nutritional care algorithm for renal patients

8/2/2019 Nutritional Care Algorithm for Renal Patients

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Nutritional status assessement inchronic kidney disease patients

Dr. Cristian Serafinceanu

Institutul de Diabet, Nutri ie i Boli metaboliceN. Paulescu

Bucharest


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Nutritional care algorithm (nutritional medical therapy)for renal patients

Nutritional status assessment:1 nutritional screening2 nutritional antecedents3. nutritional behavior

4. clinical examination

Identification of therapeutic goals:1. Reasonable2. Negotiable3. Adjustable

acceptablefor ownlifestyle

Periodic evaluation:1. results monitoring -

- redefining goals1. solving current problems

Nutritional medical intervention:1. Diet2. Nutritional supplements

ROSPEN, Poiana Bra ov, 2004


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Nutritional assessment clinic objectives (afterJeejeebhoy KN et col, 1994, modified)

1. Significant antecedents: Physiologic Pathologic Therapeutic

2. Known nutritional problems or deficits3. Chronic use of drugs with nutritional effects (i.e. chimiotherapy)4. Psycho-social antecedents:

Alcohol or drug abuse Smoking Financial and social status Marital status

5. Specific signs and symptoms for nutritional deficiencies6. Subjective global assessment:

Evaluation of muscular waste Evaluation of subcutaneous tissue Presence of oedemas Dialysis related items



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Nutritional screening IBasal (level I): detection ofnutritional risk factors

-body mass index-eating habits-living environment-functional status

Complete (level II): for patientsat nutritional risk

-history of weight changes (6mo)

-mid-arm circumference-triceps skinfold-mid-arm muscle area-serum albumin

-total plasma cholesterol-clinical features-drug prescriptions-mental/cognitive status



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Reference values for classifying severityof malnutrition in body mass index (BMI)

Age BMI Malnutrition

>= 18 years

= 18,6

SevereModerate

MildNormal

14 17 years


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Nutritional screening IIEating habits (topics)

-not have to eat enough (each day)-usually eats alone-poor appetite-special (restrictive) diets-does not eat vegetables, fruit or milk at least once

daily

-difficulties in chewing or swallowing-more than two alcoholic drinks per day (one forwomen)

-has pain in mouth , teeth or gums



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Nutritional screening III

Living environment

-poor income-lives alone-housebound-is unable (or prefers not) to spend money on food



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Nutritional screening IV

Functional status - needs assistance(usually or always) with:

-bathing-dressing-toileting (grooming)

-eating (preparing food)-walking (traveling)-shopping (for food)



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Nutritional screening V- reference values foranthropometric measurements in adults

(adapted from Hammond KA et col, 2004)Targetpopulation

Mid-armcircumference(MAC)

Tricepsskinfold(TS)

Mid-armmuscle area(MAMA)

Females 30-40y 28.6 24.2 32.4

Females 60-70y 31.7 14.5 35.4

Males 30-40y 31.9 13 55.8

Males 60-70y 32.8 14.2 51


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Nutritional screening VI

Clinical features and mental/cognitive status:

-evident problems with mouth, teeth, gums

-difficulties with chewing-angular stomatitis-glossitis-skin lesions (dry, loose, wounds, etc.)-history of bone fractures-clinical evidence of mental status impairment-depressive illness (Geriatric Depression Scale, etc.)



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Nutritional history and detection of deficiencysyndromes I

Mechanism History of Suspecteddeficiency

Inadequate intake

Alcohol abuse Protein, vitamins B

Avoidance of fruits,vegetables

Vitamin C, folates,vitamins B

Avoidance of meat ,eggs Protein, vitamin B 12

Habitual

constipationDietary fibre

Poverty, isolation Energy, protein

Inadequateabsorption

Drugs (antacids,laxatives,

anticonvulsivants)Various nutrients


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Nutritional history and detection of deficiencysyndromes II


Inadequateabsorption

Malabsorption (diarrhea,weight loss, steatorrhea)

Liposolublevitamins (A,D,E,K),

energy, protein

Parasites

Iron, vitamin, B 12Pernicious anemia

Gastro-intestinal surgery

Decreasedutilization

Drugs (anticonvulsivants,antimetabolites,

isoniazide) VariousInborn errors of

metabolism


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Nutritional history and detection of deficiencysyndromes III


