MANAJEMEN TERAPI NUTRISI PADA PASIEN DIALISIS KRONIK

MANAJEMEN TERAPI NUTRISI PADA PASIEN DIALISIS KRONIK

MANAJEMEN TERAPI NUTRISI
PADA PASIEN DIALISIS KRONIK
DENGAN MALNUTRISI
Afiatin
DIVISI GINJAL HIPERTENSI
DEPARTEMEN IP DALAM FK UNPAD
RS HASAN SADIKIN BANDUNG
PERNEFRI KORWIL JAWA BARAT
CURICULUM VITAE
• Afiatin
• Internist Nephrologist, Member of INASH, ISN, ISPD and ISHD
• Staff of Nephrology Division Internal Medicine Department
Medical Faculty of Padjadjaran University –
Hasan Sadikin Hospital Bandung West Java Indonesia
• Total Nutritional Therapy TRAINER
• COURSE ON MEDICAL NUTRITION TREATMENT TRAINER
• MEMBER OF NUTRITION SUPPORT TEAM IN HASAN SADIKIN
HOSPITAL
MALNUTRITION
Overnutrition
OBESITY
Undernutrition
MALNUTRITION
Macronutrient
Malnutrition
Protein
Malnutrition
(kwashiorkor)
Micronutrient
Malnutrition
Energy
Malnutrition
(marasmus)
Protein - Energy
Malnutrition / Protein Energy Wasting
MODEL KONSEPTUAL ETIOLOGI DAN KONSEKUENSI
PASIEN PENYAKIT GINJAL KRONIK DENGAN PEW
Ikizler et al, Kideny Int 2013; May: 1-12
Mortality and BMI in 54,535 hemodialysis patients
2.2
Highest
Mortality
Relative Risk of All-Cause Death
2
Unadjusted
Case-mix*
1.8
Case-mix & MICS **
1.6
1.4
Overweight
1.2
Obese
Morbidly
Obese
1
0.8
Underweight
Normal
BMI
0.6
0.4
<18
18-19.99 20-21.49
21.522.99
23-24.49 25-27.49
27.529.99
30-34.99 35-39.99 40-44.99
>=45
Body M ass Index (kg/m2)
Kalantar-Zadeh et al, AJKD 2005, & Kidney Int 2003 (& multiple other publications)
SStrategi Terapi untuk menghambat
/menangani PEW pada PGK dengan dialisis
Suplementasi nutrisi
Stimulasi nafsu makan
Koreksi asidosis
Modulasi inflamasi/ hormon
Latihan Fisik
Dialisis yang adekuat
Modified from: Robert et al., J Cachexia Sarcopenia Muscle, 2011;2:9-25
Algoritma Manajemen Nutrisi pada
pasien PGK
Nature Reviews Nephroglogy 7,369-384 : July 2011)
DIAGNOSIS KLINIS PEW
DIAGNOSIS KLINIS PEW
Nutritional Requirements of CKD Stg 5 with dialysis
(NKF KDOQI)
Nutrients
Recommended intakes per day
Peritoneal Dialysis
Energy
Protein
Hemodialysis
35 Kcal/ kg IBW - <60 yrs
30-35Kcal/ kg IBW - ≥60 yrs
1.2-1.3g/kg IBW/ day(=50% of High
Biological Value). Some nitrogen balance
studies indicate that protein intake of ≥
1.0 g/ kg IBW may be enough.
Fats
1.2-1.3g/kg IBW/ day(=50% of High Biological
Value). Some nitrogen balance studies indicate
that protein intake of ≥ 1.0 g/ kg IBW may be
enough.
30% of total energy supply
Water and
sodium
As per residual diuresis
750 – 1000 ml + diuresis
Potassium
40-80mmol. Individualized depending on
serum levels
2-3 gr/d
Calcium
Individualized, usually not <1000mg/ day
1000 mg/d
Phosphorous
8-17 mg/ kg or 800-1000 mg/ day
(adjusted to higher protein needs), when
serum phosphorous is > 5.5 mg/ dl²
800 – 1200 mg/d
¹Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting
during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd
Edn. NY: Springer, 2009: 611-647.
