JOURNAL OF RENAL NUTRITION AND METABOLISM (2015) l: 33-34


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CASE REPORT

Nutritional Status 33


Assessment of Nutritional Status in Chronic Kidney Disease( CKD)

Bharat Shah

Director, Global Hospital, Mumbai, Managing Trustee, Narmada Kidney Foundation



Introduction:

Patients with chronic renal disease usually have poor dietary intake due to uremia. Dietary protein and energy intakes and serum and anthropometric measures of protein-energy nutritional status progressively decline as the GFR decreases. The reduced protein and energy intakes, as GFR falls, may contribute to the decline in many of the nutritional measures.


Case:

A 35 years old man with chronic kidney disease (CKD) due to tubular interstitial disease (TID) visited a nephrologist on Sept 2012. On 1st visit, his weight was 78 kg, blood pressure (BP) was 160/110, urine routine was unremarkable, serum creatinine was 5.16 mg/dl and calculated creatinine clearance (CG formula) was 22.46 ml/min. He was observed for 3 months on antihypertensive therapy and he was advised to continue his diet. Over time there was a gradual rise in creatinine. His baseline protein intake was 0.6 g/kg/day (by UNA). In view of good appetite, good weight, slowly rising creatinine and no other active disease, he was advised very low protein diet (VLPD) +ketoanalogues (KA). Over the next 3 months his weight (edema-free) dropped from 75 kg to 70

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Cholestern l :1


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Albumin


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Weilht


Creatinine image


Figure 1Changes in serum cholesterol, albumin, creatinine and body weight of the patient.


kg. He was counselled, energy intake was increased and then his weight gradually improved. His albumin and cholesterol which dropped initially also improved. His serum creatinine remained stable (Figure 1).


Discussion:

Importance of assessment of nutritional status and how to assess it:

As kidney function declines, the nutritional status deteriorates due to decreased appetite (retained uremic toxins & dietary modification prescribed), increased catabolism due to uremic toxins. Deteriorating nutritional status has a significant impact on morbidity. MDRD study has shown that with decline in GFR below 60ml/min, protein and energy intake also declines and so does the serum albumin. Study by Shah etal on dietary protein intake in patients with chronic renal failure has shown that in Indian vegetarian population, the protein intake is 0.64 ±0.15 g/kg/d whicj is according to KDOQI recommendations for non-dialyzed CKD patients. Hence protein restriction should not be recommended until protein consumption is known. In this case, the patient was put on VLPD along with KA because of creeping creatinine. However, on switching over this patients from low protein diet to VLDL along with KA resulted in gradual loss of weight because with restriction of protein his energy intake reduced. Hence his energy intake was increased which reflected in rise in weight along with maintenance of renal function due to VLDL+KA. Hence until protein and energy intake of the patient is known, drastic changes in diet prescriptions should be avoided.

Nutritional Approach For CKD Patients: It is imperative that on patients first visit to the clinic, complete nutritional assessment should be done which as follows:

  1. Anthropometry

    1. Percent usual body weight (% UBW) = (WT/ UBW) X 100


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      1. Percent standard body weight % SBW = (WT/ SBW) X 100

      2. Body mass index (BMI) = (WT/HT in m2)

      3. Skinfold thickness (Biceps, triceps, subscapular, suprailliac)

      4. Mid upper arm circumference (MUAC)

  2. iochemical Parameters -serum albumin, prealbumin, transferrin, creatinine & creatinine index and cholesterol (every three months). Presence of infection and inflammation can affect levels of serum albumin, prealbumin, transferring.

  3. Nutritional Status: Subjective global assessment (SGA) on first visit and every six months

  4. Dietary Intake: To evaluate dietary intake following tools can be used:

    1. Dietary interviews & dietary diaries

      JOURNAL OF RENAL NUTRITION AND METABOLISM (2015) 1: 33-34


    2. Urea nitrogen appearance (UNA)

    3. Protein equivalent of total nitrogen appearance (PNA) but the technique is expensive, labour intensive & impractical for routine clinical use.

  5. Advanced studies : Bioelectrical impedance analysis (BIA), near Infrared reactance (NIR), hand grip strength and DEXA.


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References:

1. Kopple JD, Greene T, Chwnlea WC, Hollinger D etal MDRD Study Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney International 2000 Apr;57(4):1688-703.

2. SS Beheray and Shah BV Dietary protein intake in patients with chronic renal failure Indian J Neph. Vol 6 No 1page 19-21