Ondervoeding. Ondervoeding Protein Energy Wasting Vraag 3. Vraag 1. PEW: multifactorial and multiple consequences.

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1 Vraag 3 Ondervoeding Protein Energy Wasting Prof dr. P.M. ter Wee Department of Nephrology and IcAR-VU VU university medical center Amsterdam Voor de behandeling van PEW geldt dat patienten 1. baat hebben bij dagelijkse lichamelijke inspanning 2. dagelijks een eiwitrijk, calorierijk renaal specifiek oraal voedingssupplement moeten gebruiken 3. eiwit en calorieen tijdens dialsye moeten gebruiken 4. allemaal 4: is goed Vraag 1 a) Overgewicht en adipositas zijn bij dialysepatiënten geassocieerd met betere overleving b) Toegenomen waist circumference is bij dialysepatiënten geassocieerd met toegenomen mortaliteit Ondervoeding Protein Energy Wasting 1: a goed, b fout 2: a goed, b goed Fouque et al. Kidney Int 28; 73:391-8 Vraag 2 PEW: multifactorial and multiple consequences Voor de associatie van PEW is aangetoond dat a) voor mortaliteit geldt dat albumine dit beter voorspelt dan de MIS b) voor mortaliteit geldt dat de MIS dit beter voorspelt dan albumine c) voor kwaliteit van leven geldt dat albumine dit beter voorspelt dan de MIS d) voor kwaliteit van leven geldt dat de MIS dit beter voorspelt dan albumine d: is goed Fouque et al. Kidney Int 28; 73:

2 Geen gouden standard om PEW vast te stellen veel testen en laboratorium waarden CONvective TRAnsport STudy (CONTRAST) Prevalente, volwassen ESRD patienten 489 patiënten geëvaluaeerd Mortaliteit Kwaliteit van leven PEW: 3 abnormal findings Fouque et al. Kidney Int 28; 73:391-8 GFR CKD Progression Protein-Energy Wasting (PEW) Stage 1 Kidney Damage With Normal or Kidney Function 13 U.S. Prevalence Protein-Energy Wasting (PEW) Stage 2 Kidney Damage With Mild Kidney Function Stage 3 Moderate Kidney Function Stage 4 Severe Kidney Function 3% 4% 7%.5% ESRD Stage 5 Kidney Failure % 48% Up to 75% Conclusies Mortaliteit wordt vergelijkbaar goed voorspeld met MIS Serum albumine Kwaliteit van leven heeft beste relatie Alleen met MIS (geldt ook voor maar hier niet getoond voor cardiovasculaire complicaties en infecties) MIS lijkt de meest belovende meetmethode om PEW vast te stellen USRDS 29 Annual Data Report Stratton JD, et al. J Ren Nutr 23 Fouque D, Kalantar-Zadeh K, Kopple J, et al. Kidney Int 28 Kovesdy C, et al. Am J Clin Nutr 29 de Roij van Zuijdewijn et al, J Ren Nutr, 25: , 215 de Roij van Zuijdewijn, ter Wee, J Ren Nutr, 216 [in press] Increasing prevalence of PEW with advancing CKD MIS Verandering gewicht post-dialyse Intake Gastro-intestinale symptomen Functionele capaciteit Co-morbiditeit/dialyse vintage Verminderd vet Spierverlies BMI Albumine TYBC Alle waarden tellen -3 Totaal score dus -3 Hoger is slechter Hulp van dietist Hyun et al. J Korean Med Sci 217;32: Kalantar-Zadehet al, Am J Kidney Dis, 38: , 21 2

3 Higher MIS values are associated with increased mortality Each 2-unit rise in MIS 2-fold greater death risk Rambod et al. Am J Kidney Dis 29;53: MIS in 3 CKD stages 3-5 (18-37 months follow-up) Amparo et al. Nephrol Dial Transplant;215,3: Update on PEW Normal: Journal of Renal Nutrition 213,23:77-9 Kidney International 213,84:

4 CKD and ESRD: Mak et al. J Cachexia Sarcopenia Muscle 211;2:9-25 Dietary Protein Intake During Progression of Renal Disease 1,4 1,2 1,8,6,4,2 > < 1 Creatinine Clearance ml/min Dietary protein intake g/kg/d 23 Ikizler JASN 1995 Course of APPETITE feeling during CKD progression GFR less than 1-25% of normal Retention of appetite depressants? Increased dialysis dose improves feeding behavior 4 2 GFR <9 ml/min GFR <6 ml/min GFR <3 ml/min GFR <15 ml/min RRT Transplantation Carrero JJ: J Renal Nutr 19: 1-15, Courtesy of Juan Jesus Carrero 4

