Effect of nutritional counseling in the form of individualized meal plan on serum albumin - PowerPoint Presentation

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Effect of nutritional counseling in the form of individualized meal plan on serum albumin level among Hemodialysis patients

Author:Suheir Abdallah Khalil,Ph.DConsultant Clinical Nutrition, Acting Chief- Clinical Nutrition DepartmentKing Faisal Specialist Hospital & Research Center Jeddah, KSACo. Author:Prof. Yousif Babiker YousifProfessor of Clinical Nutrition, Ahfad University for Women, Khartoum/Sudan

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Global Facts: About Kidney Disease CKD is a worldwide public health problem.10% of the population worldwide is affected by CKD, and millions die each year.

According to the Global Burden of Disease study, CKD was ranked 27th in the list of causes of total number of deaths worldwide in 1990, but rose to 18th in 2010. In 2013, nearly one million people died from CKD . it is a 135% increase from the number of CKD -related deaths in 1990Among the major non-communicable killers (nearly 70 % of all deaths globally), one of the lesser-recognized but increasingly significant causes of death is CKD

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Stages of CKD

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ESRD

SourceU.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014.ESRD is increasing

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Complications of ESRD on Dialysis

Nutrition in HD is very important in decreasing complications & improving quality life of patients.Hypoalbuminemia is a serious problem with kidney disease pt

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Hypoalbuminemia

Hypoalbuminemia is a medical condition where levels of albumin in blood serum are ↓ & Treatment focus on its underlying cause

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Some studies (Beddhu 2002, Panichi 2006) describe hypoalbuminemia in HD patients as a strong indicator for mortality & morbidity.

As a result of malnutrition, albumin synthesis decreases and develops hypoalbuminemia.

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Assessment of Nutrition status with ESRD on HD

As Assessment of the nutrition status is an integral part of the nutrition management. Several parameters should be evaluated together including:

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Serum Albuminone measure of total body protein, both muscle & visceral which is the most frequently used marker of protein status and is the standard recommended by KDOQI to be used in assessing the nutritional status among CKD.

A strong marker for the evaluation of malnutrition (estimated prevalence of 10-70%) and Hypoalbuminemia among HD patientsA decreased albumin results in an increased in morbidity & mortality. Which has been shown for ESRD patients whose albumin is below 4.0 g/dL, and result in an excess risk of death.

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Serum albumin level at dialysis initiation is an independent risk factor for mortalitySerum albumin ≥ 4.0 g/dL at initiation of dialysis is associated with reduced mortality risk.

Only 11% of new dialysis patients had serum albumin ≥ 4.0 g/dL

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There are 0.2-0.5 g/kg or 10-14 g/day of protein, amino acids (aa) and peptide losses with the dialysis fluid during HD pt do not consistently take the recommended amounts of energy and protein for ESRD patients on HD (which lead to hypoalbuminemia). In research, it is emphasized that the inadequate protein intake increases mortality

The lost in amino acids needs to be replaced to avoid negative nitrogen balance. According to "KDOQI)" and studies by other investigators, dietary protein should be adjusted at least 1.2 g/kg/day in HD patients.According to ESPEN, adjusted diet protein should be consumed as 1.1-1.2 g/kg/d and should be high in the biological value (of animal origin) of 50 % protein in HD patients.

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They are in need of individualized meal plans but they rarely consult a dietitian. A special diet is needed for ESRD patients on HD. Recommended daily nutrients intake for an adult on HD are

Recommended daily nutrients intake for an adult on HDNutrients

Recommendation

Calorie

30-35 (30>60yr,35<60yr) kcal/kg/day

Protein

1.2 gm/kg/day

Phosphorus

17 mg/kg/day

Potassium

40 mg/kg/day

Fluids

urine output + 500-750 ml/day

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50%

50%renal dietitian will figure out the needs to include a mixture of both. 10-14 g free amino acids lost per treatment during dialysis

Individual Diet must be followed up closely by renal dietitians

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Inclusion Criteria

ESRD patients on regular HD (2-3 times weekly)Patient, who dialyzed for at least 3 months, dialyzed 4 hours per sessionBoth sexes ˃18 years of age Consent given for participation in the studyAbsence of active underlying disease Absence of active infection (free from infections and inflammations)No requirement for hospitalization during the month preceding the studyExclusion Criteria

Patients younger than 18 years of ageHaving infections or inflammations, having any underlying diseaseon hospitalization during the month preceding the studyNot on regular HD receiving HD more or less than 2-3 times per week.

