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 Undernutrition
OBESITY MALNUTRITION

Macronutrient Micronutrient
Malnutrition Malnutrition

Protein Energy
Malnutrition Malnutrition
(kwashiorkor) (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 Unadjusted
2
Mortality Case-mix*
1.8
Relative Risk of All-Cause Death

Case-mix & MICS **

1.6

1.4

Over- Obese Morbidly

1.2
weight Obese
1

Under- Normal
0.8
weight BMI
0.6

0.4
<18 18-19.99 20-21.49 21.5- 23-24.49 25-27.49 27.5- 30-34.99 35-39.99 40-44.99 >=45
22.99 29.99
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 Hemodialysis
Energy 35 Kcal/ kg IBW - <60 yrs
30-35Kcal/ kg IBW - ≥60 yrs

Protein 1.2-1.3g/kg IBW/ day(=50% of High 1.2-1.3g/kg IBW/ day(=50% of High Biological
Biological Value). Some nitrogen balance Value). Some nitrogen balance studies indicate
studies indicate that protein intake of ≥ that protein intake of ≥ 1.0 g/ kg IBW may be
1.0 g/ kg IBW may be enough. enough.

Fats 30% of total energy supply

Water and As per residual diuresis 750 – 1000 ml + diuresis

sodium

Potassium 40-80mmol. Individualized depending on 2-3 gr/d

serum levels
Calcium Individualized, usually not <1000mg/ day 1000 mg/d

Phosphorous 8-17 mg/ kg or 800-1000 mg/ day 800 – 1200 mg/d

(adjusted to higher protein needs), when
serum phosphorous is > 5.5 mg/ dl²

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 NO

ASSESSMENT
YES 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 DIETARY MONITORING

TERAPI EVALUASI
RECALL PLAN

JANGAN MEMBUAT
RENCANA TERAPI TANPA Ahli Gizi /Nutrisionist/Dietician harus
TAHU MASALAH masuk dalam tim
SEBENARNYA
 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
Functional GIT Parenteral
Nutrition
(TPN)
Yes
Enteral
Nutrition
(EN)
HDx
1st Intradialytic PN
(IDPN)
Tube Oral (+edn & counseling):
• Food fortification
feeding +/- • Oral nutrition
+/-
(TF) supplementations (ONS) PDx
Intra- Peritoneal
MO: Nutrition
• Control co-morbidities/ Exercise
inflammation Nursing training
• Medications / Appetite stimulant Psychosocial support

Multi-disciplinary
Approach
 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
formulae
Standard 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 long-
long-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, low-
low-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,
immune-
immune-enhancing diets
 Oral Nutrition Support
Diet counseling (1) ± (2) ± (3)
(+ prescription & Food Food enriching/ Oral Nutrition
meal plan) fortifications Supplements
Characteristic/ • Use energy & nutrient • adding protein, fat & • Ready –made
strategy dense foods & drinks CHO to foods and formula & desserts
drinks, e.g. egg, • protein & energy
cheese, milk, milk bar
powder sugars, fats
• commercial modules
e.g. protein powder,
tasteless sugars

Advantage • economical • economical • easy to use

• familiar items: • familiar items: • convenient
• taste • taste • easy handling (in
• texture • texture institutions) staff
• cultural specific • cultural specific and hygiene
Limitation “larger” volume “larger” volume • cost
• acceptance
• taste
• possible intolerance
 SUMBER KALORI
NON PROTEIN PROTEIN Essentiale Non-Essentiale Conditioned

• Specific
• (NEPHROSTERIL)
• Immunomodulator
BCAA • (DIPEPTIVEN)
KARBOHIDRAT LIPID ASAM AMINO (comafusin) • Ketoanalog
• (KETOSTERIL)

NON
DEXTROSE
DEXTROSE
9 kcal
20%
Mannitol
dextrose
4 kcal
40%
Xylitol
dextrose

Sorbitol
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 DIETARY MONITORING

TERAPI EVALUASI
RECALL PLAN

JANGAN MEMBUAT
RENCANA TERAPI TANPA Ahli Gizi /Nutrisionist/Dietician harus
TAHU MASALAH masuk dalam tim
SEBENARNYA
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 1400 kcal/d

30 kcal/kgIBW/d(>60
yrs)
Or to attain IBW
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 LUNCH DINNER

1 bowl of cereal 1 cup of soft Milk 150 ml
steam rice 1 cup of noodle
1 cup of tea with ½ bowl of soup
2 tsp sugar chicken broth Juice 100 ml
Vegetable 1 cup

2 biscuits 1 cup of tea

2 tsp sugar
 EXAMPLE
Mrs C, 40 year old, CKD stg 3 on chronic HD, 40 kg

ENERGY Mrs C requirement Mrs C actual

NUTRIENTS intake
Energy 1400 kcal/d 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 1 cup of soft steam Milk 150 ml
porridge rice 1 cup of noodle soup
1 egg schootel 1 bowl of sauted beef Ready made formula
1 cup of tea with 2 and vegetable 1 serving
tsp sugar 100 ml fresh apple 1 steam tofu and
juice vegetable

10 am : ready made 4 pm : ready made 2 biscuits

formula formula
1 serving 1 serving
260 kcal prot 13 g 260 kcal prot 13 g
As pudding

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 Mrs C requirement Mrs C actual

NUTRIENTS intake
Energy 1400 kcal/d 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 masing-
masing pasien
• Modalitas terapi meliputi oral , enteral dan parenteral
TERIMA KASIH