²National Kidney Foundation. K/DOQI clinical practice guidelines for managing bone metabolism in chronic kidney
disease. Am J Kidney Dis2003; 42(suppl 1):S1-S92
FLOW OF NUTRITIONAL SUPPORT
PROCESS
IDENTIFICATION
POPULATION AT RISK (CHRONIC DISEASE)
SCREENING
YES
YES
NO
ASSESSMENT
NO
DIAGNOSIS AND INTERVENTION
MONITORING AND EVALUATION (MONEV)
SCREENING TOOL FOR DIALYSIS PATIENTS
• MALNUTRITION INFLAMMATION SCORE
•
•
•
•
SGA : + ASPEK DIALISIS
PEMERIKSAAN FISIK
BODY MASS INDEX
PARAMETER LABORATORIUM
MIS : > 6
MALNUTRISI
MEMERLUKAN INTERVENSI
NUTRISI
STEPS
DIETARY
RECALL
DIETARY
PLAN
JANGAN MEMBUAT
RENCANA TERAPI TANPA
TAHU MASALAH
SEBENARNYA
TERAPI
MONITORING
EVALUASI
Ahli Gizi /Nutrisionist/Dietician harus
masuk dalam tim
MONITORING DAN EVALUASI TERAPI
• Buatlah jadwal untuk evaluasi
• Evaluasi dengan formulir
• Interval : tiap 2 – 4 minggu
NUTRITIONIST IS A MUST IN THE TEAM
Nutrition Support in CKD
No
Total
Parenteral
Nutrition
(TPN)
Functional GIT
Yes
Enteral
Nutrition
(EN)
HDx
1st
Tube
feeding
(TF)
Oral (+edn & counseling):
+/-
• Food fortification
• Oral nutrition
supplementations (ONS)
+/PDx
Intra- Peritoneal
Nutrition
MO:
• Control co-morbidities/
inflammation
• Medications / Appetite stimulant
Intradialytic PN
(IDPN)
Nursing
Exercise
training
Multi-disciplinary
Approach
Psychosocial support
Nutritional Therapy / Nutritional Support
Enteral
• Oral Nutrition Support
• Meals during dialysis treatment
• Tube feeding
Parenteral
• IDPN (intra-dialytic parenteral nutrition)
• TPN
Pharmacologic
• Appetite stimulators
• Anti-Depressant
• Anti-inflammatory
• Anabolic &/or muscle enhancing
Kalantar-Zadeh … Ikizler, Nature Nephrology 2011
KOMPOSISI
NUTRISI PADA PENYAKIT KHUSUS – RENAL
FAILURE
4
parenteral
parente
ral
KARBOHIDRAT
KALORI
Non-protein
protein
LIPID
enteral
MACRONUTIENT
ASAM AMINO
MiCRONUTIENT
kombin
asi
Standard
Standard
formulae
formulae
composition, which
are enteral formulae with a
reflects the reference values for
macro
macro-- and micronutrients for a healthy population.
population.
Most standard formulae contain carbohydrate, whole
protein, lipid in the form of longlong-chain triglycerides
(LCT), and fiber.
fiber.
Low, normal and high energy formulae
Normal energy formulae provide 0.9–1.2
kcal/ml,
kcal
high energy formulae are anything above
this, low energy formulae anything below.
High lipid formulae = High kalori Low volume
High lipid formulae contain more than 40% of
total energy from lipids.
High monounsaturated fatty acid (MUFA)
formulae
High MUFA formulae contain 20
20%
% or more of total energy
from MUFA.
lemak
Whole protein formulae
Whole protein formulae contain intact proteins.
Synonyms used in the literature: polymeric, high
molecular weight or nutrient defined formulae
Peptide--based energy formulae
Peptide
protein
Peptide-based
formulae
contain
protein
predominantly in peptide form (2–50 amino acid
chains). Synonyms used in the literature:
oligomeric,
oligomeric, lowlow-molecular weight, chemically
defined formulae.
formulae.
Free amino acid formulae
Free amino acid formulae contain single aminoacids
as the protein source.
