SRNMCON 2023
Nashik, 12-14th Jan
Read to Know More!
NUTRITION IN CKD
Understand the Role of Nutrition in CKD Patients
FORMULA FEED & GUT MICROBIOME
Blenderised Tube Feed V/S
Commercial Feed
SALT SUBSTITUTE
Can salt be replaced?
IDPN BODY
Learn about Intradialytic
Parenteral Nutrition
COMPOSITION
Importance of body composition in renal diseases
EDITOR IN-CHIEF/ BANSARI RAO
CO- EDITORS / SONU MISHRA, DR. DVIJ MEHTA
WEBSITE / NUTRITIONINSIGHTS.IN
CONTRIBUTORS / DR.DEODATTA / HIMANI PURI / SAPNA KAMDAR / MS.MEGHA KAPOOR / DR.NANCY SAHNI / SHILPA CHADHA THAKUR /
RANU SINGH / ANKITA GHAG / MRS.ZAMURRUD PATEL / IPSITA
CHAKRAVARTI / SUNEETHA RAO / PRIYANKA KORI / DR MANSI PATIL
COVER PAGE /
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INTRADIALYTIC PARENTERAL NUTRITION IN HD PATIENTS
Dr Deodatta Chafekar
11
BASELINE CHARACTERISTICS AND PROGNOSTIC NUTRITION INDEX (PNI) IN PATIENTS WITH RENAL CELL CARCINOMA (RCC)
By Ms. Megha Kapoor20
BLENDERISED TUBE VS COMMERCIAL FORMULA FEEDS: HOW THEY AFFECT THE GUT MICROBIOTA?
By Himani Puri29
A NEW JOURNEY WITH A NEW ORGAN
By Priyanka Kori15 INFLAMMATION IN CKD- ROLE OF NUTRITION & FOOD PH
By Shilpa Chadha Thakur27
NUTRITIONAL LOSSES IN HAEMODIALYSIS & PERITONEAL DIALYSIS (HD & PD) PATIENTS AND HOW TO REPLENISH IT
By Ipsita Chakravarti16 CHALLENGES IN THE MANAGEMENT OF MALNUTRITION, INFLAMMATION AND ATHEROSCLEROSIS (MIA) SYNDROME IN PATIENTS WITH CKD IN INDIAN SCENARIO
By Ranu Singh18 SALT SUBSTITUTES
By Dr. Mansi Patil22
ROLE OF BODY COMPOSITION IN RENAL PATIENTS
By Ankita Ghag12
REVIEW ON RENAL NUTRITION GUIDELINESGOLDEN PAST TO DIAMOND PRESENT AND PLATINUM FUTURE
By Dr. Nancy Sahni24
PRE AND PROBIOTIC USE IN CLINICAL PRACTICE
By Mrs. Zamurrud M Patel & Sapna Kamdar28
PATIENT CASE STORIES THAT SHOW THE IMPORTANCE OF NUTRITION IN CKD
By Suneetha Rao
THE SRNMCON 2023 NASHIK ORGANIZED THE CONFERENCE BASED ON THE THEME, “CHANGING OUTCOMES WITH NUTRITION INTERVENTION " , WHICH WAS HELD FROM JANUARY 13TH TO 15TH, 2023 HERE NEPHROLOGISTS, PHYSICIANS, NUTRITIONISTS, DIETICIANS, PROFESSORS, SCIENTISTS, RESEARCHERS, RESEARCH SCHOLARS, HEALTH EXPERTS, DELEGATES, AND STUDENTS PARTICIPATED. IT TALKED ABOUT THE LATEST TRENDS, INNOVATIONS, CONCERNS, AND PRACTICAL CHALLENGES THAT COME ACROSS IN RENAL NUTRITION CARE AND DISCUSS THE SOLUTIONS
SRNMCON 2023 NASHIK NOT ONLY SHARED THE KNOWLEDGE BUT ALSO PROVIDED A PLATFORM TO HELP IN BUILDING A PROLIFIC NETWORK AND PROFESSIONAL OPPORTUNITIES TO BOOST ONE’S CAREER THE THREE DAYLONG CONFERENCE HAD VARIOUS SCIENTIFIC SESSIONS FROM EXPERTS, INFORMATIVE LECTURES, PANEL DISCUSSIONS, WORKSHOPS, A COMMUNITY OUTREACH PROGRAM, A SYMPOSIUM, A RECIPE CONTEST, A RESEARCH PAPER POSTER PRESENTATION, AND A LOT MORE. THE EVENT HELD AT EXPRESS INN, NASHIK WAS SUCCESSFULLY PUT FORTH BY DR. VIJAY GHATGE (CHAIRMAN), AND DR DEODATTA CHAFEKAR (ORGANIZING SECRETARY), DMS HIMANI PURI (JTORGANIZING SECRETARY), AND DR KAILAS SHEWALE (SCIENTIFIC COMMITTEE) ALONG WITH THE ORGANIZING COMMITTEE.
