Nutrition and metabolic considerations in elderly dialysis patients

1. Nutritional and Metabolic
Considerations in Elderly Dialysis
Patients
MARC EVANS M, ABAT, MD, FPCP, FPCGM
Head, Center for Healthy Aging, and Section of Geriatrics
The Medical City
Clinical Associate Professor, Section of Adult Medicine,
Department of Medicine, PGH

2. Outline
• Elderly Hemodialysis
– Frailty
– Metabolic Considerations
– Nutritional Considerations
• Interventions to Slow Down or Minimize
Frailty and Malnutrition in the Elderly
Hemodialysis Patient

3. Frailty
• Refers to a loss of physiologic reserve that
makes a person susceptible to disability from
minor stresses.
• An inherent vulnerability to challenge from
the environment.
• Not necessarily dependent on age, diagnosis
or functional ability

4. Common Features of Frailty
1. Weakness
2. Weight loss (unexplained)
3. Muscle wasting (sarcopenia)
4. Exercise intolerance
5. Frequent falls
6. Immobility
7. Incontinence
8. Instability of chronic diseases

5. J Am Soc Nephrol 24: 337–351, 2013

6. Reduced food intake
• Anorexia caused by uremic toxins (RF), other
anorexigens (TNF-a, cholecystokinin, or leptin(RF)
• impaired sense of taste/smell (RF,A)
• inflammation (RF,A)
• emotional depression (RF,A),
• medications (RF,A)
• Dementia (A)
• Poverty (RF,A)
• Loss of teeth or loss of dentures (A)
J Am Soc Nephrol 24: 337–351, 2013

7. Dialysate and urine nutrient losses (RF)
• Losses of protein into dialysate (~1 g/HD with
MHD; ~9 g/d with CPD)
• Losses of amino acids into dialysate (~10–12
g/HD with MHD; ~2.0–3.5 g/d with CPD)
• Losses of protein into urine and nephrotic
range proteinuria
J Am Soc Nephrol 24: 337–351, 2013

8. Inflammation associated with clinically
apparent diseases
• Medical illnesses (e.g., diabetes, infection,
heart failure, or cancer) and surgical illnesses
(RF,A)
Increased levels or activities of catabolic
hormones
• Parathyroid hormone (RF), glucagon (RF),
corticosteroids (RF), or angiotensin II (RF)
J Am Soc Nephrol 24: 337–351, 2013

9. Deficiency or resistance to anabolic hormones
• Insulin (RF,A), growth hormone (RF, A), IGF-1
(RF,A), testosterone (RF,A), 25(OH)D3 (RF,A), or
• 1,25-dihydroxycholecalciferol (RF)
Metabolic acidemia (RF)
• Activates the caspase-3 and the ubiquitin–
proteasome system in skeletal muscle, promoting
protein catabolism
• Suppress protein synthesis
J Am Soc Nephrol 24: 337–351, 2013

10. Primary neuromuscular disorders
• Central nervous system dysfunction
– Specific neuronal changes (RF,A)
– Dementia (A)
• Peripheral nervous system dysfunction (RF,A)
• Muscular changes
– Loss of myocytes (A)
• Reduced numbers of satellite cells and
myogenic factors (RF,A)
• Tendon stiffness (RF,A)
J Am Soc Nephrol 24: 337–351, 2013

11. • Physical inactivity and deconditioning (RF,A)
• Accelerated/impaired apoptosis (A)
• Increased number of senescent cells (A)
• Decreased cellular replenishment by stem cells
(A)
• Reduced autophagy (A)
• Accumulation of chemically altered proteins
(RF,A)
• Impaired DNA repair (RF,A)
• Epigenetic alterations (RF,A)
• Genetic predisposition (A)
J Am Soc Nephrol 24: 337–351, 2013

12. J Am Soc Nephrol 24: 337–351, 2013

13. Comprehensive Geriatric Assessment
• Detailed History
• Physical and Neurological Examination
• Cognitive Evaluation
• Behavioral/Emotional Evaluation
• Functional Evaluation
• Environmental Evaluation
• Social Evaluation

