PRINSIP TERAPI NUTRISI PASIEN DIALISIS
Haerani Rasyid Sub Divisi Ginjal Hiprtensi Departemen Ilmu Penyakit Dalam FK UNHAS 2015
Pendahuluan Status nutrisi individu dipengaruhi oleh berbagai faktor - Intake makanan
-
Jumlah dan kualitas makanan Kondisi individu
Tujuan penilaian nutrisi - Status fxonal, intake makanan dan komposisi tubuh (refleksikan kalori dan protein ) - Memprediksi morbiditas dan mortalitas - Memprediksi lama tinggal/biaya di RS
Bagaimana dengan pasien Dialisis??
Memperbaiki asupan makan
Meningkatkan pengetahuan gizi
Dukungan nutrisi untuk perbaikan metabolik
Tujuan Tatalaksana Gizi
Mencapai dan mempertahankan status gizi baik
Mencegah PEW
Faktor-faktor yang mempengaruhi gangguan status nutrisi pasien PGK non-D / PGK - D Condition
Mechanism
Anorexia
Inadequate protein or calorie intake
Metabolic acidosis
Stimulation of amino acid and protein degradation
Infection/inflamatory illness
Stimulation of protein degradation
Diabetes
Stimulation of protein degradation and suppression of protein synthesis
Profil nutrisi pasien CKD Pre-ESRD Dialysis
Transplant* Transplant
1. Malnourished (Undernutrition)+
++
++
+/-
2. Obese
+
+
++
++
* first 3 months
(An expert panel from the International Society of Renal Nutrition and Metabolism proposed the term ‘protein energy wasting’ (PEW) to designate malnutrition in kidney diseases) Protein Energy Wasting’ (PEW)
Malnutrisi Penyakit Ginjal Kronik
NDT Plus (20 ) 3: 118–124
The International Society of Renal Nutrition and Metabolism (2013)
Wasting bukan hanya
disebabkan oleh asupan zat gizi yang inadekuat atau meningkatnya kehilangan zat gizi
Kovesdy CP, Kopple JD, KalantarKalantar-Zadeh K. Management of proteinprotein-energy wasting in nonnon-dialysis dependent chronic kidney disease: reconciling low protein intake with nutritional therapy. Am J Clin Nutr 2013;97:1163 2013;97:1163--77
2 tipe malnutrisi / PEW „Type II“
„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
Serum Albumin Comorbidity Presence of inflamation Food intake Resting energy expenditure Oxidative catabolism Reversed by dialysis and nutritional support
Type 1
Type 2
Associated with uremic syndrome
Associated with MIA syndrome
Normal/low Uncommon No Decreased Normal Increased Decreased Yes
Low Common Yes Low/Normal Elevated Markedly Increased Increased No
Clinical Queries : Nephrology I (2012) ; 222-235
Kriteria Diagnostik PEW Suggested by the PEW Consensus Conferences PRIMARY CRITERIA
SUPORTIVE CRITERIA
1. Biochemical markers Albumin < 3.8g/dl (BCG) Prealbumin (transthyretin) < 30mg/dl (dyalisis pts) Total cholesterol < 100mg/dl 2. Body composition indices Body Mass Index <22 kg/m2 (<65 years) or <23 kg/m2 (>65 years) Unintentional weight loss > 5% over 3 mo or 10% over 6 mo Total body fat percentage < 10% 3. Muscle mass Muscle wasting 5% over 3 mo or 10% over 6 mo Reduced mid-arm muscle circumference area Creatinin appearence 4. Dietary intake Unintentional dietary protein intake (DPI) < 0,80 g/kg/day (Evidence indicates that ≤ 1.0 g protein/kg/day may engender protein wasting in some patients) Unintentional dietary energy intake (DEI) < 25 Kcal/kg/day (Data indicate that some patient may need ≥ 30 kg/day)
1.Appetite,food intake, and energy expenditure Appetite assessment Food frequency questionnaires 2. Body Mass and composition Total body nitrogen or potassium Energy-beam based methods Dual-emmision X-ray absorptiometry Bioelectric Impedance Analysis Near Infrared Reactance 3.Other laboratory biomarkers Serum biochemistry : transferin, urea, triglyceride, bicarbonate Hormones : leptin, ghrelin, growth hormones Inflammatory markers : CRP,IL-6, TNF-α, IL-1β,SAA Peripheral blood cell count lymphocyte count or percentage 4.Nutritional scoring systems Subjective Global Assessment Malnutrition-Inflation Sore (MIS ) 5.Other novel markers 14kD 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 Kronik Laju Filtrasi Glomerulus
Konsentrasi solut meningkat (urea, kreatinin, fosfat, sulfat, as. urat, H+, fenol,guanidin, as. organik, indol, mioinositol, poliamin, 2-mikroglobulin, Al, Zn, Cu, Fe)
Gangguan metabolisme tubuh
Pasien hemodialisis Gangguan metabolisme glukosa Gangguan metabolisme lipid Gangguan metabolisme protein
Gangguan metabolisme asam amino
Gangguan metabolisme glukosa Resistensi Insulin Hipoglikemia
Gangguan metabolisme lipid Abnormalitas 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
Gangguan Metabolisme Protein
Terjadi peningkatan turnover protein otot dan protein di seluruh tubuh
Penyebab kehilangan lean body mass pasien HD:
Inflamasi meningkatkan katabolisme protein
