1. Aasim Ahmad ahmadaasim@yahoo.com
(Mal)Nutrition & CKD
Aasim Ahmad

2. Outline Goals of CKD management Terminologies Burden Causes Evaluation
Rationale

3. Goals of CKD Management
Achieve/maintain optimal nutritional status
Prevent protein energy malnutrition
Slow the rate of disease progression
Prevention/treatment of complications and other medical conditions DM
HTN
Dyslipidemias and CVD
Anemia
Metabolic acidosis
Secondary hyperparathyroidism

4. Nutrition & CKD an age old issue
“After the first hemodialysis sessions in the early sixties, Dr Scribner rapidly pointed out key questions that emerged after these first treatments: how to better control blood pressure, how to manage chronic anemia, and which nutrients should be recommended to these patients. Fifty years later in 2010, the two first issues have been largely solved. By contrast, there is still much to do to fight protein–energy wasting as present epidemiological studies report between 30 and 50% of patients with signs of malnutrition”.
Nutrition and chronic kidney disease Kidney International (2011) 80

5. Extensive literature on nutrition & CKD

6. Terminologies used
Malnourishment -pure malnutrition can be associated with reduced serum albumin concentrations, but marked reductions are unusual
Inflammation -while the presence of inflammation is frequently associated with a decrease and sometimes marked reductions of albumin in serum albumin
Protein Energy Wasting (PEW) -
Cachexia - very severe form of PEW, often associated with profound physiological, metabolic, psychological, and immunological disorders

7. Protein–energy wasting is determined by anorexia, increased protein catabolism and enhanced resting energy expenditure, with inflammation playing a major role and leading to accelerated protein catabolism and reduced muscle and liver protein synthesis

8. This consensus paper recommends the term
Protein-energy wasting (PEW) instead of malnutrition due to the tremendous influence of inflammation, uremia, and catabolism on nutrition status. The consensus paper recommends standardizing the diagnosis of PEW with 4 categories of assessments

9. Protein-Energy Wasting
(PEW) Categories
Malnutrition Clinical
Characteristics
Energy intake
Weight loss
Fat loss
Muscle wasting
Fluid accumulation
Hand grip strength
Appetite, food intake, energy expenditure
Body mass and composition
Nutrition scoring (SGA, MIS)
Laboratory markers

10. Deterioration of Nutritional Status Begins Early
GFR 28 – 35 mL/min or greater
Protein–energy wasting affects up to 70–75% of patients with end-stage renal disease
Protein Energy Malnutrition (PEM) is often present at the time patients begin dialysis.
Malnutrition in pts beginning dialysis is a strong predictor of poor clinical outcome

11. Causes of PEW in CKD Patients
1. Decreased protein and energy intake
a. Anorexia
i. Dysregulation in circulating appetite mediators
ii. Hypothalamic amino acid sensing
iii. Nitrogen-based uremic toxins
b. Dietary restrictions
c. Alterations in organs involved in nutrient intake
d. Depression
e. Inability to obtain or prepare food
Etiology of the Protein-Energy Wasting Syndrome in Chronic Kidney Disease: A Consensus Statement From the International Society of Renal Nutrition and Metabolism (ISRNM) Journal of Renal Nutrition, Vol 23, No 2 (March), 2013

12. 2. Hypermetabolism a. Increased energy expenditure
i. Inflammation
ii. Increased circulating proinflammatory cytokines
iii. Insulin resistance secondary to obesity
iv. Altered adiponectin and resistin metabolism
b. Hormonal disorders
i. Insulin resistance of CKD
ii. Increased glucocorticoid activity

13. 4. Decreased physical activity 5. Decreased anabolism
3. Metabolic acidosis
4. Decreased physical activity
5. Decreased anabolism
a. Decreased nutrient intake
b. Resistance to GH/IGF-1
c. Testosterone deficiency
d. Low thyroid hormone levels

14. 6. Comorbidities and lifestyle
a. Comorbidities (diabetes mellitus, CHF, depression,
coronary artery disease, peripheral vascular disease)
7. Dialysis
a. Nutrient losses into dialysate
b. Dialysis-related inflammation
c. Dialysis-related hypermetabolism
d. Loss of residual renal function

15. Schematic representation of the causes and manifestations of the protein–energy wasting syndrome in kidney disease
A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease Kidney International

16. Evaluation

17. Clinical practice guidelines-UK Renal association
Guideline – Screening methods for undernutrition in CKD
We recommend that all patients with stage 4-5 CKD should have the following parameters measured as a minimum in order to identify undernutrition (1C):
Actual Body Weight (ABW) (< 85% of Ideal Body Weight (IBW))
Reduction in oedema free body weight (of 5% or more in 3 months or 10% or more in 6 months)
BMI (<20kg/m2)
Subjective Global Assessment (SGA) (B/C on 3 point scale or 1-5 on 7 point scale)