THE SOCIETY OF RENAL NUTRITION & METABOLISM (SRNM) IS THE FIRST AND FOREMOST INDIAN SCIENTIFIC ORGANIZATION DEDICATED TO THE ENTIRE SPECTRUM OF NUTRITION AND METABOLISM IN KIDNEY DISEASE. THE FOREMOST GOAL OF SRNM IS TO DISSEMINATE KNOWLEDGE AND PRACTICE OF RENAL NUTRITION AMONG PHYSICIANS AND DIETICIANS THROUGH THE ANNUAL ADVANCED COURSE AND ANNUAL CONFERENCE (SRNMCON) AND TO PROMOTE RESEARCH
ESRD is usually associated with high morbidity and low quality of life Altered nutritional status and protein-energy wasting are important factors that leads to these in ESRD patients on haemodialysis. Nutritional support strategies are usually restricted to dietary counseling and oral nutritional supplements However, patients may not comply with this advice or oral nutritional supplements.
Factors contributing to malnutrition in chronic renal failure
Metabolic alterations (Acidosis, high parathyroid hormone levels, endocrine disorders, altered glucose metabolism, low insulin-like growth factor-1, uremic toxins )
Gastrointestinal disturbances (Gastroparesis, nausea, vomiting, anorexia, altered taste sensation )
Dialysis treatment (Ineffective haemodialysis, bioincompatible membranes, nutrient losses…)
Dietary factors (Low protein diets in pre-dialysis state, diets
restricted in phosphorus and potassium )
Concomitant illness (Congestive heart failure, pulmonary disease, diabetes mellitus, depression, other chronic or acute diseases, multiple medications )
Chronic inflammation (Decreased clearance of inflammatory cytokines, dialysate impurity, oxidative stress, exposure to foreign bodies (tubing, membranes, vascular access grafts or catheters ) ~ 40% of HD patients are malnourished, 68% thereof severely!!!
Intradialytic parenteral nutrition (IDPN) may be a possibility in CKD patients on dialysis
What is Intradialytic Parenteral Nutrition?
HD access is used for the delivery of Parenteral Nutrition, so no need for an additional permanent catheter or port system
It is delivered through the venous drip chamber in the extracorporeal circuit.
IDPN is administered throughout the HD session, which typically
lasts about 4 hours and can be done twice a week
The IDPN admixture typically contains dextrose, amino acids, and lipids and may contain electrolytes, trace elements, and vitamins.
IDPN is time and volume restricted and is a form of supplemental nutrition support adjuvant to any oral intake
IDPN can only provide up to 25% of a patient’s targeted nutrient intake as it is intermittently delivered
Clinical Indications where IDPN is considered.
Established risk of malnutrition
A failed attempt at intensive oral nutrition or poor compliance with ONS
Possible Contraindications
requiring a delay in IDPN. Severe malnutrition will require more intensive intervention
Baseline triglyceride level >500 mg/dl
Uncontrolled DM or HT.
Evidence of volume overload.
DR DEODATTA CHAFEKAR, MD (MED), DNB (MED), DM (NEPHRO ), DNB (NEPHRO) FRCP (London), FICP, FISN, FASN, FACP, FICCM, FISOT, FGSI, Consultant Nephrologist & Director, Supreme Kidney Care, Nashik, Director Renal Services, Medicover Hospital, NashikRRenal Cell Carcinoma (RCC) accounts for 85% of all renal malignancies with a 5-year survival rate of 73% and if
metastatic then <10 %. The prognostic nutritional index (PNI) is a parameter that reflects nutritional and inflammatory status It has been proposed as a simple, feasible, and robust biomarker for RCC. Cancerrelated inflammation is currently recognized as the seventh hallmark of cancer Systemic inflammation responses, including increased peripheral blood cell counts and decreased hemoglobin and serum albumin levels. Identification of the contributing modifiable risk factors would impede the prognostication of patients with inflammatory diseases such as renal cell carcinoma. Patient data included; demographic characteristics, Eastern Cooperative Oncology Group (ECOG), anthropometric measurements, dietary habits, addictions, comorbidities, biochemical parameters, and clinical characteristics. The data were collected from the nutrition clinic of a tertiary care hospital. Prognostic nutrition Index (PNI), a multiparametric indicator was calculated as PNI= [(10 × serum albumin (g/dL)) + (0 005 × total lymphocyte count].