Inflamasi sistemik terjadi (50% pasien) Penyebab sindroma inflamasi pasien HD kronik :
Gangguan metabolisme Asam amino BCAA
Essential AA Non Non--essential AA Special AA
threonine lysine serine
valine leucine isoleucine
oxidation in muscles
NORMAL KIDNEY
glycine
phenylalanine hydroxylation
tyrosine
citruline cystine aspartate methionine methyl methyl-histidine
tryptophane arginine ↓
protein binding
Mitch WE. Handbook of Nutrition and the Kidney, 2003
Essential AA Non Non--essential AA Special AA
BCAA↓ valine ↓ ↓ leucine ↓ isoleucine ↓
threonine ↓ lysine ↓ serine ↓
decrease production
oxidation in muscles
metabolic acidosis glycine ↑ citruline ↑ cystine ↑ aspartate ↑ methionine ↑ methyl methyl-histidine ↑
KIDNEY FAILURE
defective phenylalanine hydroxylation
tyrosine ↓ tryptophane ↓
arginine ↓
reduce protein binding
Mitch WE. Handbook of Nutrition and the Kidney, 2003
Abnormalitas asam amino pasien PGK-HD Amino Acid
type
changes
Valine Leucine Iso--leucine Iso
E E E
↓↓ ↓ ↓
Threonine Lysine Serine
E E NE
↓ ↓ ↓
Tyrosine Tryptophane
spE E
↓ ↓
Glycine Aspartate Methionine Methyl-Methyl Histidine
NE NE E
↑ ↑ ↑
spAA
↑
Rekomendasi asupan protein dan energi pasien HD kronik
Kebutuhan mineral pasien HD kronik
Rekomendasi asupan mikronutrien pasien HD
Alur dukungan nutrisi pasien HD PEW
SGA or MIS
indikasi Kontra indikasi oral
dosis ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009
Cara pemberian
Monitoring
Pasien CAPD Nutritional status of PD and HD patients PD
HD
51
169
Well-nourished
34 (67%)
139 (82%)
Mildly malnourished
8 (15%)
24 (14%)
Moderately malnourished
7 (14%)
6 (4%)
Severely malnourished
2 (4%)
0
Total
33% of PD patients were malnourished compared to 18% of HD patients.
Park YK et al, J Ren Nutr 1999; 9: 149-56
• Asupan makan tidak cukup • Metabolisme zat gizi abnormal • Inflamasi • Abnormalitas hormonal
• Cepat kenyang dan perut terasa penuh • Waktu pengosongan lambung lambat karena dialisat menyebabkan aktivitas elektrik lambung abnormal • Distensi abdomen akbat dialisat • Peningkatan leptin
Pola dan Nafsu Makan
• Nyeri abdomen, konstipasi, diare, stool urgency
Gejala GI
• Kehilangan PD > HD • Peritonitis >> 15100 g/hari • Loss terutama albumin dan immunoglobulin
Kehilangan protein
• Cairan dialisat mengandung glukosa • Agen osmotik • Absorpsi sekitar 100 – 200 g glukosa per hari (20% asupan energi total) • Absorpsi glukosa dapat diestimasikan sebagai kalori yang diabsorbsi
Absorpsi glukosa (membran peritoneum)
CAPD 60% glukosa yang diabsorpsi Setiap gram glukosa 3.4 kcal
Dialysate (dextrose concentration)
Gram of dextrose/L
Kcal/L from dextrose
Kcal/L with CAPD
1.5 %
15
51
31
2.5%
25
85
51
4.25%
42.5
144.5
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 4.25% = 346.8 kcal (86.7 kcal/L x 4 L Total Kcal absorbed = 470 kcal
Rekomendasi : Protein dan energi pasien CA PD
Mineral dan vitamin pasien CAPD
Algoritme tatalaksana PEW pada PD
Algorithm for nutritional management and support in patient with CKD (Clinical Journal of the American Society of Nephrology) Nutritional Assessment (as indicated) Sprealb, SGA, Anthropometrics
*Periodic Nutritional Screening Salb, Weight, BMI, MIS, DPI, DEI
Continuous Preventive Measures : Continuous Nutritional Counseling Optimize RRT-Rx and Dietary Nutrient Intake Manage co-morbidites (Acidosis,DM,Inflamation,CHF,Depression)
• • • • • •
Salb > 3,8 ; Sprealb >28 Weight or LBM gain
• • • •
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 Salb < 3,8 g/dl or Sprealb < 28 mg/dl Worsening Nutritional Markers Over Time SGA in PEW range
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 dialysis treatment ; in-centre meals)
Maintenance Nutritional Therapy Goals : 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
• • • •
No Improvement or Deterioration
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 nutritional counseling to encourage increased intake - Optimal dose of dialysis (Kt/V > 1.4 or URR > 65%) - Use of biocompatible dialysis membranes - Enteral or intradialytic parenteral nutritional supplements (hemodialysis) and amino acid dialysate (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 dengan intervensi nutrisi
KASUS 1
KASUS 1
KASUS 2
KASUS 3
KASUS 2
KASUS 3
Summary of Clinical Practice Guideline for Nutrition in CKD Frequency of screening for PEW in CKD Weekly for inpatient 2-3 mo for outpetients with eGFR < 20 but not on dialysis Within one mo of commencement of dialysis then 6-8 weeks later 4-6 mo for stable haemodialysis patients 4-6 mo for stable peritoneal dialysis patients Nephron Clin Pract 2011; 118 (suppl):c153-c164