18. 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 commencement of dialysis then 6-8 weeks later
4-6 monthly for stable haemodialysis patients
4-6 monthly for stable peritoneal dialysis patients
Screening may need to occur more frequently if risk of undernutrition is increased (for example by intercurrent illness)

19. Subjective Global Assessment
Valid assessment tool
Strong correlation with other subjective and objective measures of nutrition
Highly predictive of nutritional status in a number of different patient groups including CKD
Quick, simple and reliable

20. Subjective Global Assessment
Recognized by KDOQI as a useful measure of PEM
Provides a nutritional score based on 2 components
Medical history: history of wt. loss (6 months), eating habits, GI symptoms, physiological functions and metabolic stress
Physical assessment: visual assessment of loss of subcutaneous fat and muscle mass
Patient is scored on a 7–point scale (1)
6-7 well nourished
3,4,5 mild to moderately nourished
1 or 2 severely malnourished

21. Subjective Global Assessment
History
Unintentional weight loss over the past 6 months
Pattern and amount of weight loss is considered
Weight change in past 2 weeks
Weight of <5% is small, loss >10% is significant
Dietary intake change (relative to normal)
GI symptoms >2 weeks (nausea, vomiting, diarrhea, anorexia)
Functional capacity (energy level: daily activities, bedridden)
Metabolic demands of primary condition noted

22. Subjective Global Assessment
Physical Exam
Each feature is noted as normal, mild, moderate, or severe based on clinician’s subjective impression
Loss of subcutaneous fat measures in the triceps and the mid-axillary line at the lower ribs
Muscle wasting in the quadriceps and deltoid area
Presence of edema in ankle or sacral region
Presence of ascites

23. SGA Rating Determined by subjective weighting
May choose to place more emphasis on weight loss, poor dietary intake, subcutaneous tissue loss, muscle wasting
Must be trained in this technique to achieve consistency
Scoring may predict development of infection more accurately than other objective measures of nutritional status (albumin)
A = well nourished (60% reduction in post-op complications)
B = moderately malnourished ( at least 5% wt loss with decreased intake and subcutaneous loss)
C = severely malnourished (4X more post op complications, 10% wt loss and physical signs of malnutrition)
Ascites and edema decrease significance of body weight

24. Subjective Global Assessment
Advantages
Predicts post-surgical complications
Does not require lab testing
Can be taught to a broad range of health professionals
Compares favorably with objective measurements
Validated in liver transplant, dialysis, and HIV patients
Disadvantages
Subjective and dependent on the experience of the observer
Not sensitive enough to use in following nutrition progress

25. Optimal Nutritional Status
Albumin > 4.0
Stable, desirable dry weight
Adequate fat stores and muscle mass
Appropriate appetite and intake

26. Low Albumin Non-nutritional factors Infection Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Blood loss
Metabolic acidosis

27. Calories Recommended energy intake = 30 to 35 day kcals/kg Challenges
Spares body protein
Maintains neutral nitrogen balance
Promotes higher serum albumin levels
Challenges
Decreased appetite from uremia
Various CKD dietary restrictions
Finding food sources for added calories

28. Stages of CKD Nutrient Recommendations
Pro
g/kg
Kcal
Na+
g/day K+
Phos
Calcium 1
.75
Based on energy expenditure
1-4 g to NAS
No restriction
Unless high
Monitor and restrict if nec 2 3
mg/day 4 .6
30-35 kcal/kg
<2000 mg/day 5

29. protein

30. Protein Important for growth and maintenance of body tissue
Provides energy and fights infection
Keep fluid balance in the blood
2 types of Protein
High Biological Value (HBV) or animal protein-meat, fish, poultry, eggs, tofu, soy milk, and dairy
Low Biological Value (LBV) or plant protein – breads, gains, vegetables, dried beans and peas and fruits

31. Reduction of protein intake
Most of the scientific societies worldwide recommend a daily allowance of 0.6–0.8 g protein/kg/day for CKD 3-5 patients with or without diabetes
Decreasing protein intake is particularly important in patients with proteinuria, including those with diabetic nephropathy,
decreases proteinuria as efficiently as ACE-I
has an additional effect on proteinuria reduction
improves serum lipid profile
Decreases cardiovascular mortality

32. K/DOQI protein guidelines
(Average American Intake = 1.2 g per kg/day)
0.75 grams per kg/day for CKD stages 1 thru 3
0.6 grams per kg/day for CKD stages 4, 5
50% of the dietary protein should be HBV
HBV protein produces less nitrogenous waste
45 to 60 grams protein per day
No Protein Restriction for Dialysis Patients
1.2 g per kg/day hemodialysis
10-12 grams lost per HD treatment
1.3 g per kg/day peritoneal dialysis
5-15 grams lost per PD treatment

