MANAJEMEN TERAPI NUTRISI PADA PASIEN DIALISIS KRONIK DENGAN MALNUTRISI
Afiatin DIVISI GINJAL HIPERTENSI DEPARTEMEN IP DALAM FK UNPAD RS HASAN SADIKIN BANDUNG PERNEFRI KORWIL JAWA BARAT
CURICULUM VITAE • Afiatin • Internist Nephrologist, Member of INASH, ISN, ISPD and ISHD • Staff of Nephrology Division Internal Medicine Department Medical Faculty of Padjadjaran University – Hasan Sadikin Hospital Bandung West Java Indonesia
• Total Nutritional Therapy TRAINER • COURSE ON MEDICAL NUTRITION TREATMENT TRAINER • MEMBER OF NUTRITION SUPPORT TEAM IN HASAN SADIKIN HOSPITAL
MALNUTRITION Overnutrition OBESITY
Undernutrition MALNUTRITION
Macronutrient Malnutrition
Protein Malnutrition (kwashiorkor)
Micronutrient Malnutrition
Energy Malnutrition (marasmus)
Protein - Energy Malnutrition / Protein Energy Wasting
MODEL KONSEPTUAL ETIOLOGI DAN KONSEKUENSI PASIEN PENYAKIT GINJAL KRONIK DENGAN PEW
Ikizler et al, Kideny Int 2013; May: 1-12
Mortality and BMI in 54,535 hemodialysis patients 2.2
Highest Mortality
Relative Risk of All-Cause Death
2
Unadjusted Case-mix*
1.8
Case-mix & MICS **
1.6 1.4
Overweight
1.2
Obese
Morbidly Obese
1 0.8
Underweight
Normal BMI
0.6 0.4 <18
18-19.99 20-21.49
21.522.99
23-24.49 25-27.49
27.529.99
30-34.99 35-39.99 40-44.99
>=45
Body M ass Index (kg/m2)
Kalantar-Zadeh et al, AJKD 2005, & Kidney Int 2003 (& multiple other publications)
SStrategi Terapi untuk menghambat /menangani PEW pada PGK dengan dialisis Suplementasi nutrisi Stimulasi nafsu makan Koreksi asidosis Modulasi inflamasi/ hormon Latihan Fisik Dialisis yang adekuat
Modified from: Robert et al., J Cachexia Sarcopenia Muscle, 2011;2:9-25
Algoritma Manajemen Nutrisi pada pasien PGK
Nature Reviews Nephroglogy 7,369-384 : July 2011)
DIAGNOSIS KLINIS PEW
DIAGNOSIS KLINIS PEW
Nutritional Requirements of CKD Stg 5 with dialysis (NKF KDOQI) Nutrients
Recommended intakes per day Peritoneal Dialysis
Energy
Protein
Hemodialysis
35 Kcal/ kg IBW - <60 yrs 30-35Kcal/ kg IBW - ≥60 yrs 1.2-1.3g/kg IBW/ day(=50% of High Biological Value). Some nitrogen balance studies indicate that protein intake of ≥ 1.0 g/ kg IBW may be enough.
Fats
1.2-1.3g/kg IBW/ day(=50% of High Biological Value). Some nitrogen balance studies indicate that protein intake of ≥ 1.0 g/ kg IBW may be enough.
30% of total energy supply
Water and sodium
As per residual diuresis
750 – 1000 ml + diuresis
Potassium
40-80mmol. Individualized depending on serum levels
2-3 gr/d
Calcium
Individualized, usually not <1000mg/ day
1000 mg/d
Phosphorous
8-17 mg/ kg or 800-1000 mg/ day (adjusted to higher protein needs), when serum phosphorous is > 5.5 mg/ dl²
800 – 1200 mg/d
¹Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd Edn. NY: Springer, 2009: 611-647. ²National Kidney Foundation. K/DOQI clinical practice guidelines for managing bone metabolism in chronic kidney disease. Am J Kidney Dis2003; 42(suppl 1):S1-S92
FLOW OF NUTRITIONAL SUPPORT PROCESS IDENTIFICATION POPULATION AT RISK (CHRONIC DISEASE)
SCREENING YES
YES
NO
ASSESSMENT
NO
DIAGNOSIS AND INTERVENTION
MONITORING AND EVALUATION (MONEV)
SCREENING TOOL FOR DIALYSIS PATIENTS
• MALNUTRITION INFLAMMATION SCORE • • • •
SGA : + ASPEK DIALISIS PEMERIKSAAN FISIK BODY MASS INDEX PARAMETER LABORATORIUM
MIS : > 6 MALNUTRISI
MEMERLUKAN INTERVENSI NUTRISI
STEPS
DIETARY RECALL
DIETARY PLAN
JANGAN MEMBUAT RENCANA TERAPI TANPA TAHU MASALAH SEBENARNYA
TERAPI
MONITORING EVALUASI
Ahli Gizi /Nutrisionist/Dietician harus masuk dalam tim
MONITORING DAN EVALUASI TERAPI
• Buatlah jadwal untuk evaluasi • Evaluasi dengan formulir • Interval : tiap 2 – 4 minggu
NUTRITIONIST IS A MUST IN THE TEAM
Nutrition Support in CKD No