Descriptive statistics were used to analyze the data. Out of 255, majorly patients were from Maharashtra (30 7%), West Bengal (17 2%), and UP (10 4%) 218 patients (85 4%) had ECOG 0 status. Of the total, 112 patients, 43.9% had the habit of tobacco chewing or smoking. Hypertension has been studied as one of the potential risk factors to develop RCC In this study, 32 7% were hypertensive, 17 6% were diabetic and 25.7% had both. Of the total, 21.6% had multiple comorbidities. Together with smoking habits and hereditary syndromes, obesity is considered one of the risk factors for RCC In the study, 45% of patients were malnourished wherein 10% were underweight and 35% were either overweight or obese Weight loss was projected in 70 5% of patients when compared with their usual weight From the available data, 132 patients were anemic (Hb <12g/dL) and out of which 17 patients had severe anemia (<8g/dL) Albumin is the most abundant protein in the plasma, and its level represents the nutritional and inflammatory statuses. 45.4% of patients (98 out of 216) had hypoalbuminemia (<3.5 mg/dL). Albumin to globulin ratio (AGR) has been evaluated as an emergent prognostic
marker in predicting the overall survival of various tumors and it was seen that 68 6% (101 out of 148) had low AGR (≤1 2) It was interesting to observe that 33 nondiabetic patients were reported with hyperglycemia (FBS >99 mg/dL). Clinical symptoms were assessed. It was observed that 44 7% of patients had more than one symptom such as anorexia, poor appetite, nausea, vomiting, and fatigue at the baseline level
The prognostic nutritional index (PNI) was calculated for 216 patients 78 7% had a low PNI score (<45) indicating poor disease progression 54 out of 72 overweight and obese patients (60%) fall into the low PNI category. Interestingly, 80.4% of patients with normal BMI also had low PNI values suggesting that certain hidden biomarkers can give a better idea of the nutritional status of the patients We can conclude that early identification of modifiable risk factors will help to better tailor counseling and potential treatment strategies for patients Lifestyle and Dietary management i e , including antiinflammatory nutrients in the diet should be an alarming focus for maintaining good nutritional status which improves treatment outcomes and reduce the risk of mortality
It is rightly said by Thomas Edison that the doctors of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition. Since the 19th century, protection of the health & function of the diseased kidney as well as preservation or improvement of the overall health of the patient are the two different views that have been advanced regarding the potential benefits of dietary treatment for people with chronic kidney disease (CKD) In the 1960s, renal replacement therapies (RRT) started debating suggestions on protein intake by the different renal nutrition workers to be either 40 g or 20 g per day asserting that a lower protein intake would prepare the patient well for RRT In the late 1960s and early 1970s, this became apparent that the 20 g protein/day diet was inadequate therefore, three alternatives to dietary protein restriction were suggested and shown to be nutritionally adequate, i e , a low protein diet (LPD) containing approximately 0.55-0.60 g protein/kg/day (40 g protein/day), secondly an essential amino acid supplemented very low protein diet (VLPD) containing approximately 20 g of protein/day
supplemented with 16-20 g of EAA and lastly, a keto acid and hydroxy acid analogues VLPD (SVLPD)with approximately 20 g protein/day supplemented with nearly 16-20 g/day of a mixture of ketoacid and hydroxy acid analogues (KAs) of some EAA plus other EAA The latest evidence also says that a restricted protein diet supplemented with keto analogues could slow down the progression of CKD in patients with eGFR >18 without causing malnutrition and reverse CKDMBD in patients with eGFR <18.
