Participants will be able to Discuss the markers of malnutrition in CKD Identify causes of malnutrition in CKD Discuss current recommendations for treatment of malnutrition in CKD

1. Combating Malnutrition in Chronic
Kidney Disease
Vishal Bagchi MBA RD LD
Director of Medical and Scientific Affairs
Patient Care America
3/2/2020 1

2. Disclosure
• Vishal Bagchi is an employee of Patient Care
America
• Slides are scientific and based on information and
research evidence available during the time of the
lecture
• Examples of products used are for educational and
demonstration purpose and not for defamation of a
company or product.
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3. Objectives
• Participants will be able to
 Discuss the markers of malnutrition in CKD
 Identify causes of malnutrition in CKD
 Discuss current recommendations for treatment
of malnutrition in CKD
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4. Why RD’s are so important!
• A person with chronic kidney disease
should always eat a diet that has low-
protein content. Too much protein
makes the kidney problem to get
worse. The diet should also contain
low amounts of potassium and
sodium. For some patients, it is also
important for fluid restrictions to be
imposed.
• Some people suffer from both
diabetes and chronic kidney disease.
In this case, a diet that is low on
carbohydrates is recommended
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5. The Pre-Dialysis Diet
• Low protein or no restriction??
• Self restriction
• Keto acids with low protein
• Recently released USRDS report found that only about 25%
of patients starting dialysis in 2009 had > 12 months of a
Nephrologists care prior to starting dialysis.
• Only 10.5% of the patients beginning dialysis in 2005 had
received dietary counsel before starting ESRD therapy.
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6. Consensus Statement – JRN 9/2009
• Keto acid/ Amino acid-supplemented protein restricted diets should
be considered for diabetic and non diabetic patients with
CKD
– 0.3-0.6 g protein per kg body weight per day depending on stage
– Keto acid/ amino acid supplementation of one tablet/5 kg body weight
per day (0.1 gm/ kg)
– Energy at 30-35 kcal body weight per day
– Phosphate at 5-7 mg/kg body weight per day (>800 mg)
– Sodium at <2 g/day
– Vitamins and trace elements (iron)
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7. Patient: Joe Schmo
• 165#(75kg), 70”, type 1 DM, A1C
6.5%, CKD4
• Protein: 30-40 grams
• Calories:2500
• # of keto acid pills daily: 15
• PO4 daily: 525mg
• Sodium: 2000mg
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8. 1850 calories, 37gm protein
• Breakfast: 1 orange, 1 egg or egg substitute, 1/2 cup rice or creamed cereal, 1 slice
whole wheat bread (toasted), 1/2 tablespoon margarine or butter, 1/2 cup whole
milk, hot, non-caloric beverage, 1 tablespoon sugar (optional).
• Lunch: 1 ounce sliced turkey breast, 1/2 cup steamed broccoli, 1 slice whole wheat
bread, 1/2 tablespoon margarine or butter, 1 apple, 1/2 cup gelatin dessert, 1 cup
grape juice, hot, non-caloric beverage, 1 tablespoon sugar (optional).
• Mid-Afternoon Snack: 6 squares salt-free soda crackers, 1/2 tablespoon margarine
or butter, 1 to 2 tablespoons jelly, 1/2 cup apple juice.
• Dinner: 1/2 cup tomato juice, 1 ounce beef, 1 baked potato, 1 teaspoon margarine
or butter (optional), 1/2 cup steamed spinach, 1 slice whole wheat bread, 1/3 cup
sherbet, 4 apricot halves, hot, non-caloric beverage.
• Evening Snack: 1 banana.425 kcal, 10gm protein each
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9. Benefits of low protein
• Decreases cytokines and CRP
• Improved fasting glucose, hyperglycemia, insulin
resistance
• Decreased retention of waste products
• Improved acid/base, Calcium and PO4 metabolism
• 49% slower rate of decline in eGFR compared to pts on
traditional mixed LPD
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10. Protein restricted
• Very specific patients
• CLOSE medical
monitoring by MD and
RD
• Patient should be VERY
motivated
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11. Starting RRT
• One study found that patients entering the ESRD
program (Fresenius) in 2004 and 2005, the mean
serum albumin was 3.1 g/dL
• ~50% of pts who started 2005-2009 had low
albumins
• MDRD - mean albumin 4.2 mg/dL, after 9
months
• GFR
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12. Pre dialysis
diet for 90KG
man – 0.6gm
Protein per
Kg
Hemo
dialysis diet
for 90 Kg
man – 1.2
gm
protein/ Kg
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13. Obesity – Good or Bad ?
• An independent risk
factor for CKD
• In dialysis there is an
inverse relationship
between BMI and
mortality
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14. BMI
Mortality
Unintentional
weight loss
Malignancy
Infections
Chronic
conditions
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15. Anorexia
• A metabolic effect of inflammation
• Animal studies have shown that cytokines have a direct
effect on the satiety center
• Animal studies have also shown an increase in skeletal
muscle breakdown in response to TNF- administration
• Diminished appetite (anorexia) is associated with higher
concentration of proinflammatory cytokines, higher levels
of EPO hyporesponisveness and poor clinical outcome.
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16. How does inflammation effect
appetite?
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17. Protein
Energy
Wasting
Poor
Appetite
Protein
breakdown
Chronic
disease
Inflammation
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18. Protein energy wasting
• PEW is found in 20-50% of patients with
advanced kidney disease
• PEW sharply increases mortality risk and
frequency of hospitalizations
• One study found that in the first 48 hours of
hospitalization pts met only 7% of protein
needs and 14% of calorie needs
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19. CRP
• Studies have shown an inverse
relationship between serum
albumin and CRP levels in
hemodialysis patients.
• CRP has been found to be
elevated in PD patients with
chronic infection
• CRP values become
significantly elevated during
peritonitis
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20. Hemodialysis
• Borah et al – study on nitrogen balance
 High (1.44) and low protein diets (0.5)
 Low always negative nitrogen balance
 High in negative nitrogen balance on dialysis days
only
• The process of dialysis increases CRP and IL-6
3/2/2020 20

