Nutritional and Metabolic Considerations in Elderly Dialysis

Patients

MARC EVANS M, ABAT, MD, FPCP, FPCGM

Head, Center for Healthy Aging, and Section of Geriatrics

The Medical City

Clinical Associate Professor, Section of Adult Medicine, Department of Medicine, PGH

Outline

• Elderly Hemodialysis

– Frailty

– Metabolic Considerations

– Nutritional Considerations

• Interventions to Slow Down or Minimize Frailty and Malnutrition in the Elderly Hemodialysis Patient

Frailty

• Refers to a loss of physiologic reserve that makes a person susceptible to disability from minor stresses.

• An inherent vulnerability to challenge from the environment.

• Not necessarily dependent on age, diagnosis or functional ability

Common Features of Frailty

1. Weakness

2. Weight loss (unexplained)

3. Muscle wasting (sarcopenia)

4. Exercise intolerance

5. Frequent falls

6. Immobility

7. Incontinence

8. Instability of chronic diseases

J Am Soc Nephrol 24: 337–351, 2013

Reduced food intake

• Anorexia caused by uremic toxins (RF), other anorexigens (TNF-a, cholecystokinin, or leptin(RF)

• impaired sense of taste/smell (RF,A)

• inflammation (RF,A)

• emotional depression (RF,A),

• medications (RF,A)

• Dementia (A)

• Poverty (RF,A)

• Loss of teeth or loss of dentures (A)

J Am Soc Nephrol 24: 337–351, 2013

Dialysate and urine nutrient losses (RF)

• Losses of protein into dialysate (~1 g/HD with MHD; ~9 g/d with CPD)

• Losses of amino acids into dialysate (~10–12 g/HD with MHD; ~2.0–3.5 g/d with CPD)

• Losses of protein into urine and nephroticrange proteinuria

J Am Soc Nephrol 24: 337–351, 2013

Inflammation associated with clinically apparent diseases

• Medical illnesses (e.g., diabetes, infection, heart failure, or cancer) and surgical illnesses (RF,A)

Increased levels or activities of catabolic hormones

• Parathyroid hormone (RF), glucagon (RF), corticosteroids (RF), or angiotensin II (RF)

J Am Soc Nephrol 24: 337–351, 2013

Deficiency or resistance to anabolic hormones

• Insulin (RF,A), growth hormone (RF, A), IGF-1 (RF,A), testosterone (RF,A), 25(OH)D3 (RF,A), or

• 1,25-dihydroxycholecalciferol (RF)

Metabolic acidemia (RF)

• Activates the caspase-3 and the ubiquitin–proteasome system in skeletal muscle, promoting protein catabolism

• Suppress protein synthesis

J Am Soc Nephrol 24: 337–351, 2013

Primary neuromuscular disorders

• Central nervous system dysfunction– Specific neuronal changes (RF,A)

– Dementia (A)

• Peripheral nervous system dysfunction (RF,A)

• Muscular changes– Loss of myocytes (A)

• Reduced numbers of satellite cells and myogenic factors (RF,A)

• Tendon stiffness (RF,A)

J Am Soc Nephrol 24: 337–351, 2013

• Physical inactivity and deconditioning (RF,A)• Accelerated/impaired apoptosis (A)• Increased number of senescent cells (A)• Decreased cellular replenishment by stem cells

(A)• Reduced autophagy (A)• Accumulation of chemically altered proteins

(RF,A)• Impaired DNA repair (RF,A)• Epigenetic alterations (RF,A)• Genetic predisposition (A)

J Am Soc Nephrol 24: 337–351, 2013

J Am Soc Nephrol 24: 337–351, 2013

• Detailed History

• Physical and Neurological Examination

• Cognitive Evaluation

• Behavioral/Emotional Evaluation

• Functional Evaluation

• Environmental Evaluation

• Social Evaluation

Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment

Among the dialysis patients,

• the vast majority showed a moderate (58.3%) or high risk score (19.4%)

• Compared to geriatric patients without renal failure, all MPI score domains were more compromised in the dialysis population.