Total Parenteral Nutrition (TPN)
Functional GIT Yes Enteral Nutrition (EN)
HDx
1st Tube feeding (TF)
Oral (+edn & counseling):
+/-
• Food fortification • Oral nutrition supplementations (ONS)
+/PDx Intra- Peritoneal Nutrition
MO: • Control co-morbidities/ inflammation • Medications / Appetite stimulant
Intradialytic PN (IDPN)
Nursing
Exercise training
Multi-disciplinary Approach
Psychosocial support
Nutritional Therapy / Nutritional Support Enteral • Oral Nutrition Support • Meals during dialysis treatment • Tube feeding Parenteral • IDPN (intra-dialytic parenteral nutrition) • TPN Pharmacologic • Appetite stimulators • Anti-Depressant • Anti-inflammatory • Anabolic &/or muscle enhancing
Kalantar-Zadeh … Ikizler, Nature Nephrology 2011
KOMPOSISI
NUTRISI PADA PENYAKIT KHUSUS – RENAL FAILURE
4
parenteral parente ral
KARBOHIDRAT
KALORI
Non-protein protein
LIPID
enteral
MACRONUTIENT
ASAM AMINO
MiCRONUTIENT
kombin asi
Standard Standard formulae formulae composition, which
are enteral formulae with a reflects the reference values for macro macro-- and micronutrients for a healthy population. population. Most standard formulae contain carbohydrate, whole
protein, lipid in the form of longlong-chain triglycerides (LCT), and fiber. fiber.
Low, normal and high energy formulae Normal energy formulae provide 0.9–1.2 kcal/ml, kcal high energy formulae are anything above this, low energy formulae anything below.
High lipid formulae = High kalori Low volume High lipid formulae contain more than 40% of total energy from lipids.
High monounsaturated fatty acid (MUFA) formulae High MUFA formulae contain 20 20% % or more of total energy from MUFA. lemak
Whole protein formulae
Whole protein formulae contain intact proteins. Synonyms used in the literature: polymeric, high molecular weight or nutrient defined formulae
Peptide--based energy formulae Peptide
protein
Peptide-based formulae contain protein predominantly in peptide form (2–50 amino acid chains). Synonyms used in the literature: oligomeric, oligomeric, lowlow-molecular weight, chemically defined formulae. formulae.
Free amino acid formulae Free amino acid formulae contain single aminoacids as the protein source. Synonyms used in the literature: elemental, monomeric, low molecular weight, chemically defined formulae.
High protein formulae High protein formulae contain 20% or more of total energy from protein.
Immune modulating formulae Immune modulating formulae contain substrates to modulate (enhance or attenuate) immune functions. Synonyms used in literature: immunonutrition, immunonutrition, immuneimmune-enhancing diets
Oral Nutrition Support 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
SUMBER KALORI NON PROTEIN
PROTEIN
Essentiale
Non-Essentiale
Conditioned • Specific • (NEPHROSTERIL)
KARBOHIDRAT
LIPID
DEXTROSE
NON DEXTROSE
20% dextrose
Mannitol
40% dextrose
Xylitol
Sorbitol
ASAM AMINO
9 kcal 4 kcal
BCAA (comafusin)
• Immunomodulator • (DIPEPTIVEN) • Ketoanalog • (KETOSTERIL)
ENERGY
LIPIDS
Ketosteril ©
• EXAMPLE 2 Ny C , 42 tahun CKD stg 5 on HD kronik (2 tahun HD frekuensi 2x/ 2x/minggu minggu:: Permasalahan: Permasalahan: Gastropati erosiva ec NSAID keluhan nyeri ulu hati ketika makan , mula muntah , tidak nafsu makan. makan. Berat badan kering turun 4 kg dalam 2 bulan, bulan, tidak ada diare Lemah badan, badan, tidak masuk kerja 2 – 3 kali seminggu ( guru SMP ) TB: 152 cm, BB : 40 kg (BMI : 17.3, Ideal BMI : 22--22---IBW IBW 50.82 kg), Laboratorium : Hb 9 gr/dl, Albumin : 3,0 gr/dl,
MIS 12
Perlu terapi nutrisi
Clinical diagnosis of PEW
BMI : 17,3 (< 23) Berat badan turun 4 kg/2 bulan : > 5 % Serum Albumin : 3.0 (< 3.8 gr/dl) Intake : ??
