PRINSIP TERAPI NUTRISI PASIEN DIALISISPRINSIP TERAPI NUTRISI PASIEN DIALISIS

Haerani RasyidHaerani Rasyid

Sub Divisi Ginjal HiprtensiDepartemen Ilmu Penyakit Dalam

FK UNHAS2015

Sub Divisi Ginjal HiprtensiDepartemen Ilmu Penyakit Dalam

FK UNHAS2015

PendahuluanPendahuluan

Status nutrisi individu dipengaruhi oleh berbagai faktorStatus nutrisi individu dipengaruhi oleh berbagai faktor

-- Intake makananIntake makanan-- Intake makananIntake makanan

-- JJumlah dan kualitas makananumlah dan kualitas makanan

-- Kondisi individuKondisi individu

Tujuan penilaian nutrisi- Status fxonal, intake makanan dan komposisi

tubuh (refleksikan kalori dan protein )- Memprediksi morbiditas dan mortalitas

Bagaimana dengan pasienDialisis??

- Memprediksi morbiditas dan mortalitas- Memprediksi lama tinggal/biaya di RS

Memperbaikiasupan makan

Dukungan nutrisi untukperbaikan metabolik

Mencegah PEWMeningkatkan Tujuan Mencegah PEW

Mencapai danmempertahankan status gizi

baik

Meningkatkanpengetahuan gizi

TujuanTatalaksana Gizi

Faktor-faktor yang mempengaruhi gangguan status nutrisipasien PGK non-D / PGK - D

Condition Mechanism

Anorexia Inadequate protein or calorieintake

Metabolic acidosis Stimulation of amino acid andprotein degradation

Infection/inflamatory illness Stimulation of proteindegradation

Diabetes Stimulation of proteindegradation and suppressionof protein synthesis

Pre-ESRD

+

Profil nutrisiProfil nutrisi pasienpasien CKDCKD

Transplant*

++

Dialysis

++

Transplant

+/-1. Malnourished

(Undernutrition)

++ ++

* first 3 months

++2. Obese

Protein Energy Wasting’ (PEW)

(An expert panel from the International Society ofRenal Nutrition and Metabolism proposed the term

‘protein energy wasting’ (PEW) to designatemalnutrition in kidney diseases)

Protein Energy Wasting’ (PEW)Malnutrisi Penyakit Ginjal

Kronik

NDT Plus (20 ) 3: 118–124

Wasting bukan hanyadisebabkan oleh asupan zat gizi

The International Society of RenalNutrition and Metabolism (2013)

disebabkan oleh asupan zat giziyang inadekuat atau meningkatnya

kehilangan zat gizi

Kovesdy CP, Kopple JD, KalantarKovesdy CP, Kopple JD, Kalantar--Zadeh K. Management of proteinZadeh K. Management of protein--energy wasting in nonenergy wasting in non--dialysisdialysisdependent chronic kidney disease: reconciling low protein intake with nutritional therapy. Am J Clindependent chronic kidney disease: reconciling low protein intake with nutritional therapy. Am J Clin

Nutr 2013;97:1163Nutr 2013;97:1163--7777

„Type II“

2 tipe malnutrisi / PEW

„Type I“

„uremic“ malnutrition/wasting

Pupim L, Ikizler TA: Uremic malnutrition: New insights into old problem.Semin Dial 2003; 16: 224-232

Uremic Condition

Patomekasme inflamasi menyebabkan PEW

Perbedaan tipe Malnutrisi / PEW pasien CKD

Factors Type 1 Type 2

Associated with uremicsyndrome

Associated with MIAsyndrome

Serum AlbuminComorbidityPresence of inflamation

Normal/lowUncommon

No

LowCommon

YesFood intakeResting energyexpenditureOxidative catabolismReversed by dialysis andnutritional support

DecreasedNormal

IncreasedDecreased

Yes

Low/NormalElevated

Markedly IncreasedIncreased

No

Clinical Queries : Nephrology I (2012) ; 222-235

Kriteria Diagnostik PEWSuggested by the PEW Consensus Conferences

PRIMARY CRITERIA

1. Biochemical markersAlbumin < 3.8g/dl (BCG)Prealbumin (transthyretin) < 30mg/dl (dyalisis pts)Total cholesterol < 100mg/dl

