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: 118124

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-, IL-1,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%)

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