STEPS
DIETARY RECALL
DIETARY PLAN
JANGAN MEMBUAT RENCANA TERAPI TANPA TAHU MASALAH SEBENARNYA
TERAPI
MONITORING EVALUASI
Ahli Gizi /Nutrisionist/Dietician harus masuk dalam tim
EXAMPLE Mrs C, 40 tahun tahun,, CKD stg 5 on chronic HD, 40 kg TB: 152 BMI :17.39 Ideal Body Weight : 50.82 kg (BMI 22) ENERGYNUTRIENTS Requirements
Mrs C requirement
Energy
35 kcal/kg IBW/d 30 kcal/kgIBW/d(>60 yrs) Or to attain IBW
1400 kcal/d
Protein
1.2 g/kg IBW/d
48 g/d
Sodium(mmol/d)
80-100
80-100
Potassium (mmol/d)
70
70
Phosphorus (mg/d)
<1000
1000
Fluid (ml/d))
Urine Output + 500
1000 ml
Mrs C daily intake recall BREAKFAST 1 bowl of cereal 1 cup of tea with 2 tsp sugar 2 biscuits
LUNCH 1 cup of soft steam rice ½ bowl of chicken broth Vegetable 1 cup 1 cup of tea 2 tsp sugar
DINNER Milk 150 ml 1 cup of noodle soup Juice 100 ml
EXAMPLE Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg ENERGY NUTRIENTS Energy
Mrs C requirement 1400 kcal/d
Mrs C actual intake 800 kcal/d (20 kcal/d)
Protein
48 g/d
20 g/d ( 0.5 g/kg/day)
Sodium(mmol/d)
80-100
120
Potassium (mmol/d) 70
<70
Phosphorus (mg/d)
1000
500
Fluid (ml/d))
1000 ml
1100 ml
Meeting : 57.1 % of estimated energy and 41.6 % protein requirements Unbalanced and inadequate intake of the core food groups Need nutritional support - repletion
Mrs C daily menu BREAKFAST
LUNCH
DINNER
1 bowl of chicken porridge 1 egg schootel 1 cup of tea with 2 tsp sugar
1 cup of soft steam rice 1 bowl of sauted beef and vegetable 100 ml fresh apple juice
Milk 150 ml 1 cup of noodle soup Ready made formula 1 serving 1 steam tofu and vegetable
10 am : ready made formula 1 serving 260 kcal prot 13 g
4 pm : ready made formula 1 serving 260 kcal prot 13 g As pudding
2 biscuits
JUMLAH KALORI DITINGKATKAN SECARA BERTAHAP SAMPAI KEBUTUHAN BERAT BADAN IDEAL (50 KG = 1650 Kcal/day)
PADA EVALUASI TERNYATA DAILY RECALL MASIH BURUK Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg ENERGY NUTRIENTS Energy
Mrs C requirement 1400 kcal/d
Mrs C actual intake 700 kcal/d (17,5 kcal/d)
Protein
48 g/d
20 g/d ( 0.5 g/kg/day)
Sodium(mmol/d)
80-100
120
Potassium (mmol/d) 70
<70
Phosphorus (mg/d)
1000
500
Fluid (ml/d))
1000 ml
1100 ml
Meeting : 57.1 % of estimated energy and 41.6 % protein requirements Unbalanced and inadequate intake of the core food groups Need nutritional support - repletion
NUTRITIONAL MONITORING AND EVALUATION
• 2 minggu, gastropati tidak membaik • Evaluasi asupan nutrisi • Asupan nutrisi baru sd : 15 kcal/kg /hari dan protein 0,5 gr/kg/hari
EXAMPLE Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
• INTRADIALYTIC PARENTERAL NUTRITION • Nutrisi parenteral yang diberikan secara intermiten pada saat dialisis • Preparat yang bisa diberikan selama jam dialisis : 4 – 5 jam
Kadar dan komposisi asam amino memenuhi kebutuhan • Keseimbangan asama amino eensial dan non esensial • Asam amino spesifik untuk pasien dialisis
Amino acid IV : Balanced supply of amino acids in acute and chronic renal insufficiency, as well as, during dialysis treatment • TPN, IDPN, or AA substitution • When GFR < 50 ml/min/1.73m2 – creatinine clearance < 50 ml/min – serum creatinine > 2.0 mg/dl
• Dosage Recomendation : – patients without dialysis 0.3-0.5 g AA/kgBW/d ( 2 btl ) – patients with dialysis 1.0 g AA/kgBW/d ( 4 btl ) – intradialytic supplementation 0.5-1.0 g AA/kgBW/d ( 2 – 4 btl ) – maximum dosage 1.5 g AA/kgBW/d ( 6 btl ) – maximum infusion rate 20 drops/min
KESIMPULAN Protein Energy Wasting : • Prevalensi cukup tinggi dengan konsekuensi peningkatan morbiditas dan mortalitas • Manajemen terapi nutrisi harus dilakukan oleh tim yang lengkap termasuk ahli gizi • Terapi nutrisi disesuaikan dengan kebutuhan masingmasing pasien • Modalitas terapi meliputi oral , enteral dan parenteral
TERIMA KASIH
