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EBPG Guideline on Nutrition (Recommendations for protein and energy intake…
EBPG Guideline on Nutrition
Guideline 1. Prevalence of malnutrition and outcome
Malnutrition
complications of chronic renal failure
Predialysis
protein intake of <0.7 g/kg/day
36% of the patients.
Low protein intake and low dialysis efficacy
Guideline 2. Diagnosis and monitoring of malnutrition
not a single measurement
provides complete and unambiguous assessment
nutritional marker
should be
inexpensive,
reproducible
easily performed test
Diagnosis of malnutrition
Dietary assessment
Dietary records
24 h-recall
patient consumed as food and drink during the previous 24 h
depends on memory
3 days diet diaries
patients with a stable food intake
(K/DOQI)
includes
a dialysis day
a weekend day
a non-dialysis day
special computerized food composition
programmes
7 days food records
Appetite assessment
calculate nutrient intake
Diet Assessment Tool (ADAT)
Body mass index (BMI)
Haemodialysis patients should maintain a BMI>23.0
Subjective global assessment (SGA)
combination of
subjective features
objective features
medical history
physical examination
Anthropometry
detect a potential risk for Protein and Energy Wasting (PEW)
Four-site skin fold thickness (SFT)
mid-armcircumference (MAC)
assess muscle mass
mid-arm-muscle-circumference (MAMC)
assess muscle mass
BMI
Frisancho Tables
calculate lean body mass
calculate body fat percentage
Normalized protein nitrogen appearance (nPNA)
provides
consuming assessment of dietary protein intake
haemodialysis patients and be above 1.0 g/kg ideal BW/day
Serum albumin and serum prealbumin
defines
normal serum albumin values
Serum albumin
indicator of visceral protein stores
predictor of future mortality
should be above 40 g/l
Serum cholesterol
Low (<1.5 g/l)
predictive of increased mortality risk
Hypocholesterolaemia
associated with
chronic protein–energy deficits and/or the presence of comorbid conditions
low–normal (1.5–1.8 g/l)
possible nutritional deficits
Monitoring and follow-up of nutritional status
Dietary interviews
Body weight
Post dialysis body weight
Percent interdialytic weight gain (IDWG)
‘dry weight’
nPNA, serum albumin and serum cholesterol
Recommendations for protein and energy intake
Recommended protein intake
clinically stable chronic haemodialysis patients
1.1 g protein/kg ideal body weight/day
balanced intake
high quality animal protein
vegetable protein source
the dialysis treatment
induces a loss of nutrients
is a catabolic event responsible for protein catabolism
negative metabolic balance
protein intake of 0.8–0.85 g/kg BW/day
neutral or positive balance
1.1 g/kg/day or more
Recommended energy intake
clinically stable chronic haemodialysis patient
30–40 kcal/kg IBW/day
chronic kidney disease
Harris-Benedict or Schofield formulas
Recommendations for vitamins, minerals and trace elements administration in MHD patients
Vitamins
status in individual patients depends on
age
gender
actual vitamin intake
previous supplementation
dialysis losses
residual renal function
time on dialysis
Water-soluble vitamins
Thiamine (B1)
1.1–1.2 mg
deficiency
beriberi
atypical neurological symptoms
Riboflavin (B2)
1.1–1.3 mg
contained in
milk, bread and cereals, lean meat and egg
Pyridoxine (B6)
10 mg
deficiency
Some drugs and other substances interfere
hyperhomocysteinaemia
contained in
yeast, cereal buds, green vegetables, egg yolk and meat
Ascorbic Acid (vitamin C)
A daily supplement of 75–90 mg
sources
Vegetables and fresh fruit
deficiency
abnormal amino acid metabolism
supplements
improve functional iron deficiency and hence the response to EPO
Folic Acid (Folate, vitamin B9)
A daily supplement of 1 mg
contained in
yeast, liver, green vegetables, fruit and meat
B12 (cobalamin)
combined with the gastric intrinsic factor
optimal folate metabolism
normal nonmegaloblastic erythropoiesis
is found in
meat, liver, seafood, milk and egg yolk
Fat-soluble vitamins
Vitamin A (retinol)
A daily intake of 700–900
is found in
fish oil, liver, spinach and carrots
necessary for
night vision and epithelium maintenance
Vitamin E (alpha-tocopherol)
A daily supplement of 400–800 IU
strong antioxidant
is mainly found
vegetable oils (corn, sunflower and soybean) and wheat germs
Vitamin K
A daily intake of 90–120 mg
contained in
green leaves vegetables (cabbage, spinach) and cow milk
be reduced
oral antibiotic administration
Minerals
Phosphate (phosphorus)
A daily intake of 800–1000 mg
should be restricted in MHD patients
avoid hyperphosphataemia
Calcium
The total intake of elemental calcium should not exceed 2000 mg/day
Sodium and fluid
A daily intake of no more than 80–100 mmol
(2000–2300 mg) sodium
5–6 g (75 mg/kg BW) per
day of sodium chloride
Interdialytic weight gain (IDWG) should not exceed
4–4.5% of dry body weight
Potassium
pre-dialysis serum potassium
greater than 6 mmol/l
daily intake of potassium of 50–70 mmol (1950–2730 mg) or 1 mmol/kg IBW
Hyperkalaemia
Trace elements
Iron (Fe)
A daily intake
8 mg Fe for men
15 mg for women
Supplementary
all haemodialysis patients treated with an erythropoiesisstimulating agent (ESA)
Zinc (Zn)
A daily nutritional intake
8–12 mg for women
10–15 mg for men
supplementation
50 mg Zn element per day
for 3–6 months
in haemodialysis patients with a chronic inadequate protein/energy
Selenium (Se)
A daily intake of 55 mg
supplementation
3–6 months should be
considered in haemodialysis
Treatment of malnutrition
Dietary intervention
MHD diet requires
changes
protein and energy, sodium and fluid, potassium,
calcium and phosphate
Four parameters
nutritional status
potential medical barriers
behavioural barriers
socio-economic barriers
Oral supplements and enteral feeding
Clinical benefits
daily protein supplement
7.8 g amino acids
Renal specific formulas
maximize protein and energy supply
Intradialytic parenteral nutrition
recommended in
malnourished patients only if spontaneous nutrient intake is >20 kcal/kg IBW
Anabolic agents
In case of
severe malnutrition
should be administered
weekly or bimonthly
Metabolic acidosis
Mid-week predialysis
serum bicarbonate levels should be maintained at 20–22 mmol/l
In patients with venous predialysis bicarbonate persistently <20 mmol/l,
oral supplementation with sodium bicarbonate