KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update

Guideline 1. Prevalence of malnutrition and outcomeGuideline 2. Diagnosis and monitoring of malnutrition2.1. Diagnosis of malnutrition2.2. Monitoring and follow-up of nutritionalstatusGuideline 3. Recommendations for protein and energyintake3.1. Recommended protein intake3.2. Recommended energy intakeRecommendation 4. Recommendations for vitamins,minerals and trace elementsadministration in maintenancehaemodialysis patients.4.1. Vitamins4.2. Minerals4.3. Trace elementsGuideline 5. Treatment of malnutrition5.1. Dietary intervention5.2. Oral supplements and enteral feeding5.3. Intradialytic parenteral nutrition5.4. Anabolic agents5.5. Other interventions: daily dialysisGuideline 6. Metabolic acidosisAppendices

https://www.renacare.com/downloads/4_Nutrition.pdf

EBPG Guideline on Nutrition

https://www.ajkd.org/article/S0272-6386(00)70064-3/pdf

Re-evaluation of risks associated with hyperphosphatemia and hyperparathyroidism in dialysis patients: Recommendations for a change in management

https://www.ajkd.org/article/S0272-6386(06)00551-8/pdf

Longitudinal Associations Between Dietary Protein Intake and Survival in Hemodialysis Patients

About 40% of patients undergoing maintenance dialysis suffer from varying degrees of protein-energy malnutrition. This is a problem of substantial importance because many measures of nutritional status correlate with the risk of morbidity and mortality. There are many causes of protein-energy malnutrition in maintenance dialysis patients. Evidence indicates that nutritional decline begins even when the reduction in glomerular filtration rate is modest, and it is likely that the observed decrease in dietary protein and energy intake plays an important role. The nutrient intake of patients receiving maintenance dialysis also is often inadequate, and several lines of evidence suggest that toxins that accumulate with renal failure suppress appetite and contribute to nutritional decline once patients are on maintenance dialysis. Recent epidemiologic studies have suggested that both increased serum levels of leptin and inflammation may reduce nutrient intake and contribute to the development of protein-energy malnutrition. It is likely that associated illnesses, which are highly prevalent, contribute to malnutrition in maintenance dialysis patients. Recent data from the United States Renal Data System registry suggest that in the United States, the mortality rate of dialysis patients is improving. However, it remains high. We offer suggestions for predialysis and dialysis care of these patients that can result in improvement in their nutritional status. Whether this improvement will result in a decrease in patient morbidity and mortality is unknown.

NUTRITIONAL MANAGEMENT OF MAINTENANCE DIALYSIS PATIENTS: Why Aren't We Doing Better?

Background. The monitoring of energy and protein intake is considered fundamental in uraemic patients. However, in the clinical practice only protein ingestion is indirectely evaluated by the protein catabolic rate. Methods. In a cross-sectional study we evaluated the relationship between caloric and protein intake of 29 stable chronic haemodialysis patients (18M, 11F, mean age 49±17 years, 68±6 months on maintenance haemodialysis), and the validity of protein catabolic rate determination. Normalized protein catabolic rate was obtained according to Sargent's formula, and Watson's equation was used to calculate urea distribution volume. Caloric and protein intake were recorded during a 3-day period, and average daily ingestion of nutrients was calculated using a computerized diet analysis system. Results. A greater reduction of daily energy intake (26.8±11.9 Kcal/kg bw) than daily protein intake (1.02±0.4 g/kg bw) was observed. Fifty-nine percent of patients had low protein intake while 86% of patients had lower caloric intake than recommended. An inverse relationship between age and protein (r= -0.65, P<0.001) or caloric intake (r=-0.67, P<0.001) was observed. Negative relationships between daily protein (r=-0.60, P<0.01) and also caloric intake (r=-0.39, P<0.05) and the ratio between the urea generation rate and the total dietary nitrogen were found, indicating that in patients with low nutrient intake the nitrogen balance tends to be negative. Normalized protein catabolic rate was directly correlated with protein intake (r=0.77, P<0.001). A protein catabolic rate cut-off of 1 g/kg bw correctly identified all patients with normal daily protein intake, and 14 of 17 patients with deficient daily protein intake (<1 g/kg bw). Thus in only 10% of haemodialysis patients an imbalance between both parameters was observed. Moreover, patients with a daily protein intake lower than 1 g/kg bw were older and showed lower BUN and protein catabolic rate values than their counterparts. Conclusions. Nutritional abnormalities are frequently found, even in apparently clinically stable patients on chronic haemodialysis. Caloric rather than protein undernutrition is the major abnormality of their wasting. Inadequate intake of proteins and calories appears more commonly in older patients, and in association with lower BUN and protein catabolic rate values. Although normalized protein catabolic rate shows a direct correlation with a daily protein intake, the identity line shows that when daily protein intake was lower than 1 g/kg bw, it was overestimated by protein catabolic rate. Conversely, when daily protein intake is higher than 1 g/kg bw it is underestimated by the protein catabolic rate. This relationship should to be considered when interpreting the protein catabolic rate in a clinical setting.

