The Role of Specific Enteral Nutrition for CKD Predialysis Patients

for Prevent Disease Progression

RIA BANDIARADept/KSM I. Penyakit DalamFK UNPAD/ RS Hasan Sadikin Bandung

Complications of CKDAssociated with Level of GFR

HypertensionAnemia

MalnutritionBone DiseaseNeurological ChangesFunctioning & Well-being

Ko G.J. Curr Opin Clin Nutr Metab Care. 2017

Low protein diet

0.6-0.8 g/kg/day

Glomerularhyperfiltration Proteinuria

Uremictoxins

• Inadequate calorie intake

(<30 Cal/kg/d)

• Protein loss and

hypercatabolism

• Inflammation

• Worsening acidemia

• Altered glucosa

homeostasis

Proteinenergywasting

Worse clinical outcomes ?Better uremia control

Delaying dialysis initiation

Oxidativestress

Metabolic

acidosisPhosphorus

PTH

Insulinresistance

Blood

pressure

Benefit Risks

Diagram of the role of low-protein diet in the management of chronic kidney disease.

Ko G.J. Curr Opin Clin Nutr Metab Care. 2017

Nutritional status derangement is essentially characterized by loss of muscle mass and visceral proteins (wasting/cachexia), and eventually by a loss of fat mass (the concept of protein-energy wasting or PEW, as compared to simple malnutrition)

Lodebo BT. Journal of Renal Nutrition 2018; 28(6) 369-379

MALNUTRION IS A FACTOR THAT SPEED UP

PROGRESSION CKD

1Clinical Practice Guidelines For Chronic Kidney Disease: Evaluation, Classification, and Stratification. National Kidney Foundation -

K/DOQI, 2006.2Nurko S. Cleveland Clinic Journal of Medicine 2006; 73 (3): 289-297

3Weiner DE et al, J Am Soc Nephrol 2005; 16: 1803-1810

Diagnosis of PEWwhen at least

one parameter isfound below

recommendationin three of thefour nutritionalvariable groups

Diagnosis PEW

in CKD

Methods of evaluation for diagnosis of PEW in CKD patients

Kovesdy. Am J Clin Nutr 2013;97:1163–77

Serum albumin concentration and survival in patients with non dialysis dependent CKD

Kalantar-Zadeh, K. et al. Nat. Rev. Nephrol. 7, 369–384 (2011)

Journal of Renal Nutrition, Vol 28, No 6 (November), 2018: pp 380-392

PEW PREVALENCE IN CKD STAGES 3-5 : 11% - 54%

Interventions to prevent and/or treat PEW in CKD patients

(1) Pre-dialysis patients

- Optimal dietary protein and calorie intake

- Optimal timing for initiation of dialysis, before onset of indices of malnutrition

(2) Dialysis patients

- Appropriate amount of dietary protein intake (> 1.2 g/kg/day) along with nutritional counseling to encourage increased intake

- Optimal dose of dialysis (Kt/V > 1.4 or URR > 65%)

- Use of biocompatible dialysis membranes

- Enteral or intradialytic parenteral nutritional supplements (hemodialysis) and amino acid dialysate(peritoneal dialysis) if oral intake is not sufficient

- Growth factors (experimental):

• Recombinant human growth hormone

• Recombinant human insulin-like growth factor-I

(3) Transplant patients:

- Appropriate amount of dietary protein intake

- Avoidance of excessive use of immunosuppressives

- Early reinitiation of dialytic therapy with proper steroid tapering in patients with chronic rejection

Kidney Int. 1996;50:343-357

Nutrition TypeNeeds

Predialysis Dialysis

Total calorie

requirement1<60 years old: 35 kcal/kgBW/day

≥60 years old: 30-35 kcal/kgBW/day

Protein1

0,60-0,80

gram/kgBW/day

HD: 1,2 gram/kgBW/day

PD: 1,2-1,3 gram/kgBW/day

Minimal 50% from high bioavailability protein

Carbohydratet2The rest of daily calorie requirement after reduced by

protein & fat

Lipid230% of total calorie

USFA : SFA = 1 : 1

1K/DOQI. Am J Kidney Dis 2000; 35 (6 suppl 2): S1-S1032Kopple JD, Massry SG. Nutritional Management of Renal Disease. Pennsylvania : Williams & Wilkins, 1997: 17

NUTRITION RECOMMENDATION

Nutritional support is indicated in maintenance CKD patients with :

severe malnutrition: BMI less than 20 kg/m2

body weight loss >10% over 6 months serum albumin <35 g/l serum transthyretin <300 mg/l

Moderate malnutrition will be managed with dietary counselling as a fist step.

