NUTRITIONAL KEYS TO CARE FOR CHRONIC KIDNEY PATIENTS

Interview by Meg Marquardt, Nestlé Health Science at ESPEN 2018 with Professor Alessio Molfino from University Hospital, La Sapienza, Rome.

From ESPEN 2018, Madrid September 1-4 September.

MB: Hello again I’m here at the ESPEN Congress in Madrid with Professor Molfino from University Hospital, La Sapienza in Rome and Professor Molfino has just presented on nutrition in the chronic kidney disease population. Professor Molfino what are your thoughts about the importance of nutrition in this cohort?

AM: Yes chronic kidney disease patients are increasing worldwide, not only in Italy, Europe, but also in America and China and most of the problem related to the management of these patients are also related to nutritional and metabolic alterations.  So what we enhanced by our oral communication, was to evaluate with a multiple prognostic index, a complete evaluation clinic, evaluation of this population, to reduce the complications, the morbidity in particular to cardiovascular mortality of these type of patients.

MB: So this is a very old problem, chronic kidney disease, why are we still talking about nutrition in this group? Why haven’t we understood it before now?

AM: Probably because it’s still underestimated, risk especially related to nutritional problems,and metabolic derangement.  So what is important also is to diagnose early.  Since the early stage of the disease exactly has in other conditions, like in cancer patients or other chronic kidney disease, also in chronic kidney disease I believe that we need to diagnose modification in nutritional status and metabolic status from the early stage and to try to modify them to improve their prognosis.

MB: So let’s be specific here, we have five stages of CKD, and we tend to talk about it less than 60mls per hour GFR for chronic kidney disease. Are you talking already stage three or mainly stage four and five?

AM: Maybe it is also important to evaluate at the earlier stage because we know that the decline in especially other parameters, also in physical activity that is extremely important and relevant, is a proven predictor of mortality, is important to diagnose since the early stage.  So we don’t have to arrive at stage four or five to diagnose or treat because probably can be too late.

MB: So in an ideal world, how would you treat this population from a nutritional point of view?

AM: Yes.  One thing that is extremely important that we always consider is for example the intakes of these patients.  In particular like we investigate the presence or not of anorexia and the presence of low food intake.  This is probably one of the most important codes of malnutrition associated with other of course metabolic factors, inflammatory factors, and also with the reduction of physical activity.  So it is important to evaluate dietary intakes and to try to improve this since the early stage.  We don’t want to arrive to a protein-energy-wasting that can affect negatively the prognosis.  So it’s important to nutritional counselling and of course to dietary intervention since the early stage.  This is one of the first step.  And of course with other indices like in particular the daily activity indices, the muscle strength, are all important components that we have to consider.

MB: So some kind of oral supplementation early in the course of the disease would be something you could recommend?

AM: Absolutely yes.  Because sometimes, especially when we considering the early stage of chronic kidney disease, some low protein diet we generally, as a physician sometimes we are  the cause of malnutrition and therefore it is important to reduce of course, and to delay, the disease, the progression of the disease.  But also to improve nutritional status and of course our extremely important also, oral nutritional supplement associated with diet.  And of course a strict follow up of these patients.

MB: Thank you. Just moving to the acuteon chronic, or the critical care population who might have AKI, do you think there are special nutrition requirements for this group?

AM: Yes of course.  Like in particular we have not so much strong evidence of one treatment stronger with respect to another, but what is important is that we need to evaluate their hydration status, the nutritional status also in the acute.  And in this case we don’t have to consider restriction, but we of course, need to make our patients, they have to eat if possible, or eventually we need to use other strategies as artificial nutrition when this is not possible the natural, oral feeding.

MB: And what profile of nutrition formula for an enterally fed patient would you prefer?

AM: Well when you have an acute like you don’t have to reduce basically so much the protein, it depends of course on different comorbidity that are present.  Especially if the patients can have an increase of urea you know the azotaemia you have to consider of course probably a reduction in  uremic doses but of course it’s important also to consider that the intake is preserved in terms of carbohydrates, lipids and also protein intake, so well balanced.

MB: So a standard formula or you look for a certain type of formula?

AM: No. Of course, especially when we have both in acute then chronic disease, we have a specific formula that sometimes can be high protein when they are highly catabolic or low protein in a chronic more disease, but of course associated sometimes with different types of amino acids that are enriched to ensure a better anabolism.

MB: That’s outstanding.  Thank you that’s a very big topic and I’ve tried to cover a lot with your expertise in these few minutes, but I appreciate that very much. And perhaps we can talk again for our blog together? Thank you.