PRINSIP TERAPI NUTRISI PASIEN DIALISIS

PRINSIP TERAPI NUTRISI PASIEN DIALISIS
Haerani Rasyid
Sub Divisi Ginjal Hiprtensi
Departemen Ilmu Penyakit Dalam
FK UNHAS
2015
Pendahuluan
Status nutrisi individu dipengaruhi oleh berbagai faktor
- Intake makanan
-
Jumlah dan kualitas makanan
Kondisi individu
Tujuan penilaian nutrisi
- Status fxonal, intake makanan dan komposisi
tubuh (refleksikan kalori dan protein )
- Memprediksi morbiditas dan mortalitas
- Memprediksi lama tinggal/biaya di RS
Bagaimana dengan pasien
Dialisis??
Memperbaiki
asupan makan
Meningkatkan
pengetahuan gizi
Dukungan nutrisi untuk
perbaikan metabolik
Tujuan
Tatalaksana Gizi
Mencapai dan
mempertahankan status gizi
baik
Mencegah PEW
Faktor-faktor yang mempengaruhi gangguan status nutrisi
pasien PGK non-D / PGK - D
Condition
Mechanism
Anorexia
Inadequate protein or calorie
intake
Metabolic acidosis
Stimulation of amino acid and
protein degradation
Infection/inflamatory illness
Stimulation of protein
degradation
Diabetes
Stimulation of protein
degradation and suppression
of protein synthesis
Profil nutrisi pasien CKD
Pre-ESRD Dialysis
Transplant* Transplant
1. Malnourished
(Undernutrition)+
++
++
+/-
2. Obese
+
+
++
++
* first 3 months
(An expert panel from the International Society of
Renal Nutrition and Metabolism proposed the term
‘protein energy wasting’ (PEW) to designate
malnutrition in kidney diseases)
Protein Energy Wasting’ (PEW) 
Malnutrisi Penyakit Ginjal
Kronik
NDT Plus (20 ) 3: 118–124
The International Society of Renal
Nutrition and Metabolism (2013)
Wasting bukan hanya
disebabkan oleh asupan zat gizi
yang inadekuat atau meningkatnya
kehilangan zat gizi
Kovesdy CP, Kopple JD, KalantarKalantar-Zadeh K. Management of proteinprotein-energy wasting in nonnon-dialysis
dependent chronic kidney disease: reconciling low protein intake with nutritional therapy. Am J Clin
Nutr 2013;97:1163
2013;97:1163--77
2 tipe malnutrisi / PEW
„Type II“
„Type I“
„uremic“ malnutrition/wasting
Pupim L, Ikizler TA: Uremic malnutrition: New insights into old problem.
Semin Dial 2003; 16: 224-232
Uremic Condition
Patomekasme inflamasi menyebabkan PEW
Perbedaan tipe Malnutrisi / PEW pasien CKD
Factors
Serum Albumin
Comorbidity
Presence of inflamation
Food intake
Resting energy
expenditure
Oxidative catabolism
Reversed by dialysis and
nutritional support
Type 1
Type 2
Associated with uremic
syndrome
Associated with MIA
syndrome
Normal/low
Uncommon
No
Decreased
Normal
Increased
Decreased
Yes
Low
Common
Yes
Low/Normal
Elevated
Markedly Increased
Increased
No
Clinical Queries : Nephrology I (2012) ; 222-235
Kriteria Diagnostik PEW
Suggested by the PEW Consensus Conferences
PRIMARY CRITERIA
SUPORTIVE CRITERIA
1. Biochemical markers
Albumin < 3.8g/dl (BCG)
Prealbumin (transthyretin) < 30mg/dl (dyalisis pts)
Total cholesterol < 100mg/dl
2. Body composition indices
Body Mass Index <22 kg/m2 (<65 years) or <23 kg/m2
(>65 years)
Unintentional weight loss > 5% over 3 mo or 10% over 6
mo
Total body fat percentage < 10%
3. Muscle mass
Muscle wasting 5% over 3 mo or 10% over 6 mo
Reduced mid-arm muscle circumference area
Creatinin appearence
4. Dietary intake
Unintentional dietary protein intake (DPI) < 0,80
g/kg/day
(Evidence indicates that ≤ 1.0 g protein/kg/day may
engender protein wasting in some patients)
Unintentional dietary energy intake (DEI) < 25
Kcal/kg/day
