ESPEN Congress Nice 2010 · 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
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
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
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