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European Best Practice Guidelines European Best Practice Guidelines
NutritionNutrition
Marianne Venegoor, RD, Surrey, UK
Pieter Ter Wee, MD, Amsterdam, Netherlands
Christof Wanner, MD, Würzburg, Germany
Denis Fouque, MD, Lyon, France, Chair
Publiées dans: Nephrol Dial Transplant, juin 2007
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Recommandations Précédentes
1. NKF USA: K-DOQI guidelines in Nutrition, 1998-2000, in AJKD
2. ESPEN: consensus paper, 2001 in Clin Nutr
3. EDTA: Accord paper 2003, in NDT
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MéthodologieMéthodologie
- Assistance méthodologique par le Cochrane Renal Group
- Depuis K-DOQIs (2000), app. 400 nouvelles publications
- « Grading » (14 experts) pour le degré d’évidence (I , II, III, et opinion)
- Revue externe Avril à Juin 2006 (tous les membres de l’ EDTA et sociétés impliquées en Néphrologie, Nutrition et Diététique)
- 7 meetings 2003-2006
- Assistance technique par l’EDTA et FMC
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Fréquence de la Dénutrition
Albumin (g/L)
36.3 ± 5.0 g/l
0
150
300
450
600
750
900
1050
1200
10 15 20 25 30 35 40 45 50 55 60 et +
Observatoire Phosphocalcique, Janvier 2006
14.000 pts
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European Best Practice GuidelinesEuropean Best Practice Guidelines
NutritionNutrition
Guideline 1: ÉpidémiologieGuideline 2: Diagnostic et SurveillanceGuideline 3: Besoins en Energie et ProtéinesGuideline 4: Besoins en Vitamines et OligoélémentsGuideline 5: Traitement de la DénutritionGuideline 6: Acidose Métabolique
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Épidémiologie
6 m
3 m
1. Bilan nutritionnel au début de la dialyse
2. Éviter la dénutrition protéino-énergétique en raison du pronostic catastrophique
3. Si l’état nutritionnel est considéré normal, bilan nutritionnel tous les 6 mois (< 50 ans)
4. Si il existe une dénutrition OU si > 50 ans, bilan nutritionnel tous les 3 mois
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European Best Practice GuidelinesEuropean Best Practice Guidelines
Guideline 2: Diagnostic et Surveillance
Diagnostic Surveillance
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European Best Practice European Best Practice GuidelinesGuidelines
A. Enquête alimentaireB. BMI -IMCC. SGAD. AnthropométrieE. nPNAF. Albumine et préalbumineG. Cholesterol totalH. Investigations techniques (bioimpedance, DEXA, NIR)
Diagnostic
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L’état nutritionnel doit être suivi par (Opinion):
A. Enquête alimentaireB. Poids secC. nPNA, Albumine et cholestérol total
Les investigations techniques seront réservées à la recherche (Opinion)
European Best Practice European Best Practice GuidelinesGuidelinesSurveillance I
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A. Enquête alimentaire :
• 6 à 12 mois (patients stables)• 3 mois si > 50 ans (approx. 2/3 des patients HD)• 3 mois si > 5 ans de dialyse• plus fréquent si phase aigüe ou si dénutrition sévère
European Best Practice GuidelinesEuropean Best Practice Guidelines
Surveillance II
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B. Poids sec
• Moyenné par mois• Perte de poids significative si >10% (Poids sec post
dialyse)• Prise de poids interdialytique optimale : 2-2.5 kg (4- 4.5%)
European Best Practice GuidelinesEuropean Best Practice Guidelines
Surveillance III
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C. nPNA, albumine et cholestérol
• Patient stable : tous les trois mois• Début de dialyse ou instable : tous les mois
•DEXA et BIA; recherche seulement
European Best Practice GuidelinesEuropean Best Practice Guidelines
Surveillance IV
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Guideline 3: Besoins en Énergie et Protéines
Besoins en Énergie : 30 - 40 kcal/kg/j selon l’activité physique
Depuis 2000, il existe un débat entre les conseils théoriques et la pratique quotidienne
1. Dépense énergétique de repos 2. Dépense énergétique quotidienne
DEE = REE x F
F entre 1.2 et 2.5 (moyenne 1,4)
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Comment estimer la dépense énergétique?Comment estimer la dépense énergétique?