33. Dietary Protein Restriction…
Reduces nitrogenous waste
Reduces inorganic ions
Reduces metabolic/ clinical disturbance (uremia)
Slows rate of decline in GFR

34. Reduction of protein intake
Limiting protein intake is associated with an instant
decrease in wasted products and uremic toxins, blood urea
nitrogen levels, and acid load.
reduction in oxidative stress, amelioration of insulin resistance,
better control of metabolic bone disorders in response to a reduced phosphate load, and subsequent improvement in anemia

35. Protein in Foods 1 oz meat, poultry, fish = 7 g 1 cup milk = 8 g
¼ cup tuna
½ cup beans, peas, or lentils
2 Tablespoons peanut butter
2 egg whites = 7 g
1 cup milk = 8 g
1 oz cheese
1/3 cup cottage cheese
1 cup veg = 2 g
1 slice bread = 3 g
½ cup rice or pasta
½ cup cereal
Fruit, fats, sugars = 0

36. Protein The following list contains foods and their protein content:
▪ 1 egg=7 g protein ▪ 1-2 ounce (oz) chicken thigh=14 g protein ▪ 8 oz skim milk=8 g protein ▪ 1 slice of bread=2 g protein ▪ 1 cup (C) cooked rice=4 g protein ▪ ½ C corn=2 g protein

37. Phosphorous

38. Phosphorus
A mineral found in almost all foods.
Normal kidneys will balance the amount of phosphorus in our bodies. When the kidneys fail the phosphorus increases in the blood.
It is necessary to limit and/or avoid high-phosphorus foods.
Control of phosphorus is often difficult for kidney failure patients.
Dietary goal is 1-1.5gms/day
Normal range <5.5

39. Phosphorus Foods high in phosphorus include: Dairy products
Dried beans and peas
Nuts
Peanut butter
Bran cereals
Whole wheat bread
Meats
Food Additives

40. Sodium

41. Low sodium intake
High dietary sodium intake is associated with high blood pressure, worsening of proteinuria and a blunting of the response to agents that block the RAAS (it also increases thrist)
Irrespective of blood pressure, dietary sodium restriction should be a component of nutrition therapy for all patients with proteinuria, including those on RAAS blockade
Effect of reducing sodium in diet is more pronounced in
Hypertensives
Elders
African Americans

42. Guidelines
Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend a sodium restriction of less than 2000 mg per day in people with stages 1 through 4 CKD
Canadian Hypertension Education Program(CHEP) guidelines recommend limiting sodium intake to no more than
1500 mg of sodium per day for those younger than 50 years of age
1300 mg for those between 50 and 70 years of age
and no more than 1200 mg for those over the age of 70

43. Limitation
Restricting sodium intake to the recommended levels is often difficult to achieve in practice, especially for those younger and more active individuals requiring larger caloric intakes. Nutrition counselling should focus on processed and prepackaged foods (including canned soups and deli meats), meals taken outside of the home and bread products that have high sodium content.

44. DASH Diet
Dietary Approaches to Stop Hypertension (DASH) diet is a dietary pattern commonly recommended, along with a sodium restriction, for nutritional treatment of hypertension in people with diabetes because of its potent reductions in both blood pressure and its effect on insulin resistance
Principles of the DASH diet include the use of whole grains, fruits and vegetables, and low-fat dairy products. As a result, the diet is designed to be high in potassium and phosphorus and may be best suited only to individuals with stage 1 to 2 CKD

45. Algorithm for nutritional management

46. Protein, sodium & phosphorous
0.6Gms/Kg = 42 Gms Proteins, Na 1500mg & Phos 1500 mg
Protein Sodium Phos
Egg Gms 55 mg mg
Glass of milk 8.2 Gms 100 mg mg
Half a Chicken breast 15 Gms 35 mg mg
Meat (same size as above) 13 Gms 35 mg mg
Lentils 8 Gms 02 mg mg
3 Bread/chapatis 9 Gms 450 mg/ mg
1 pinch of table salt

47. Conclusion
• The nutritional response to therapy is directly correlated with severity of PEW at baseline.
• The nutritional response to therapy is directly correlated with the amount of nutrients delivered.
• Underlying systemic inflammatory response does not hinder the beneficial effects of nutritional supplementation.
• Diabetic patients differ in their response to nutritional therapy and may require individualized prescription

48. The route of administration of nutritional supplementation (that is, oral or parenteral) does not have any significant effect on the response to therapy as long as equal and adequate amounts of protein and calories are provided.
• The optimal targets for dietary protein and energy intake in maintenance hemodialysis (MHD) patients is >1.2 g/kg/day and >35 kcal/kg/day, respectively.

49. • Routine nutritional markers such as serum albumin and prealbumin can be used as surrogate markers not only of nutritional status but also possibly of hospitalization, cardiovascular outcomes, and survival.