1. Cano NJM et al. Clin Nutr 2009; 28:401-414

Indication for nutrition support

Interventions to treat undernutrition in people with kidney disease

Clinical Nutrition (2006) 25, 295–310

The goals of enteral nutrition in adult renal failure are :• prevention and treatment of undernutrition• correction of uremic metabolic disturbances• prevention of electrolyte disturbances• attenuation of CKD progression through restriction of protein and phosphate• preservation of intestinal mucosal integrity and function

Management of PEW in ND-CKDFrom Low Protein Diet to Good Protein Diet

A strategy is to provide a specially formulated commercial

supplements

acid/EAA ).

that have low uremic toxin production (e.g., keto

LPD (low protein diet)(stable CKD)

SVLPD ( supplemented VLPD)(stable CKD)

Protein supplements(malnourished CKD)

Kovesdy CP et al. Am J Clin Nutr 97:1163–1177, 2013

0.6 g protein/kg/d(≥50% high biological value)

Commercial supplement?

0.3 g protein/kg/d

0.3 gEAAs/kg/d

0.6 g protein/kg/d(≥50% high biological value)

Functional GIT

Enteral

Nutrition

(EN)

HDxIntradialytic PN

(IDPN)

Tube

feeding

(TF)

Oral (+edn & counseling):• Food fortification

• Oral nutrition

supplementations (ONS)

Total

Parenteral

Nutrition

(TPN)

No

Yes

PDx Intra- Peritoneal

Nutrition

+/-

Exercise

trainingPsychosocial support

1st

+/-

MO:• Control co-morbidities/

inflammation

• Medications / Appetite stimulantNursing

Multi-disciplinary

Approach

Nutrition Support in CKD

1. Adapted from Cano NJM et al. Clin Nutr 2009;28:401-4142. Bossola et al. Am J Kidney Dis 2005; 46: 371-386

Dietary intakes and nutritional status evaluationDietary intakes and nutritional status evaluation

Moderate undernutritionSpontaneous intakes

≤ 30 kcal/kg/day< 1 g protein/kg/ day

Severe undernutritionBMI < 20 kg/m2

Body weight loss > 10% within 6 monthsAlbumin < 35 g/l

Transthyrein (Prealbumin) < 300 mg/l

Spontaneousintakes

> 20 kcal/kg/day

Spontaneousintakes

> 20 kcal/kg/day

Spontaneous intakes< 20 kcal/kg/day

or stress conditions

Spontaneous intakes< 20 kcal/kg/day

or stress conditions

Lack ofcompliance

Lack ofcompliance

Enteral Nutritionif EN is not possible:Central venous PN

Enteral Nutritionif EN is not possible:Central venous PN

ParenteralParenteralDietary

counsellingDietary

counselling

No improvementNo improvement No improvementNo improvement

Oralsupplements

Oralsupplements

ALGORITHM OF NUTRITION SUPPORT FOR CKD PATIENTS

Clinical Nutrition (2006) 25, 295–310

2.6. Which feeding formulae should be used in CRF patients?

Standard formulae can be used for short-term EN in undernourished CRF patients but, for EN for more than 5 days, special or disease-specific formulae (protein-restricted formulae with reduced electrolyte content) should be used (C).

Ready-to-use formulae have been developed for EN in stable patients with compensated CRF. These products have a reduced protein content, are electrolyte-restricted and have a high energy density (1.5–2.0 kcal/ml)

• When dietary counseling is not sufficient to achieve planned nutritional requirements oral nutritional supplements (ONS) or supplementary enteral nutrition (EN) can be prescribed

• Oral supplementation should be given two to three times a day, preferably 1 h after main meals

• Oral supplementation can provide an additional 7–10 kcal/kg per day of energy and 0.3–0.4 g/kg per day of protein requiring a minimum spontaneous intake of 20 kcal/kg per day of energy and 0.4–0.8 g/kg per day of protein in order to meet the recommended targets of both DEI and DPI

• In patients with severe PEW, spontaneous intakes less than 20 Kcal/kg/day, stress conditions and/or with major swallowing difficulties, the use of EN as nocturnal supplementation or complete daily nutritional support should be preferred

Oral and enteral nutritional supplementation

Ikizler T.A. Kidney International (2013) 84, 1096–1107Fiaccadori E. J Nephrol 2017. DOI 10.1007/s40620-017-0435-5

Diet counseling

(+ prescription &

meal plan)

(1)

Food

(2)

Food enriching/

fortifications

(3)

Oral Nutrition

Supplements

Characteristic/

strategy

• Use energy & nutrient

dense foods & drinks

• adding protein, fat &

CHO to foods and

drinks, e.g. egg,

cheese, milk, milk

powder sugars, fats

• commercial modules

e.g. protein powder,

tasteless sugars

• Ready –made

formula & desserts

• protein & energy

bar

Advantage • economical

• familiar items:

• taste

• texture

• cultural specific

• economical

• familiar items:

• taste

• texture

• cultural specific

• easy to use

• convenient

• easy handling (in

institutions) staff

and hygiene

Limitation “larger”  volume “larger”  volume • cost

• acceptance

• taste• possible intolerance

± ±

Oral Nutrition Support

Energi 300 Kkal/saji

Lemak 10 g [30%]

Protein 5 g [7 %]

Karbohidrat 49 g [63%]

MAKANAN DIET KHUSUS GANGGUAN FUNGSI GINJAL PRE-DIALISIS

MineralAKG PGK

Mg/hari

Nephrisol

Per saji %

Natrium 750-1500 108mg 7

Kalium 2000 219 mg 11

Kalsium 1400-1600 144 mg 9

Fosfor 300-600 136 mg 23

Mg 200-300 25 mg 8

NEPHRISOL [Product Information].PT.kalbe Farma Tbk 2018

201 g

3 sachet

67g

• Tinggi Kalori

• Rendah Protein

• Pemanis sucralose

• Kandungan mineral disesuaikan

bagi pasien ginjal predialisis

SUSU KHUSUS PASIEN PGK

1. Kandungan protein rendah :

sesuai rekomendasi pasien

ginjal predialisis

2. Kandungan fosfat, kalium

dan natrium disesuaikan

untuk pasien ginjal.

