency of monitoring?
Insulin usage is required when greater than 50g carbohydrates/bag of IDPN is to be administered for a diabetic AHD patient. The Academy of Nutrition and Dietetics reviewed that dextrose in IDPN treatment during a condensed time frame can cause hyperglycemia in patients with diabetes and insulin resistance. Their guidelines advise that clinicians should measure arterial or peripheral glucose • before starting IDPN, • halfway through the infusion and, • 30-60 minutes after discontinuation of IDPN infusion • Avery’s research has demonstrated that 2 hours postprandial
is recommended for safety of the diabetic patient. Hospitalized patients are to follow the same protocol as above . No insulin is to be given until the 2 hour post dialysis.
B B and C
16 16
6. The authors recommend short acting
insulin only for AHD patient with Diabetes
Mellitus receiving IDPN.
Clinical Recommendation Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What is the acceptable management of
hyperglycemia during IDPN and postprandial
blood sugar for the diabetic patient.
The goal is not to avoid hyperglycemia but to monitor to ensure an acceptable level that ensures the 2 hour post infusion will be <10mmol/L, and to avoid hypoglycemia post treatment. • The key point is blood glucose can drop by as much as 10 mmol/L
two hours post IDPN treatment. It is important to note that post treatment hypoglycemia is possible even in non diabetics in the absence of insulin administration.
Non-diabetics: If the patient can eat, 30g of CHO post treatment it will reduce the risk of hypoglycemia due to sudden withdrawal of parenteral nutrition.
B B and C
16 16
7. The authors recommend <10mmol/L 2 hours
post infusion.
Clinical Recommendation
Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What is the recommended PN formula for
IDPN?
Veronesi et al stated that IDPN within one month increased plasma levels of all observed AA
compared to baseline concentration prior to administration of IDPN. A case series report by Avery
showed that that the use of IDPN for longer periods of time (3 months to 6 years) can improve and
sustain nutritional markers in HD patients. This supports the hypothesis the use of IDPN can
increase protein synthesis for longer periods and may improve survival.
Three chamber bag system of amino acid solution with electrolytes, glucose solution and lipid
emulsion for intravenous infusion.
3 Chamber Bag Impact on Quality and Safety One lead from the three chamber bag ↓ chances of possible rate errors
No access to the chamber bag ↓ chances of contamination
Storage is at room temperature, no additional refrigeration
The formula is designed to accommodate the needs of malnourished patients (↑PHOS).
The nursing time is ↓ with one administration line.
Pharmacy monitoring time is ↓ significantly, due to the choice of electrolyte and non-electrolyte 3CB
systems.
B B and C
13 14,15
8. The authors recognize the variations in PN
formulation; it is a complex mixture
containing up to 40 different chemical
components. Therefore 50g protein and ≥3g
Leucine are the minimum amounts
recommended in a ≈ 1 liter bag.
http://www.physoc.org/proceedings/abstract/Proc%2037th%20IUPSSA425
2-3g of Leucine maximally stimulates protein synthesis
Clinical Recommendation Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
What are the routine laboratory requirements for a patient receiving IDPN?
B and C
1, 18
9. The authors recommend:
Clinical Recommendation
Evidence
rating
References
Establishing the management of IDPN for
Adult Hemodialysis patients.
10.a What is the nutrition care plan for a patient
on IDPN?
10.b What is the long term nutrition care plan for
a patient on IDPN?
Factors that should be included in this plan are
• Define the individual's nutritional goals. • Create a patient-specific nutrient prescription. • Establish schedule for infusion of IDPN • Establish and document a plan for monitoring nutrition therapy Monitoring
Because a variety of complications may develop in long-term nutritional support,
diligent patient monitoring is necessary.
C
1,8,16
10.a The authors recommend once it is decided that a patient
is a candidate for IDPN, the specifics of care should be
established through a nutrition plan of care.
10.b The authors recommend that the following be monitored
for long term IDPN patients:
• Metabolic bone disease
• Vitamin K deficiency
• Folic acid and Vitamin B-12 deficiency
• Liver and gallbladder disease
All images are for education purposes only.
References 1. Kresge et al. DNA Polymerase and Leading and Lagging Strand Synthesis: the Work of
Bruce Alberts. http://www.jbc.org/content/282/4/e3. April 2017
2. Alberts B et al. Chapter 4: Intracellular Compartments & Transport- Via Vesicles. August 11, 2011 Delve inside a cell,2011
3. DNA Replication 1. www.youtube.com/watch?v=gL3aigv7w4A Apr 21, 2009 4. Research Gate. Parathyroid hormone (PTH)-calcium feedback loop 5. synaptic SNARE proteins
.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225952/figure/A005637F2/ 6. Protein machines scaffolding. http://pubs.rsc.org/en/content/articlehtml/2015/CP/C5CP00480B 7. Vasantha J et al Prediction of Malnutrition Using Modified Subjective Global Assessment-dialysis Malnutrition Score in Patients on Hemodialysis. Indian J Pharm Sci. 2011 Jan-Feb; 73(1): 38–45.
8. Ikizler, Cano et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by thInternational Society of e Renal Nutrition and Metabolism. Kidney International. 2013, 84,1096-1107 http://renal-nutrition.com/details/Prevention.html 9. E. A. Gurzell, H. Teague, M. Harris, J. Clinthorne, S. R. Shaikh, J. I. Fenton. DHA-enriched fish oil targets B cell lipid microdomains and enhances ex vivo and in vivo B cell function. Journal of Leukocyte Biology, 2012; 93 (4): 463. http://www.jleukbio.org/content/93/4/463 10. KDOQI Guidelines: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease: L-Carnitine, 3.3.3. http://www2.kidney.org/professionals/KDOQI/guidelines_anemia/cpr33.htm 11. Druml et al. Parenteral nutrition in patients with renal failure- guidelines on Parenteral Nutrition, Chapter 17. Ger Med Sci. 2009; 7:Doc11. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2795369/ 12. Cano et al. Intradialytic parenteral nutrition does not improve survival in malnourished in hemodialysis patients: a two year multicenter, perspective, randomized study. JASN. September 2007 vol. 18no. 9 2583-2591. http://jasn.asnjournals.org/content/18/9/2583.full 13. Borrelli et al . Amino acid loss during dialysis treatment. G Ital Nefrol. 2011 (28):26-31. http://www.ncbi.nlm.nih.gov/pubmed/21341242 abstract only 14. Veronesi et al. The effect of intradialytic parenteral nutrition (IDPN) on the amino acid pool, a kinetic study. G Ital Nefrol. 2013 (30):2. http://www.ncbi.nlm.nih.gov/pubmed/23832462 abstract only 15. Avery-Lynch M. Intradialytic Parenteral Nutrition in Hemodialysis Patients: Acute and Chronic Intervention. CANNT Journal. 2006;2:30-33. http://www.ncbi.nlm.nih.gov/pubmed/16875291 16. Dieticians In Nutrition Support /Academy of Nutrition and Support http://www.coramhc.com/documents/medicalPubs/articles/Support_Line_2015_IDPN.pdbabbf 17. Sabatino et al. Intradialytic parenteral nutrition in end-stage renal disease: practical aspects, indications and limits. J Nephrol. 2014;27:377-383. file:///C:/Users/Mavery/Downloads/JN2014%20IDPN.pdf 18. Escott-Srump S., Nutrition and Diagnosis-related Care. 832-837, 2008 19. http://pubs.rsc.org/en/content/articlehtml/2015/CP/C5CP00480B