JNEPHROL 2012; 25(Suppl 19): S85-S89

Drugs that can cause ANOREXIA

• digoxin

• phenytoin

• SSRI’s / lithium

• Ca++ channel blockers

• H2 receptor antagonists / PPIs

• Any chemotherapy

• metronidazole

• narcotic analgesics

• K+ supplements

• furosemide

• ipratropium bromide

• theophylline

• spironolactone

• levodopa

• fluoxetine

Drugs That Interfere With Gustation (taste) and Olfaction (smell)

Gustation• Allopurinol• Amitriptyline• Ampicillin• Baclofen• Dexamethasone• Diltiazem• Enalapril• Hydrochlorothiazide • Imipramine• Labetalol• Mexiletine• Ofloxacin• Nifedipine• Phenytoin• Promethazine• Propranolol• Sulfamethoxazole• Tetracyclines

Olfaction • Amitriptyline• Codeine• Dexamethasone• Enalapril• Flunisolide• Flurbiprofen• Hydromorphone• Levamisole• Morphine• Pentamidine• Propafenone

Int. J. Med. Sci. 2011, 8

J Am Soc Nephrol 24: 337–351, 2013

Clinical Nutrition (2006) 25, 295–310

Water-soluble vitamin replacement:

folic acid (1 mg/day), pyridoxin(10–20 mg/day) and vitamin C(30–60 mg /day)

Clinical Nutrition (2006) 25, 295–310

• Oral Nutritional Supplementation

• Tube feeding

– NGT

– PEG

• Intradialytic Parenteral Nutrition

Treatment of Underlying Co-morbidities

• Antidepressants

• Dementia medications

• Other medications

J Ren Nutr. 2014 Jan;24(1):42-9.

Nutritional Education

• 4 months of nutritional education

• nutritional knowledge was increased in all patients (P < .050) after the NEP

• decrease in the prevalence of malnutrition

• Creatinine clearance, total protein serum values, and other biochemical parameters improved significantly in both groups (P < .050 in all cases)

Antioxidants

• 353 patients• prospective, placebo-controlled, double-blind clinical trial• mixed tocopherols (666 IU/d) plus α-lipoic acid (ALA; 600

mg/d) or matching placebos for 6 months (NCT00237718)• High-sensitivity C-reactive protein (hsCRP) and IL-6

concentration were measured as biomarkers of systemic inflammation, and F2 isoprostanes and isofurans were measured as biomarkers of oxidative stress.

• the administration of mixed tocopherols and ALA was generally safe and well tolerated, but did not influence biomarkers of inflammation and oxidative stress or the erythropoietic response.

J Am Soc Nephrol. 2014 Mar;25(3):623-33.

Anabolic Agents: Hormones

• 29 predialysis patients with CKD,

• randomly divided into control (n = 13) and nandrolonedecanoate (NAN, n = 16) 100 mg per for 3 months.

• NAN group had increased LBM (P < .01) and decreased serum albumin levels (P < .05), but no changes in the values of normalized protein catabolic rate, serum lipids, hematocrit, and glomerular filtration rate.

• Changes in LBM in the NAN group were significantly higher than in the control group (P < .05)

• Minor adverse effects were observed in a few patients in the NAN group.

J Ren Nutr. 2007 May;17(3):173-8.

Low Intensity Strength Training in HD

Nephrol Dial Transplant (2010) 25: 1936–1943

Nephrol Dial Transplant (2010) 25: 1936–1943

Nephrol Dial Transplant (2010) 25: 1936–1943

Nephrol Dial Transplant (2010) 25: 1936–1943

Summary

• Older patients are at risk to become frail and malnourished

• End-stage kidney disease and dialysis increases the risk further through multiple interacting factors

• Adequate comprehensive assessment is needed

• Existing and novel interventions can be tailored based on the accurate assessment