Increased losses

Alcohol abuse Magnesium, zinc

Blood loss IronCentesis (ascitic,

pleural) Protein

Uncontrolleddiabetes mellitus Energy, protein

Diarrhea Protein, electrolytes

Nephrotic syndrome Protein

DialysisProtein, vitamins

(water soluble)


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Nutritional history and detection of deficiencysyndromes IV


Increasedrequirements

Fever,hyperthyroidism Energy

Physiologicdemands

(adolescence,pregnancy, lactation)

Energy, variousnutrients

Surgery, burns,trauma

Energy, protein,vitamin C

Infection, hypoxia Energy

Smoking Vitamin C, folates


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Clinical nutrition examination (Adaptedfrom Mahan LK, 2004) I

Organ/system Abnormal finding Nutritional deficiency

Non-nutritionalassociation

Skindry, scaly

environmental


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Clinical nutrition examination (Adaptedfrom Mahan LK, 2004) II

Organ/system Abnormal finding NutritionaldeficiencyNon-nutritional

association

eyes dry, grayish, nightblindness Vit A Gauchers disease

lips

bilateral (angular

stomatitis) orvertical cracks(cheilosis)

Vit B2, B6, niacindentures problems,

herpes, syphilis,AIDS

tongue magenta, loss ofpapillae, swollen Vit B2Crohndisease,

bacterial or fungalinfections

gums spongy, bleeding,receding Vit. C

Drugs (dilantin),lymphoma,

thrombocytopenia,aging, poor dental

hygiene

parotid glandsBilateral

enlargement Protein deficiency

Tumors,

hyperparathyroidism


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Nutritional status assessement

Methods to assess protein and energy status

Protein stores Other methods Energy balance

visceral somatic

SalbSprealbStransf

Ret. bind. prot.IGF-1

AnthropometryBIA

Nitrogen balanceDensitometry

Creat. KineticsIsotope studies

DEXANMR

others

SGA expenditure balance


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Markers of visceral protein status I

Parameter

range

Plasmatic

life (d)

ormal Nutritional

significance

Albumin 35-45 18-20 Coloid-osmoticpressure

late malnutrition marker

Transferrin 2.6-4.3 8-9 plasma ironcarrier

malnutrition (moreearly) marker; negativeinflammation marker

Prealbumin(transthyretin)

0.2-0.4 2-3 Thyroidhormonestransporter

Malnutrition (earlymarker); acutehypercatabolic states

Rhetynolbinding 0.37 0.5 (12h) Pro-vitamin Atransporter Proteic intakemarkerhypercatabolic


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Markers of visceral protein status II

Method Advantages Disadvantages Clinicalapplication

Serum albumin Redily avalableInexpensiveGood outcomepredictor

Late markerInfluenced by:extracellularvolume,inflammation, renalfunction

ScreeningLongitudinalevaluation

Serumprealbumin


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Subjective Global Assessment (from Detsky AS, McLaughlin JR,Baker JP, Johnston N, Whittaker S, 1987, What is subjective globalassessment, Journal of American Medical Association 271:54-58)

1. Weight Change

Maximum body weight _______________

Weight 6 months ago _______________

Current weight _______________

Overall weight loss in past 6 months _______________

Percent weight loss in past 6 months _______________

Change in past weeks: _______increase _______no change ________decrease

2. Dietary Intake (relative to normal)

_________ No change Duration: __________ Weeks

_________Change Type: __________ Increased intake

__________ Suboptimal solid diet

__________ Full liquid diet __________ IV or hypocaloric liquids

__________ Starvation

3. Gastrointestinal Symptoms (lasting >2 weeks)

__________ None

__________ Nausea __________ Vomiting ____________ Diarrhea ___________ Anorexia

6

6%

agmowt cuagomonwt

changeWt


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Subjective Global Assessment II ( from Detsky AS, McLaughlin JR,Baker JP, Johnston N, Whittaker S, 1987, What is subjective globalassessment, Journal of American Medical Association 271:54-58)

4. Functional Capacity

___________ NO dysfunction Duration: ____________ weeks

___________ Dysfunction Type: ____________ Works suboptimally

____________ Ambulatory

____________ Bedridden

PHYSICAL EXAMINATION

(For each trait specify: 0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe)

