Efficacy of Dietary Intervention in ESRD

PatientsDr. Ch. M. Junaid Nazar

Senior Medical Officer/Research AssociateMBBS, MPH, M.Sc. Nephrology, MD Internal Medicine, FRSPH

Nephrology Department,Pakistan Kidney Institute,

Shifa International Hospital,Pakistan

Content• Introduction• Prevalence• Pathophysiology• Risk Factor• Association of Nutrition and outcome of Kidney Disease • Extent of malnutrition in ESRD patients • Methodology• Discussion• Conclusion

Introduction Chronic Kidney is a internationally recognized epidemic. The Third National Health and Nutrition Examination

Survey has noted that more than 20 million American have chronic renal kidney disease

One study suggests that 40 to 70 % of patients with end-stage renal disease are malnourished

It is very common and latest data suggest that it affects about 8 % of the UK adult population. The incidence of end stage renal disease (ESRD) patients joining renal replacement therapy (RRT) program in the UK is about 125/million each year

Prevalence The incidence of end stage renal disease

(ESRD) patients joining renal replacement therapy (RRT) program in the UK is about 125/million each year

The figure is almost 300/million in parts of the USA (because of racial factors and increased population prevalence of diabetes and hypertension

In United Kingdom, the number of patients on RRT is around 600/million.

Pathophysiologykeys1.Adaptive changes to nephron injury promote various effects the ultimately contributes to progression of CKD.

2.Hypertension, hyperfilteration, hyperglycemia, high grade proteinuria, and over activation of RAAS cause renal injury and progression of kidney to ESRD 3.CKD patients with high levels of proteinuria are at highest risk to progress to ESRD.

4.Therapies that reduce blood pressure to appropriate goals, reduce proreinuria, and inhibit the RAAS provide the most benefit to slow loss of renal function in diabetic and non- diabetic patients with proteinuria kidney disease.

5.ACE inhibitors and ARBs provides renoprotection in CKD patients: combination therapy with these drugs and aldosterone antagonist may provide further kidney protection but needs further validation.

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Risk FactorsDecreased protein and caloric intake Anorexia, Frequent Hospitalization, Inadequate

dialysis dose

Comorbidities hypertension, Diabetes mellitus, gastrointestinal

diseases, on-going inflammatory response autoimmune disorders

 

Increased protein and energy requirement Losses of nutrients Increased resting energy expenditure Older age Family history of chronic kidney disease

Association of Nutrition and outcome of Kidney Disease

• A number of studies have evaluated the nutritional status of advance CKD stage (3-5) has reported some degree of poor nutritional status. The prevalence of abnormalities has been estimated to range from approximately 20 % to 60 % using various nutritional parameters.

• Similarly in stage 4-5, mild to severe malnutrition by subjective global assessment is reported in 44 % of patients and for patients on HD it was 30 % and for PD patients it was 40 patients

Indices of Nutritional Status

The parameters which have been proposed to assess the nutritional status are albumin, cholesterol and creatinine as well more complex and not yet readily available parameters such as plasma and muscle amino acid profiles, pre albumin and insulin growth factor (IGF)

Analysis of body composition there will be different body techniques such as anthropometric, bioelectrical impedance.

Serum albumin is most extensively used method to measure malnutrition in CKD patients

Extent of malnutrition in ESRD patients

Pre -dialysis patients Dialysis dependent patients Transplant patient

Dialysis

• Hemodialysis• Peritoneal dialysis

Predialysis• Malnutrition is not specific to any stage of end

stage renal disease but it is evident that it is present even before the starting RRT.

• Report which is published by MDRD study indicated that early signs of malnutrition such as reduction in body mass index (BMI), weight, anthropometric measurements and notable decline in urinary biochemistry parameters including urinary creatinine excretion were observed in the chronic renal failure were noted.

Transplant The extent of malnutrition in transplant is

still under process and little is known about its effects

However, the treatment and prevention of malnutrition has not been discussed in these patients.

Malnutrition in pre-dialysis, dialysis, and post dialysis stage is related to multiple factors.

Methodology

Outcomes Related with Diet

•  Hypertension• Diabetes Mellitus• Cardiovascular Diseases• Obesity• Protein• Protein Calorie malnutrition (PCM)• Potassium• Vitamins

Different risk factor effecting Nutrition in ESRD

• Education and Understanding • Late Referrals• Mistakes in Prescription• Low immune status and Lack of

donors• Poor Diagnostic Methods

FindingsEnvironmental Physiological

Anorexia related to uremia, fever, or treatmentsMalabsorption and diarrhea, Nausea and vomiting related to chemotherapy, gastritis, esophagitis, reduced peristalsis, Low calorie or palatable diet, altered mental status related to dementia etc

DepressionDesire for deathFood aversions related to alteration in taste, texture, and smellAltered perception of food value: fat diet, junk food, mega dosing nutrition’s, using special food.

Target for Future Research

  The development of new practice guidelines,

particularly for fluid management, Special attention needs to be focused on the

additional impact of immunosuppressive medications

Clinical research efforts using interventional dietary trials for multiple post transplant complications

Conclusion

• Life style, particularly diet is a critical component of treatment for these conditions.

• Registered dietitians paly a key role in bridging the gap between the science of nutrition and the empowerment of individuals to alter their lifestyles in a healthy manner

• Diet intervention in relation with end stage renal disease is really complicated topic

References

• Available on Request

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