NUTRITIONAL

MANAGEMENT
IN DIALYSIS
PATIENTS
dr. Nyoman Paramita Ayu,
Sp.PD-KGH
Divisi Ginjal dan Hipertensi, Departemen Ilmu Penyakit Dalam,
Fakultas Kedokteran Universitas Udayana,
RSUP Prof IGNG Ngoerah Denpasar Bali
Kidney are involved in maintaining nutrient
homestasis
Elimination of sodium, potassium, and phosphate

Excretion of waste nitrogen (urea), creatinine, and ammonia

Homeostasis of the amino acid pool

Homeostasis of glucose metabolism

Catabolism and clearance of low molecular weight plasma peptides and hormones, e.g.
insulin, growth hormone, leptin
 CHRONIC KIDNEY DISEASE AND
PROTEIN ENERGY WASTING
Protein-energy
wasting (PEW) refers
to→ multiple
nutritional and
catabolic alterations
that occur in CKD and
associate with
morbidity and
mortality

TA Ikizleret al.: Prevention and treatment of PEW in CKD patients

Kovesdy CP et al. Am J Clin Nutr 97:1163–1177, 2013
 PEW Increase Mortality in
Hemodialysis Patients Relative risk of all cause death and categories of Body Mass Index

Relative risk of mortality and categories of

modified subjective global assessment (mSGA)

Pifer TB. Kidney International, Vol. 62 (2002)

Sahathevan s. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients 2020, 12, 3147
 Causes of Anorexia in Hemodialysis and Peritoneal Dialysis Patients

Factors of anorexia in both haemodialysis and

peritoneal dialysis
• Frequent hospitalization, multiple medications
• Comorbidities
• Depression
Peritoneal Dialysis Related
• Low social status
• Uncontrolled anaemia • Early satiety or feelings of fullness
• Restrictive regimens: fluid, phosphorus, sodium, • Suppression of appetite due to the abdominal
potassium distension
• Dysgeusia: metal flavour (often associated with zinc • Suppression of appetite due to glucose and
deficiency), dry mouth amino acid-based dialysates
• Inadequate dialysis • Impairment in gastric emptying due to the
• Exocrine pancreatic insufficiency and reduced mucosal
instillation of dialysate
enzyme activities
• Gastroparesia
• Cardiovascular disease and fluid overload
• Altered plasma amino acids and neurotransmitters • Inadequate dialysis dose
synthesis
• Inflammatory cytokines: plasma TNF-alpha, leptin
• Uremic toxins: middle size molecule
• Insulinoresistance inducing increases in serotonin
synthesis
Heng AE. Nutritional problems in adult patients with stage 5 chronic kidney disease on dialysis (both haemodialysis and peritoneal dialysis). NDT Plus (2009) 1 of 9
PEW Decrease EPO Responsiveness
Factors of lean body mass loss in
haemodialysis and peritoneal dialysis patients
Causes of inflammatory syndrome in dialysis
patients
• Reduced protein–energy intakes
• Metabolic acidosis
• Dialysis-independent inflammation
• Inflammatory cytokines
• Renal failure per se, reduced cytokine clearance
• Hormone disturbances: insulin resistance, abnormal • Inflammatory kidney disease
growth factor action, male hormone • Cardiovascular disease, fluid overload
deficiency,hyperparathyroidism, decreased in 1,25(OH) • Other inflammatory disease; Chronic infections or
vitamin D synthesis, increased in plasma catabolic acute infections
hormones (cortisol, glucagon, adrenaline) • Haemodialysis and peritoneal dialysis-related
• Diabetes mellitus inflammation
• Nutrient losses during haemodialysis and peritoneal • Cytokine and complement activation due to the use
of the non-biocompatible dialysis membrane
dialysis
• Dialysis fluid contamination
• Reduced physical activity • Uptake of pyrogen from the dialysis fluid
• Uptake of endotoxins
• Infection of the dialysis access (arterio-venous graft
or temporary vascular access)
• Peritoneal infections

Heng AE. Nutritional problems in adult patients with stage 5 chronic kidney disease on dialysis (both haemodialysis and peritoneal dialysis). NDT Plus (2009) 1 of 9
 Protein and amino-acid losses according to types of dialyzer membranes

Sahathevan s. Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review. Nutrients 2020, 12, 3147
PASIEN HD KEHILANGAN ASAM AMINO

