ESPEN Congress Nice 2010 · ESPEN Congress Nice 2010 Nutrition in chronic kidney disease....

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Nutritional support in patients on chronic dialysis Noël CANO ESPEN Congress Nice 2010 Nutrition in chronic kidney disease

Transcript of ESPEN Congress Nice 2010 · ESPEN Congress Nice 2010 Nutrition in chronic kidney disease....

Nutritional support in patients on chronic dialysis

Noël CANO

ESPEN Congress Nice 2010

Nutrition in chronic kidney disease

Nutritional support in patients on chronic dialysis

Prof. Noël CANOHuman Nutrition Research Center

Clermont-Ferrand, France

Protein-energy wastingA proposed nomenclature and diagnostic criteria

for protein-energy wasting in kidney disease

• low serum levels of albumin, transthyretin, or cholesterol

• reduced body mass (low or reduced body or fat mass or weight loss) with reduced intake of protein and energy,

• reduced muscle mass (muscle wasting or sarcopenia, reduced mid-arm muscle circumference).

Fouque D et al. Kidney int 2008

Aparicio M et al. Nephro Dial Transplant 1999

BMI < 20 kg/m2 24 % Muscle mass < 90 % th. 62 % Serum Albumin < 35 g/l 20 % Serum transthyretin < 300 mg/l 36 % nPNA < 1 g/kg/j 35 %

• French multicenter study, n=7,123

Protein-energy wasting

Molsted S et al. Scand J Urol Nephrol 2007

Muscle structure in organ failure: Fiber type shift from type I (oxidative) to type II

(glycolytic)

70 028 patients Survival according to urinary creatinine before dialysis initiation and BMI

Beddhu S et al. J Am Soc Nephrol 2003

Body composition and survival

g/j

Protein-energy wasting & survival

K/DOQUI, NKF (1) EBPG, EDTA (2)

Routine follow-up

• Serum albumin: monthly (≥ 40 g/l)• % of usual postdialysis BW• % of standard (NHANES II) BW, every 4 months• SGA every 6 months• Dietary interviewand/or diary nPNA, every 6 months

• Dietary interviews: every 6–12 mo. or every 3 mo in patients > 50 y. or hemodialysis > 5 y. • Average postdialysis BW/mo. and % change • BMI > 23.0• nPNA > 1.0 g/kg ideal BW/day• Serum albumin: 1 mo. after beginning of hemodialysis and three monthly thereafter: > 40 g/l• Serum transthyretin: > 300 mg/l• Serum cholesterol: > minimal laboratory threshold value

1-Am J Kidney Dis 2000;35(6 Suppl 2):S1-140.2- Fouque D et al. Nephrol Dial Transplant 2007;22 Suppl 2:ii45-87.

Recommandation for nutritional follow-up

Recommended intakes: Macronutients

ESPEN (1) NKF (2) EBPG (3)

Protein 1.2 - 1.4 1.2 >1.1g/kg/day

Energy 35 < 60 y: 35 30-40kcal/kg/day > 60 y: 30

1 - Toigo G et al. Clin Nutr, 20002 - National Kidney foundation. Am J Kidney Dis, 20003 - Fouque D et al. EBPG. Nephrol Dial Transplant 2007

Toigo G et al. Clin Nutr, 2000Fouque D et al. EBPG. Nephrol Dial Transplant 2007

ESPEN 2000 Pyridoxin, mg 10-15Vitamin C, mg 30-60Folic Acid, mg 1 Vitamin D according to plasma Ca++ & PTH

Zinc, mg 15 Selenium,µg 50-70

EBPG 2007 Thiamine, Riboflavin, cobalamine, Niacin, Biotine, pentothenic A & tocopherolshould be supplemented (expert opinion)

