Nutrition guidelines for HD patients with PEW

NUTRITION &
HD
Mona Tawfik
Lecturer of internal Medicine
Nephrology Unit
MNDU
What can I eat ?

CASE PRESENTATION-1
Renal Nutrition Forum 2013 • Vol. 32 • No. 4
 A 63-year-old male patient who has ESRD secondary to diabetes.
He has been on dialysis for three years. Prior to his multiple
hospitalizations. He was an active person, had a good appetite and
was viewed as a “non-compliant” patient as his phosphorus was
always out of control and he usually forgot to take his binders.
 He recently had multiple extended hospitalizations.
 His first hospitalization was due to altered mental status and
hypoglycemia which lasted 9 days. He was then admitted to a
rehabilitation facility. His chest x-ray showed a pleural effusion. A MRI
of the brain was free. He received dialysis; however, it did not resolve
his pleural effusion .

CASE PRESENTATION-2
 His second admission lasted 26 days and was secondary to
confusion after a fall at the rehabilitation facility. A carotid ultrasound
detected a bilateral internal carotid arterystenosis and Because of
these findings, RS underwent a carotid endarterectomy. He then
developed diarrhea postoperatively and was diagnosed with C.
difficile colitis which was treated with vancomycin
 His total time spent in the sub-acute rehabilitation facility was
about three months.
 His past medical history included type 2 diabetes mellitus,
hypertension, hypothyroidism, and congestive heart failure. is a
smoker and does not drink alcohol.

CASE STUDY
Changes in DW over past
4 months
117150
1

1.What is PEW?
2.How to screen and assess
patients with PEW?
1.What is the recommendation of
PE intake for HD patient?
2.How to treat HD patient with
PEM

PEW
(protein energy wasting )
“Is a states of under-
nutrition that could result
from decreased nutrient
intake and/or increased
catabolism”
Seminars in Dialysis. 2012;25(4):423-27.

TERMINOLOGIES
 Uremic malnutrition
 Protein–energy malnutrition
 Malnutrition–inflammation atherosclerosis
syndrome
 Malnutrition–inflammation complex syndrome
 Inflammatory wasting
Protein-energy wasting (PEW)
Kidney Int. 2008 Feb;73(4):391-8

PROTEIN-ENERGY WASTING(PEW)
 Is very common problem among patients with
advanced chronic renal failure (CRF) and those
undergoing maintenance dialysis (MD) therapy
worldwide.
 Different reports suggest that the prevalence of
this condition varies from roughly 18-75% of adult
MD patients (average 40%).
Seminars in Dialysis. 2012;25(4):423-27

THE MAGNITUDE OF THE PROBLEM
 In HD patients, the presence of PEW is one of the
strongest predictors of morbidity and mortality.
 In addition it was shown that for each one-unit
decrease in BMI the risk for cardiovascular death
rose by 6%
 Each 1 g/dl fall in serum albumin level was
associated with a 39% increase in risk of
cardiovascular death
Am J Kidney Dis (2002)

Inadequate food intake secondary to:
• Anorexia caused by the uremic state
• Altered taste sensation
• Intercurrent illness
• Emotional distress or illness
• Impaired ability to procure, prepare, or
mechanically ingest foods
• Unpalatable prescribed diets
Predialysis patients appeared to have a
spontaneous protein intake of <0.6 g/kg/day
Adv Chronic Kidney Dis. 2013 March ; 20(2): 181–189

The catabolic response to superimposed
illnesses
The dialysis procedure itself
which may promote wasting by removing such
nutrients as amino acids, peptides, protein,
glucose, water-soluble vitamins, and other bioactive
compounds, and may promote protein catabolism,
due to bioincompatibility

Endocrine disorders of uremia
(resistance to the actions of insulin and IGF-I,
hyperglucagonemia, and hyperparathyroidism)
Loss of blood due to:
• Gastrointestinal bleeding
• Frequent blood sampling
• Blood sequestered in the hemodialyzer
and tubing

SCREENING
 Guideline 1.2 – Frequency of screening for
undernutrition in CKD
We recommend that screening should be
performed (1D)
 Weekly for inpatients
 2-3 monthly for outpatients with eGFR <20 but
not on dialysis
 Within one month of starting of dialysis.

ASSESSMENT IN MHD
 Nutritional status should be assessed at the
start of haemodialysis (Opinion).
 In absence of malnutrition, nutritional status
should be monitored every 6 months in patients
<50 years of age (Opinion).
 In patients >50 years of age, and patients
undergoing maintenance dialysis for more than
5 years, nutritional status should be monitored
every 3 months (Opinion).

