S1-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der AKE, der GESKES und der DGfN^[1]

Zusammenfassung

Fragestellung: Patienten mit Niereninsuffizienz bilden eine sehr heterogene Gruppe von Personen mit unterschiedlichen metabolischen Störungen und Bedarf an Nährstoffen. Zu diesen gehören Patienten mit akutem Nierenversagen (ANV), die rasch zunehmende Zahl von Patienten mit akut-auf-chronischem Nierenversagen (A-C-NV), Patienten mit chronischer Niereninsuffizienz (CNI) und Patienten mit terminaler Niereninsuffizienz unter Nierenersatztherapie (Hämodialyse, Peritonealdialyse), jeweils ohne bzw. mit begleitenden Akuterkrankungen. In der vorliegenden Leitlinie sollen die ernährungstherapeutischen Interventionen, welche in der Betreuung aller dieser Patientengruppen eine entscheidende Rolle für Krankheitsverlauf und Prognose spielen, evidenzbasiert dargestellt werden.

Methodik: Die Leitlinie basiert auf den früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM, 2003, 2007), der European Society for Parenteral and Enteral Nutrition (ESPEN, 2006, 2009) und der International Society for Renal Nutrition and Metabolism (ISRNM 2008, 2013). Es wurde eine systematische Analyse der Literatur 2006 – 2014 zur oralen Supplementierung, zur enteralen und parenteralen Ernährung und intradialytischen Ernährung bei diesen Patientengruppen vorgenommen. Die Empfehlungen wurden innerhalb der Arbeitsgruppe sowie dem DGEM Steering Committee verabschiedet.

Ergebnisse: Zur klinischen Ernährung bei Patienten mit Nierenversagen liegen nur wenige randomisiert-kontrollierte Studien vor, sodass die meisten Empfehlungen Expertenmeinungen darstellen. Die Leitlinie umfasst 15 Aussagen und 27 Empfehlungen, wobei in einem Einleitungskapitel die gemeinsamen Aspekte in 15 Aussagen bzw. Empfehlungen abgehandelt werden. Zu der Ernährung von akut-kranken Patienten ohne Nierenersatztherapie gibt es in dieser Leitlinie 5, zu stabilen CNI-Patient ohne Nierenersatztherapie 5, zu akut-krankem Patient unter Nierenersatztherapie 9 und zu chronisch-malnutrierten Hämodialysepatienten 8 Aussagen bzw. Empfehlungen.

Schlussfolgerung: Ernährungsbehandlung und metabolische Führung spielen eine zentrale Rolle in der Betreuung von Patienten mit Nierenfunktionsstörungen. Dabei müssen die metabolischen Folgen der Nierendysfunktion per se, der Komorbiditäten und begleitenden Akuterkrankungen sowie der ausgeprägte Einfluss der Nierenersatztherapie auf Metabolismus und Nährstoffbilanz berücksichtigt werden. Nährstoffbedarf und Ernährungstherapie können sich grundsätzlich zwischen diesen unterschiedlichen Patientengruppen unterscheiden und sich auch individuell im Krankheitsverlauf ganz wesentlich ändern. Damit erfordern gerade Patienten mit Nierenfunktionsstörungen eine individualisierte Planung, Durchführung und Überwachung der Ernährungstherapie.

Abstract

Rationale: Renal failure patients comprise an extremely heterogeneous group of subjects with different metabolic patterns and nutritional requirements. These patients comprise patients with acute kidney injury (AKI), the rapidly increasing number of cases with acute-on-chronic renal failure (A-CRF), chronic kidney disease (CKD) and patients on regular renal replacement therapy (RRT) (haemodialysis, peritoneal dialysis), all with or without associated acute disease processes. In the present guideline, nutritional interventions that have a major impact on morbidity and mortality of these patient groups, will be present in an evidence-based manner.

