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Enrico [email protected]
Nephrology Department
Parma University Medical School
Parma - Italy
Pathophysiology of disease-related
malnutrition in CKD patients
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Agenda
• Protein-energy wasting (PEW) in ESRD on HD: causes and consequences
• Nutritional supplementation in ESRD on HD: Oral Nutritional Supplementation (ONS) and Intradialytic Parenteral Nutrition (IDPN)
• The role of specific nutrients
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Epidemiology of Protein-Energy Wasting
(PEW) in CKD/ESRD
USRDS 2009 Annual Data Report
Fouque D et al., Kidney Int 2008; 73:391-398
Kovesdy C et al. Am J Clin Nutr 2009; 29;3-14
Kovesdy CP et al. Am J Clin Nutr 2013; 97: 1163-1177
PEW is a frequent
finding in ESRD
PEW prevalence
increases from
stages 3 to 5
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Protein-Energy Wasting (PEW) is associatedwith increased mortality risk in HD patients
Kalantar-Zadeh, K. et al. Nephrol Dial Transplant 2005; 20:1880–1888
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Protein Energy Wasting: the final pathway of «poor» dialysis», «poor» nutrition, and «poor» clinical conditions
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Pathogenesis of PEW in ESRD patients: the result of complex interactions between acute/chronic comorbidities, reduced nutrient
intake and anorexia, loss of nutrients, catabolism, and inflammation
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Sabatino A, Fiaccadori E. NDT 2015; 30:924-933
Intestinal dysbiosis (i.e. changes in intestinal bacterial
flora) could represent an important proinflammatory
condition in ESRD
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PEW
Complications
of PEW
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The concept of «vicious circle» of PEW in CKD/ESRD:
PEW leads to complications, complications lead to PEW
Ikzler TA et al. Kidney Int 2013; 84: 1096-1107
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The ultimate goal of
nutritional
supplementation in
ESRD patients on
dialysis is to
prevent/break the
vicious circle of PEW
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Reaching and maintaining
macronutrientstargets in ESRD
Giving the right nutrients to counteract
the main factorsinvolved in the
pathogenesis of PEW
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What are the nutrient intake targets in ESRD patients on dialysis?
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When spontaneous
nutritional intake is not
enough
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Nutritional support in ESRD patients
• Oral nutritional supplementation (ONS), as intradialytic or daily ONS
• Enteral nutrition (n.g. tube, PEG)
• Parenteral nutrition (in-hospital PN; home PN; intradialytic parenteral nutrition, IDPN)
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ESPEN Guidelines on PN in Adult Renal Failure, Clin Nutr 2009; 28:401-414
The starting point for planning nutritional supplementationis the evaluation of spontaneous intake of nutrients
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Intradialytic oral supplementation
• Snacks during dialysis
• Intradialytic (commercial) liquid oral supplements
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Advantages are likely to be
more than adverse effects
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Standard
enteral diet
Renilon 7.5 Nutricomp
Drink Renal
Nepro HP
Nutricia BBraun Abbott
Kcal/ml 1 2 2 1.8
Prot, g/L 40 75 70 81
Energy
ratio %
16 prot
35 fat
49 CHO
15 prot
45 fat
40 CHO
14 prot
44 fat
40 CHO
18.1 prot
48.4 fat
33.5 CHO
8.4 g FOS
Na/K,
mmol/L
43.5 Na
38.5 K
25.6 Na
5.6 K
39.6 Na
41.3 K
30 Na
27 K
Fibers no no yes yes
Omega -3 Not always no yes yes
Liquid oral supplements for ESRD on HD
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What can be expected from ONSby using commercial liquid diets
• Single 200 ml can 360-400 kcal, 14-16 g protein
• Intradialytic administration (one can) total weekly supplementation 1100-1200 Kcal, 42-48 g protein
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Kaplan-Meier curve
shows survival probabilities
by nutritional supplement
protocol (NSP) status,
derived from propensity
score– matched analyses,
for the primary
cohort
Survival is improvedwith intradialytic ONS
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ONS
No ONS
Hospitalization rates lowerwith intradialytic ONS
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Two daily
servings
containing 40
Kcal and 14 g
of proteins
Nutritional status improvedby intradialytic ONS
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Intradialytic parenteral nutrition (IDPN) is a specific form of nutritional supplementation for ESRD patients on hemodialysis, based on
the administration of nutrients (usually a mixture of amino acids, dextrose and lipids as lipid emulsions) during each dialysis session
What is IDPN
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Hemodialysis
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Hemodialysis with IDPN
The use of a
parenteral nutrition
pump is mandatory
All-in-
one
bag
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Modalities of IDPN
Pharmacy-compounded IDPN
Commercial all-in-one admixtures
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Sabatino A & Fiaccadori E, J Nephrol 2014; 27:377-383
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Sabatino A, Fiaccadori E, J Nephrol 2014; 27:377-383
All-in-one total admixtures for IDPN
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Safe IDPN
• Volume: not more than 1000 ml/dialysis
• Infusion rate: not more than 250 ml/hour*
• Aminoacids: not more than 50 g/dialysis
• Glucose: not more than 500 Kcal/dialysis
• Lipids: < 1 g/Kg/dialysis, i.e. not more than500 Kcal/dialysis
* 3 ml/Kg/hour
Sabatino A, Fiaccadori E, J Nephrol 2014; 27:377-383
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What we can expect from IDPN
• 1 L of IDPN /dialysis (1000 Kcal, 50 g of AA) for three HD/week
• Weekly amount of nutrients by IDPN: 3000 Kcal + 150 g
• 10-15% of AA lost through the filter
• Daily supplementation (including non dialysis days): 5-6 kcal/Kg/day, 0.25 g/Kg/day of AA i.e, not more than 20-25% of ideal daily nutrient intake targets
Sabatino A, Fiaccadori E, J Nephrol 2014; 27:377-383
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Practical aspects and safety during IDPN
Sabatino A, Fiaccadori E. Sem Dial 2018, in press
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Is IDPN safe in daily
clinical practice?
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Low rate of metabolic complicationsduring IDPN in ESRD patients on HD
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What are the nutritional
effects of intradialytic nutritional
support in ESRD patients?
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Positive effects of intradialytic
nutritional support (oral or parenteral)
• Improved energy balance
• Improved protein (AA) balance
• Improved albumin synthesis rate
• Improved nutritional parameters
Pupim LB et al., Sem Nephrol 2006; 26:134-157
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Positive effects of ONS on nutritional status
ONS and nutritional outcomes
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Positive nutritional and metabolic effects of IDPN
on nutritional status in ESRD
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The FINE study from France:
One-yr IDPN on top of optimaldaily oral supplementation
(limitation in the study design by the local IRB)
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The role of specific nutrients in the nutritional supplementation for ESRD
patients: fibers and omega-3 fatty acids
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Adequate fiber intake,
by improving
intestinal dysbiosis,
may reduce
inflammation
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Inverse relationship between fiber intakeand inflammation in
CKD
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Potential effects of long-chain n-3 fatty acids on outcomes in HD
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Higher omega-3 fatty acid intake associated with reduced CRP values
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Take home messages
• Protein-energy wasting (PEW) is frequent among ESRD patients on dialysis and represents a negative prognostic factor
• Nutritional support is able to improve nutritional status in ESRD and, likely, the vicious circle of PEW
• Along with ONS, IDPN is a safe and effective modality for nutritional supplementation in selected patients
• Some specific nutrients, such as fibers and omega-3 fatty acids may exert positive effects beyond the simple nutritional supplementation effect