pr denis fouque department of nephrology centre …...centre de recherche en nutrition humaine...
TRANSCRIPT
![Page 1: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/1.jpg)
Pr Denis FOUQUE
Department of NephrologyCentre de Recherche en Nutrition Humaine
University Claude BernardLyon - France
![Page 2: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/2.jpg)
![Page 3: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/3.jpg)
Serum Albumin (g/L)
36.1 ± 5.0 g/l
0
150
300
450
600
750
900
1050
1200
10 15 20 25 30 35 40 45 50 55 60 et +
Observatoire Phosphocalcique, January 2011
6 000 pts
PEW < 38 g/l
Normal values
![Page 4: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/4.jpg)
AJKD 2006;48-S39
Serum Albumin of MHD patients, USA, 1993-2004ESRD Clinical Performance Measures Project
![Page 5: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/5.jpg)
Protein Energy Wasting - 2008
Kidney Int 2008;73:391
![Page 6: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/6.jpg)
CV I
![Page 7: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/7.jpg)
Protein Energy Wasting - 2008
Gr 1: BiologyGr 2: Body MassGr 3: MuscleGr 4: Dietary intake
At least one criterion in 3 of the 4 groups
![Page 8: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/8.jpg)
Protein Energy Wasting - 2008
- Serum Albumin < 38 g/l (BCG)
- Serum prealbumin < 300 mg/l
- Serum cholesterol < 1 g/l
Gr 1
Biology
![Page 9: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/9.jpg)
Kalantar et al, NDT 2005
![Page 10: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/10.jpg)
Serum Prealbumin response to renutrition
Cano et al, J Am Soc Nephrol 2007
0 6 12 18 24
200
220
240
260
280
300
Serum prealbumin mg/L
Months
FineS study, oral ±IDPN support in malnourished MHD pts
+ 55 mg/l+ 23%
![Page 11: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/11.jpg)
Cano et al, J Am Soc Nephrol 2007
Albumin d0 (+1 g/L)
Creatinine d0 (+10 µmol/L)
Comorbidity (+1)
∆ Prealbumin d0-m3 (> 30 mg/L)
Hazard ratio10.0 0.25 0.50 0.75 1.25 1.50 1.75 2.001
Multivariate Cox
![Page 12: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/12.jpg)
Protein Energy Wasting - 2008
- Body Mass Index < 23 (WHO: 18.5)
- Weight loss > 5 % (3 months)
- Weight loss > 10 % (6 months)
- Body Fat < 10 %
Gr 2
Anthropometry
![Page 13: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/13.jpg)
Kalantar et al, Am J Kidney Dis 2005
WHO
![Page 14: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/14.jpg)
Kalantar et al, Am J Kidney Dis 2005
![Page 15: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/15.jpg)
Cabezas et al, C JASN 2013;8:1725
COSMOS study, 6300 MHD Fup 3 yr
Weight loss
Weight gain
![Page 16: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/16.jpg)
Kalantar et al, Am J Clin Nutr 2006
<10 %
![Page 17: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/17.jpg)
Protein Energy Wasting - 2008
-Loss of muscle mass > 5% (3 months)-Loss of muscle mass > 10% (6 months)-Reduced MAMC (>10% below 50th
percentile)-Predialysis S Creatinine (K-DOQIs)-Creatinine kinetics (Garred et al.)