Pasien HD

Kehilangan 8 – 15 g
asam amino setiap sesi
HD

+ nafsu makan turun

→ meningkatkan risiko
PEW
Hendriks FK et al, J Clinical Nutrition 37 (2018) S46eS314
PEW is present in 30% to 65% or more of dialysis
patients around the world
 Readily utilizable criteria for the clinical diagnosis of PEW in AKI or CKD

Serum chemistry
Serum albumin 3.8 g per 100 ml (Bromcresol Green)a
Serum prealbumin (transthyretin) o30 mg per 100 ml (for maintenance dialysis patients only; levels may vary
according to GFR level for patients with CKD stages 2–5)a
Serum cholesterol 100 mg per 100 mla

Body mass
BMI <23b
Unintentional weight loss over time: 5% over 3 months or 10% over 6 months
Total body fat percentage <10%

Muscle mass
Muscle wasting: reduced muscle mass 5% over 3 months or 10% over 6 months
Reduced mid-arm muscle circumference area (reduction 410% in relation to 50th percentile of reference population)
Creatinine appearance d

Dietary intake
Unintentional low DPI o0.80 g kg-1 day-1 for at least 2 monthse for dialysis patients or o0.6 g kg1 day1 for patients
with CKD stages 2–5
Unintentional low DEI o25 kcal kg-1 day-1 for at least 2 monthse

Kalantar. A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease . Kidney International (2008) 73, 391–398
 European best practice guidelines for nutritional parameter monitoring in
haemodialysis (HD) and peritoneal dialysis (PD) patients

Nutritional parameters Intervals (Months) Recommended levels

Body weight (HD and PD) Every dialysis
Dietary interview (HD and PD) 6–12 months
BMI (HD and PD) 1 month >23 kg/m2
nPNA (HD and PD) 1 month >1 g/kg BW/day
Midweek predialysis creatine (HD) 1 month

Serum albumin (HD and PD) 1-3 months ≥40 g/l

Serum transthyretin (HD) 1-3 months ≥300 mg/l
Serum cholesterol (HD) 3 months >Minimum laboratory
threshold value

Subjective global assessment (PD 3 months

Heng AE. Nutritional problems in adult patients with stage 5 chronic kidney disease on dialysis (both haemodialysis and peritoneal dialysis). NDT Plus (2009) 1 of 9
Dietary Protein Intake, MHD and PD Patients
Without Diabetes
3.0.3 In adults with CKD 5D on MHD (1C) or PD
(OPINION) who are metabolically stable,
we recommend prescribing a dietary
protein intake of 1.0-1.2 g/kg body weight
per day to maintain a stable nutritional
status. 3.1 Statement on Energy Intake
3.1.1 In adults with CKD 1-5D (1C) or posttransplantation
Dietary Protein Intake, Maintenance (OPINION) who are metabolically stable, we
Hemodialysis and Peritoneal Dialysis Patients recommend prescribing an energy intake of 25-35
With Diabetes kcal/kg body weight per day based on age, sex,
3.0.4 In adults with CKD 5D and who have level of physical activity, body composition, weight
diabetes, it is reasonable to prescribe a status goals, CKD stage, and concurrent illness or
dietary protein intake of 1.0-1.2 g/kg body presence of inflammation to maintain normal
weight per day to maintain a stable nutritional status.
nutritional status. For patients at risk of
hyper- and/or hypoglycemia, higher levels
of dietary protein intake may need to be
considered to maintain glycemic control
(OPINION).
 Selected nutritional parameters for varying levels of kidney disease*

Jadeva PY. Indian Journal of Endocrinology and Metabolism / Mar-Apr 2012

Algorithm for nutritional
management and support in
patients with CKD

Ikizler. Clin J Am Soc Nephrol 8: 2174–2182, 2013

 Potential Metabolic Complications of IDPN administration

Singh S. ENABLING INTRADIALYTIC PARENTERAL NUTRITION IN MAINTENANCE HAEMODIALYSIS PATIENTS IN MALAYSIA: THE WHAT, WHO AND HOW SCENARIOS OF IMPLEMENTATION? Malays. Appl. Biol. (2018) 47(3): 1–11
 Strategies to enhance oral intake

• Avoid diet restriction in patients with poor intake

• Offer oral liquid supplements and snacks
• Treat gastroparesis and other gastrointestinal conditions
• Achieve glycemic control
• Correct electrolyte abnormalities
• Evaluate for and address depression
CONCLUSION
• Nutrition plan should be individualized (precision medicine)
• Importance of patients and family educational approach
• Motivating patients by showing examples and improvement
• Nutritional team work (Clinical Nutrition Specialist,
Nephrologist, Dialysis Nurse, Dietitian)
• Focusing on a stepwise approach