Methods: These recommendations are based on earlier versions issued by the German Society for Nutritional medicine (DGEM, 2003, 2007), the European Society for Parenteral and Enteral Nutrition (ESPEN, 2006, 2009) and the International Society for Renal Nutrition and Metabolism (ISRNM 2008, 2013). A systematic review of the literature was performed for the years 2006 – 2014 using the search strategies for oral supplementation, for enteral and parenteral nutrition and intradialytic nutrition for the mentioned patient groups. The statements were finally approved by the working-group and the DGEM steering committee.

Results: There are only a few randomized controlled trials available on nutrition support for renal failure patients and thus, most recommendations are based on limited evidence or they represent clinical consensus points. The guideline includes 15 statements and 27 recommendations. In an introductory chapter, common aspects are covered by 15 statements/recommendations. Nutrition in acutely ill renal patients without requirement of RRT is addressed in 5 statements, nutrition in stable CKD patients without RRT in 5, nutrition in acutely ill patients on RRT in 9, and nutrition in malnourished chronic dialysis patients in 8 statements/recommendations.

Conclusions: Nutrition support and metabolic management play a central role in the care of patients with renal dysfunction. Both the metabolic consequences of renal dysfunction per se, and of comorbidities and associated acute disease processes and complications, as well as the profound impact of RRT on metabolism and nutrient balances have to be taken into consideration when designing a nutritional program. It should be noted that nutrition needs may differ widely between these heterogeneous groups of patients but also within the same patient in the course of disease. Thus, patients with renal failure require particularly an individualized approach when designing, delivering and monitoring nutritional support.

Schlüsselwörter

Nierenversagen - Niereninsuffizienz - Hämodialyse - Peritonealdialyse - orale Trinknahrung - enterale Ernährung - parenterale Ernährung - intradialytische Ernährung

Keywords

acute kidney injury - chronic kidney disease - end stage renal disease - hemodialysis - peritoneal dialysis - oral nutritional supplements - enteral nutrition - parenteral nutrition - intradialytic nutrition

¹ DGfN (Deutsche Gesellschaft für Nephrologie)

^* DGEM Steering Committee: Bischoff SC, Lochs H, Weimann A sowie das DGEM-Präsidium