21. 90 kg Male eating 1.44
gms protein/ kg BW =
18 oz daily or 6 three oz
servings.
Recommendation for
PD is 1.2-1.3 gm/kg BW
= 15oz daily or 5 3oz
servings
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22. Peritoneal dialysis
• Protein loss in dialysate
• Feeling of fullness due
to PDF
• Uremia associated
cachexia
• Protein energy wasting
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23. Figure 3
Source: American Journal of Kidney Diseases 2011; 58:418-428 (DOI:10.1053/j.ajkd.2011.03.018 )
Copyright © 2011 National Kidney Foundation, Inc. Terms and Conditions
3/2/2020 23

24. High is….. GOOD????
Shouldn’t everything be low?
Low PTH
Low weight
Low cholesterol
Poor nutrition status
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25. Albumin management and ESA use
• There is an inverse relationship between ESA
dose and appetite
– (Locatelli et al. Nutritional inflammation status and resistance to erythropoietin therapy in
hemodialysis patients; Nephrol Dial Transplant 21: 991-998, 2006)
• Increase in serum albumin concentration is
associated with rapid improvement in anemia.
Such a rate of anemia correction can only be
realized by tripling the dose of ESAs
– (Agarwal R, Davis J, Smith L, Serum albumin is strongly associated with erythropoietin
sensitivity in hemodialysis patients; Clin J Am Soc Nephrol 3:98-104, 2008)
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26. From: doi:10.2215/CJN.03330807.3/2/2020 26

27. Swimming up-stream?
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28. What is being studied?
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29. Projections for the US ESRD population regarding potential
cost savings from an intervention that improves nutritional
status in patients with serum albumin < 3.5 g/dL
Improvement in Alb from
<3.5 g/dL
25% 50% 75%
+ 0.1 g/dL $ 14,469,231 $ 28,938,462 $ 43,400,769
+ 0.2 g/dL $ 18,166,154 $ 36,325,385 $ 54,491,538
+ 0.3 g/dL $ 29,229,231 $ 58,465,385 $ 87,694,615
Adapted from; Lascon et al. Potential Impact of Nutritional Intervention on End Stage Renal Disease Hospitalization, Death
and Treatment costs. Journal of Renal Nutrition; 2007; 17(6) 363-3713/2/2020 29

30. Carnitine
• Plays a critical role in energy
balance across cell
membranes
• Plasma carnitine levels can
drop by 60% during
hemodialysis
• IV L-Carnitine
– Muscle myopathies
– Impaired exercise capacity
– Intradialytic hypotension
– EPO resistant anemia
3/2/2020 30

31. More carnitine benefits
• Carnitine promotes
positive protein balance
• Reduces insulin resistance
• Reduces inflammation
• However:
– Studies are limited in
subject number and all
have been “open labeled”
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32. Zinc
• Zinc deficiency is common in HD
and associated with uremia
– Anorexia
– Hypogeusia
– Disorders in sexual and
immunologic functions
• Zinc supplementation can correct
zinc deficiency in HD and may
help to decrease CRP levels
• Exact daily requirement for HD is
unknown
• MVI with Zinc
3/2/2020 32