•Eau deutérée•Chambre calorimétrique•Calorimétrie indirecte (Datex®)•Harris Benedict (MdRepos)•Mesures d’activité physique
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Exemple de mesure Armband témoinExemple de mesure Armband témoin
2000 /70 kg = 28,5 kcal/j
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Guideline 3: Besoins en Énergie
DE = 1155 x 1.4 = 1617 = 32 kcal/kg
DE = 1155 x 1.2 = 1386 = 28 kcal/kg
Exemple :
Femme 75 ans, 52 kg, arthrose
MDR: 1155 kcal
Facteur d’Activité F entre 1.2 et 2.5 (moy 1,4)Âge moyen HD : 67 ans (France 2006)
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Guideline 3: Besoins en Protéines
Depuis 2000, inadéquation entre études métaboliques et données prospectives de cohortes
Balances azotées = nPNA
Les besoins en protéines sont :
• Apports > 1.1 g prot/kg/j (prescrit - recueils)• nPNA > 1.0 (estimation des sorties)
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Quel Apport Protéique ?
Kalantar-Zadeh, NDT 2006
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Quel Apport Protéique ?
Ohkawa Am J Kidney Dis 2004
• 129 HD, cross sectional• nPNA • MM, MG sc et viscerale• Plateau ≥ 1.1 g prot/kg/d
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Phosphatémie et Apports ProtéiquesPhosphatémie et Apports Protéiques
Kalantar et al, ASN San Diego 2006
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Kalantar et al, ASN San Diego 2006
Mortalité et Apports protéiquesMortalité et Apports protéiques
0,6 0,7 0,8 0,9 1,0 1,1 1,2 1,3 1,4 >1,4
nPNA (g/kg/day)
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Âge < 50 50-59 60-69 70-80
Nb 47 28 71 61
P mg/l 59.8 56.3 50.6 44.7
PTH ng/ml 361 357 215 150
Sans chélateurs 4 4 13 13
Protéines (g/kg/j) 1.30 1.10 0.88 0.84
Calories (kcal/kg/j) 27.2 19.5 19.5 19.6
207 patients hémodialysés
Apports Alimentaires et statut Apports Alimentaires et statut phosphocalciquephosphocalcique
Lorenzo et al, Am J Kidney Dis 2001
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ContrContrôle de l’hyperphosphatémieôle de l’hyperphosphatémie
Apport ApportProtéique Phosphore
(g/kg/j) (mg/j)
>1.2 1353 253
1.0-1.2 1052 219
0.8-1.0 936 217
1 g protéines = 13 mg P
100 g prot/j = 1300 mg P/j
Rufino M, et al. NDT 1998;13:65-67.
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ContrContrôle de l’hyperphosphatémieôle de l’hyperphosphatémiePour 100 g dans l’assiette…ou le verre
Beaufort 750 mg Saint Nectaire 375 mgHollande 300 mgChèvre 220 mgFromage blanc 60 mgLait 80 mg
Viandes rouges 200 mgPigeon 400 mgThon 180 mgCabillaud 160 mgSardines 500 mg
Coca-Cola light 80 mg/l Coca-Cola 160 mg/l
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Objectifs et techniques de dialyseObjectifs et techniques de dialyse
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D’après Urena 2004
Élimination quotidienne de phosphate selon la technique d’épuration
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Hémodialyse Quotidienne CourteHémodialyse Quotidienne Courte
0
1
2
3
4
5
6
SHD DHD 6mDHD 12m1,6
1,7
1,8
1,9
2
2,1
2,2
CaxP
Ap Prot
Ap Phos
Phosphorˇmie
Chélateurs: -70 % Galland et al, Kidney Int Oct 2001
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Guideline 4: Vitamins and trace elements requirements
Not a Guideline but a Recommendation
• Great number of vitamins and trace elements• Small number of low grade quality trials• Different dialysis techniques• Important and/or long-lasting stores for some• Almost no adequate clinical trial…
• Mainly dietary requirements from food• Few to be supplemented to an adequate diet• Possible use of multivitamin pills, which vary widely across Europe
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European Best Practice GuidelinesEuropean Best Practice Guidelines
Vitamins Daily recommendation
Thiamine hydrochloride (B1) 1.1-1.2 mg supplement
Riboflavin (B2) 1.1-1.3 mg supplement
Pyridoxine hydrochloride (B6) 10 mg supplement
Ascorbic Acid (C) 75-90 mg supplement
Folic Acid (B9) 1 mg supplement
Cobalamine (B12) 2.4 µg supplement
Niacin (B3, nicotinamide, nicotinic acid, PP) 14-16 mg supplement