Talking about KDOQI guidelines 2010 versus 2020 protein restriction in pre-dialysis, nondiabetic CKD patients suggested 0.6g-0.8g and 0.55–0.60 g /kg body weight/day respectively. Interestingly, 2020 KDOQI guidelines reverted to the protein requirement suggested in the late 1960s i e 0 55-0 60 g/kg/day For diabetic, on dialysis CKD patients, a protein-controlled diet providing 0.8g- 0.9 g verses 0.6-0.8 g/kg body weight/day was suggested to optimize glycemic control and maintain a stable nutritional status as per KDOQI guidelines 2010 and 2020 respectively. Again it is noticeable here that the upper limit has been cut down by
Dietician0.01 g/kg/day and the lower limit has been cut down by 0.02 g/kg/day as compared to a decade before guidelines Similarly, the protein requirement has ranged between 1 0 to 1 2 g/kg/day as per the new guidelines for patients on maintenance dialysis instead of a fixed 1 2 g/kg/day from previous guidelines(KDOQI,2010)
Therefore, the new guidelines advise a lower protein intake but give a range that points out towards informed protein intake advised by a registered dietician after considering patients' overall nutritional status and energy intake at every CKD stage.
The recommendation of 50% protein from high biological value sources (animal protein) has been removed from the latest guidelines in view of the benefits of plant based diets and resulting acidosis from animal protein sources. Also, there is insufficient evidence to support the benefit of this division However further research is required in this area
Dr Nancy Sahni Chief & Head, Department of Dietetics, PGIMER, ChandigarhWorldwide, Renal failure is a major health concern, in recent years it’s increased estimated prevalence of 8–16%. Kidney diseases comprise acute and chronic kidney disease (CKD) Acute kidney issue is a reversible condition if unattended which may lead to end-stage renal disease (ESRD) CKD is a chronic condition characterized by reduced glomerular filtration rate (GFR) proteinuria, normal or and progressive glomerular, interstitial, and tubular damage
The main function of the kidney is to maintain fluid and electrolyte and metabolic acid–base balance, maintenance of nutrients, and excretion of metabolic bodily waste Reactive oxygen species (ROS) - In a cell, a form of unstable molecule that comprises of oxygen which easily reacts with other molecules. If more ROS build up it may cause damage to RNA, DNA, and proteins, and may lead to cell death These ROS are produced during mitochondrial oxidative metabolism and in the cellular response to, cytokines, bacterial invasion, and xenobiotics. Reactive oxygen species (ROS) leads to the progress of inflammatory disorders
An imbalance between endogenous oxidants and antioxidants causes oxidative stress, leading to vascular dysfunction. The ROS-induced activation of transcription factors and proinflammatory genes increases inflammation
This phenomenon is of critical importance in patients with chronic kidney disease (CKD) because atherosclerosis is one of the serious factors causing cardiovascular disease (CVD) and increased mortality Inflammation is characterized by an increase in inflammatory markers, including acute phase proteins, adhesion molecules, and cytokines.
The buildup of acid in the body due to kidney disease or kidney failure is called metabolic acidosis Diet plays an important role in slowing the progression of kidney disease. NAE lowers after consumption of a lacto-vegetarian diet, a medium NAE under a moderate proteincontaining diet, and the highest NAE under a protein-rich diet
Taking alkali supplements to neutralize the daily acid load improves nitrogen balance in healthy elderly patients and overcomes metabolic acidosis
A diet rich in fruits and vegetables instead of bicarbonate therapy is feasible and economical and appears to have a positive effect on kidney hemodynamic function. An animal study states ionized alkaline water are safe approach in the management of metabolic acidosis secondary to renal failure or dialysis or urinary diversion(18). Further studies and researches are needed for Alkaline Water as it is rich in calcium and magnesium carbonate which can lead to hypercalcaemia
The Phosphorus Pyramid for CKD -The food pyramid color codes food items similar to a traffic light: greens for go, yellows for slow, and reds for stop It consists of 6 levels of phosphorus to protein ratio (no more than 12 mg/g is favorable) and phosphorus bioavailability Here’s an overview of each level from 1 (low phosphorus) to 6 (high phosphorus)(21). PLADO's new strategy for CKD is plant-dominant low-protein diet (PLADO) of 0 6–0 8 g/kg/day composed of >50% plant-based sources Conclusion:
Reducing inflammation and supplementing plant based diet improves metabolic acidosis conditions by slowing down the progress of CKD