33. Vitamin D
• Studiesin mice have shown that vitamin D may delay
the progressionof CKD
• Vitamin D receptor knockoutmice have an activated
renin-angiotensin system, are more hypertensive,and
have increased cardiac hypertrophy
• End stage kidney disease patients on active vitamin D
have a 26% reduction in mortality
• Nutritional D
Wolf M, Thadhani R: Vitamin D in Patients with Kidney Disease: Cautiously Optimistic. Adv Chronic Kidney Dis 2007,
14:22-26.
3/2/2020 33

34. Copyright ©2008 American Heart Association
Alborzi, P. et al. Hypertension 2008;52:249-255
hsCRP in the 3 groups. hsCRP increased by 50% in the placebo group and decreased by
20% in the 1-{micro}g paricalcitol group and 30% in the 2-{micro}g paricalcitol group
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35. Malnutrition
Immune paresis
Anorectic
cytokines
Increased risk of
malnutrition
Atherosclerosis
For every 0.1 mg/dL
albumin increases, the
risk of calcification
decreases by 20%
3/2/2020 35

36. Diet Counseling
• Participants in the HEMO
study had average daily
intakes of 23 Kcal per Kg of
body weight
• Complicated diet, needs
constant reinforcement
• Intensive dietary counseling
increased albumin while
ONS decreased
• Eating on dialysis
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37. Steroids and appetite stimulants
• Megace
• Original use
• Side effects
• Weight gain
• Marinol
• Derivative of??
• Side effects
• Effectiveness
• Use in dialysis
• Corticosteroids
• Dexamethasone (Decadron)
• Comparable to Megace
• Side effects
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38. Megace and elderly dialysis patients
• 24 week, randomized, double blind placebo controlled pilot
study
• Pts also received weight resistant physical therapy for 40
minutes, 2x per week prior to dialysis
• 9 patients – 6 completed, 3 withdrew
• Significant improvements in weight, fat mass and ability to
exercise
• Improved quality of life and decrease in CRP
• No significant lean muscle gain or improvement in ADL’s
3/2/2020 38

39. Megace study
• Hs CRP decreased in both groups with progressive
resistance exercise training
• Megace may “blunt” the effects of training equaling less
muscle strength and decreased performance
3/2/2020 39

40. Unsaturated Fat!
• Hypothesis: Adding fat
to the diet would
increase energy intake,
improve nutrition status
and lower CRP
• A caloric increase of 380
kcal in MUFA and PUFA
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41. Results
• Results: Only 14
completed the study
– 5 – adverse effects
– 2- refused to take
• No significant difference
in blood lipids
• Dry body weight higher
• CRP lower
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42. Brazil Nuts
• Study found that when dialysis patients eat one
Brazil Nut daily levels of selenium improve
• 81 pts, for 3 months
• Before supplementation plasma levels were 18.8
mcg/L
• After supplementation levels were 104 mcg/L
• Erythrocytes and GSH-Px increased as well
3/2/2020 42

43. Table 1: Selected Food Sources of Selenium [11]
Food
Micrograms
(mcg)
Percent
DV*
Brazil nuts, dried, unblanched, 1 ounce 544 777
Tuna, light, canned in water, drained, 3 ounces 68 97
Cod, cooked, 3 ounces 32 46
Turkey, light meat, roasted, 3 ounces 27 39
Bagel, egg, 4 inch 27 39
Chicken breast, meat only, roasted, 3 ounces 24 34
Beef chuck roast, lean only, roasted, 3 ounces 23 33
Sunflower seed kernels, dry roasted, 1 ounce 23 33
Egg noodles, enriched, boiled, ½ cup 19 27
Macaroni, enriched, boiled, ½ cup 19 27
Cheddar cheese, 1 ounce 4 6
3/2/2020 43

44. Statins and inflammation
 Recent study by Lundberg et al. measured the effect of
statins on patients with IgA Nephropathy.
 Results showed that free radical production can be
decreased with statin therapy
 Previous studies have established that statins exert anti
inflammatory effects that may slow the progression of CKD
by improving inflammatory cell signaling pathways as well
as improving lipid profiles
 Statins also protect against the oxidation of LDL and as a
result reduce oxidative stress
Lundberg, S. et al. Atorvastatin-induced modulation of monocyte respiratory burst in vivo in patients with IgA
nephropathy: a chronic inflammatory kidney disease. Clinical Nephrology, Vol 73-No. 3/2010 (221-8).3/2/2020 44