(Data indicate that some patient may need ≥ 30 kg/day)
1.Appetite,food intake, and energy expenditure
Appetite assessment
Food frequency questionnaires
2. Body Mass and composition
Total body nitrogen or potassium
Energy-beam based methods
Dual-emmision X-ray absorptiometry
Bioelectric Impedance Analysis
Near Infrared Reactance
3.Other laboratory biomarkers
Serum biochemistry : transferin, urea, triglyceride,
bicarbonate
Hormones : leptin, ghrelin, growth hormones
Inflammatory markers : CRP,IL-6, TNF-α, IL-1β,SAA
Peripheral blood cell count lymphocyte count or percentage
4.Nutritional scoring systems
Subjective Global Assessment
Malnutrition-Inflation Sore (MIS )
5.Other novel markers
14kD Actin fragment [82,97]
Gelsoiln [98]
Nutritional Management of Renal Disease
http://dx.doi.org/10.1016/B978-0-12-391934-2.00011-4
INTERVENSI NUTRISI
Penyakit Ginjal Kronik
Laju Filtrasi Glomerulus 
Konsentrasi solut meningkat
(urea, kreatinin, fosfat, sulfat, as. urat, H+,
fenol,guanidin, as. organik, indol, mioinositol,
poliamin, 2-mikroglobulin, Al, Zn, Cu, Fe)
Gangguan metabolisme tubuh
Pasien hemodialisis
Gangguan metabolisme glukosa
Gangguan metabolisme lipid
Gangguan metabolisme protein
Gangguan metabolisme asam amino
Gangguan metabolisme glukosa
Resistensi Insulin
Hipoglikemia
Gangguan metabolisme lipid
Abnormalitas utama lipid sirkulasi
Kwan BCH; Kronenberg F, Beddhu S, and Cheung AK: Lipoprotein metabolism and lipid management in chronic kidney disease. J Am Soc Nephrol 18: 1246-1261, 2007
Gangguan Metabolisme Protein
 Terjadi peningkatan turnover protein otot
dan protein di seluruh tubuh
 Penyebab kehilangan lean body mass
pasien HD:
 Inflamasi meningkatkan katabolisme
protein
 Inflamasi sistemik terjadi (50% pasien)
 Penyebab sindroma inflamasi pasien HD
kronik :
Gangguan metabolisme Asam amino
BCAA
Essential AA
Non
Non--essential AA
Special AA
threonine
lysine
serine
valine
leucine
isoleucine
oxidation in
muscles
NORMAL
KIDNEY
glycine
phenylalanine
hydroxylation
tyrosine
citruline
cystine
aspartate
methionine
methyl
methyl-histidine
tryptophane
arginine ↓
protein binding
Mitch WE. Handbook of Nutrition and the Kidney, 2003
Essential AA
Non
Non--essential AA
Special AA
BCAA↓
valine ↓ ↓
leucine ↓
isoleucine ↓
threonine ↓
lysine ↓
serine ↓
decrease
production
oxidation in
muscles
metabolic
acidosis
glycine ↑
citruline ↑
cystine ↑
aspartate ↑
methionine ↑
methyl
methyl-histidine
↑
KIDNEY
FAILURE
defective
phenylalanine
hydroxylation
tyrosine ↓
tryptophane ↓
arginine ↓
reduce
protein binding
Mitch WE. Handbook of Nutrition and the Kidney, 2003
Abnormalitas asam amino pasien PGK-HD
Amino Acid
type
changes
Valine
Leucine
Iso--leucine
Iso
E
E
E
↓↓
↓
↓
Threonine
Lysine
Serine
E
E
NE
↓
↓
↓
Tyrosine
Tryptophane
spE
E
↓
↓
Glycine
Aspartate
Methionine
Methyl-Methyl
Histidine
NE
NE
E
↑
↑
↑
spAA
↑
Rekomendasi asupan protein dan energi pasien HD kronik
Kebutuhan mineral pasien HD kronik
Rekomendasi asupan mikronutrien pasien HD
Alur dukungan nutrisi pasien HD PEW
SGA or MIS
indikasi
Kontra indikasi
oral
dosis
ESPEN Guidelines on Parenteral Nutrition. Clin Nutr 2009
Cara pemberian
Monitoring
Pasien CAPD
Nutritional status of PD and HD
patients
PD
HD
51
169
Well-nourished
34 (67%)
139 (82%)
Mildly
malnourished
8 (15%)
24 (14%)
Moderately
malnourished
7 (14%)
6 (4%)
Severely
malnourished
2 (4%)
0
Total
33% of PD patients were malnourished compared to 18% of HD patients.
