12-nutritional care algorithm for renal patients

7/28/2019 12-Nutritional Care Algorithm for Renal Patients

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Nutritional status assessement inchronic kidney disease patients

Dr. Cris t ian Seraf inceanu

Institutul de Diabet, Nutriie i Boli metabolice

N. PaulescuBucharest


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Nutritional care algorithm (nutritional medical therapy)

for renal patients

Nutritional status assessment:

1 nutritional screening

2 nutritional antecedents

3. nutritional behavior

4. clinical examination

Identification of therapeutic goals:

1. Reasonable

2. Negotiable

3. Adjustable

acceptable

for own

lifestyle

Periodic evaluation:1. results monitoring -

- redefining goals

2. solving current problems

Nutritional medical intervention:

1. Diet

2. Nutritional supplements


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Nutritional assessment clinic objectives (after

Jeejeebhoy KN et col, 1994, modified)

1. Significant antecedents:

Physiologic

Pathologic

Therapeutic

2. Known nutritional problems or deficits

3. 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 deficiencies

6. Subjective global assessment: Evaluation of muscular waste Evaluation of subcutaneous tissue

Presence of oedemas

Dialysis related items


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Nutritional screening I

Basal (level I): detection ofnutritional risk factors

-body mass index

-eating habits

-living environment

-functional status

Complete (level II): forpatients at 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 severity

of malnutrition in body mass index (BMI)

Age BMI Malnutrition

>= 18 years

= 18,6

Severe

Moderate

Mild

Normal

14 17 years


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Nutritional screening II

Eating 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 oncedaily

-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 for

anthropometric measurements in adults

(adapted from Hammond KA et col, 2004)

Target

population

Mid-arm

circumference

(MAC)

Triceps

skinfold

(TS)

Mid-arm

muscle 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 deficiency

syndromes I

Mechanism History of Suspecteddeficiency

Inadequate intake

Alcohol abuse Protein, vitamins B

Avoidance of fruits,

vegetables

Vitamin C, folates,

vitamins B

Avoidance of meat ,

eggsProtein, vitamin B12

Habitual

constipation

Dietary fibre

Poverty, isolation Energy, protein

Inadequate

absorption

Drugs (antacids,

laxatives,

anticonvulsivants)

Various nutrients


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syndromes II

Mechanism History ofSuspected

deficiency

Inadequateabsorption

Malabsorption (diarrhea,

weight loss, steatorrhea)

Liposoluble

vitamins (A,D,E,K),

energy, protein

Parasites

Iron, vitamin, B12Pernicious anemia

Gastro-intestinal surgery

Decreased

utilization

Drugs (anticonvulsivants,

antimetabolites,

isoniazide) Various

Inborn errors of

metabolism


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syndromes III


deficiency

Increased losses

Alcohol abuse Magnesium, zinc

Blood loss Iron

Centesis (ascitic,

pleural)Protein

Uncontrolled

diabetes mellitusEnergy, protein

Diarrhea Protein, electrolytes

Nephrotic syndrome Protein

Dialysis

Protein, vitamins

(water soluble)


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syndromes IV


deficiency

Increased

requirements

Fever,

hyperthyroidismEnergy

Physiologicdemands

(adolescence,

pregnancy, lactation)

Energy, various

nutrients

Surgery, burns,

trauma

Energy, protein,

vitamin C

Infection, hypoxia Energy

Smoking Vitamin C, folates


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Clinical nutrition examination (Adapted

from Mahan LK, 2004) I

Organ/

systemAbnormal finding Nutritional deficiency

Non-nutritional

association

Skin

dry, scalyessential fats, vit.A environmental

hyperpigmentation ofsunlight exposed areas

niacin or tryptophan chemical burns,Addisons disease

pallor iron, vit B12hemorrhage,

pigmentation disorders

Petechiae,

ecchymoses

Vit K, CLiver disease, aspirin

overdose

nails spoon-shaped ironpulmonary or heart

chronic disease

hairlack of shine, easy

pluckableproteins, Zn, linoleic acid

hypothyroidism,

chemotherapy,

psoriasis


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Clinical nutrition examination (Adapted

from Mahan LK, 2004) II

Organ/system Abnormal findingNutritional

deficiency

Non-nutritional

association

eyesdry, grayish, night

blindnessVit A Gauchers disease

lips

bilateral (angular

stomatitis) orvertical cracks

(cheilosis)