Chronic kidney disease (CKD) is a major contributor to the global burden of non-communicable diseases Renal disease is multifactorial, It does not exist in isolation As the disease progresses, it affects other organ systems as well Three principal outcomes of CKD are progressive loss of renal function, development and progression of cardiovascular disease, and development of malnutrition(protein-energy wasting) Protein-energy malnutrition with muscle wasting is common in patients with chronic kidney disease(CKD) Besides malnutrition, conditions such as inflammation and atherosclerosis are noteworthy complications, leading to increased incidence of infection, hospitalization, and cardiovascular mortality in patients with CKD. In India due to the increased incidence of diabetes and hypertension, an estimated 100 -220 /million populations reach end-stage renal disease, (ESRD )
Approximately only 10% of ESRD patients in India receive renal replacement therapy (RRT) mainly due to social and economic constraints. Malnutrition in dialysis patients is common and prevalence varies widely between 20% and 60% The causes of malnutrition in Indian CKD patients are late referral to a nephrologist, late initiation of dialysis, at times non-compliance to dialysis schedule due to financial constraints, inadequate dialysis dose, inadequate dietary counselling due to paucity of renal dieticians, depression, and associated comorbidities. Poor appetite in these patients is usually the result of coexisting inflammation, metabolic acidosis, and hormonal derangements
Atherosclerosis manifesting as a cardiovascular disease continues to be a significant killer in HD patients The diagnosis of CVD is made late and consequently, intervention is delayed. Many patients do not stick to their original prescription of statins and anti-platelets.
CommunityNutritionistA low-sodium diet is a cornerstone of healthy eating for almost all kidney-related medical conditions. Those who have kidney stones, polycystic kidney disease, FSGS, nephrotic syndrome, or chronic kidney disease should limit their salt intake. High blood pressure, which is bad for the kidneys, can result from a high-sodium diet Actually, the second most common cause of chronic kidney disease is excessive blood pressure. Patients with chronic hypertension frequently experience renal problems, which can be dangerous from excessive potassium levels
For kidney sufferers, products labeled "salt replacements" or "reduced sodium salt" can be harmful. The majority of these products use potassium chloride instead of sodium chloride (salt) These salt substitutes provide far too much potassium for many kidney patients' kidneys to handle However, various medical diseases predispose to the development of hyperkalaemia by impairing renal excretion of potassium in the high risk population that may benefit most from an increased consumption of potassium. These illnesses include obstructive uropathy, diabetes mellitus with hyporeninaemic hypoaldosteronism, and renal failure
The frequent prescription of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and potassium sparing diuretics in these patients significantly raises the risk of hyperkalaemia Non-steroidal antiinflammatory medications (NSAIDs) are sometimes used by elderly osteoarthritis patients, and these medications may also raise the potassium levels in the blood
Without the requisite information and stakeholder education, the easy accessibility of supplements and foods high in potassium in the public market is likely to be harmful to the health of these individuals They should be avoided in patients with chronic kidney disease and cardiac complications and patients on angiotensin II receptor blockers, potassium sparing diuretics, and nonsteroidal anti inflammatory drugs
Very often we assume that saltsubstitute are the healthier alternative to regular salt and frequently miss the intricacies of its use- be it in renal patients or cardiac patients. It is commonly seen that the term ‘salt-substitute’ is misleading and has led to an excess intake due to preconceived notions of patients and physicians
It is best to avoid salt-substitutes, and instead include natural foods which enhance taste and flavour. Indian cooking offers us with diverse opportunities for including herbs and spices which improve the palatability of the foods cooked without the inclusion of salt. It is often said that the tastes we have are learned by us, and are acquired- thus it is upto us to unlearn the tastes
In conclusion, we must understand that the diet should be planned as per the total amount of
sodium or potassium recommended as per the calculations made depending on the health condition of a person. To be able to adhere to these amounts of sodium and potassium, it becomes essential to consume a well-planned and customised diet. Evidence based practice has shown that over a period of time following a planned diet is effective to manage renal conditions, although compliance to the same is often a challenge
IN
Nutritional Guidance And Education For The Patients
Suffering From Kidney Disease
Effective Tool To Assist Dieticians About Do’s And Don’t’s Of Renal Nutrition Care
Simple Language, Easy To Understand And Beautiful
Illustrations
Contact: Sattvanutricare@Gmail.Com
Himani Puri, Founder SattvaNutricare. Program Officer – Renal Nutrition India
Enteral nutrition (EN) is the provision of nutrients via the gastrointestinal tract (through a feeding tube, catheter, or stoma) and is the preferred route in patients who cannot meet their nutritional needs through voluntary oral intake.