Synonyms used in the literature: elemental, monomeric,
low molecular weight, chemically defined formulae.
High protein formulae
High protein formulae contain 20% or more of total
energy from protein.
Immune modulating formulae
Immune modulating formulae contain substrates to
modulate (enhance or attenuate) immune
functions.
Synonyms used in literature: immunonutrition,
immunonutrition,
immuneimmune-enhancing diets
Oral Nutrition Support
Diet counseling
(+ prescription &
meal plan)
(1)
Food
±
(2)
±
Food enriching/
fortifications
(3)
Oral Nutrition
Supplements
Characteristic/
strategy
• Use energy & nutrient
dense foods & drinks
• adding protein, fat &
CHO to foods and
drinks, e.g. egg,
cheese, milk, milk
powder sugars, fats
• commercial modules
e.g. protein powder,
tasteless sugars
• Ready –made
formula & desserts
• protein & energy
bar
Advantage
• economical
• familiar items:
• taste
• texture
• cultural specific
• economical
• familiar items:
• taste
• texture
• cultural specific
• easy to use
• convenient
• easy handling (in
institutions) staff
and hygiene
Limitation
“larger” volume
“larger” volume
• cost
• acceptance
• taste
• possible intolerance
SUMBER KALORI
NON PROTEIN
PROTEIN
Essentiale
Non-Essentiale
Conditioned
• Specific
• (NEPHROSTERIL)
KARBOHIDRAT
LIPID
DEXTROSE
NON
DEXTROSE
20%
dextrose
Mannitol
40%
dextrose
Xylitol
Sorbitol
ASAM AMINO
9 kcal
4 kcal
BCAA
(comafusin)
• Immunomodulator
• (DIPEPTIVEN)
• Ketoanalog
• (KETOSTERIL)
ENERGY
LIPIDS
Ketosteril ©
• EXAMPLE 2
Ny C , 42 tahun
CKD stg 5 on HD kronik
(2 tahun HD frekuensi 2x/
2x/minggu
minggu::
Permasalahan:
Permasalahan:
Gastropati erosiva ec NSAID
keluhan nyeri ulu hati ketika makan , mula
muntah , tidak nafsu makan.
makan.
Berat badan kering turun 4 kg dalam 2
bulan,
bulan, tidak ada diare
Lemah badan,
badan, tidak masuk kerja 2 – 3 kali
seminggu ( guru SMP )
TB: 152 cm, BB : 40 kg (BMI : 17.3, Ideal
BMI : 22--22---IBW
IBW 50.82 kg),
Laboratorium : Hb 9 gr/dl, Albumin : 3,0
gr/dl,
MIS
12
Perlu terapi
nutrisi
Clinical diagnosis of PEW
BMI : 17,3 (< 23)
Berat badan turun 4 kg/2 bulan : > 5 %
Serum Albumin : 3.0 (< 3.8 gr/dl)
Intake : ??
STEPS
DIETARY
RECALL
DIETARY
PLAN
JANGAN MEMBUAT
RENCANA TERAPI TANPA
TAHU MASALAH
SEBENARNYA
TERAPI
MONITORING
EVALUASI
Ahli Gizi /Nutrisionist/Dietician harus
masuk dalam tim
EXAMPLE
Mrs C, 40 tahun
tahun,, CKD stg 5 on chronic HD, 40 kg TB:
152 BMI :17.39
Ideal Body Weight : 50.82 kg (BMI 22)
ENERGYNUTRIENTS Requirements
Mrs C requirement
Energy
35 kcal/kg IBW/d
30 kcal/kgIBW/d(>60
yrs)
Or to attain IBW
1400 kcal/d
Protein
1.2 g/kg IBW/d
48 g/d
Sodium(mmol/d)
80-100
80-100
Potassium (mmol/d)
70
70
Phosphorus (mg/d)
<1000
1000
Fluid (ml/d))
Urine Output + 500
1000 ml
Mrs C daily intake recall
BREAKFAST
1 bowl of cereal
1 cup of tea with
2 tsp sugar
2 biscuits
LUNCH
1 cup of soft
steam rice
½ bowl of
chicken broth
Vegetable 1 cup
1 cup of tea
2 tsp sugar
DINNER
Milk 150 ml
1 cup of noodle
soup