45. However,
• Statins have not produced the same results in
maintenance hemodialysis patients
• No difference was found in the control vs.
treatment group
• The recent AURORA trial found that a high
phosphate level was one of the strongest risk
factors for the occurrence of cardiovascular
endpoints in their study
Venkata Narla, Michael J Blaha, Roger S Blumenthal, and Erin D Michos. The JUPITER and AURORA clinical trials for
rosuvastatin in special primary prevention populations: perspectives, outcomes, and consequences. Vasc Health
Risk Manag. 2009; 5: 1033–1042. Published online 2009 December 29.3/2/2020 45

46. Statins
• Antioxidant properties
• Spare selenium
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47. Omega 3 Fish Oil
• EPA and DHA
• Fish intake and
albuminuria
• Cost
• # of pills
3/2/2020 47

48. Implications
• Increase Fat?
• More nuts?
• Olives?
• Supplements?
• Use olive oil and canola
oil
• Low K, low PO4 and low
Na++ foods that are high
in unsaturated fatty acids
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49. Protein and caloric supplementation
• Oral • IDPN/ IPN
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50. PO Supplements
• Initial intervention
• Readily available and
convenient
• Adherence to oral
supplements is variable
and low
• Peridialytic use
– Provided to patient
– At no cost
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51. PO Supplements
• Recent study found
maintenance of KDOQL
score
• Increased albumin
• Non treatment group had
decreased albumin
• Some participants
consumed 40%, others
200%, average was 84%
• Drawbacks: Staff missing
or patients refusing 30%
of the time
3/2/2020 51

52. IPN/ IDPN
• Non invasive
• Compliance
• Studies have shown safety
• IKizler et al showed that IDPN promoted a 96%
increase whole body protein synthesis and a 50%
decrease in whole body proteolysis compared
with controls
• Cost
3/2/2020 52

53. Figure 3 Effect of nutritional therapy modality on forearm muscle homeostasis
Kalantar-Zadeh, K. et al. Diets and enteral supplements for improving outcomes in chronic kidney disease Nat. Rev.
Nephrol. doi:10.1038/nrneph.2011.60
Data obtained from Pupim, L. B., Majchrzak, K. M., Flakoll, P. J. & Ikizler, T. A.3/2/2020 53

54. Projections
• IKizler, “Nutrition Support for the Chronically Wasted or
Acutely Catabolic Chronic Kidney Disease Patient” Dec 2009
• An increase in albumin of 0.2 in 50% of the US dialysis
population
• Approximately 1,400 lives saved
• Approximately 6,000 hospitalizations averted
• Approximately $36 Million in Medicare cost savings resulting
from a reduction of approximately 20,000 hospital days over 1
year.
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55. The bottom line in nutrition
• 30-75% of dialysis patients are malnourished
• Inflammation and malnutrition are multifactorial and virtually inevitable in CKD
and Dialysis
• Adequate calories from all sources as well as essential and conditionally essential
vitamins and minerals
• Calories can be administered enterally or parenterally
• There are new approaches being studied constantly
• Considerations
• Compliance/ adherence
• Ability to understand importance
• Quality of life
• Bundling
– Improved nutrition/ improved inflammation = better EPO responsiveness
3/2/2020 55

56. Thank You
Vishal Bagchi MBA RD LD
Director of Medical and Scientific Affairs
Patient Care America
214-736-7969
vbagchi@pcacorp.com
www.pcacorp.com
3/2/2020 56

57. FINE Study
• Best designed study to date
• There was no non treatment group
• Patients on CHD with PEW
• Compared the effects of the route of
supplementation on morbidity and mortality
• Found that the route was not a factor
• The important thing was to deliver the nutrients
3/2/2020 57

58. Ghrelin
• TNF- administration in rats decreased plasma acyl ghrelin levels
and reduced food intake in mice
• Injections of Des Acyl ghrelin in mice decreased food intake,
induces negative energy balance and delays gastric emptying
• There is a strong inverse relationship between CRP and acyl ghrelin
levels
• Higher acyl ghrelin levels are found in pts without inflammation
compared to pts with inflammation
• SubQ Ghrelin increases appetite in dialysis short-term
• In PD it doubled intake
3/2/2020 58

59. 3/2/2020 59

60. Speaker-Vishal Bagchi
• UT Southwestern Medical Center School of Allied
Health- Clinical Nutrition
• University of Dallas MBA- Healthcare and Marketing
• UT Southwestern – Critical Care and Acute Dialysis
• Fresenius 2007-2013- Home Therapies, Peritoneal
Dialysis, Nocturnal, Conventional HD
• NKF-CRN Dallas Chair
3/2/2020 60