__________ Loss of subcutaneous fat (shoulders, triceps, chest, hands)

__________ Muscle wasting (quadriceps, deltoids)

__________ Ankle edema

__________ Ascites

SUBJECTIVE GLOBAL ASSESSMENT RATING (select one)

__________ A = well nourished

__________ B = moderately (or suspected of being) malnourished

__________ C = severely malnourished



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Modified SGA score for chronic kidneydisease patients

Parameter/score

0 1 2 3 4

Weightchanges/6 mo

no 5% 5-10% 10-15% 15%

Dietary intake

changes/ 6mo

no Suboptimal

solid food

Moderate

globaldecrease

Liquid/hypocalor

ic diet

starvation

Digestivesymptoms

no nausea Vomiting/othermoderate

Frequentdiarrhea/vomiting

Anorexia

Functionalstatus

Good/normalfor age

Walkingdifficulty

Usual effortsdifficulty

(housekeeping)

Minimal effortsdifficulty

(toileting)

Bedriding

Co-morbidities*

No mild moderate 1 severe Multiple,severe

Dialysisduration**

Less than 12mo, RRF

Less than 12mo, no RRF

12-24 mo, RRF 24-48 mo, RRF More than 48mo

**: absence of RRF translates the score in the superior class


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Modified SGA score for chronic kidneydisease patients- contd

Malnutrition:

-absent: 0 4-mild: 5 8-moderate: 9 14

-severe: 15 -24



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Anthropometric assessment of nutritionalstatus

1. Reference values for classifying nutritionaldeficits in weight - for - height (after Torm B,Chen F, 1994, modified)

Weight - for - height ratio = actual bodyweight/reference weight for height (RWH)

RWH = 50+0,75(H-150)+(Age-20)/4

Normal: 90-110%Mild deficit: 80-89%Moderate deficit: 70-79%Severe deficit:


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Anthropometric assessment ofnutritional status II

2. Body mass index (BMI, Quetelet index)3. Tricipital skinfold (TS)

4. Mid-arm circumference (MAC)5.Mid-arm muscular area (MAMA)(MAC - TS) 2 /12.56

All anthropometric measurements must be interpreted for age, sex, race



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Biochemical assessment of nutritional status

Indication = patients with significant risk of malnutrition afternutritional history and physical examination (SGA).

Aim = to detect specific nutritional deficiencies before onset ofclinic or anthropometric manifestations.

1. Protein status: central for the prevention, diagnosis and treatment of

malnutrition: Bi - compartmental pattern (of evaluation):

Metabolic active proteins (30 50%) Muscle (somatic) proteins (75%)

Visceral proteins (25%)

Metabolic inactive proteins (50 70%): Bones, joints

2. Iron status.

3. Calcium and phosphorus status.

4. Vitamins status.



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Protein metabolism status assessment I

a. Nitrogen balance = ratio between the amount ofnitrogen consumed as proteins and the amountexcreted by the body.

The expected value for healthy adults is 1 the rate ofproteins synthesis (anabolism) equals the rate of proteindegradation (catabolism)

Formula: PRO(g)/6,25 = UUN(g) 4(g), where:PRO: protein ingestion/24h(g)6,25: protein nitrogen indexUUN: urinary urea nitrogen/24h (g)

4(g): constant for non urea nitrogen + non urinarynitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary and/ornon dietary correction (i.e.: increased losses in criticallyill patients).



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Protein metabolism status assessment II

a. Somatic protein status Lean body mass assessment (muscle mass) can

be estimated by the 24h urinary creatinine excretion comparing with a standard (expected) excretion

based on height Urinary creatinin excretion:

Is a constant on ideal weight:

23 mg/Kgc/day in men

18 mg/Kgc/day in women

Its variation is exclusively determined by height (seestandards in table)



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Expected 24 hour urinary creatinine values forheight in adults (after Blackburn GL, Bistrian

BR, Maini BS et al, 1977)

Males Females

Height (cm) Urinary creatinine/24h (mg) Height (cm)Urinary creatinine

/24h (mg)

160 1325 150 851

165 1386 155 900

170 1467 160 950

180 1642 165 1001

185 1739 170 1076

190 1831 175 1141

nutritional care algorithm for renal patients

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