Nutritional status assessement in chronic kidney disease patients

Dr. Cristian Serafinceanu Institutul de Diabet, Nutriie i Boli metabolice N. Paulescu Bucharest

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 acceptable 2. Negotiable for own lifestyle 3. Adjustable

Periodic evaluation: 1. results monitoring - redefining goals 1. solving current problems

Nutritional medical intervention: 1. Diet 2. Nutritional supplements

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

1.

Significant antecedents:
Physiologic Pathologic Therapeutic

2. 3. 4.

Known nutritional problems or deficits Chronic use of drugs with nutritional effects (i.e. chimiotherapy) Psycho-social antecedents:
Alcohol or drug abuse Smoking Financial and social status Marital status

5. 6.

Specific signs and symptoms for nutritional deficiencies Subjective global assessment:
Evaluation of muscular waste Evaluation of subcutaneous tissue Presence of oedemas Dialysis related items

Nutritional screening I
Basal (level I): detection of nutritional risk factors -body mass index -eating habits -living environment -functional status Complete (level II): for patients at nutritional risk -history of weight changes (6 mo) -mid-arm circumference -triceps skinfold -mid-arm muscle area -serum albumin -total plasma cholesterol -clinical features -drug prescriptions -mental/cognitive status

Reference values for classifying severity of malnutrition in body mass index (BMI)
Age BMI
<16 16 16,9 17 18,5 >= 18,6 <16,5

Malnutrition
Severe Moderate Mild Normal Present

>= 18 years

14 17 years

11 13 years

<15

Present

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 once daily -difficulties in chewing or swallowing -more than two alcoholic drinks per day (one for women) -has pain in mouth , teeth or gums

Nutritional screening III

Living environment

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

Nutritional screening IV
Functional status - needs assistance (usually or always) with:
-bathing -dressing -toileting (grooming) -eating (preparing food) -walking (traveling) -shopping (for food)

Nutritional screening V- reference values for anthropometric measurements in adults (adapted from Hammond KA et col, 2004)
Target population
Females 30-40y

Mid-arm Triceps circumference skinfold (MAC) (TS)

28.6 24.2

Mid-arm muscle area (MAMA)

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

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.)

Nutritional history and detection of deficiency syndromes I

Mechanism History of Alcohol abuse Suspected deficiency Protein, vitamins B

Avoidance of fruits, vegetables

Avoidance of meat , eggs Inadequate intake Habitual c o n s t i p a t

Vitamin C, folates, vitamins B

Protein, vitamin B12

Dietary fibre

Nutritional history and detection of deficiency syndromes II

Mechanism History of Malabsorption (diarrhea, weight loss, steatorrhea) Inadequate absorption Parasites Suspected deficiency Liposoluble vitamins (A,D,E,K), energy, protein

Pernicious anemia
Gastro-intestinal surgery Drugs (anticonvulsivants, antimetabolites, isoniazide) Inborn errors of metabolism

Iron, vitamin, B12

Decreased utilization

Various

Nutritional history and detection of deficiency syndromes III

Mechanism History of Suspected deficiency

Alcohol abuse
Blood loss

Magnesium, zinc
Iron Protein Energy, protein Protein, electrolytes Protein Protein, vitamins (water soluble)

Centesis (ascitic, pleural) Increased losses

Uncontrolled diabetes mellitus Diarrhea Nephrotic syndrome

Dialysis

Nutritional history and detection of deficiency syndromes IV

Mechanism History of Fever, hyperthyroidism Suspected deficiency Energy

Increased requirements

Physiologic demands (adolescence, pregnancy, lactation)

Surgery, burns, trauma Infection, hypoxia

Energy, various nutrients Energy, protein, vitamin C Energy

Smoking

Vitamin C, folates

Clinical nutrition examination (Adapted from Mahan LK, 2004) I

Organ/ system
Abnormal finding
dry, scaly

Nutritional deficiency
essential fats, vit.A

Non-nutritional association
environmental
chemical burns, Addisons disease hemorrhage, pigmentation disorders Liver disease, aspirin overdose pulmonary or heart chronic disease hypothyroidism, chemotherapy, psoriasis

hyperpigmentation of sunlight exposed areas

niacin or tryptophan

pallor
Skin Petechiae, ecchymoses spoon-shaped

iron, vit B12

Vit K, C iron

nails

hair

lack of shine, easy pluckable

proteins, Zn, linoleic acid

Clinical nutrition examination (Adapted from Mahan LK, 2004) II

Organ/system
eyes

Abnormal finding
dry, grayish, night blindness bilateral (angular stomatitis) or vertical cracks (cheilosis) magenta, loss of papillae, swollen