5 Hemodialysis additional causes for PEW: Significant Amount of Amino Acids are Lost Into Dialysate during Dialysis 12 1 total g/dialysis CU PMMA PS PD/Day Mak et al. J Cachexia Sarcopenia Muscle 211;2:9-25 Ikizler & Hakim 1994 Kidney Int Plasma Amino Acid profile during one Dialysis Tx total d'aa umol/l Tx total d'aa T T1 T2 T3 T4 temps (heure) N= 1 The dialysis session blocks muscle protein synthesis in response to a rapid and profound decrease in plasma AA Deléaval et al, 27 Hemodialysis additional causes for PEW: HD Causes Net Whole-body Protein Loss (mg/kgffm/min) 4,5 3,5 2,5 1,5,5 -,5-1,5 proteolysis synthesis net balance * * 21% 96% * * B D PD Ikizler et al, AJP, 22 5

6 Plasma Amino Acid profile during one Dialysis Change in Serum Albumin and Survival in HD Patients Tx total d'aa umol/l 2 15 Tx total d'aa 1 5 T T1 T2 T3 T4 temps (heure) N= 1 Muscle protein catabolism occurs in order to maintain plasma amino acids Deléaval et al, 27 Kalantar-Zadeh et al, NDT 2:188-88, 25 Conclusions Clinical nutrition scores define patients at risk Possibly MIS preferable test for PEW For clinical practice it can be suggested to: measure and follow-up with albumin and BMI use MIS dietitian should be part of team ISRNM PEW Prevention / Management Algorithm KDOQI Dietary Recommendations for Dialysis Patients Serum albumin concentration Dietary energy intake (DEI) Dietary protein intake (DPI) Recommendation 4. g/dl 3-35 kcal/kg per day 1.2 g/kg per day in HD patients 1.3 g/kg in PD patients Kidney International 213,84: Spontaneous Intake?? DEI (kcal/kg/d) DPI (g/kg/d) Non-dialysis days Dialysis days 23.2 ± ± ±.43.9 ±.41 Required nutritional supplementation: 7-1 kcal/kg per day and.3-.4 g/kg per day 6

7 Protein and energy intake are insuffcient in HD-treated patients (n=2) Snack during HD Need Intake on dialysis day Intake on non-dialysis day J. Struijkand PM ter Wee; M J Nutr 216;1(1):6 15 gram protein and 24 kcal Meals or Renal-Specific ONS During HD Treatments Snack during HD restores protein (and energy) deficit in HD-treated patients (n=23) ADVANTAGES Counteract HD-related catabolism Improve nutritional status Increase protein synthesis Increase albumin Improve compliance Better PO 4 and fluid removal DISADVANTAGES Risk of aspiration Hypotension Patient and unit hygiene Infection control Inconvenience to staff Kalantar-Zadeh et al, Nat Rev Nephrol 7:369-84, 211 Total Malnourished Well-nourished Need Intake before Intake after 6 weeks J. Struijkand PM ter Wee; M J Nutr 216;1(1):6 Treatment options for PEW Intradialytic ONS improves outcome in HD patients with salb < 3.5 g/dl a) Nutritional support (oral, IDPN) N=4289 N=4289 Lacson et al. Am J Kidney Dis 212;6:

8 Intradialytic Nutrition Support reduces HD-induced catabolism Pupim et al, J Am Soc Nephrol 17: , 26 Treatment options for PEW a) Nutritional support (oral, IDPN) b) Metabolic acidosis correction c) Exercise d) Changes in dialysis regimen e) Growth hormone f) Anabolic steroids - testosterone g) Apetite stimulants (megestrol acetate, dronabinol, cyproheptadine, thalidomide) h) Ghrelin (agonists): improved energy intake in MHD (inhibit sympathic nerve overreactivity and inflammatory response, improve LVH and exercise capacity) i) Leptin and central melanocortin modulation (MC4-R antagonists) Take home messages 2 HD patients have dietary deficiency (calories and protein) especially on HD-treatment days Oral supplementation during HD does result in calorie and protein balance, improvement of PEW and better outcome (especially in patients with salb 3.5 g/dl) 8