2. Body composition indicesBody Mass Index <22 kg/m2 (<65 years) or <23 kg/m2(>65 years)Unintentional weight loss > 5% over 3 mo or 10% over 6mo

SUPORTIVE CRITERIA

1.Appetite,food intake, and energy expenditureAppetite assessmentFood frequency questionnaires2. Body Mass and compositionTotal body nitrogen or potassiumEnergy-beam based methodsDual-emmision X-ray absorptiometryBioelectric Impedance AnalysisNear Infrared Reactancemo

Total body fat percentage < 10%3. Muscle mass

Muscle wasting 5% over 3 mo or 10% over 6 moReduced mid-arm muscle circumference areaCreatinin appearence

4. Dietary intakeUnintentional dietary protein intake (DPI) < 0,80g/kg/day(Evidence indicates that ≤ 1.0 g protein/kg/day mayengender protein wasting in some patients)Unintentional dietary energy intake (DEI) < 25Kcal/kg/day(Data indicate that some patient may need ≥ 30 kg/day)

Near Infrared Reactance3.Other laboratory biomarkersSerum biochemistry : transferin, urea, triglyceride,bicarbonateHormones : leptin, ghrelin, growth hormonesInflammatory markers : CRP,IL-6, TNF-α, IL-1β,SAAPeripheral blood cell count lymphocyte count or percentage4.Nutritional scoring systemsSubjective Global AssessmentMalnutrition-Inflation Sore (MIS )5.Other novel markers14kD Actin fragment [82,97]Gelsoiln [98]

Nutritional Management of Renal Disease

http://dx.doi.org/10.1016/B978-0-12-391934-2.00011-4

INTERVENSI NUTRISI

Penyakit Ginjal KronikPenyakit Ginjal Kronik

Laju Filtrasi GlomerulusLaju Filtrasi Glomerulus

Konsentrasi solut meningkatKonsentrasi solut meningkat

(urea, kreatinin, fosfat, sulfat, as. urat, H(urea, kreatinin, fosfat, sulfat, as. urat, H++,,fenol,guanidin, as. organik, indol, mioinositol,fenol,guanidin, as. organik, indol, mioinositol,

poliamin,poliamin, 22--mikroglobulin, Al, Zn, Cu, Fe)mikroglobulin, Al, Zn, Cu, Fe)

Gangguan metabolisme tubuhGangguan metabolisme tubuh

Gangguan metabolisme glukosaGangguan metabolisme glukosaGangguan metabolisme lipidGangguan metabolisme lipid

Gangguan metabolisme proteinGangguan metabolisme protein

Pasien hemodialisisPasien hemodialisis

Gangguan metabolisme proteinGangguan metabolisme proteinGangguan metabolisme asam aminoGangguan metabolisme asam amino

GangguanGangguan metabolismemetabolisme glukosaglukosaResistensiResistensi InsulinInsulin

HipoglikemiaHipoglikemia

GangguanGangguan metabolismemetabolisme lipidlipidAbnormalitas utama lipid sirkulasi

Kwan BCH; Kronenberg F, Beddhu S, and Cheung AK: Lipoprotein metabolism and lipid management in chronic kidney disease. J Am Soc Nephrol 18: 1246-1261, 2007

Terjadi peningkatanTerjadi peningkatan turnoverturnover protein ototprotein ototdan protein di seluruh tubuhdan protein di seluruh tubuh

Penyebab kehilanganPenyebab kehilangan lean body masslean body masspasien HD:pasien HD:

Gangguan Metabolisme Protein

Inflamasi meningkatkan katabolismeInflamasi meningkatkan katabolismeproteinprotein

Inflamasi sistemik terjadi (50% pasien)Inflamasi sistemik terjadi (50% pasien)