Recommended intakes: Micronutients

Nutritional objectives: 1.2 g protein & 30-35 kcal/kg/d

Mean nutritional intakes in malnourished HD patients: 20-25 kcal/kg/d

0.8-1 g protein/kg/d

Required nutritional supplementation: 5-10 kcal et 0.2-0.4 g de protein/kg/d

Nutritional objectives in hemodialysis

Nutritional support

Dietary counsellingOral supplements

Intradialytic parenteral nutritionEnteral nutrition

Grade of malnutritionSpontaneous alimentation

Patient compliance

Oral supplements: six RCTs in malnourished hemodialysis patients

Study design Energy supply

Protein supply, g

Suppl.length

Improved Nutritional

Parameters

Acchiardo 1982

AA+ E., n = 7E., n = 8

660 kcal/dEAA + His

6.6 105

Albumin, tranferrin, bone density

Allman 1990

Suppl, n = 9Cont., n=12

400-600 kcal/d

- 180 BW, LBM

Tietze1991

Cross-overn = 19

-Fish protein,

8120 BW, AMC

Eustace2000

Suppl, n = 23Cont., n=24

-EAA+His+Tyr,

10.890

Albumin, muscle strength

Hiroshige 2001

Cross-overn=14

-BCAA,

12180 Albumin

Sharma 2002

Suppl, n = 23Cont., n=24

500 kcal/HD 15 g /HD30

AlbuminFunctional score

Oral supplements: effects of BCAAsN=44, cross-over study , BCAA 12 g/d during 6 months vs. placebo

Hiroshige K et al. Nephrol dial Transplant

Study design

Energy(kcal/HD)

Protein(g/HD)

Length(days)

Improved NP

GuarnieriAm J Clin Nutr, 1980

G1: 6G2: 6G3: 6

G1: 0G2: 0G3: G5%

G1:EAA+his, 14gG2 :sd AA, 14gG3 : 0

60 BW in G1 and G2

CanoAm J Clin Nutr, 1990

G1: 12G2: 14

G1: 1000G2: 0

G1: sdAA+tyr,30 gG2: 0

90

Appetite, BWAMC, TSF AlbuminPrealbumin, Creatinine

NavarroAm J Clin Nutr, 2001

G1: 10G2: 7

G1: 0G2: 0

G1: sdAA+tyr,26 gG2: 0

90TSFAlbumin, nPCR

CanoBr J Nutr, 2006

G1: 17G2: 18

G1: 0G2: 0

G1: AA+G+soja oilG2: AA+G+olive oil

35AlbuminPrealbuminnPCR, creatinine

Nutritional effect of IDPN: RCTs

Intradialytic Parenteral Nutrition

Chertow GM et al. Am J Kidney Dis 1994

Overall population of Health care systemIDPN, n=1679 Controls, n=22517

IDPN initiation

IDPN

800-1200 kcal/HD

• 5-8 kcal/kg/d (glucose+fat emulsions)• 0.2-0.4 g AA/kg/d

Both ONS and IDPN can only reach the nutritional objectives when spontaneous intakes are

≥ 20 kcal & 0.8 g protein/kg/d

Nutritional support

Oral Nutr. Suppl.

500 kcal/day(standard formulas)

• 5 -10 kcal/kg/d• 0.4 - 0.6 g prot/kg/d

• Both oral supplements and IDPN can improve nutritional status

• Oral supplement are more simple and cheaper

Is there any advantage to prescribe IDPN ?- on a nutritional point of view ?- in terms of morbidity and mortality ?

Nutritional supportOral supplements or IDPN ?

French Intradialytic Nutrition Evaluation Study (Fines)

• Main objective: to evaluate, in a intention-to-treat

study, the effects of a one-year IDPN on nutritional

status, morbidity and mortality in malnourished MHD

patients.

• Secondary objective: to define the parameters

predicting the response to nutritional therapy.

French Intradialytic Nutrition Evaluation Study (Fines)

Months0 6 12 18 24

30

34

Serum albumin, g/L

31

32

33

34

NS

Months

300

280

260

240

220

200NS

0 6 12 18 24

Prealbumin, mg/L

Treatment period

Treatment period

Control group (n=93): ONS during 12 mo. IDPN group (n=93): ONS + IDPN during 12 mo.

