1. Nutrition in renal disease
Attaa A Ali

2. Groups of renal failure
Acute renal failure
Chronic renal failure
Stable
With critical illness
Patients on renal replacement therapy (RRT)
Intermittent haemodialysis (IHD)
Continuous renal replacement therapy (CRRT)

3. Why nutrition in renal failure patients
Malnutrition is a risk factor for death
Patient are hypercatabolic due to
The primary disease
ARF
Loose nutrients in dialysis
Renal failure affects GIT
Motility and absorption are impaired
Increased risk for GIT bleeding
Nutritional effect on regeneration of renal function

4. Malnutrition in renal disease
A prospective cohort study in 309 patients (ARF)
Severe malnutrition (By SGA) was present in 42%
LOS and Mortality was increased
Malnutrition appeared to be an independent factor of in-hospital mortality
French series of 7000 HD patients
Albumin < 3.5 mg/dl, prealbumin < 0.3 mg/dl, nPNA < 1 g/kg/d in 20%, 36%, 35% resp.
DOPPS II (HD patients)
20.5% of patients had albumin < 3.5 mg/dl
Fiaccadori E et al, J Am Soc Nephrol (1999) 10,
Aparico M et al, Nephrol Dial Transplant (1999) 14,
Port FK et al, Blood Purif (2000) 22,

5. ARF effect on nutrition
Water content
Electrolytes imbalance
Alteration of protein metabolism, amino acids
Alteration of carbohydrate metabolism
Alteration of lipid metabolism
Proinflammatory action
Profound effect on antioxidant system
Underlying disease process
Comorbidity, different organ dysfunction
Method and intensity of RRT
Cano et al, Clinical Nutrition (2006) 25,

6. Protein metabolism
Insulin resistance causes release of amino acids from muscles increasing gluconeogensis and ureagensis
Tyrosine and other amino acids becomes essential
Decrease renal synthesis of amino acids
Acidosis activates proteases
Release of cytokines (TNF-α and others)
Loss in RRT (0.2g/L of filtrate)

7. Carbohydrate metabolism
Increase available amino acids causes increase gluconeogensis uncontrolled by hyperglycaemia feedback
Insulin resistance
Inhibited glycogen synthesis in muscles
All will cause persistent hyperglycaemia
Heat loss in RRT increases caloric requirements

8. Lipid metabolism
Impairment of lipolysis with delayed fat clearance following enteral and parentral nutrition is a characteristic of renal failure that will lead to hypertriglyceridaemia.
This will manifest by elevated LDL and VLDL- cholesterol with decreased levels of HDL- cholesterol.

9. Renal Replacement Therapy
Increased proteolysis
Loss of substrates 0.2g/L filtrate
10-15g amino acids per day
Increase catabolic mediators
Increase lipid oxidation with decreased carbohydrate oxidation
Glucose losses 25g / session
Water and electrolyte disturbances
Hypophosphataemia, hypomagnesaemia, hyponatraemia
Hyperlactacidaemia, metabolic alkalosis
Loss of water soluble substrates
Vitamin B, C
L-carnitine

10. Patients on CAPD CAPD usually have better residual renal function
Peritoneal losses of various nutrients are significant
Protein 10 g/d
Amino acids 3-4 g/d 30% essential amino acids
Peritonitis increases losses to15 g/d reaching100 g/d
Protein bound micronutrients are also lost
Absorption of glucose from the dialysate is enhanced
g/d that increases with peritonitis
Induction or aggravation of diabetes, hypertriglyceridemia with increased body weight and decreased lean body weight

11. Nutritional goals (ARF)
Prevent PEM
Preserve lean body mass
Maintenance of nutritional status
Avoidance of further metabolic derangement
Enhancement of wound healing
Support of immune function
Reduction of mortality
Attenuation of inflammatory status
Improvement of the oxygen radical scavenging system and endothelial system
Cano et al, Clinical Nutrition (2009) 28, 1-14

12. Nutritional goals (CKD, RRT)
Prevent and treat PEM leading to cachexia
Ensuring the provision of optimal levels of energy, essential nutrients and trace elements
Attenuation of CKD progression through protein or phosphate restriction
Cano et al, Clinical Nutrition (2006) 25,

13. When to provide nutritional support
No specific indications
GIT is the primary route
Data on influence of PN on acute renal failure are inconclusive and there is a possible that nutritional support disregarding the route and associated kidney injury could explain the reduction of mortality and morbidity
Balance on the toxic effects of nutrients (excess nitrogen and pro-oxidants) and the need to prevent PEM is crucial
Cano et al, Clinical Nutrition (2009) 28, 1-19

14. How to provide nutritional support
GIT functioning
Increase dietary intake by augmenting energy and protein intake either by kitchen food or ONS
If targets not reached start tube feeding (TF)
If goals not reached start PN
GIT not functioning
Peripheral PN: in cases of short-term therapy with or without fluid restriction
Central PN: in cases of long-term therapy with fluid restriction
When GIT function is recovered tapper PN to EN