Penyebab sindroma inflamasi pasien HDPenyebab sindroma inflamasi pasien HDkronik :kronik :

oxidation inoxidation inmusclesmuscles

BCAABCAAvalinevalineleucineleucineisoleucineisoleucine

threoninethreoninelysinelysineserineserine

Essential AAEssential AANonNon--essential AAessential AASpecial AASpecial AA

GangguanGangguan metabolismemetabolisme AsamAsam aminoamino

NORMALNORMALKIDNEYKIDNEY

phenylalaninephenylalaninehydroxylationhydroxylation

tyrosinetyrosine

tryptophanetryptophane

protein bindingprotein bindingarginine ↓arginine ↓

glycineglycine

citrulinecitrulinecystinecystineaspartateaspartatemethioninemethioninemethylmethyl--histidinehistidine Mitch WE. Handbook of Nutrition and the Kidney, 2003

oxidation inoxidation inmusclesmuscles

BCAA↓BCAA↓valine ↓ ↓valine ↓ ↓leucine ↓leucine ↓isoleucine ↓isoleucine ↓

threonine ↓threonine ↓lysine ↓lysine ↓serine ↓serine ↓

decreasedecreaseproductionproduction

Essential AAEssential AANonNon--essential AAessential AASpecial AASpecial AA

KIDNEYKIDNEYFAILUREFAILURE

metabolicmetabolicacidosisacidosis

defectivedefectivephenylalaninephenylalaninehydroxylationhydroxylation

tyrosine ↓tyrosine ↓

tryptophane ↓tryptophane ↓

reducereduceprotein bindingprotein bindingarginine ↓arginine ↓

glycine ↑glycine ↑citruline ↑citruline ↑cystinecystine ↑↑aspartate ↑aspartate ↑methionine ↑methionine ↑methylmethyl--histidinehistidine ↑↑ Mitch WE. Handbook of Nutrition and the Kidney, 2003

Amino AcidAmino Acid typetype changeschanges

ValineValine EE ↓↓ ↓↓LeucineLeucine EE ↓↓IsoIso--leucineleucine EE ↓↓

ThreonineThreonine EE ↓↓LysineLysine EE ↓↓SerineSerine NENE ↓↓

Abnormalitas asam amino pasien PGK-HD

TyrosineTyrosine spEspE ↓↓TryptophaneTryptophane EE ↓↓

GlycineGlycine NENE ↑↑AspartateAspartate NENE ↑ ↑ MethionineMethionine EE ↑↑MethylMethyl--HistidineHistidine spAAspAA ↑↑

Rekomendasi asupan protein dan energi pasien HD kronikRekomendasi asupan protein dan energi pasien HD kronik

Kebutuhan mineral pasien HD kronik

Rekomendasi asupan mikronutrien pasien HDRekomendasi asupan mikronutrien pasien HD

SGA or MIS

Alur dukungan nutrisi pasien HD PEWAlur dukungan nutrisi pasien HD PEW

indikasi

Kontra indikasi

dosis

Cara pemberian

oral

MonitoringESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009

Pasien CAPDPasien CAPD

Nutritional status of PD and HDpatients

PD HD

Total 51 169

Well-nourished 34 (67%) 139 (82%)

• Asupan makantidak cukup

• Metabolisme zatgizi abnormal

Mildlymalnourished

8 (15%) 24 (14%)

Moderatelymalnourished

7 (14%) 6 (4%)

Severelymalnourished

2 (4%) 0

33% of PD patients were malnourished compared to 18% of HD patients.

Park YK et al, J Ren Nutr 1999; 9: 149-56

gizi abnormal

• Inflamasi

• Abnormalitashormonal

• Cepat kenyang dan perutterasa penuh

• Waktu pengosongan lambunglambat karena dialisatmenyebabkan aktivitaselektrik lambung abnormal

• Distensi abdomen akbat

• Nyeri abdomen, konstipasi,diare, stool urgency

• Distensi abdomen akbatdialisat

• Peningkatan leptin

Pola danNafsu Makan

Gejala GI

• Kehilangan PD > HD• Peritonitis >> 15-

100 g/hari• Loss terutama

albumin dan

• Cairan dialisatmengandung glukosa

• Agen osmotik• Absorpsi sekitar 100 – 200

g glukosa per hari (20%asupan energi total)

