Agkpada PGK Dengan Terapi Pengganti

1
AGKPADA PGK
DENGAN
TERAPI
PENGGANTI
2
3
HEMODIALISIS
(HD)
• HD  Terapi
pengganti untuk
mengganti sebagian
kerja ginjal untuk
mengeluarkan hasil
sisa metabolisme
dan kelebihan cairan
• Proses HD
mengeluarkan asam
amino, glukosa dan
vitamin larut air
4
DIALISIS PERITONEAL MANDIRI BERKESINAMBUNGAN

(DPMB = CAPD)
5
Dr. Susetyowati, DCN.M.Kes PS Gizi FK-UGM 6
NUTRITION
ASSESSMEN
T
PENILAIAN BERAT BADAN PADA

CKD
• Gunakan Berat kering atau berat badan bebas udema
• Pada HD: BB setelah HD
• In PD: berat setelah drainase dialisat dengan peritoneum kosong
• In obese or very underweight people, use adjusted
edema-free body weight
Adjusted EFBW=
BWef + [SBW*-BWef x .25]
*Use NHANES II data for standard body weight

(SBW)
Use adjusted edema-free body weight for dialysis patients who are less than
95% or greater than 115% of standard body weight from table below. Ref
NKF K/DOQI
National Kidney Foundation. K/DOQI clinical practice guidelines for nutrition in chronic
STANDARD BODY WEIGHT - STANDARD BODY WEIGHT -

FEMALES MALES
*Estimated with linear regression formula From Standard Body Weight NHANES 2 Tables.
Frisancho AR. New standards of weight and body composition by frame size and height for assessment of
nutritional status of adults and the elderly. Am J Clin Nutr. 1984 Oct;40(4):808-19.
PENILAIAN STATUS GIZI

Evaluasi status Berat Badan
• Weight changes
• Intentional vs. unintentional weight loss
• Dry weight changes vs. fluid shifts
• Clinically significant weight loss
• 5% or > within 1 month
• 7.5% or > within 3 months
• 10% or > within 6 months
• Attitude toward changes
• Goals for weight changes
PENILAIAN STATUS GIZI

Interdialytic Weight Gain
(IDWG)
• General recommendation +2 kg
• >5% fluid gains
• Excessive fluid intake
• Weight gain
• <2% fluid gain
• Inadequate fluid and/or food intake
• Weight Loss/Decreased body mass
Optimal Nutritional
Status
 Body mass index = 23 -26
 Albumin > 4.0
 Stable, desirable dry weight
 Adequate fat stores and muscle mass
 Appropriate appetite and intake
Sumber: Evidence Based Practice. Guidelines for the Nutritional

Management of Chronic Kidney Disease
Reverse epidemiology of obesity in dialysis

patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

Nutrition
Assessment Diet
History
• Diet
Assessment
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Sodium
• Potassium
• Phosphorus
• Fluid
• Vitamins
• Minerals
Nutrition
Assessment
Laboratory Analysis 6
Monthly Quarterly
• Albumin: 4.0g /dL or > • Hemoglobin A1C: < 7%
• Potassium: 3.5-5.3 mEq/L
• PTH: 150-600 pg/mL
• Phosphorus: 3.5-5.5
• Lipid Panel
mg/dL
• Calcium: 8.4-10.2 • Chol < 200 mg/dL
mg/dl • HDL > 40mg/dL
• Glucose <200 • LDL <100mg/dL
mg/dL • Triglycerides <200 mg/dL
• Non-fasting
• Product: < 55
• URR: >65%
Nutrition Assessment:
Subjective Global
Assessment
• Protein-energy nutritional status measurement
6
• Valid and reliable8

• KDOQI recommended9
• Medical history and physical exam
• Body composition focus on nutrient intake
• Subjective rating: 7 point scale6
• Well-nourished
• Mild to moderately malnourished
• Severely malnourished
Malnutrition-Inflammation
Score (MIS)
• Disusun dan dikembangkan oleh Kalantar-Zadeh
(2001)
• Practical and reproducible measure for assessing
malnutrition and inflammation in maintenance
haemodialysis patient*
• 7 komponen SGA & 3 komponen tambahan
*Ebrahimzadehkor, B., Dorri, A., Yapan-Gharavi, A. (2014) Malnutrition-Inflammation