• Literaturverzeichnis

• 1 Li Y, Tang X, Zhang J et al. Nutritional support for acute kidney injury. Cochrane Database Syst Rev 2012; 8 CD005426
• 2 Cano NJ, Aparicio M, Brunori G et al. ESPEN Guidelines on Parenteral Nutrition: adult renal failure. Clin Nutr 2009; 28: 401-414
• 3 Fiaccadori E, Cremaschi E, Regolisti G. Nutritional assessment and delivery in renal replacement therapy patients. Semin Dial 2011; 24: 169-175
• 4 Druml W. Nutrition and renal insufficiency. Med Klin Intensivmed Notfmed 2013; 108: 384-390
• 5 Druml W, Kuhlmann M, Mann H et al. DGEM-Leitlinie Enterale Ernährung: Nephrologie. Aktuel Ernahrungsmed 2003; 28: 93-102
• 6 Druml W, Kierdorf H. Leitlinie Parenterale Ernährung der DGEM – 17. Nierenversagen. Aktuel Ernahrungsmed 2007; 32: 106-113
• 7 Cano N, Fiaccadori E, Tesinsky P et al. DGEM (German Society for Nutritional Medicine). ESPEN Guidelines on Enteral Nutrition: Adult renal failure. Clin Nutr 2006; 25: 295-310
• 8 Fouque D, Kalantar-Zadeh K, Kopple J et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008; 73: 391-398
• 9 Carrero JJ, Stenvinkel P, Cuppari L et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM). J Ren Nutr 2013; 23: 77-90
• 10 Metnitz GH, Fischer M, Bartens C et al. Impact of acute renal failure on antioxidant status in multiple organ failure. Acta Anaesthesiol Scand 2000; 44: 236-240
• 11 Himmelfarb J, McMonagle E, Freedman S et al. Oxidative stress is increased in critically ill patients with acute renal failure. J Am Soc Nephrol 2004; 15: 2449-2456
• 12 Ikizler TA, Cano NJ, Franch H et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int 2013; 84: 1096-1107
• 13 Schneeweiss B, Graninger W, Stockenhuber F et al. Energy metabolism in acute and chronic renal failure. Am J Clin Nutr 1990; 52: 596-601
• 14 Singer P, Berger MM, Van den Berghe G et al. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr 2009; 28: 387-400
• 15 Mouser JF, Hak EB, Kuhl DA et al. Recovery from ischemic acute renal failure is improved with enteral compared with parenteral nutrition. Crit Care Med 1997; 25: 1748-1754
• 16 Metnitz PG, Krenn CG, Steltzer H et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002; 30: 2051-2058
• 17 Kalantar-Zadeh K, Cano NJ, Budde K et al. Diets and enteral supplements for improving outcomes in chronic kidney disease. Nat Rev Nephrol 2011; 7: 369-384
• 18 Krishnamurthy VM, Wei G, Baird BC et al. High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease. Kidney Int 2012; 81: 300-306
• 19 Fiaccadori E, Maggiore U, Giacosa R et al. Enteral nutrition in patients with acute renal failure. Kidney Int 2004; 65: 999-1008
• 20 Ross EA, Koo LC. Improved nutrition after the detection and treatment of occult gastroparesis in nondiabetic dialysis patients. Am J Kidney Dis 1998; 31: 62-66
• 21 Smolle KH, Kaufmann P, Fleck S et al. Influence of a novel amino acid solution (enriched with the dipeptide glycyl-tyrosine) on plasma amino acid concentration of patients with acute renal failure. Clin Nutr 1997; 16: 239-246
• 22 Czekalski S, Hozejowski R. Malnutrition Working Group. Intradialytic amino acids supplementation in hemodialysis patients with malnutrition: results of a multicenter cohort study. J Ren Nutr 2004; 14: 82-88
• 23 Roth E, Druml W. Plasma amino acid imbalance: dangerous in chronic diseases?. Curr Opin Clin Nutr Metab Care 2011; 14: 67-74
• 24 Hu YM, Pai MH, Yeh CL et al. Glutamine administration ameliorates sepsis-induced kidney injury by downregulating the high-mobility group box protein-1-mediated pathway in mice. Am J Physiol Renal Physiol 2012; 302: F150-158
• 25 Heyland D, Muscedere J, Wischmeyer PE et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368: 1489-1497
• 26 Heyland DK, Elke G, Cook D et al. Glutamine and Antioxidants in the Critically Ill Patient: A Post Hoc Analysis of a Large-Scale Randomized Trial. JPEN J Parenter Enteral Nutr 2014; May 5. [Epub ahead of print]
• 27 Druml W, Fischer M, Sertl S et al. Fat elimination in acute renal failure: long-chain vs medium-chain triglycerides. Am J Clin Nutr 1992; 55: 468-472
• 28 Chou HH, Chiou YY, Hung PH et al. Omega-3 fatty acids ameliorate proteinuria but not renal function in IgA nephropathy: a meta-analysis of randomized controlled trials. Nephron Clin Pract 2012; 121: c30-35