14. Comprehensive Geriatric Assessment
Among the dialysis patients,
• the vast majority showed a moderate (58.3%)
or high risk score (19.4%)
• Compared to geriatric patients without renal
failure, all MPI score domains were more
compromised in the dialysis population.
JNEPHROL 2012; 25(Suppl 19): S85-S89

16. Drugs that can cause ANOREXIA
• digoxin
• phenytoin
• SSRI’s / lithium
• Ca++ channel blockers
• H2 receptor antagonists
/ PPIs
• Any chemotherapy
• metronidazole
• narcotic analgesics
• K+ supplements
• furosemide
• ipratropium bromide
• theophylline
• spironolactone
• levodopa
• fluoxetine

17. Drugs That Interfere With Gustation (taste) and
Olfaction (smell)
Gustation
• Allopurinol
• Amitriptyline
• Ampicillin
• Baclofen
• Dexamethasone
• Diltiazem
• Enalapril
• Hydrochlorothiazide
• Imipramine
• Labetalol
• Mexiletine
• Ofloxacin
• Nifedipine
• Phenytoin
• Promethazine
• Propranolol
• Sulfamethoxazole
• Tetracyclines
Olfaction
• Amitriptyline
• Codeine
• Dexamethasone
• Enalapril
• Flunisolide
• Flurbiprofen
• Hydromorphone
• Levamisole
• Morphine
• Pentamidine
• Propafenone

19. Int. J. Med. Sci. 2011, 8

20. J Am Soc Nephrol 24: 337–351, 2013

21. Water-soluble vitamin
replacement:
folic acid (1 mg/day), pyridoxin
(10–20 mg/day) and vitamin C
(30–60 mg /day)
Clinical Nutrition (2006) 25, 295–310

22. • Oral Nutritional Supplementation
• Tube feeding
Clinical Nutrition (2006) 25, 295–310
– NGT
– PEG
• Intradialytic Parenteral Nutrition

23. Treatment of Underlying Co-morbidities
• Antidepressants
• Dementia medications
• Other medications

24. Nutritional Education
• 4 months of nutritional education
• nutritional knowledge was increased in all
patients (P < .050) after the NEP
• decrease in the prevalence of malnutrition
• Creatinine clearance, total protein serum
values, and other biochemical parameters
improved significantly in both groups (P < .050
in all cases)
J Ren Nutr. 2014 Jan;24(1):42-9.

25. Antioxidants
• 353 patients
• prospective, placebo-controlled, double-blind clinical trial
• mixed tocopherols (666 IU/d) plus α-lipoic acid (ALA; 600
mg/d) or matching placebos for 6 months (NCT00237718)
• High-sensitivity C-reactive protein (hsCRP) and IL-6
concentration were measured as biomarkers of systemic
inflammation, and F2 isoprostanes and isofurans were
measured as biomarkers of oxidative stress.
• the administration of mixed tocopherols and ALA was
generally safe and well tolerated, but did not influence
biomarkers of inflammation and oxidative stress or the
erythropoietic response.
J Am Soc Nephrol. 2014 Mar;25(3):623-33.

26. Anabolic Agents: Hormones
• 29 predialysis patients with CKD,
• randomly divided into control (n = 13) and nandrolone
decanoate (NAN, n = 16) 100 mg per for 3 months.
• NAN group had increased LBM (P < .01) and decreased
serum albumin levels (P < .05), but no changes in the
values of normalized protein catabolic rate, serum
lipids, hematocrit, and glomerular filtration rate.
• Changes in LBM in the NAN group were significantly
higher than in the control group (P < .05)
• Minor adverse effects were observed in a few patients
in the NAN group.
J Ren Nutr. 2007 May;17(3):173-8.

27. Low Intensity Strength Training in HD
Nephrol Dial Transplant (2010) 25: 1936–1943

28. Nephrol Dial Transplant (2010) 25: 1936–1943

29. Nephrol Dial Transplant (2010) 25: 1936–1943

30. Nephrol Dial Transplant (2010) 25: 1936–1943

31. Summary
• Older patients are at risk to become frail and
malnourished
• End-stage kidney disease and dialysis
increases the risk further through multiple
interacting factors
• Adequate comprehensive assessment is
needed
• Existing and novel interventions can be
tailored based on the accurate assessment