ASSESSMENT TOOLS OF NUTRITION
 Predict the outcome
 Inexpensive
 Easily performed
 Reproducible
Not affected by
o Inflamation
o Gender
o Age
o Systemic disease
There is No Single IDEAL Nutritional marker is available

DIATARY ASSESSMENT
 24 h diatary recall
 3 day recall
 7 day recall
(K/DOQI) 2000
Recommendations for
Nutritional Management
Diet Assessment
Calories
Protein
Carbohydrates
Fat/Cholesterol
Sodium
Potassium
Phosphorus
Fluid
Vitamins
Minerals

USRDS DIALYSIS, MORBIDITY AND MORTALITY
WAVE II STUDY (DMMS).
Kidney International, 2004 ·
P<0.01

SUBJECTIVE GLOBAL ASSESSMENT (SGA)
EBPG 2007
DOPPS study
The investigators concluded that in haemodialysis
patients malnutrition, as indicated by low values
obtained with the SGA, was associated with higher
mortality risk
Kidney Int 2002; 62: 2238–2245

MAC (MID-ARM
CIRCUMFERENCE)
MAMC( mid-arm muscle circumference)
=MAC in cm __TSF×

Weight 55 kg
ID Hours 44 h
ID BUN Rise 45 mg/dl
Urine Urea Nitrogen 0 gm
nPCR = 1.1 g/kg/day
Example:

SERUM ALBUMIN AS A TOOL OF NUTRITIONAL ASSESSMENT
Strong predictor of morbidity and mortality ,
However
Albumin is affected by non-nutritional
factors
 Infection
 Inflammation
 Co-morbidities
 Fluid overload
 Inadequate dialysis
 Blood loss
 Metabolic acidosis

J Bras Nefrol 2015;37(2):198-205

SERUM PREALBUMIN
 Prealbumin half life is approximately 2 days instead
of 20 days for albumin
 Serum prealbumin is a more sensitive indicator for the
nutrition status than albumin due to its shorter half life
and not strongly affected by inflamation like albumin
 The patients 2-year survival rate was 50% with a
serum prealbumin level <0.3 g/l and 90% in patients
with a prealbumin level >0.3 g/l.
Kidney Int 2000; 58: 2512–2517

TECHNICAL INVESTIGATIONS
BIT
It might be the preferred
method, as BIA is not
operator dependent and
requires minimal training
to assess fluid status.
Clin Nephrol 1998; 49: 180–185

PHYSICAL EXAMINATION
Include
 General physical appearance
 Oral , skin health & Signs of
vitamin deficiency
 Handgrip strength (Heimburger
et al 2000)
 Subjective visual assessment of
subcutaneous tissue and muscle
mass (Enia1993)

Kidney International (2008) 73, 391–398

As there is no single IDEAL ‘gold
standard’ measure of nutritional
state

Kidney Int. 2008;73:391-98ISRNM

CASE STUDY: DIETETIC HISTORY
 Before hospitalization; the patient was following the
clinic’s standard HD diet (80gm protein, 2gm sodium,
2gm potassium, <900mg phosphorus and 1000mL fluid
restriction).
 His diets during hospitalizations has interrupted
frequently from NPO to clear liquids, to the hospital’s
diabetic diet.
1

CASE STUDY: DIETETIC HISTORY
 His meal completion during 1st admission recorded by the
hospital’s dietitians for this admission was 0-50%.
2nd admission 25-75%( 3 day average intake of 55%)
1
RecievedRecommended
1116 kcal/kg/dCalories (35 kcal/kg/d)
2030 kcal
35gm/dProtein (1.2 – 1.3g/kg/day)
70-75 gm/d

CASE STUDY
Changes in DW over
past 4 months
117180
1
Back to the case

CASE STUDY: INTERPRETATION
Patient’s albumin levels dropped.
He had a decrease in weight of >15% over one
month (58 to 49)
nPCR has decreased (1.43 to 0.58,0.59)
Decreasing serum cholesterol (150-117-106)
BMI was 15.5 based on his height and most
recent weight (58kg)
His intake had decreased considerably from his
usual intake following his first hospitalization.
1
PEW

Prevention and treatment of PEW
Multidisciplinary team
 Nephrologist
 Nurse
 pharmacist
 Social Worker
 patient's best
friend
 renal specialist
dietitian
 psychotherapist

Ideally worsening nutrition should be identified early
and proactively managed as correcting established
malnutrition is difficult.
 All reversible factors (including inflammation and
occult sepsis) should be identified and corrected.
Initiation of dialysis may be required in pre-dialysis
patients (2B) KDOQI 2012.
Increased dialysis dose ,the use of biocompatible
membranes and ultrapure water have been associated
with improved nutritional state.
NEPHROLOGIST FROM OPC TO DIALYSIS UNIT

o Improve appetite & food intake
o General feeling of well being, ↑ed physical activity
o Fewer dietetic restrictions
o Decrease dose of medications → Phosphate & K
binders, antihypertensive drugs
o Increase clearance of potential anorexic factors
o Improve metabolic acidosis
DIALYSIS

DIALYSIS
 Removal of :
 Amino acids (about 10 to 12 g per HD)
 Some peptides
 low amounts of protein (< 1 to 3 g per dialysis, including
blood loss)
 Small quantities of glucose (about 12 to 25 g per dialysis if
glucose-free dialysate is used)
 Inflamatory Cytokine release due to membrane contact.