Score in Haemoialysis Patients. Zahedan J Res Med Sci. 2014 Aug: 16(8): 25-28
*Yamada, K., Furuya, R., Takita T., Maruyama, Y., et al. 2008. Simplified nutritional
screening tool for patients on maintenance hemodialysis. Am J Clin Nutr. 2008;87:106-13
7 component SGA Additional component

•Medical history 1. BMI (dry weight)
1.Weight loss during 6 mo 2. Serum albumin
2.Gastrointestinal 3. Serum TIBC
symptoms 3.Food intake
4. Functional capability
5.Co-morbidity (duration of
dialysis) Each component had 4
levels of severity (0-3 ;
•Physical examination normal-very severe)
1.Loss of subcutaneous
fat 2.Muscle wasting 1. Normal nutrition (0-
5)
2. Mild malnutrition (6-
10)
3. Moderate-severe
malnutrition
20
Assessing Anemia in
CDK
TEST K/DOQI Goal
Hgb 11 to 12 mg/dL Hct can be falsely low
due to fluid overload
Iron SAT > 20% Monthly test
Ferritin 200-500 ng/mL Reflects tissue iron
stores
INTERVENSI GIZI
TUJUAN DIET
HEMODIALISIS DPMB
Memberikan protein yg Mencukupi kebutuhan

cukup untuk mengganti AAE protein, untuk
dan N yang hilang dalam
dialisat
Mencegah penimbunan hasil