Park YK et al, J Ren Nutr 1999; 9: 149-56
• Asupan makan
tidak cukup
• Metabolisme zat
gizi abnormal
• Inflamasi
• Abnormalitas
hormonal
• Cepat kenyang dan perut
terasa penuh
• Waktu pengosongan lambung
lambat karena dialisat
menyebabkan aktivitas
elektrik lambung abnormal
• Distensi abdomen akbat
dialisat
• Peningkatan leptin
Pola dan
Nafsu Makan
• Nyeri abdomen, konstipasi,
diare, stool urgency
Gejala GI
• Kehilangan PD > HD
• Peritonitis >> 15100 g/hari
• Loss terutama
albumin dan
immunoglobulin
Kehilangan
protein
• Cairan dialisat
mengandung glukosa
• Agen osmotik
• Absorpsi sekitar 100 – 200
g glukosa per hari (20%
asupan energi total)
• Absorpsi glukosa dapat
diestimasikan sebagai
kalori yang diabsorbsi
Absorpsi glukosa
(membran
peritoneum)


CAPD  60% glukosa yang diabsorpsi
Setiap gram glukosa  3.4 kcal
Dialysate
(dextrose
concentration)
Gram of
dextrose/L
Kcal/L from
dextrose
Kcal/L with CAPD
1.5 %
15
51
31
2.5%
25
85
51
4.25%
42.5
144.5
86.7

Pasien CAPD menggunakan 4 L of 1.5%
dialysate and 4 L of 4.25% dialysate perhari
 4 L 1.5% = 124 kcal (31 kcal/L x 4 L)
4 L 4.25% = 346.8 kcal (86.7 kcal/L x 4 L
Total Kcal absorbed = 470 kcal
Rekomendasi :
Protein dan energi pasien CA PD
Mineral dan vitamin pasien CAPD
Algoritme tatalaksana PEW pada PD
Algorithm for nutritional management and support in patient with CKD
(Clinical Journal of the American Society of Nephrology)
Nutritional Assessment (as indicated)
Sprealb, SGA, Anthropometrics
*Periodic Nutritional Screening
Salb, Weight, BMI, MIS, DPI, DEI
Continuous Preventive Measures :
Continuous Nutritional Counseling
Optimize RRT-Rx and Dietary Nutrient Intake
Manage co-morbidites (Acidosis,DM,Inflamation,CHF,Depression)
•
•
•
•
•
•
Salb > 3,8 ; Sprealb >28
Weight or LBM gain
•
•
•
•
Indication for Nutritional Interventions Despite Preventive Measure :
Poor appetite and/or poor oral intake
DPI<1,2(CKD 5D) or <0.7(CKD 3-4:DEI<30Kcal/kg/d
Unintentional weight loss >5% of IBW or EDW over mo
Salb < 3,8 g/dl or Sprealb < 28 mg/dl
Worsening Nutritional Markers Over Time
SGA in PEW range
Start CKD-Specific Oral Nutritional Supplementation :
•CKD 3-4 : DPI target of > 0.8g/kg (±AA/KA or ONS)
•CKD 5D : DPI target >1.2g/kg/d (ONS at home or during dialysis
treatment ; in-centre meals)
Maintenance Nutritional Therapy
Goals :
Salb > 4.0g/dl
Sprealb > 30 mg/dl
DPI > 1,2 (CKD-5D) & >0.7 g/kg/d
(CKD 3-4)
DEI 30-35 Kcal/kg/d
•
•
•
•
Intensified Therapy :
Dialysis prescription alterations
Increase quantity of oral therapy
Tube, feeding or PEG if indicated
Parenteral interventions :
• IDPN (esp.if salts <3.0g/dl)
• TPN
•
•
•
•
No Improvement
or Deterioration
Adjuvant Therapies :
Anabolic hormones
• Androgen,GH
Appetite stimulants
Antiinflamatory interventions
• Omega 3; IL-1ra
Exercise (as tolerated)
Interventions to prevent and/or treat PEW in CKD patients
(1) Pre-dialysis patients
- Optimal dietary protein and calorie intake
- Optimal timing for initiation of dialysis, before onset of indices of malnutrition
(2) Dialysis patients
- Appropriate amount of dietary protein intake (> 1.2 g/kg/day) along with nutritional
counseling to encourage increased intake
- Optimal dose of dialysis (Kt/V > 1.4 or URR > 65%)
- Use of biocompatible dialysis membranes
- Enteral or intradialytic parenteral nutritional supplements (hemodialysis) and amino acid
dialysate (peritoneal dialysis) if oral intake is not sufficient
- Growth factors (experimental):
• Recombinant human growth hormone
• Recombinant human insulin-like growth factor-I
(3) Transplant patients:
- Appropriate amount of dietary protein intake
- Avoidance of excessive use of immunosuppressives
- Early reinitiation of dialytic therapy with proper steroid tapering in patients with chronic rejection
Kidney Int. 1996;50:343-357
Laporan 3 pasien CAPD dengan
intervensi nutrisi
KASUS 1
KASUS 1
KASUS 2
KASUS 3
KASUS 2
KASUS 3
Summary of Clinical Practice Guideline for Nutrition in CKD
Frequency of screening for PEW in CKD
Weekly for inpatient
2-3 mo for outpetients with eGFR < 20
but not on dialysis
Within one mo of commencement of
dialysis then 6-8 weeks later
4-6 mo for stable haemodialysis patients
4-6 mo for stable peritoneal dialysis
patients
Nephron Clin Pract 2011; 118 (suppl):c153-c164