Unless there is any contraindication for enteral nutrition, EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patients who require nutrition therapy as supported by current international guideline recommendations
Compared to PN, EN is associated with fewer infectious complications, reduced cost, earlier gut function, and reduced length of stay Patients in the intensive care unit are at high risk of developing nosocomial infections. Studies have suggested that contaminated EN solutions represent a significant cause of nosocomial infections (1)
EN feeds are currently available as
Blenderized or kitchen prepared feeds, and Scientifically developed commercial feeds – which are
mainly of 2 types: Powdered form that needs to be reconstituted and the Liquid or ready-to-hang form
In terms of patient safety and care, many questions need to be considered before choosing the appropriate system (2):
Can we limit any source of contamination and infection?
How can we meet at least 60% of the patient’s nutrient needs safely?
Can we use the nursing time more efficiently?
Can we cut the cost–long-term?
– an IAPEN India Core groupBody composition analysis (BCA) is a vital tool in assessing the health of renal patients(1). The kidneys play a crucial role in regulating fluid balance, removing waste products, producing hormones, and maintaining overall health Chronic Kidney Disease (CKD) is a gradual loss of kidney function and affects millions of people worldwide It can lead to a range of health complications, including changes in body composition, which can be monitored and evaluated through BCA
BCA is a non-invasive diagnostic test that measures the amount of fat, muscle, water, and bone mass in the body (2) It provides a quantitative assessment of body composition, which is important in understanding the overall health of a person BCA is performed using various methods, including Dual-Energy X-Ray Absorptiometry (DEXA), Bioelectrical Impedance Analysis (BIA), and Skinfold Thickness Measurement (3)
CKD results in changes in body composition that are not always reflected in body weight or body mass index (BMI). For example, a person with CKD may have normal body weight and BMI but have a high level of body fat or fluid overload and low muscle mass(4) BCA can identify these changes and provide a more comprehensive assessment of a person's health status (5)
In Renal patients, changes in body composition are a result of the loss of kidney function
The kidneys play an important role in regulating fluid balance and electrolyte levels, and as kidney function declines, fluid and electrolyte imbalances can occur This can result in fluid accumulation, leading to edema, anasarca, and changes in muscle mass and bone mass BCA can identify these changes and provide important information for treatment planning (5).
One of the major complications of CKD is muscle wasting, also known as sarcopenia Sarcopenia is a progressive loss of muscle mass and strength and is a common problem in renal patients. It can result in decreased physical function and a decreased ability to perform activities of daily living. BCA can help to quantify muscle mass and provide information on the severity of sarcopenia, which can be used to guide treatment and rehabilitation efforts (6) BCA can also play a role in the assessment of bone health in renal patients. Osteoporosis, a condition that results in weak and brittle bones, is a common and serious problem in renal patients
CDE, RD,HOD, Chief Consultant Dietician, Global Hospitals, Mumbai
Convener - Indian Dietetic Association Mumbai Chapter
Gut microbiota imbalance is common in patients with chronic kidney disease (CKD) and associates with factors such as increased circulating levels of gut-derived uremic toxins, inflammation, and oxidative stress, which are linked to cardiovascular disease and increased morbimortality
The use of pre and probiotics in people with CKD is gaining momentum because altered gut micro flora affects the patient in a myriad of ways Pre and Probiotics are bacteriacontaining foods, such as milk and milk solids, yoghurt, and kefir, that may favourably alter the floral composition of the gut through competition of one type of culture with another The gastrointestinal tract is inhabited by a multitude of different micro-organisms, the blend of which varies depending on the type of bacteria consumed However, there is very limited data available from published
studies to help the efficacy & safety of pre and probiotics
What drug?
What doses?
What duration?
What is the safety assessment
All these questions have no answer at present. The limited number of articles on the topic precluded the generalization of the obtained results Therefore, additional long-term studies are needed to further elucidate the possible role of probiotics in the treatment of individuals with CKD.