Vit B2, B6, niacin

dentures problems,

herpes, syphilis,

AIDS

tonguemagenta, loss of

papillae, swollenVit B2

Crohndisease,

bacterial or fungal

infections

gumsspongy, bleeding,

recedingVit. C

Drugs (dilantin),lymphoma,

thrombocytopenia,

aging, poor dental

hygiene

parotid glands

Bilateral

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

Salb

Sprealb

Stransf

Ret. bind. prot.IGF-1

Anthropometry

BIA

Nitrogen balance

Densitometry

Creat. Kinetics

Isotope studiesDEXA

NMR

others

SGA expenditure balance


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Markers of visceral protein status I

Parameter Normal

range(g/l)

Plasmatic

life (d)

Normal

function

Nutritional

significance

Albumin 35-45 18-20 Coloid-osmotic

pressure

late malnutrition marker

Transferrin 2.6-4.3 8-9 plasma iron

carrier

malnutrition (more

early) marker; negativeinflammation marker

Prealbumin

(transthyretin)

0.2-0.4 2-3 Thyroid

hormones

transporter

Malnutrition (early

marker); acute

hypercatabolic states

Rhetynol

bindingprotein (RBP)

0.37 0.5 (12h) Pro-vitamin A

transporter

Proteic intake

markerhypercatabolicstates

Insulin-like

growth factor

1 (IGF 1)

0.55-1.4

UI/ml

2-6 h Anabolic growth

factor

Immediate proteic

intake marker


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Markers of visceral protein status IIMethod Advantages Disadvantages Clinical application

Serum albumin Redily avalable

Inexpensive

Good outcome predictor

Late marker

Influenced by: extracellular

volume, inflammation, renal

function

Screening

Longitudinal evaluation

Serum prealbumin Readily available

Inexpensive

Excellent outcome predictor

Can detect early changes

Influenced by renal function,

inflammation

No evidence based data

Screening

Longitudinal evaluation

Serum transferrin Readily available

Inexpensive

Excellent outcome predictor

Can detect early changes

Influenced by iron stores,

inflammation


Diagnosis or screening

Clinical or research

Retinol-binding protein Short half-life (can detect early

changes)

Limited availability, expensive

Influenced by renal function,

inflammation

Decreased by hypertiroidism

and vit. A defficiency



Serum IGF-1 Good association with other

markers

Very short half-life

Limited availability, expensive

Acute influenced by dietary

intake





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Subjective Global Assessment (from Detsky AS, McLaughlin JR,

Baker JP, Johnston N, Whittaker S, 1987, What is subjective global

assessment, 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

1006

6%

agomoswt

wtcurrentagomonthswtchangeWt


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Subjective Global Assessment II ( from Detsky AS, McLaughlin JR,

Baker JP, Johnston N, Whittaker S, 1987, What is subjective global

assessment, 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 kidney

disease patientsParameter

/score

0 1 2 3 4

Weight

changes/6 mo

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

Dietary intake

changes/ 6mo

no Suboptimal

solid food

Moderate

globaldecrease

Liquid/hypocalor

ic diet

starvation

Digestive

symptoms

no nausea Vomiting/other

moderate

Frequent

diarrhea/vomitin

g

Anorexia

Functional

status

Good/normal

for age

Walking

difficulty

Usual efforts

difficulty

(housekeeping)

Minimal efforts

difficulty

(toileting)

Bedriding

Co-

morbidities*

No mild moderate 1 severe Multiple,

severe

Dialysis

duration**

Less than 12

mo, RRF

Less than 12

mo, no RRF

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

mo

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


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Modified SGA score for chronic kidney

disease patients-contd

Malnutrition:

-absent: 0 4-mild: 5 8

-moderate: 9 14

-severe: 15 -24


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Anthropometric assessment of nutritional

status

1. Reference values for classifying nutritional

deficits in weight - for - height (after Torm B,

Chen F, 1994, modified)

Weight - for - height ratio = actual body

weight/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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Biochemical assessment of nutritional status

Indication = patients with significant risk of malnutrition after

nutritional history and physical examination (SGA).

Aim = to detect specific nutritional deficiencies before onset of

clinic 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 of

nitrogen 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 index

UUN: 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

b. 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 (see

standards in table)


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Expected 24 hour urinary creatinine values for

height 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

12-nutritional care algorithm for renal patients

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