• Absorpsi glukosa dapatalbumin danimmunoglobulin

Kehilanganprotein

• Absorpsi glukosa dapatdiestimasikan sebagaikalori yang diabsorbsi

Absorpsi glukosa(membranperitoneum)

CAPD 60% glukosa yang diabsorpsi Setiap gram glukosa 3.4 kcal

Dialysate(dextrose

Gram ofdextrose/L

Kcal/L fromdextrose

Kcal/L with CAPD(dextroseconcentration)

dextrose/L dextrose

1.5 %

2.5%

4.25%

15

25

42.5

51

85

144.5

31

51

86.7

Pasien CAPD menggunakan 4 L of 1.5%dialysate and 4 L of 4.25% dialysate perhari

4 L 1.5% = 124 kcal (31 kcal/L x 4 L) 4 L 1.5% = 124 kcal (31 kcal/L x 4 L)4 L 4.25% = 346.8 kcal (86.7 kcal/L x 4 LTotal Kcal absorbed = 470 kcal

Rekomendasi :Protein dan energi pasien CA PD

Mineral dan vitamin pasien CAPD

Algoritme tatalaksana PEW pada PD

*Periodic Nutritional ScreeningSalb, Weight, BMI, MIS, DPI, DEI

Nutritional Assessment (as indicated)Sprealb, SGA, Anthropometrics

Continuous Preventive Measures :Continuous Nutritional Counseling

Optimize RRT-Rx and Dietary Nutrient IntakeManage co-morbidites (Acidosis,DM,Inflamation,CHF,Depression)

Indication for Nutritional Interventions Despite Preventive Measure :• Poor appetite and/or poor oral intake• DPI<1,2(CKD 5D) or <0.7(CKD 3-4:DEI<30Kcal/kg/d• Unintentional weight loss >5% of IBW or EDW over mo

Algorithm for nutritional management and support in patient with CKD(Clinical Journal of the American Society of Nephrology)

• Unintentional weight loss >5% of IBW or EDW over mo• Salb < 3,8 g/dl or Sprealb < 28 mg/dl• Worsening Nutritional Markers Over Time• SGA in PEW range

Salb > 3,8 ; Sprealb >28Weight or LBM gain

Start CKD-Specific Oral Nutritional Supplementation :•CKD 3-4 : DPI target of > 0.8g/kg (±AA/KA or ONS)•CKD 5D : DPI target >1.2g/kg/d (ONS at home or during dialysistreatment ; in-centre meals)

No Improvementor Deterioration

Maintenance Nutritional TherapyGoals :

• Salb > 4.0g/dl• Sprealb > 30 mg/dl• DPI > 1,2 (CKD-5D) & >0.7 g/kg/d

(CKD 3-4)• DEI 30-35 Kcal/kg/d

Intensified Therapy :• Dialysis prescription alterations• Increase quantity of oral therapy• Tube, feeding or PEG if indicated• Parenteral interventions :

• IDPN (esp.if salts <3.0g/dl)• TPN

Adjuvant Therapies :• Anabolic hormones

• Androgen,GH• Appetite stimulants• Antiinflamatory interventions

• Omega 3; IL-1ra• Exercise (as tolerated)

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 nutritionalcounseling to encourage increased intake

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

- Use of biocompatible dialysis membranes- Use of biocompatible dialysis membranes

- Enteral or intradialytic parenteral nutritional supplements (hemodialysis) and amino aciddialysate (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

Laporan 3 pasien CAPD denganintervensi nutrisi

KASUS 1 KASUS 2 KASUS 3

KASUS 1 KASUS 2 KASUS 3

Frequency of screening for PEW in CKD

Weekly for inpatient

2-3 mo for outpetients with eGFR < 20but not on dialysis

Summary of Clinical Practice Guideline for Nutrition in CKD

Within one mo of commencement ofdialysis then 6-8 weeks later

4-6 mo for stable haemodialysis patients

4-6 mo for stable peritoneal dialysispatients

Nephron Clin Pract 2011; 118 (suppl):c153-c164