Gr 3
Muscle
![Page 18: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/18.jpg)
Kalantar et al, Mayo Clin Proc 201058 000 MHD pts, retrospective 2001-06
![Page 19: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/19.jpg)
![Page 20: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/20.jpg)
Protein Energy Wasting - 2008
- Unintentional Dietary Protein Intake< 0.8 g/kg BW/day for 2 months
- Unintentional Dietary Energy Intake< 25 kcal/kg BW/day for 2 months
Gr 4
Nutrients intake
![Page 21: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/21.jpg)
Kalantar et al, Am J Clin Nutr 2004
VGG
F
P
One year survival331 californian MHD patients
![Page 22: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/22.jpg)
Carrero et al, Am J Clin Nutr 2007223 swedish MHD patients
![Page 23: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/23.jpg)
Gr 4: Dietary intake
Protein intake-Should be assessed monthly-nPNA (nPCR) or food report
Energy intake-Only by food report (every three to six month)
European Best Practice Guidelines NDT June 2007
![Page 24: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/24.jpg)
Gr 4: Dietary intake
-Unintentional Dietary Protein Intake< 0.8 g/kg BW/day for 2 months
-Unintentional Dietary Energy Intake< 25 kcal/kg BW/day for 2 months
![Page 25: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/25.jpg)
Shinaberger et al, AJKD 2006
Mortality RR
Da Vita cohort, 47 000 HD pts
![Page 26: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/26.jpg)
Defining a new predictive nutritional score
1. Which criteria1. simple, accessible, routine2. Include lean body mass
2. Which targets1. Serum Albumin > 38 g/l2. nPNA > 0.8 g/kg/day3. BMI > 234. Screat/BSA > 380 µmol/l.m2
3. Calculation0 to 4
4 : No PEWAbove all targets
0 : Severe PEWUnder all targets
Moreau-Gaudry et al, J Renal Nutr 24,2014: 395-400
![Page 27: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/27.jpg)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
0.6
0.7
0.8
0.9
1.0
Time (years)
Surv
ival
Score = 0 + 1Score = 2Score = 3Score = 4
Global score applied to the global cohort
P<0.001; Alb=38 g/dl,nPCR=0.8,BMI=23,SCr/S=380 µmol/l/m²
A new predictive nutritional index: Baseline
Moreau-Gaudry et al, J Renal Nutr 24,2014: 395-400
![Page 28: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/28.jpg)
• A new terminology: Protein Energy Wasting• A pragmatic asessment tool• A preliminary validation in patients • A potential useful predictive score• Impact of nutritional disorders most powerful on patients survival
![Page 29: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/29.jpg)
![Page 30: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/30.jpg)
Need for AA
![Page 31: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/31.jpg)
Plasma Aminoacid Profile during one Dialysis
1. The dialysis session blocks muscle protein synthesis in response to a rapid and profound decrease in plasma AA
Tx total d'AA
0
500
1000
1500
2000
2500
3000
3500
T0 T1 T2 T3 T4
te m p s (h e u re )
umol
/l
Tx total d'AA
Deléaval et al, 2007
N= 10
![Page 32: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/32.jpg)
Plasma Aminoacid Profile during one Dialysis
Muscle protein catabolism occurs in order to maintain plasma amino acids
Tx total d'AA
0
500
1000
1500
2000
2500
3000
3500
T0 T1 T2 T3 T4
te m p s (h e u re )
umol
/l
Tx total d'AA
N= 10
Deléaval et al, 2007
![Page 33: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/33.jpg)
PEW treatment
1. Oral- Enteral support2. Intradialytic nutrition (IDPN)3. Androgens
![Page 34: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/34.jpg)
Per Dialytic Oral Supplement
Veeneman Am J Physiol 2003
1. Oral supplement during the EER session
2. Every 30 min (enriched yoghourt)
3. Total: 0.6 g prot/kg + 15 kcal/kg (45 g prot, 1125 kcal)
1050 kcal x3/week = 450 kcal/d
![Page 35: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/35.jpg)
Per Dialytic Oral SupplementPlasma Amino acids
Veeneman Am J Physiol 2003
FED
![Page 36: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/36.jpg)
Per Dialytic Oral SupplementNitrogen Balance
Veeneman Am J Physiol 2003
FASFED
![Page 37: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/37.jpg)
Oral-enteral nutrition: long term
Case control study 2007-2009, FMC cohort, USA5000 pts receiving Oral supplement vs 5000 controlsS Alb < 35 g/LOne supplement during the sessionOne year, 156 food supplements
Lacson et al. AJKD 2012 60:591-600
![Page 38: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/38.jpg)
Oral-enteral nutrition: long term
Lacson et al. AJKD 2012 60:591-600
![Page 39: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/39.jpg)
No impact of inflammation (CrP < or > 10 mg/l)
Relationship between variations in Albumin and nPNA
Fouque et al, NDT 2008