UK RENAL ASSOCIATION GUIDLINE 2010
 Guideline 2.1 – Dose of small solute removal to
prevent undernutrition
We recommend that dialysis dose meets
recommended solute clearance index guidelines
(e.g. Kt/V) (1C)

Our results showed that nPCR has increased significantly
with increasing the dialysis dose (target Kt/V), also serum
albumin was significantly higher at the end of the study.
The Kt/V had a beneficial effect on neuromuscular and
cardiac functions. Also it had a positive impact on the
patients well-being at the end of our study.

DITEITIANS :
 Dietitians
are qualified
professionals and
experts in the
application of
science in
nutrition and
metabolism.
.

HD DIETS AIMS TO
 Limit the build up of waste product
(urea, phosphate, K, Na & salt)
 Prevent metabolic complication
(renal bone disease, hyperkalemia )
 Replace nutrient losses associated
with the dialysis process
 Optimize and maintain nutritional
state

Adequate energy intake essential to optimize
nutritional status
 Present in (Carbohydrates – Fats - Protein)
 Calculated based on
 Current weight,
 Age and gender
 Physical activity and metabolic stress
30-35 kcal/kg/d 1B
CALORIES
UK Renal Association 2010,EBPG, 2007AND KDOQI 2000

WEIGHT AND HD
 ABW: actual body weight—the patient’s present
body weight at the time of the observation.
 IBW: Ideal body weight—normal weight of
healthy individuals of similar sex, age, height and
skeletal frame size.
 USB: usual body weight—the patient’s weight
obtained through history or previous measurements,
considered to be stable over time.

 efBW: oedema free body weight, corresponding to
‘dry weight’—obtained post-dialysis in HD patients
based on clinical judgement wether the patient still
presents clinical oedema.
 AefBW: adjusted oedema-free body weight—
should be used in order to calculate the optimal
dietary intake of protein and energy.
Nephrol Dial Transplant (2007) 22 [Suppl 2]: ii45–ii87

FEMALE 40 YS, ACTUAL BW=80 KG , HEIGHT 170CM
Ideal Body Weight (IBW)
For men = [ (height(cm) – 154) x 0.9) ] + 50
For women= [ (height(cm) – 154) x 0.9) ] + 45.5
IBW={(170-154) x 0.9} +45.5= 59.9 kg
Adjusted BW = (actual weight- IBw) x 0.38) + IBw
=( 80 – 59.9 ) x (0.38) + 59.9 = 67.5Kg
Energy = 35 x 67.5 = 2363 k cal.

Food
Carbohydrate
4 kcal/g
Protein
4 kcal/g
Fat
9 kcal/g
1 cup milk 12 8 0 –10
1 oz meat 0 7 1 – 12
1 oz bread 15 3 0
1 cup veg. 5 2 0
1 fruit 15 0 0
1 teaspoon
fat/ oil
0 0 5
Caloric content of different food composition

PROTEIN
There are two kinds of proteins
 (HBV) or animal protein-meat, fish, poultry, eggs and dairy
 (LBV) or plant protein – breads, grains, vegetables, dried beans
and peas and fruits
50 -70% should be of HBV.
 Protein Alternatives
 protein bars, protein powders, supplement drinks

PROTEIN INTAKE
Guideline 2.3 – Minimum daily dietary protein
intake
o 0.75 g/kg IBW/day for patients with stage 4-5 CKD not on dialysis
o 1.2 g/kg IBW/day for patients treated with dialysis (2B)
No Protein Restriction for
Dialysis Patients

EXAMPLE 1
PROTEIN intake for male patient whose
weight is 68 kg, on maintenance HD
• 82 grams
• ½ cup milk
• 2 eggs or 4
egg whites
• 5-6 oz meat
• 3 vegetables
• 8 servings of
grains
1.2 (protein per kg
BW)×68 (BW)
=
81.6 gm of protein
50-70% of HBV

SODIUM
 Plays vital role in regulation of fluid balance and blood
pressure
In CKD& HD:-
 May result in :-
High blood pressure,
Fluid retention/swelling (edema)
Excessive thirst
CHF

Cook At home with low-sodium ingredients
2ooo mg/d
(4-5 gm Na Cl)
for
HD patient
EBPG
2007
• Salt
• High-sodium condiments
• Processed, cured foods
• Herbs
• Spices
• Lemon
• Vinegar
No Added Salt (NAS)
Avoid
Add
Eat out less (especially Fast Food)
TIPS FOR SALT REDUCTION