Cano N et al. J Am Soc Nephrol 2007

Body weight & albumin changes before, during and after refeeding

Body weight Serum albumin

Body weight, kg Serum albumin, g/L

Months

56

57

58

59

60

61

62

63

64

31

32

33

34

35

36

-6 0 6 12 18 24

p<0.05

p<0.01

Cano N et al. J Am Soc Nephrol 2007

French Intradialytic Nutrition Evaluation Study (Fines)

Cano N et al. J Am Soc Nephrol 2007

Fines: Do inflammed patients respond to nutritional support ?

0 6 12 18 24

30

31

32

33

34

35

0 6 12 18 24

200

220

240

260

280

300

MonthsMonths

P<0.05 NS

Baseline CRP < 10 mg/L, n=88 Baseline CRP ≥ 10 mg/L, n=86

Serum albumin, g/L Prealbumin, mg/L

Cano N et al. J Am Soc Nephrol 2007

Months0 6 12 18 24

200

220

240

260

280

300

Months0 6 12 18 24

30

31

32

33

34

35

**

*

Non diabetics, n=141 Diabetics, n=45

FineS

Fines: Do diabetic patients respond to nutritional support ?

Serum albumin, g/L Prealbumin, mg/L

Cano N et al. J Am Soc Nephrol 2007

• Polymeric EN, administered via naso-gastric tube or gastrostomy

• Necessary during severe undernutrition, particularlywhen spontaneous intakes are < 20 kcal/kg/day (1):

- IDPN cannot reach recommended supplies- daily nutritional support is needed- enteral nutrition should be prefered to

parenteral nutrition

• Poorly investigated

Tube feeding

ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009

Decisional algorithm for the management of undernutrition in HD patients

ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009

Nephrol Dial Transplant 2008

n=23 n=22 n=23 n=22

Energy intake Protein intake

How to improve the efficacy of nutritional support?

Amino acids

Hormones

Exercise

Sedentarity

Inadequate intakes

Muscleloss

Muscle growth

Musclemass

Synthesis

CatabolismHormone dysfunction

InflammationInsulin resistance

Metabolic disturbances

Multimodal approach of malnutrition

Inadequate intakes

Physical inactivity

Hormone disturbancies

InflammationInsulin resistance

Other metabolic disturbances

INTEGRATED TREATMENT

§ Orexigens

§ Healthy diet

§ Nutritional support

§ Exercise

§ Androgens

§ Other agents:

• n-3 FA

• N-acetylcysteine

• anti-TNF ..

Modulation of

inflammation through

NF-kB pathway

Activation ofIGF I and II

Oxidative capacity, GLUT4

Myofiber type Composition

Increased protein synthesis

Decreased protein breakdown

Cell energycontrol

Luquet S et al. Faseb J 2003Sandri M et al. PNAS 2006Narkar VA et al. Cell 2008

Remels AHV et al. Am J Physiol 2008, 2009

Activation ofAMPKinase

Increased endurance

Insulin Sensitivity

Activation ofPPARs

g d

EFFECTS OF EXERCISE TRAINING ON MYOCYTES

Galland et al. Kidney Int 2001

Daily dialysis

0.5

0.7

0.9

1.1

1.3

1.5

1.7

1.9

Protein (g/kg/day)25

30

35

40

45

Energy (kcal/kg/day)

Standard HD daily HD (6 mo) daily HD (12 mo)

• In HD patient, protein-energy wasting is associated withincreased morbidity and mortality

• Dietary counselling, oral supplements and IDPN canimprove nutritional status, independent of serum CRP

• The increase in serum transthyretin during nutritionalsupport is associated with an increase in survival

• A multimodal approach of malnutrition, integrating exercise and, in selected patients androgen and daily dialysis may increase the response rate to the treatment of malnutrition

Conclusions