Caloric rather than protein deficiency predominates in stable chronic haemodialysis patients

Is it possible to control hyperphosphatemia with diet, without inducing protein malnutrition?

A pathological Oral Glucose Tolerance test (OGTT) is an early marker of peripheral insulin resistance. Nevertheless, its utility in nondiabetic patients with CRF stage IV-V is undetermined. Aim: We wanted to detect, in a population of non diabetic patients with CRF, the presence of carbohydrates metabolism anomalies, by means of the OGTT and to relate it with metabolic, anthropometric, cardiovascular parameters and renal function. We studied 45 non diabetic patients with advanced CRF (stage IV-V), 26 men, mean age 66.5 years, with average CockroftGault of 23.6 ml/min. We measured weight, height, waist and BMI. Biochemical: glucose, insulin, OGTT, C peptide, lipid profile, HbA1C and Hto. Cardiovascular comorbidity, mean proteinuria and systolic and diastolic blood pressure (6 months pre and post analytical measure) were measured. Pulse pressure was also calculated. Results: 47% of the patients presented normal fasting glucose, whereas 53% had isolated impaired fasting glucose (IFG). After the OGTT, 36% of the patients presented impaired glucose tolerance (IGT) and 14% diabetes (> 200 mg/dl). Of the patients with normal fasting glucose, 38% had IGT after OGTT and 5% diabetes. Patients with IFG (n = 24), 33% presented IGT and 21% diabetes. Patients with abnormal OGTT were older (71 ± 13.6 versus 60 ± 18.8 years, p = 0.03), had greater HbA1C (5.6 ± 0.5 versus 5.2 ± 0.3%, p = 0.02), total cholesterol (193 ± 37.7 versus 169.8 ± 44.9 mg/dl, p = 0.03), pulse pressure (63.4 ± 14.5 versus 52.3 ± 9.7 mmHg, p = 0.0001) and greater prevalence of ischemic heart disesase (28% versus 5%, p = 0.05). Creatinine Clerance negatively correlated with the OGTT (r = -0.39, p = 0.01) and plasma creatinine positively with fasting insulin (r = 0.33, p = 0.02) and C-peptide (r = 0.42, p = 0.006). Urinary Proteins were correlated with fasting glucose (r = 0.30, p = 0.04), C-peptide (r = 0.52, p = 0.001), triglycerides (r = 0.36, p = 0.01) and with the HOMA-IR index (r = 0.30 p = 0.05) Conclusion: Fasting Glucose did not predict OGTT results in patients with CRF. For this reason, we think that the OGTT can be very useful tool to identify states of «prediabetes» and diabetes in patients with CRF, specially in those whose present an elevated Pulse Pressure, age greater than 65 years, hyperlipidaemia and HbA1C above 5.2%. The early detection of these metabolic anomalies, may lead to intensify dietetic and pharmacological measures directed to delay or to attenuate the appearance of diabetes and its serious complications in a population in which the cardiovascular risks factors are very elevated.

M. Rufino

Papers

Caloric rather than protein deficiency predominates in stable chronic haemodialysis patients

Is it possible to control hyperphosphatemia with diet, without inducing protein malnutrition?

Importance of oral glucose overload test (OGOT) at a specific clinic for advanced CRF stages IV and V