FLUIDS
 Excess fluid :
Edema, HTN, CHF and
Breathlessness
any food that is liquid at room
temp”
Soup, gelatin, ice cream, popsicles,
tea, coffee, ice

INTERDIALYTIC WEIGHT GAIN (IDWG)
General recommendation 4-4.5% of DBW
(EBPG 2007)

PHOSPHORUS
 Dietary intake ~800 to 1000 mg/day ( EBPG 2007)
 Dietary education improves phosphate control.
 Dietary phosphate control should not compromise
protein intake.
Control = Binders + Diet + Adequate dialysis

HIGH PHOSPHOROUS FOODS
DAIRY
 Cheese
 Milk
1 oz
½ cup
150 mg
120 mg
PROTEIN
 Egg
 Liver
 Peanut butter
 Salmon or tuna
 Nuts
1 large
1 oz
2 Tbsp
1 oz
1 oz
100 mg
150 mg
120 mg
75 mg
100 mg
VEGETABLES
 Baked beans
 Soybeans
½ cup
½ cup
130 mg
160 mg
BREADS
 Bran
 Cornbread
 Whole-grain bread
½ cup
2 inch square
1 slice
350 mg
200 mg
60 mg
BEVERAGES
 Beer
 Cola
12 oz can
12 oz can
50 mg
50 mg

AVOID PHOSPHORUS
ADDITIVES
 Inorganic Phosphorus absorbed easily
 Phosphorus binders ineffective with many additives
 READ THE INGREDENTS LABEL!!
 Phosphoric acid
 Sodium hexametaphosphate
 Calcium phosphate
 Disodium phosphate
 Trisodium triphosphate
 Monosodium phosphate
 Sodium tripolyphosphate
 Tetrasodium pyrophosphate
 Potassium tripolyphosphate

POTASSIUM
CKD Stages 4 and 5 and HD
 Dietary Goal is usually 2 - 3 gm/day .
 Fruits & Vegetables
 Low: 20-150 mg
 High: 250-550 mg
 Avoid Salt Substitutes
 Dairy
 1 cup 380-400 mg
 High phosphorus foods

VITAMIN SUPPLEMENTATION
Guideline 2.5 – Vitamin
supplementation in dialysis
patients
We recommend that
haemodialysis patients should
be prescribed supplements of
water soluble vitamins (1C).

METABOLIC ACIDOSIS…UK RENAL
ASSOCIATION GUIDELINE 2010
 Mid-week predialysis serum bicarbonate levels
should be maintained at 20–22 mmol/l (Evidence
level III).
 In patients with venous predialysis bicarbonate
persistently <20 mmol/l, oral supplementation with
sodium bicarbonate and/or increasing dialysate
concentration to 40 mmol/l should be used to
correct metabolic acidosis (Evidence level III).

EXERCISE
 Guideline 2.6 – Exercise programs in dialysis
patients (EBPG 2007)
 We recommend that haemodialysis patients should
be given the opportunity to participate in regular
exercise programmes (1C).

ANABOLIC AGENTS
 Guideline 3.5 – Anabolic agents in established
undernutrition
 We recommend that anabolic agents such as
androgens, growth hormone or IGF-1 are not
indicated in the treatment of undernutrition in adults
(1D).
 Androgens and growth hormone have
demonstrated improvement in serum albumin levels
and lean body mass but not mortality and these
medications have significant side effects.

ORAL NUTRITIONAL SUPPLEMENTS
 Guideline 3.2 – Oral nutritional supplements in
established undernutrition
We recommend the use of oral nutritional
supplements if oral intake is below the levels
indicated above and food intake cannot be
improved following dietetic intervention (1C)

CASE STUDY: MANAGEMENT
1
 Nepro was ordered for RS, which he did not consume at
first. By the end of the admission, he was consuming some
of the supplement.
He was only receiving Nepro once daily (K/DOQI
guidelines, when a patient is unable to consume enough
nutrients, use of oral supplements is indicated).
 This quantity was not enough, in view of his low oral
intake at meals. Therefore, RS’s Nepro dose was
increased to three times daily.
 liberalize the diet and monitor labs.

CASE STUDY
117150
1
150
150150
117

ENTERAL AND PARENTAL NUTRITION
Guideline 3.3 – Enteral
nutritional supplements in
established undernutrition
(1C)
Guideline 3.4 – Parenteral nutritional
supplements in established
undernutrition
(1C)

AKNOWELGEMENT
Dr. Noha Mahmoud Abdelsalam
Lecturer of internal medicine (Rheumatology and
immunology unit)
Clinical nutritionist at National Nutrition Institute
Dr. Doaa Hamed
Clinical Nutrition Associate
National Nutrition Institute

Nutrition guidelines for HD patients with PEW

Nutrition guidelines for HD patients with PEW

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