Thus, to summarize
CKD patients have a gut microbiota imbalance
We have to know more about gut microbiota in the CKD patients who live there and what they do
We need to know whether the strains from probiotics and the prebiotics given during an intervention can improve or worsen the patient's clinical condition
The financial implication to the patients needs to be assessed
The world of the gut microbiome is not unknown to us but is rather an unexplored one! The gut microbiome is the community of microorganisms and the products they metabolize The human gut harbours more than 100 trillion bacteria which is 10 times the number of living cells in our body. There exists a symbiosis between our gut and microbiome; we provide them with a stable habitat to live whereas they provide us with various nutrients for our growth and development
In a healthy individual gut microbiota works synergistically to maintain an effective GI barrier function, regulate the absorption and utilization of water, vitamins, and minerals as well as stabilize the gut composition Among the 4 major species, Firmicutes and Bacteroidetes dominate the gut microflora that helps maintain gut symbiosis via producing beneficial metabolites like short-chain fatty acids (SCFAs), degrading undigestible plant polysaccharides, protecting against pathogens as well as shaping the mucosal immune barrier etc.
Any disbalance or disturbance in gut diversity can lead to chronic diseases like diabetes, IBS, CVD, Renal disease, etc. Surprisingly, renal disease and gut dysbiosis have a bidirectional relation; dysbiosis can impact the progression or severity of the disease (CKD) and any chronic renal disease can negatively impact gut health. An increased number of pathogenic and proteolytic gut microbes metabolise amino acids to produce uremic toxins (nephrotoxic) like
Indole-Indoxyl sulfate, Cresol-P-Cresyl Sulphate
TM- Trimethylamine-N-oxide (TMAO)
A buildup of these nephrotoxins further leads to endothelial dysfunction, renal fibrosis reduced eGFR, and increased renal impairment. Gut dysbiosis can not only impair renal health but also lead to increased morbidity and mortality related to renal disease And thus, it becomes necessary to take good care of gut health in chronic disorders.
“Probiotics refer to living microorganisms that, when consumed in adequate doses, can improve the intestinal microbiota profile by increasing beneficial bacteria” There have been numerous studies documenting the beneficial role of probiotics in restoring gut dysbiosis and its positive outcome in renal disease Fermented foods like curd, khimchi, kefir drinks, pickled vegetables, and fermented food products like idli, dhokla, etc. are traditional probiotic sources commonly found in Indian households. Incorporating a wide variety of foods along with probiotic supplementation can be beneficial for CKD patients in more than 1 way Regular consumption of probiotic strains like lactobacillus, Bifidobacterium,
Ipsita Chakravarti ,RD,CDE National Treasurer, IDA
The nutritional state of a patient at the initiation of dialysis is a clinically significant risk factor for mortality and morbidity. Protein-energy wasting (PEW) is a very common problem among patients with advanced chronic kidney disease as well as those who are undergoing maintenance dialysis (both Haemodialysis & Peritoneal Dialysis) and is associated with poor outcomes PEW is seen for 18-75% of haemodialysis & 40-66% of peritoneal dialysis patients. At a regular interval, patients need to be screened and assessed and their nutritional management is to be decided to keep a balance between nutrient requirement & intake despite poor appetite(anorexia), hyperglycaemia, hyperinsulinemia, gastroparesis & insulin resistance. There are lots of causes for PEW in both HD & PD which include losses of protein, amino acids, water soluble vitamins, and minerals, and disturbance of protein energy metabolism
Patients should be encouraged to eat orally considering all the requirements of the clinical condition & sodium, potassium, phosphate, and calcium content of the foods. If oral intake is not sufficient ONS (oral nutritional supplement) needs to be added in between meals keeping in mind the fluid restrictions High biological value protein is to be considered while planning the dietary prescriptions & for vegetarians, plant-based
protein is to be advised HD patients should get 11 2 protein gm/kg body wt & PD patients 1 3 gm/kg body wt Tube feeding should also be considered if the patient cannot eat orally at all. IDPN (Intra Dialytic Parenteral Nutrition) is a very good way to replenish the deficit which is delivered just during the day of & during dialysis only During this GI functions of the patients remained unimpaired TPN (Total parenteral nutrition) should also be considered when the gut is not working and the patient is malnourished.
