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Nutrisi - Dr. Afiatin PDF
Nutrisi - Dr. Afiatin PDF
Nutrisi - Dr. Afiatin PDF
AFIATIN
CURICULUM VITAE
Afiatin
Internist Nephrologist, Member of INASH, ISN, ISPD and ISHD
Staff of Nephrology Division Internal Medicine Department
Medical Faculty of Padjadjaran University
Hasan Sadikin Hospital Bandung Indonesia
TNT TRAINER
COURSE OF MEDICAL NUTRITION TREATMENT TRAINER
MEMBER OF NUTRITION SUPPORT TEAM IN HASAN SADIKIN
HOSPITAL
ESRD
eGFR 90 60 45 30 15 0
US Prevalence 3% 4% 7% 0.5%
Normal Appetite
Appetite derangement
Anorexia
1.6
1.4
Over- Obese Morbidly
1.2
weight Obese
1
Under- Normal
0.8
weight BMI
0.6
0.4
<18 18-19.99 20-21.49 21.5- 23-24.49 25-27.49 27.5- 30-34.99 35-39.99 40-44.99 >=45
22.99 29.99
Body Mass Index (kg/m2)
Kalantar-Zadeh et al, AJKD 2005, & Kidney Int 2003 (& multiple other publications)
Near Infra-Red body fat measurement in 535 Hemodialysis Patients
1.00
24-36%
>36%
0.98
12-24%
0.96
0.94
0.92
0 100 200 300 400 500 600 700 800 900 1000 1100
Kalantar-Zadeh et al, Am J Clin Nutr 2006
cohort days
Mid-Am Muscle Circumference
1 and 5-Year Mortality (2001-06) in 792 hemodialysis patients
DEATH (Log hazard ratio)
0 -.5 .5
0 20 40 60 80 100
MAMC percentile
Noori et al, CJASN 2010
MALNUTRITION
3
AND MORTALITY
IN 809 DIALYSIS PATIENTS OVER
Fully adjusted 5al,YEARS
Rambod et Am J Kidney Dis 2009
Case-mix variables: age, gender, race/ethnicity, diabetes mellitus, log vintage, primary insurance,
marital status, dialysis dose (Kt/V), and kidney residual urine (KRU)
-1 MICS variables: erythropoietin dose, creatinine, hemoglobin, phosphorus, normalized protein catabolic
rate (nPCR), bicarbonate, calcium, ferritin, WBC, lymphocyte percentage, and vitamin D dose
Inflammatory variables: CRP, IL-6, TNF-
0 2 4 6 8 10 12 14 16 18 20 22
Malnutrition-inflammation score
SCHEMATIC REPRESENTATION OF CAUSES AND
MANIFESTATIONS OF PEW IN KIDNEY DISEASE
ISRNM POSITION PAPER - KIDNEY INTERNATIONAL
Essential AA
Non-essential AA
Special AA
BCAA
threonine
valine
lysine
leucine
serine
isoleucine
decrease
oxidation in production
muscles
metabolic defective
phenylalanine
acidosis hydroxylation
KIDNEY
tyrosine
glycine FAILURE
citruline tryptophane
cystine
reduce
aspartate arginine protein binding
methionine
methyl-
histidine Mitch WE. Handbook of Nutrition and the Kidney, 2005
PGK DIALISIS
Masalah utama :
(1000)
BCAA ESS AA Non-ESS AA Total AA
Substansi yang hilang melalui
hemodialisis
Substansi Gram /jam dialisis
Glukosa 8.0
Vitamin +++
TUJUAN TERAPI NUTRISI PADA PGK
DIALISIS
- 30-35 kkal/kgBB/hari
Asupan Protein
(g/kgbb/hr) 1,2-1,4(>50%HBV)
1,2 (>50% HBV)
- HD 1,2-1,5(>50%HBV)
1,2-1,3 (>50% HBV)
- CAPD
Asupan Energi < 60 thn: 35
(kkal/kg/hr) > 60 thn: 30
35
HD dan CAPD
Air (ml)
750-1000 + vol urine 1000 + vol urine
1
Asam folat (mg/hari)
10-20
Piridoksin (mg/hari)
Vitamin C (mg/hari)
30-60
Zinc (mg/hari)
15
Selenium (g/hari)
50-70
METABOLIK ASIDOSIS
Deteksi Dini
1 Skrining
Penilaian
2 Diagnosis
Terapi
3 Monitoring dan evaluasi
TERAPI NUTRISI MEDIS
NUTRITION SUPPORT TEAM
Dokter
Perawat
Ahli Nutrisi
NST di RS
NST di departemen atau instalasi
NUTRITION SUPPORT TEAM
DOKTER
PERAWAT
FARMASI
PEKERJASOSIAL
PASIEN PETUGAS LAB
AHLI GIZI
SKRINING
Bisa dilakukan oleh seluruh jenis tenaga medis :
dokter, perawat, ahli gizi
Pelu memahami jenis alat yang dipakai untuk
skrining
Alat yang dikenal :
SGA
Antropometri
Khusus : MIS, DMS, dll
SUBJECTIVE GLOBAL ASSESSMENT
SGA
SEJARAH :
Dipublikasikan tahun 1987 di JPEN
Teknik :
Sistem skoring yang menggambarkan penilaian
klinis dari pemeriksa
tidak memerlukan test laboratorium
Multidisiplin (dokter, perawat, ahli gizi)
SGA
Riwayat Medis : Pemeriksaan Fisik
Perubahan berat :
Keluhan Edema
(berhubungan
gastrointestinal dengan nutrisi)
Kapasitas fisik
60 %
40 %
SGA
Variabel SGA A B C
Normal Ringan-Sedang Berat
Variable RR of death p-
(95% CI) value
Deteksi Dini
1 Skrining
Penilaian
2 Diagnosis
Terapi
3 Monitoring dan evaluasi
CONTOH
Ny C usia 42 tahun
CKD stg 5 on chronic hemodialysis
Masalah : ada nyeri ulu hati kalau makan,
sehingga makan berkurang
TB : 150 cm, BB 40 kg ( BB ideal45 kg),
Hberat kering terus turun 2 kg dalam 1 bulan
Tidak ada diare. Merasa lemah dan sudah inin
sakit selama 7 hari tidak kerja
HD 2 kali seminggu
SUBJECTIVE GLOBAL ASSESMENT (SGA)
SGA : B
MIS17
NY C
KATEGORI MALNUTRISI
PERLU INTERVENSI ATAU TERAPI
NUTRISI
Multi-disciplinary
Approach
Oral Nutrition Support
Diet counseling (1) (2) (3)
(+ prescription & Food Food enriching/ Oral Nutrition
meal plan) fortifications Supplements
Characteristic/ Use energy & nutrient adding protein, fat & Ready made
strategy dense foods & drinks CHO to foods and formula & desserts
drinks, e.g. egg, protein & energy
cheese, milk, milk bar
powder sugars, fats
commercial modules
e.g. protein powder, NEPHRISOL D
tasteless sugars
Nutrisi intradialitik
Dosis: 0.5 - 0.8g asam amino /kg BB per hari saat sesi dialisis