Juice 100 ml
EXAMPLE
Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
ENERGY
NUTRIENTS
Energy
Mrs C requirement
1400 kcal/d
Mrs C actual
intake
800 kcal/d (20
kcal/d)
Protein
48 g/d
20 g/d ( 0.5
g/kg/day)
Sodium(mmol/d)
80-100
120
Potassium (mmol/d) 70
<70
Phosphorus (mg/d)
1000
500
Fluid (ml/d))
1000 ml
1100 ml
Meeting : 57.1 % of estimated energy and
41.6 % protein requirements
Unbalanced and inadequate intake of the core food groups
Need nutritional support - repletion
Mrs C daily menu
BREAKFAST
LUNCH
DINNER
1 bowl of chicken
porridge
1 egg schootel
1 cup of tea with 2
tsp sugar
1 cup of soft steam
rice
1 bowl of sauted beef
and vegetable
100 ml fresh apple
juice
Milk 150 ml
1 cup of noodle soup
Ready made formula
1 serving
1 steam tofu and
vegetable
10 am : ready made
formula
1 serving
260 kcal prot 13 g
4 pm : ready made
formula
1 serving
260 kcal prot 13 g
As pudding
2 biscuits
JUMLAH KALORI DITINGKATKAN SECARA BERTAHAP
SAMPAI KEBUTUHAN BERAT BADAN IDEAL
(50 KG = 1650 Kcal/day)
PADA EVALUASI TERNYATA DAILY RECALL MASIH BURUK
Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
ENERGY
NUTRIENTS
Energy
Mrs C requirement
1400 kcal/d
Mrs C actual
intake
700 kcal/d (17,5
kcal/d)
Protein
48 g/d
20 g/d ( 0.5
g/kg/day)
Sodium(mmol/d)
80-100
120
Potassium (mmol/d) 70
<70
Phosphorus (mg/d)
1000
500
Fluid (ml/d))
1000 ml
1100 ml
Meeting : 57.1 % of estimated energy and
41.6 % protein requirements
Unbalanced and inadequate intake of the core food groups
Need nutritional support - repletion
NUTRITIONAL MONITORING AND
EVALUATION
• 2 minggu, gastropati tidak membaik
• Evaluasi asupan nutrisi
• Asupan nutrisi baru sd : 15 kcal/kg /hari
dan protein 0,5 gr/kg/hari
EXAMPLE
Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg
• INTRADIALYTIC PARENTERAL NUTRITION
• Nutrisi parenteral yang diberikan secara
intermiten pada saat dialisis
• Preparat yang bisa diberikan selama jam
dialisis : 4 – 5 jam
Kadar dan komposisi asam
amino memenuhi
kebutuhan
• Keseimbangan asama
amino eensial dan non
esensial
• Asam amino spesifik
untuk pasien dialisis
Amino acid IV : Balanced supply of amino acids in acute and chronic
renal insufficiency, as well as, during dialysis treatment
• TPN, IDPN, or AA substitution
• When GFR < 50 ml/min/1.73m2
– creatinine clearance < 50 ml/min
– serum creatinine > 2.0 mg/dl
• Dosage Recomendation :
– patients without dialysis
0.3-0.5 g AA/kgBW/d ( 2 btl )
– patients with dialysis
1.0 g AA/kgBW/d ( 4 btl )
– intradialytic supplementation 0.5-1.0 g AA/kgBW/d ( 2 – 4 btl )
– maximum dosage
1.5 g AA/kgBW/d ( 6 btl )
– maximum infusion rate 20 drops/min
KESIMPULAN
Protein Energy Wasting :
• Prevalensi cukup tinggi dengan konsekuensi peningkatan
morbiditas dan mortalitas
• Manajemen terapi nutrisi harus dilakukan oleh tim yang
lengkap termasuk ahli gizi
• Terapi nutrisi disesuaikan dengan kebutuhan masingmasing pasien
• Modalitas terapi meliputi oral , enteral dan parenteral
TERIMA KASIH