Refuse to sign Consent form

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134 adult patients (males & females) were divided into a test group (n=77) and a control group (n=57). The test group after nutritional counseling, consumed individualized diets for a period of 6 months that provided adequate amounts of energy and protein according to the recommendations of the National Kidney Foundation while the control group continued consuming their usual diets.

Serum albumin was determined at baseline and every 2 months. Data were analyzed using SPSS.

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baseline

2 mo

4 mo

6

mo

Nutritional status differences of the study patients according to changes in serum albumin in both groups.(n=134)

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Result & Discussion:In this study, baseline serum albumin levels were similar in both groupsvalues obtained were below the 4.0 g/dl recommended by NKF/DOQI for adults on HD

which reflects the high incidence of hypoalbuminia among both groups.

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Result & Discussion: After 6 months serum albumin levels increased in the test group but not in the control one; the difference was highly significant within the test group (P=0.000) and between the test and control groups (P=0.000).

This is explained by the higher intake of energy and protein by the test group which showed gradual increases in the albumin level during the intervention period.

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Conclusion:The study demonstrated that effective nutritional counseling rendered to MHD patients in the form of individualized meal plans that provided adequate energy & protein was effective in the control and improvement of serum albumin level among these patients.

Therefore, nutritional counseling by qualified dietitians should be mandatory in renal units as part of the medical therapy management to reduce the incidence of hypoalbminemia among HD patients.

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ReferencesAlharbi K A (2010). Assessment of nutritional status of patients on

hemodilaysis: a single center study from Jeddah, Saudi Arabia. FIU Electronic Theses and Dissertations. Paper 178. http://digitalcommons.fiu.edu/etd/178Bernardo A P, Fonseca I, Rodrigues A , Carvalho M J. Cabrita A (2009). Overweight Rather Than Malnutrition Is Widely Prevalent in Peritoneal Dialysis Patients. Advances in Peritoneal Dialysis. 25:119-124.Byham-Gray, L. and Wiesen,K (2004). A clinical guide to nutrition care in kidney disease, American Dietetic Association.Cho J, Hwang J, Lee S, Jang SP, Kim W (2008). Nutritional status and the role of diabetes mellitus in hemodialysis patients. Nutrition Research Practice Journal. 2(4): 301–307.Goldsmith, D, Jayawardene, S. and Ackland, P (2008). ABC of kidney disease. Blackwell Publishing Ltd. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. Jul 20 2013;382(9888):260-272

.Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD.: Malnutrition-inflammation complex syndrome in dialysis patients: Causes and consequences.Am

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Kopple

JD.: McCollum Award Lecture, 1996: Protein-energy malnutrition in maintenance dialysis

patients.Am

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Clin

Nutr65: 1544–1557,

1997

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ReferencesKopple JD.: National kidney foundation K/DOQI clinical practice guidelines for nutrition in chronic renal failure.Am

J Kidney Dis37[Suppl 2]: S66–S70, 2001Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health problem: approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes. Kidney Int. Aug 2007;72(3):247-259.Locatelli F, Cannata-Andia JB, Drueke TB (2002). Management of disturbances of calcium and phosphate metabolism in chronic renal insufficiency, with emphasis on the control of hyperphosphataemia. Nephrology Dialysis Transplantation. 17:723–731.Mahan LK and Escott-Stump (2008). Krause's Food, Nutrition, and Diet Therapy. 12th edition. W.B. Saunders Company. USA.Poole R, Hamad A (2008). Nutrition Supplements in Dialysis Patients: Use in Peritoneal Dialysis Patients and Diabetic Patients. Advances in Peritoneal Dialysis. 24:118-124.Saxena A, Sharma RK (2004). An update on methods for assessment of nutritional status in maintenance dialysis patients. Indian Journal of Nephrology. 14: 61-66.

Siddiqui UA, Halim A, Hussain T (2007). Nutritinal Profile and inflammatory status of stable chronic Hemodialysis Patients at Nephrology Department, Military Hospital Rawalpindi. Journal of Ayub Medical College. 19(4):29-31.

U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014

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rawansahr@hotmail.com

King Faisal Specialist Hospital & Research Center Jeddah, KSA