Biotin (B8) 30 µg supplement
Pantothenic acid (B5) 5 mg supplement
Retinol (A) 700-900 µg intake (no supplement)
Alpha-tocopherol (E) 400-800 IU supplement *
Vitamin K 90Š120 µg intake (no supplement)
Recommandation (Opinion)
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European Best Practice GuidelinesEuropean Best Practice Guidelines
Minerals and Trace elements
Phosphorus 800-1000 mg intake
Calcium 2000 mg intake including calcium from phosphate binders
Sodium 2000-2300 mg intake i.e., 5-6 g s odium chloride
Potassium 50-70 mmol intake (1950-2730 mg) or 1 mmol/kg š
Iron 8 mg (men) and 15 mg (women) intake 1
Zinc 10-15 mg (men) and 8-12 mg (women) intake (no supplement) 2
Selenium 55 µg intake (no supplement) 3
Recommandation (Opinion)
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Guideline 5 : Traitement de la Dénutrition
1. Support oral et entéral2. Nutrition Parentérale Perdialytique3. Androgènes4. Dialyse quotidienne
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Suppléments oraux : Méta-analyse
Stratton Am J Kidney Dis 2005
18 essais5 RCT13 CCT
429 pts
• Augmentation de l’Albumine de 2.9 g/L (p<0.01)• Réduction du RR de mortalité: 5% /g Alb (Combe 2001)
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Support ParentéralSupport Parentéral
1. Après suppl. oraux et surveillance diététique intensive (Evidence level IV)
2. NPPD recommandée si les apports spontanés sont > 20 kcal/kg/j et 0.8 g prot/kg/j . Sinon il faut recourir à une nutrition parentérale continue (Opinion)
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Nutrition Parentérale Perdialytique
Solution standard NPPD
1. 600 ml (300 ml AA 15%, 150 ml IL20%, 150 Gluc 50%)
2. 150 ml/h
3. 190 kcal/h
700-1000 kcal x3/semaine = 350 - 450 kcal/j
Pupim J Clin Invest 2002
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Suppléments Oraux / IV : l’étude Suppléments Oraux / IV : l’étude FineSFineS
Cano et al, J Am Soc Nephrol sept 2007
• Suivi: 2 ans (un an de traitement + un an de suivi)
• Visites à J 0 et mois 3, 6, 12, 18 et 24
Suppl Oraux + NPPD Pdt un an
Suppl OrauxPdt un an
182patients
Patients HD
Dénutris
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Suppléments Oraux / IV : l’étude FineSSuppléments Oraux / IV : l’étude FineS
1. Suppléments oraux : 5.4 kcal/kg/j0.42 g prot/kg/j
2. NPPD : 13.8 kcal/kg/HD (5.9 kcal/kg/j)0.62 g AA/kg/HD (0.27 g AA/kg/j)
Apport azoté : solution standard d’AA
Apport énergétique : 50% émulsion lipidique 50% glucose
Cano et al, J Am Soc Nephrol Sept 2007
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État NutritionnelÉtat Nutritionnel
groupe Control groupe NPPD
Mois0 6 12 18 24
30
34
S albumine, g/L
31
32
33
34
NS
Mois
300
280
260
240
220
200
NS
0 6 12 18 24
S préalbumine, mg/L
Cano et al, J Am Soc Nephrol Sept 2007
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SurvieSurvie
Albumine j0 (+1 g/L)
Créatinine j0 (+10 µmol/L)
Comorbidité (+1)
∆ Préalbumine j0-m3 (> 30 mg/L)
Hazard ratio
10.0 0.25 0.50 0.75 1.25 1.50 1.75 2.001
Cox multivarié Cano et al, J Am Soc Nephrol Sept 2007
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Johansen et al, JAMA 1999
-4
-2
0
2
4
6
BW LBM Body Fat
NanDec
PlaceboMM: gain MM: gain
MG: perte MG: perte
*
*
Kg
Androgènes
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2008
Kidney International 2008;73:391
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KIDNEY DISEASE WASTING - 2008
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Diagnostic clinique de la « PEW »Diagnostic clinique de la « PEW »
Biologie (Albumine, préalbumine, cholestérol)
Indice de masse corporelle (IMC)
Masse musculaire
Apports alimentaires
Au moins un paramètre anormal dans Au moins 3 des 4 groupes
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Conclusion
• Addition de 400 nouvelles publications depuis 1998• Ajout d’études prospectives observationnelles• Simplification du monitoring nutritionnel• Recommandation pour les vitamines et oligoéléments• Degré d’évidence plutôt bas
• Grand besoin d’essais d’intervention randomisés ++
Nutrition Guidelines Workgroup