Nutritional deficiency
Vit A

Non-nutritional association
Gauchers disease dentures problems, herpes, syphilis, AIDS Crohndisease, bacterial or fungal infections Drugs (dilantin), lymphoma, thrombocytopenia, aging, poor dental hygiene Tumors, hyperparathyroidis m

lips

Vit B2, B6, niacin

tongue

Vit B2

gums

spongy, bleeding, receding

Vit. C

parotid glands

Bilateral enlargement

Protein deficiency

Nutritional status assessement

Methods to assess protein and energy status Protein stores Other methods Energy balance

visceral

somatic

SGA

expenditure

balance

Salb Sprealb Stransf Ret. bind. prot. IGF-1

Anthropometry BIA Nitrogen balance Densitometry Creat. Kinetics Isotope studies DEXA NMR others

Markers of visceral protein status I

Parameter Normal Plasmatic range life (d) (g/l)
35-45 2.6-4.3 18-20 8-9

Normal function
Coloid-osmotic pressure plasma iron carrier Thyroid hormones transporter Pro-vitamin A transporter

Nutritional significance
late malnutrition marker malnutrition (more early) marker; negative inflammation marker Malnutrition (early marker); acute hypercatabolic states Proteic intake markerhypercatabolic states Immediate proteic intake marker

Albumin Transferrin

Prealbumin (transthyretin) Rhetynol binding protein (RBP) Insulin-like growth factor 1 (IGF 1)

0.2-0.4

2-3

0.37

0.5 (12h)

0.55-1.4 UI/ml

2-6 h

Anabolic growth factor

Markers of visceral protein status II

Method Advantages Disadvantages Clinical application Serum albumin Redily avalable Inexpensive Good outcome predictor Readily available Inexpensive Excellent outcome predictor Can detect early changes Late marker Influenced by: extracellular volume, inflammation, renal function Influenced by renal function, inflammation No evidence based data Screening Longitudinal evaluation

Serum prealbumin

Screening Longitudinal evaluation

Serum transferrin

Readily available Inexpensive Excellent outcome predictor Can detect early changes

Influenced by iron stores, inflammation No evidence based data

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 Limited availability, expensive Acute influenced by dietary intake No evidence based data

Diagnosis or screening Clinical or research

Serum IGF-1

Good association with other markers Very short half-life

Diagnosis or screening Clinical or research

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 _______________

wt 6 month ago curr wt % Wt change 10 wt 6 mos ago

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 _________Change Duration: __________ Weeks 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

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 ___________ Dysfunction Duration: ____________ weeks 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)

Modified SGA score for chronic kidney disease patients

Parameter /score Weight changes/6 mo Dietary intake changes/ 6 mo Digestive symptoms Functional status no no 0 1 2 3 4 5% Suboptimal solid food nausea 5-10% Moderate global decrease Vomiting/other moderate Usual efforts difficulty (housekeeping) 10-15% Liquid/hypocalor ic diet Frequent diarrhea/vomitin g Minimal efforts difficulty (toileting) 15% starvation

no

Anorexia

Good/normal for age

Walking difficulty

Bedriding

Comorbidities*
Dialysis duration**

No
Less than 12 mo, RRF

mild
Less than 12 mo, no RRF

moderate
12-24 mo, RRF

1 severe
24-48 mo, RRF

Multiple, severe
More than 48 mo

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

Modified SGA score for chronic kidney disease patients-contd

Malnutrition: -absent: 0 4 -mild: 58 -moderate: 9 14 -severe: 15 -24

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: <70% (or with oedemas)

Anthropometric assessment of nutritional 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

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. 3. 4.

Iron status. Calcium and phosphorus status. Vitamins status.

Protein metabolism status assessment I

a.

Nitrogen balance = ratio between the amount of nitrogen consumed as proteins and the amount excreted by the body.
The expected value for healthy adults is 1 the rate of proteins synthesis (anabolism) equals the rate of protein degradation (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 urinary nitrogen (stool, sweat)

Disequilibrium of nitrogen balance need dietary and/or non dietary correction (i.e.: increased losses in critically ill patients).

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 (see standards in table)

Expected 24 hour urinary creatinine values for height in adults (after Blackburn GL, Bistrian BR, Maini BS et al, 1977)
Males Height (cm) 160 165 170 180 Females Height (cm) 150 155 160 165

Urinary creatinine /24h (mg)

1325 1386 1467 1642

Urinary creatinine /24h (mg)

851 900 950 1001

185
190

1739
1831

170
175

1076
1141