15. Substrate requirements (ARF)
Nutritional requirements in patients with ARF
Energy (non-protein calories)
20-30 kcal/kg/d OR other estimating formula
Carbohydrates
3-5 (max. 7) g/kg/d
Fat
(max 1.5) g/kg/d
Protein (essential and non-essential amino acids)
Conservative therapy mild catabolism
(max 1) g/kg/d
RRT, moderate catabolism
1-1.5 g/kg/d
CRRT, Severe hypercatabolism
Up to max. 1.7 g/kg/d
Cano et al, Clinical Nutrition (2009) 28, 1-14

16. Substrate requirements (ARF)
Micronutrients should be supplemented as recommended for ICU patients
Vitamin A toxicity should be monitored if supplied
Limit Vitamin C to mg/day
Selenium and thiamine should be supplied at double recommended doses in patients on prolonged CCRT
Electrolytes should be monitored and intake tailored according
Slandered enteral formula are adequate except if major electrolyte derangement is present
NO disease specific IV formula has shown to improve patients outcome
Cano et al, Clinical Nutrition (2009) 28, 1-14

17. Substrate requirements (CKD)
Nutritional requirements in patients with Stable stage III-V CKD
Energy (non-protein calories)
>30-35 kcal/kg/day
Protein
GFR = ml/min
g/kg/d (2/3 HBV)
GFR < 25 ml/min (ESPEN)
OR 0.28+EAA OR EAA+KA
GFR < 25 ml/min (NKF)
g/kg/d (intolerance or inadequate energy intake)
Proteinuria
IBW kg × × proteinuria
Electrolytes
Phosphate
mg/d
Potassium
mg/d
Sodium
g/d
Fluid
Unlimited
Adapted from: Cano et al, Clinical Nutrition (2009) 28, 1-14

18. Substrate requirements (CKD)
Overweight and undernorished patients may need adjustments of energy supply
Thiamine needed to be supplied at mg/d especially with infection, surgery and glucose rich infusions
Vitamin E should be prescribed to patients with high cardiovascular risk at a daily dose of 800 IU alpha-tocopherol
Cano et al, Clinical Nutrition (2006) 25,

19. Substrate requirements (RRT)
Nutritional requirements in patients with Stable stage III-V CKD
Energy (non-protein calories)
ESPEN
35 kcal/kg/day
NKF
<60 y 35 kcal/kg/day
> 60y 30 kcal/kg/day
EBPG-ERA
30-40 kcal/kg/day
Adjust to age, gender and acitivity
Protein
Haemodialysis (ESPEN)
g/kg/d (>50% HBV)
Haemodialysis (NKF)
1.2 g/kg/d (>50% HBV)
Haemodialysis (EBPG-ERA)
≥1.1 g/kg/d
CAPD (ESPEN)
g/kg/d (>50% HBV)
CAPD (NKF)
g/kg/d (>50% HBV)
Adapted from: Cano et al, Clinical Nutrition (2009) 28, 1-14

20. Substrate requirements (RRT)
Nutritional requirements in patients on
Minerals
Phosphate
mg/d
9-11 mmol/d
Potassium
mg/d
25-30 mmol/d
Sodium
1.8 – 2.5 g/d
mmol/d
Individual requirements may differ in acute conditions
Fluids
1000+urine volume /d
40 + urine volume /hr
Adapted from: Cano et al, Clinical Nutrition (2006) 25,

21. Substrate requirements (RRT)
Phosphorus intake should be limited to mg/kg/day
Nutrients contain phosphorus protein ratio of mg: 1g so phosphate binders are usually needed (e.g. Calcium carbonate)
Thiamine needed to be supplied at mg/d especially with infection, surgery and glucose rich infusions
Vitamin E should be prescribed to patients with high cardiovascular risk at a daily dose of 800 IU alpha-tocopherol
Cano et al, Clinical Nutrition (2006) 25,

22. Intradialytic Parentral nutrition (IDPN)
Indication
If nutritional counseling and oral nutritional supplements (ONS) fail to prevent or treat PEM
Content
kcal and g protein three times per week
Route
Venous site of dialysis catheter
Evidence
No controlled randomized studies are available
Retrospective studies suggest improved survival and decreased hospitalization rate

23. Intraperitoneal parentral nutrition (IPPN)
Indication
If nutritional counseling and oral nutritional supplements (ONS) fail to maintain nutritional goals in patients on CAPD
Mechanism
Dialysate containing a 1.1% amino acids
Adverse effects
Hypokalaemia
Hypophosphataemia
Mild acidosis

24. Intraperitoneal parentral nutrition (IPPN)
Evidence
11 studies including 4 randomized studies
Improvement of nitrogen balance and nutritional parameters in 4 cohort studies
In one randomized study benefit was only observed in hypoalbumenic patients
Another should improvement of nutritional biochemical markers which was more prominent in women (no effect on survival)

25. Thank you