menggantikan tingginya
sisa metabolisme antar HD
protein yang hilang
dalam dialisat
22
KEBUTUHAN GIZI
(KDOQI
Protein
Guidelines)
HD
HD: 1.2 g/kg
PD
9
HD: 1.2 g/kg
(>/= 50% HBV protein) PD: 1.2-1.3 g/kg PD: 1.2-1.3 g/kg
Energy 35 kcal/kg <60 years 30-35 35 kcal/kg <60 years
kcal/kg > 60 years 30-35 kcal/kg > 60 years
Phosphorus 10 – 12 mg/g protein 10 – 12 mg/g protein
800-1000 mg/day 800-1000 mg/day
Adjust to meet protein needs Adjust to meet protein needs
Potassium 2-3 g Monitor serum levels 3-4 g Monitor serum levels
Fluid Output + 1000 ml Maintain fluid balance
Limit IDWG
Sodium 2g 2-3 g : Monitor fluid balance
Calcium <2g including binder <2g including binder load
load Maintain Serum Maintain Serum WNL
WNL
Fiber 20-25 g 20-25 g
KEBUTUHAN GIZI
(KDOQI
Vitamins and Minerals Guidelines) 9
HD PD
Vitamin C 60-100 mg 60-100mg
B6 2 mg 2 mg
Folate 1-5 mcg 1-5 mcg
B12 3 mcg 3 mcg
Vitamin E 15 IU 15 IU
Zinc 11-15 mg 11-15 mg
Iron Individualize Individualize
Vitamin D Individualize Individualize
B1 1.1-1.2 mg 1.5-2 mg
Other RDA RDA
1.
ENERGI
• Kalori harus cukup, agar protein tidak
dipecah menjadi energi
• KH : beras, mie, tepung2an, gula, umbi2an
• Lemak : minyak, santan, margarin
2.
PROTEIN
NB TINGGI NB RENDAH
• Kacang2an kering :
• protein Hewani : kacang ijo, tanah dll
ayam, daging, susu, • Tahu, tempe
telur, ikan sesuai
jumlah sehari
• Daging lebih banyak
hasil sisa nitrogen
dari telur dan susu
3.
KALIUM
• Kalium dibatasi terutama bila ada oliguria (urine < 400
ml/hari) dan kalium darah > 5,5 meq/liter.
• Pada DPMB pembatasan kalium tidak selalu dianjurkan,
bila hiperkalemia dibatasi
KALIUM
• Buah dan sayuran
• Low: 20-150 mg
• Medium: 150-250 mg
• High: 250-550 mg
• Portion size is
essential
• Avoid Salt
Substitutes
• Dairy
• 1 cup 380-400
mg
4.
PHOSPOR
• Retensi phospor  hiperphospatemia yang merupakan
faktor adanya hiperparathyroidsm dan renal
osteodistrophy.
• BM sumber protein mengandung tinggi pospor  pilih BM
dengan rasio posfor-protein <15mg/g
• Perlu obat pengikat fosfat, karena dari diit sulit
dikendalikan
Rasio Posfor -
Protein
Perbandingan posfor-
Bahan Makanan
protein
< 15 mg/g (bahan Daging ayam, daging sapi, daging kambing,
makanan dendeng sapi, sosis, bakso, udang segar, telur
yang dianjurkan) ikan, belut, telur ayam, putih telur, ikan kembung,
ikan bawal, ikan bandeng, tuna, kepiting, kacang
kedele, kacang tanah, tempe, tahu
>15 – 20 mg/g Susu kedele, hati ayam, hati sapi, ikan lele, cumi-
(bahan cumi, kacang merah, kacang edamame
makanan yang
dibatasi)
>20 mg/g (bahan Susu kental manis, susu skim, susu bubuk (full
makanan cream), krimmer nabati, keju mozarela, keju cedar,
yang dibatasi) teri kering, kuning telur, kacang hijau, almonds,
walnut, biji bunga matahari.
KESEIMBANGAN
POSPOR
Intake P Absorption Binding Dialysis
~60% ~50% Removal
HD
+1000 mg/day +600 mg/day -300 mg/day -700 x 3 =
(10 Phoslo) -2100
+7000 mg/wk +4200 mg/wk -2100 mg/wk mg/wk
PD
-400 x 7 =
-2800
Weekly Phosphorus Balance
mg/wk
+ 4200 (diet) – 2100 (Binders) – 2100( HD) = Balance
5.
• Hipokalsemia KALSIUM
( kalsium darah < 8,5 mg/dl)
 akibat
penyerapan Ca yang berkurang dari usus,
defisiensi vitamin D, dan berkurangnya 1,25
dihidrokolekalsiferol  absorbsi Ca menurun
• Peningkatan asupan kalsium sukar didapat
dari makanan saja, sehingga perlu
suplementasi tablet kalsium, untuk mencapai
kadar kalsium 10,5 – 11,0 mg/dl.
6. NATRIUM DAN
• CAIRAN
Penelitian mosley (1993)  mengontrol kenaikan
BB diantara waktu HD, tidak hanya dengan
membatasi cairan tetapi juga Na
• Konsumsi garam yang banyak  meningkatkan
konsentrasi Na pada cairan tubuh  haus
Mekanisme ini akan memaksa pasien HD untuk
minum sehingga konsentrasi Na kembali
normal
NATRIU
M
• ≥ 1 L fluid output: 2-3 g Na and 2 L fluid
• ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid
• Anuria: 2 g Na dan 1 L fluid
• Individualize
• IDWG, blood pressure, residual renal functions
• Increased Restrictions if ↑ IDWG, CHF, edema, HTN
• PD: liberalize restriction to 2-4 grams sodium
• High sodium intake may increase thirst
Sources of Dietary
Sodium
(62 adults who completed 7 day dietary records)
Inherent
12%
Food
Processing At the Table
77% 6%
During Cooking
5%
Mattes and Donnelly, JACN, 1991; 10: 383

CAIRA
N
• HD
• Urine Output + 1000 ml
• Limit IDWG
• 2-5% Estimated Dry weight
• PD
• Maintain fluid balance
• Vary dextrose concentrations in dialysate
• Restrict if fluid balance not obtained without frequent
hypertonic
exchanges
TERIMA
KASIH…
Semoga Bermanfaat 

Agkpada PGK Dengan Terapi Pengganti

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1

DIALISIS PERITONEAL MANDIRI BERKESINAMBUNGAN

PENILAIAN BERAT BADAN PADA

*Use NHANES II data for standard body weight

STANDARD BODY WEIGHT - STANDARD BODY WEIGHT -

PENILAIAN STATUS GIZI

PENILAIAN STATUS GIZI

Sumber: Evidence Based Practice. Guidelines for the Nutritional

Reverse epidemiology of obesity in dialysis

Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

• Valid and reliable8

*Ebrahimzadehkor, B., Dorri, A., Yapan-Gharavi, A. (2014) Malnutrition-Inflammation

7 component SGA Additional component

Memberikan protein yg Mencukupi kebutuhan

Mencegah penimbunan hasil

Mattes and Donnelly, JACN, 1991; 10: 383

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