![Page 40: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/40.jpg)
![Page 41: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/41.jpg)
IntraDialytic Parenteral Nutrition
IDPN standard solution
1. 600 ml (300 ml AA 15%, 150 ml IL20%, 150 Gluc 50%)
2. 150 ml/hr3. 190 kcal/hr
700-1000 kcal x3/week = 350 - 450 kcal/d
Pupim J Clin Invest 2002
![Page 42: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/42.jpg)
Pupim J Clin Invest 2002
IDPN: Plasma amino acids
![Page 43: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/43.jpg)
IDPN: Whole Body Protein Metabolism
Pupim J Clin Invest 2002
![Page 44: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/44.jpg)
• RCT in 107 MHD pts in Germany
• 4 months treatment followed by 3 months w/o treatment
Dose/kg/session x 3/wk
![Page 45: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/45.jpg)
Wash-outTreatment phase
![Page 46: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/46.jpg)
• Follow-up: two years (treatment period + one year)• Visits at day 0 and month 3, 6, 12, 18 and 24
Oral suppl + IDPNduring one year
Oral supplduring one year
182patients
Malnourished
MHD patients
![Page 47: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/47.jpg)
1. Oral supplement: 5.4 kcal/kg/d0.42 g protein/kg/d
2. IDPN : 13.8 kcal/kg/HD (5.9 kcal/kg/d)0.62 g AA/kg/HD (0.27 g AA/kg/d)
Cano et al, JASN 2007
![Page 48: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/48.jpg)
Control group IDPN group
Months0 6 12 18 24
30
34
Serum albumin, g/L
31
32
33
34
NS
Months
300
280
260
240
220
200NS
0 6 12 18 24
Serum prealbumin, mg/L
FineS ASN 2005
![Page 49: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/49.jpg)
Hernandez et al, J Renal Nutr 2014;24:42-49
120 MHD pts from Spain
RCT: Nutritional Education program vs Oral supplement for 4 months
Nutritional Education program: 12 sessions of nutritional knowledge and culinary recommendations and balanced menus
Oral supplement: Nepro®, 470 ml/session 3x / wk
![Page 50: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/50.jpg)
Hernandez et al, J Renal Nutr 2014;24:42-49
![Page 51: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/51.jpg)
• Growth hormone and IGF-1• Ghrelin• Androgens
![Page 52: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/52.jpg)
Ashby et al, Kidney Int April 2009
![Page 53: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/53.jpg)
-30
-20
-10
0
10
20
Total Arm Truncus Leg
rhGHControl
Hansen et al, Clin Nephrol 2000
![Page 54: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/54.jpg)
Feldt-Rasmussen et al, J Am Soc Nephrol 2007
![Page 55: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/55.jpg)
Feldt-Rasmussen et al, J Am Soc Nephrol 2007
Lean Body Mass Serum Albumin
![Page 56: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/56.jpg)
Anabolic Factors: Androgens
![Page 57: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/57.jpg)
Anabolic Factors: Androgens
1. In case of severe malnutrition resistant to optimal nutritional intervention, a course of androgens should be proposed in MHD patients for three to six months (Evidence level II)
2. Androgens should be administered weekly or bimonthly (Evidence level II)
3. Patients should be monitored at regular intervals for side effects (hirsutism, voice change, priapism, alteration in plasma lipids, liver tests and prostatic markers) (Evidence level II)
4. Patients with a known prostate cancer should not receive androgens (Evidence level II)
![Page 58: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/58.jpg)
Johansen et al, JAMA 1999
• Double blind RCT; 29 malnourished MHD patients
• 14 pts receiving Nandrolone decanoate, 100 mg IM weekly for 6 months• 15 pts receiving placebo• Body composition by DEXA• Quality of Life (SIP and Profile of Mood)• Functional status (treadmill and stair climbing)
![Page 59: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/59.jpg)
-4
-2
0
2
4
6
BW LBM Body Fat
NanDecPlacebo
*
*
Kg
Johansen et al, JAMA 1999
![Page 60: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/60.jpg)
Johansen et al, JAMA 1999
• Improvement in Treadmill time (+20% vs -28%)
• Increase in Maximum work output (+21% vs -35%)
• Reduction in Stair climbing time (-9% vs +8%)
• Reduction in Fatigue index (Profile of Mood States) (-50% vs +36%)
![Page 61: Pr Denis FOUQUE Department of Nephrology Centre …...Centre de Recherche en Nutrition Humaine University Claude Bernard Lyon - France Serum Albumin (g/L) 36.1 ± 5.0 g/l 0 150 300](https://reader033.vdocument.in/reader033/viewer/2022041820/5e5d3fd185c0ad578a744be2/html5/thumbnails/61.jpg)
Conclusion
Nutritional supplements: Oral / intravenous - limited
Nutritional education: it works !
Growth factors: many reasons - not enough evidence
Androgens: a possible short-term use in severe case