When we talk of nutrition in CKD, it is not just a support therapy but a cornerstone in managing renal disease Every stage of CKD comes with a nutritional challenge of its own In the early stages, underlying disease conditions like diabetes and hypertension have to be controlled. As the disease progresses, the diet has to focus on managing electrolytes, protein, and fluid. Patients on dialysis have the challenge of meeting their high protein requirement to prevent malnutrition
In my talk at SRNMCON 2023 Nashik, I presented the case stories which focused on how noncompliance and lack of awareness of nutrition had pushed the patients towards unnecessary hospitalizations and poor quality of life Not taking sufficient protein when on Peritoneal dialysis causes severe muscle wasting and predisposes the patient to many infections This increases the risk of morbidity and the road to recovery will be slow and long. Hence frequent follow up with the renal nutritionist to assess the overall protein intake becomes very important in peritoneal dialysis
Non compliance with potassium restriction has often landed hemodialysis patients in Emergency Rooms While chronic hyperkalemia may not present with many symptoms, a sudden rise in potassium levels can cause cardiac arrhythmias, severe fatigue, and breathlessness. Patients and care givers have to understand that, though, on dialysis, patients will have to watch the amount of fruits and other high potassium food that they can include in their diet
A 24 hour dietary recall or food interview will help in correcting any noncompliance in terms of the electrolytes in the diet In patients on conservative management of CKD, a protein intake of 0 55g to 0 65g per kg body weight is recommended by KDOQI guidelines. However, patients often restrict proteins to an undesirably low level. In the attempt to keep the serum creatinine low, all sources of protein are avoided which causes severe protein energy wasting Proper counselling in terms of how much and what kind of protein sources have to be included in the daily diet is important Believing in myths and alternate therapies that claim to cure CKD is a common feature in the CKD population. Patients’ frustration with their disease condition makes them an easy prey to the common myths that are present on social media It is very important to clarify these myths and make them understand the risks involved in alternate therapies, which otherwise can put patients’ lives in danger. Cases that depicted the above conditions and their management in the hospital were discussed during my presentation at SRNMCON 2023 The presentation was followed by question- answer session where queries from the fraternity were answered All the diet instructions and the rationale behind them should be explained in detail to the patient and care givers. It is very important to provide alternatives to the food that has to be avoided This can go a long way in improving their quality of life, preventing complications, and delaying the progress of the disease
So, to start with my Chronic Kidney Disease journey I was 16 years old when for the very first time I came to know, that I have some issues related to my Kidneys. Never from my parent's side or my ancestors have I ever come across any chronic health issues
When first I came to know I have CKD, at that point in time I was so scared that I followed each and every diet restriction possible told to me by my Dietitian. When I started learning nutrition in Mumbai it really fascinated me that our diet and food habits have so much importance in our health So when I completed my graduation then at that period of time I was sure that now or later I have to undergo a transplant or do dialysis.
So in all these years as a Dietitian, I followed every restriction of CKD. I ate only the fruits that were allowed to be taken in CKD During these years, I never ate bananas being my favorite fruit nor did I consume sugarcane juice I used to completely avoid taking green leafy vegetables and in my family, we have a habit of taking low salt in our diets. At the start, it was difficult, but then we gained a habit of these I limited my dairy intake as I was habitual of taking them
About the proteins, I took only plant based being vegetarian. All these things were still managed by me unless fluid restrictions comes into play this was the toughest part of my CKD when I started doing dialysis I have to restrict several other things too apart from the diet Restricting fluid up to 1 liter per day including everything is not at all an easy task But I followed that too or else you will end up in breathlessness, fluid retention causing swelling, or urgent dialysis. It is not at easy as it seems always.
All these came to an end when I got my Renal transplant done on 21st March 2022. My mom donated her kidney, my family always stood by me as my strength and supporting pillars throughout My transplant was done under Dr Mohan Patel Sir consulting Nephrologist and Transplant Physician at Apollo hospital Nashik. I am consulting him for the last 6 years till date and Sir bought me from my worst to my best. After my transplant, we have to be very cautious about infections Considering the diet part now my diet was as normal as it was before CKD, now I can have everything I want but with some common limits that everyone should follow like limiting your salt and avoid eating too many fried foods. The main thing now I can have as many fluids as I want. In all these years I managed a lot of things and overcame Severe sepsis, Covid, and other issues But all came to an end now, if you're fortunate then you have years of good life ahead as I have One thing I learned from all these is that good thing take time but they will happen, you just have to wait for the right time.