50. Thank you

52. The conceptual model for etiology and consequences of protein energy wasting (PEW) in chronic kidney disease

53. Figure 1
A conceptual model for etiology of PEW in CKD and direct clinical implications. PEW is the result of multiple mechanisms inherent to CKD, including undernutrition, systemic inflammation, comorbidities, hormonal derangements, the dialysis procedure, and other consequences of uremic toxicity. PEW may cause infection, CVD, frailty, and depression, but these complications may also increase the extent of PEW.
Journal of Renal Nutrition  , 77-90DOI: ( /j.jrn )
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54. AN INTEGRATIVE APPROACH FOR PREVENTION AND TREATMENT OF PEW IN CKD: SUMMARY AND RECOMMENDATIONS
Because of its metabolic and functional importance in whole body homeostasis, preservation of muscle mass is the ultimate goal in the management of PEW in CKD patients. In normal conditions, apart from genetic determinants, protein anabolism is determined by nutrient availability, especially amino acids, and a greater ratio of anabolic to the catabolic hormones, that is, insulin, androgens, growth factors, and catecholamines. In CKD and ESRD patients, where a number of catabolic signals dominate, it is critical to maintain a dietary protein and energy intake relative to needs. Preemptive treatment of concurrent conditions that contribute to catabolism, such as metabolic acidosis, insulin resistance, and systemic inflammation, is of paramount importance for the prevention of development PEW. A holistic approach to dialytic prescription is necessary to avoid the adverse nutritional side effects of uremic toxin retention. Nonconventional dialytic strategies may remove the necessity for overrestrictive diets in maintenance dialysis patients leading to improved nutritional status.38
When supplemental nutrition is indicated, it is crucial to take into account all the determinants of body and muscle mass:
protein and energy content,
exercise,
anabolizing hormones

55. Subjective Global Assessment
Alternative method to assess nutritional status of hospitalized patients
Combines information from the patient’s history with parts of a clinical exam

56. Criteria
Serum chemistry
Serum albumino 3.8 g per 100 ml (Bromcresol Green)a
Serum prealbumin (transthyretin) o30mg per 100 ml (for maintenance dialysis patients only; levels may vary according to GFR level for patients with CKD stages 2–5)a
Serum cholesterol o100mg per 100 mla
Body mass
BMI o23b
Unintentional weight loss over time: 5% over 3 months or 10% over 6
months
Total body fat percentage o10%
Muscle mass
Muscle wasting: reduced muscle mass 5% over 3 months or 10% over 6
Reduced mid-arm muscle circumference areac (reduction 410% in
relation to 50th percentile of reference population)
Creatinine appearanced
Dietary intake
Unintentional low DPI o0.80 g kg1 day1 for at least 2 monthse for
dialysis patients or o0.6 g kg1 day1 for patients with CKD stages 2–5
Unintentional low DEI o25 kcal kg1 day1 for at least 2 monthse

57. Figure 2
Response to reduced dietary protein and energy intake. (A) Normal response. Reduced dietary protein and energy drive an increase in hunger and a fall in REE, loss of protein preferentially from the visceral organs, and increased insulin sensitivity of muscle. The liver and kidney provide glucose, and serum albumin is maintained at a normal level. (B) Response with PEW. During PEW, the adaptations to increase hunger and lower REE are blunted in part by an increased half-life of leptin and ghrelin and in part by inflammation and dialysis. The loss of protein occurs preferentially from muscle because of the effects of metabolic acidosis, glucocorticoids, and inflammation, leading to increased insulin resistance. Dialysis results in the loss of amino acids, stimulating muscle protein breakdown. Under the influence of inflammation and metabolic acidosis, the liver makes glutamine for deamination in the kidney, increases acute-phase reactants, and reduces serum albumin. The kidney increases glucose production from glutamine under the influence of metabolic acidosis.
Journal of Renal Nutrition  , 77-90DOI: ( /j.jrn )
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58. Reverse epidemiology of obesity in dialysis patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:

59. Medical Nutrition Therapy Recommendations (Stages 3 to 5)
Calories
30-35 kcals/kg IBW
Protein
gm/kg IBW
Sodium mg
Fluids
Evaluate need to restrict
Potassium
Calcium
<2000mg
Phosphorus mg
Vitamins
Individualized

60. Subjective Global Assessment…features
Medical History
Weight change
Dietary intake
GI symptoms
Functional impairment
Physical Examination
Loss of subcutaneous fat
Muscle wasting
Oedema and ascites

61. Food Carbohydrate Protein Fat
4 kcals/g
Protein
Fat
9 kcals/g
1 cup milk 12 8
0 –10
1 oz meat 7
1 – 12
1 oz bread 15 3
1 cup veg 5 2
1 fruit
1 teaspoon fat/ oil