3. Energi lebih tinggi.

4. Sediaan sachet, mudah

penyajian

SUSU BIASA• Kandungan

protein tinggi.

• Kandungan fosfat,

kalium dan

natrium lebih

besar.

• Energi lebih

rendah.

• Penyajian dengan

sendok takar

Improvement

Monthly Assessment

• Monitor nutritional status for changes in appetite, food intake, weight status, serum albumin level and MIS/SGA

Start Oral Nutritional Supplementation 1–2

servings/day:

• CKD 3–4: DPI target of > 0.8 g/kg/day (±

AA/KA or ONS

• CKD 5D: DPI target > 1.2 g/kg/day (ONS at

home or during dialysis treatment; in-center

meals)

No Improvement or Deterioration

Indications for an Nutritional Interventions:

• Poor appetite and/or poor oral intake

•DPI<1.2 (CKD 5D) or <0.7 (CKD 3–4); DEI < 30 kcal/kg/day

• Unintentional weight loss – > 5% of IBWSerum albumin level <4.0 g/dL

• MIS ≥5 or SGA in malnourished range

Adjunct Pharmacologic Therapies

• Appetite stimulators

• Anti-depressant

• Anti-inflammatory &/or anti-oxidative

• Anabolic &/or muscle enhancing

Intensified Therapy or Additional Interventions

• Increase quantity of therapy

• Tube feeding

• Parenteral interventions eg IDPN (esp. if albumin<3.0 g/dL)

Maintenance Therapy

• If improving: continue oral supplements

Periodic Nutritional Assessment & Dietary Counseling

• Dry weight, lab values (serum albumin) & scores (SGA)

•Dietary counseling and high protein meals during hemodialysis

Kalantar-Zadeh et al Nature Review , 2011

Recommendation Why?

Fiber Intake of 20–30 g/day. Encourage the use of

whole grain foods, legumes, fruits and

vegetables

Management of dyslipidemia.

Control of uremia and metabolic

acidosis. Improve GI function.

Glycemic control for diabetic

patients

Protein LPD (0.6 g/kg/day) for moderate to advanced

stages of CKD.Do not give >1 g/kg/day in

early stages of CKD.

Use of protein-free foods to improve energy

intake and avoid PEW

Manage uremic symptoms and

delay the initiation of dialysis.

Avoid hyperfiltration

Carbohydrate Limit use of fructose-containing foods and drinks Limited evidence shows an

increase in uric acid production

and renal damage

Enteral Formula Use specialized formula for patients with

CKD Target to achieve a total intake >25

Kcal/kg/day and 0.6 g/kg/day of proteins.

Prefer total/nocturnal enteral nutrition when

spontaneous intake <20 Kcal/kg/day and in

the presence of swallowing difficulties

Prevention of PEW when

nutritional counseling is not

successful treatment of PEW

Lipid Fat intake based on the Mediterranean diet.

Avoid saturated fatty acids, preference for food

containing PUFA. Encourage the use of omega 3

PUFA rich foods. Encourage the use of olive oil,

rich in monounsaturated fatty acids

To improve cardiovascular health

Manage dyslipidemia

Journal of nephrology.2017; 30(suppl 2):

SUMMARY

• Protein-energy wasting (PEW) is common in patients with CKD and is manifested by low serum levels of albumin or prealbumin,sarcopenia, and weight loss

• PEW is one of the strongest predictors of mortality in patients with CKD

• Although PEW might be the result of non-nutritional conditions, dietary interventions such as oral nutrition supplements (ONS) might improve nutritional status and outcomes

• Oral supplements are inexpensive interventions that might improve survival and quality of life in patients with CKD

Thank You

• Before dialysis, there is good evidence that a longstanding nutritional care plan, with control of protein intake, is efficient for correcting many metabolic disorders, including proteinuria, and it is cost-effective. PEW is a distinct condition in CKD patients. PEW is common in CKD and is associated with adverse outcomes. Dietary interventions and nutritional support seem to be effective in mitigating or correcting PEW and improving the outcomes in patients with CKD. All patients with CKD should be assessed periodically (monthly or quarterly) for the presence of PEW and should be offered oral nutritional support whenever required. Providing meals or oral nutritional supplements and other nutritional interventions to patients with CKD is the most promising way to increase serum albumin concentration and improve longevity and quality of life in this patient population