• 29 Wang X, Li W, Li N et al. Omega-3 fatty acids-supplemented parenteral nutrition decreases hyperinflammatory response and attenuates systemic disease sequelae in severe acute pancreatitis: a randomized and controlled study. JPEN J Parenter Enteral Nutr 2008; 32: 236-241
• 30 Basi S, Pupim LB, Simmons EM et al. Insulin resistance in critically ill patients with acute renal failure. Am J Physiol Renal Physiol 2005; 289: F259-264
• 31 Schetz M, Vanhorebeek I, Wouters PJ et al. Tight blood glucose control is renoprotective in critically ill patients. J Am Soc Nephrol 2008; 19: 571-578
• 32 Aspelin P, Mac Leod A, Barsoum R et al. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2: 1-138
• 33 Fouque D, Laville M. Low protein diets for chronic kidney disease in non diabetic adults. Cochrane Database Syst Rev 2009; (03) CD001892 DOI: CD001892.
• 34 Navaneethan SD, Schold JD, Arrigain S et al. Serum bicarbonate and mortality in stage 3 and stage 4 chronic kidney disease. Clin J Am Soc Nephrol 2011; 6: 2395-2402
• 35 Susantitaphong P, Sewaralthahab K, Balk EM et al. Short- and long-term effects of alkali therapy in chronic kidney disease: a systematic review. Am J Nephrol 2012; 35: 540-547
• 36 Abramowitz MK, Melamed ML, Bauer C et al. Effects of oral sodium bicarbonate in patients with CKD. Clin J Am Soc Nephrol 2013; 8: 714-720
• 37 Goraya N, Simoni J, Jo CH et al. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney Int 2014; 86: 1031-1038
• 38 Fouque D, Pelletier S, Mafra D et al. Nutrition and chronic kidney disease. Kidney Int 2011; 80: 348-357
• 39 Druml W. Metabolic aspects of continuous renal replacement therapies. Kidney Int Suppl 1999; (72) S56-S61
• 40 Ikizler TA, Pupim LB, Brouillette JR et al. Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation. Am J Physiol Endocrinol Metab 2002; 282: E107-116
• 41 Fiaccadori E, Maggiore U, Cabassi A et al. Nutritional evaluation and management of AKI patients. J Ren Nutr 2013; 23: 255-258
• 42 Fiaccadori E, Maggiore U, Rotelli C et al. Effects of different energy intakes on nitrogen balance in patients with acute renal failure: a pilot study. Nephrol Dial Transplant 2005; 20: 1976-1980
• 43 Bellomo R, Tan HK, Bhonagiri S et al. High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance. Int J Artif Organs 2002; 25: 261-268
• 44 Scheinkestel CD, Adams F, Mahony L et al. Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal replacement therapy. Nutrition 2003; 19: 733-740
• 45 Leblanc M, Garred LJ, Cardinal J et al. Catabolism in critical illness: estimation from urea nitrogen appearance and creatinine production during continuous renal replacement therapy. Am J Kidney Dis 1998; 32: 444-453
• 46 Bellomo R, Cass A, Cole L et al. Daily Protein Intake and Patient Outcomes in Severe Acute Kidney Injury: Findings of the Randomized Evaluation of Normal versus Augmented Level of Replacement Therapy (RENAL) Trial. Blood Purif 2014; 37: 325-334
• 47 Singer P. High-dose amino acid infusion preserves diuresis and improves nitrogen balance in non-oliguric acute renal failure. Wien Klin Wochenschr 2007; 119: 218-222
• 48 Schiffl H, Lang SM. Severe acute hypophosphatemia during renal replacement therapy adversely affects outcome of critically ill patients with acute kidney injury. Int Urol Nephrol 2013; 45: 191-197
• 49 Demirjian S, Teo BW, Guzman JA et al. Hypophosphatemia during continuous hemodialysis is associated with prolonged respiratory failure in patients with acute kidney injury. Nephrol Dial Transplant 2011; 26: 3508-3514
• 50 Broman M, Carlsson O, Friberg H et al. Phosphate-containing dialysis solution prevents hypophosphatemia during continuous renal replacement therapy. Acta Anaesthesiol Scand 2011; 55: 39-45
• 51 Fortin MC, Amyot SL, Geadah D et al. Serum concentrations and clearances of folic acid and pyridoxal-5-phosphate during venovenous continuous renal replacement therapy. Intensive Care Med 1999; 25: 594-598
• 52 Morena M, Cristol JP, Bosc JY et al. Convective and diffusive losses of vitamin C during haemodiafiltration session: a contributive factor to oxidative stress in haemodialysis patients. Nephrol Dial Transplant 2002; 17: 422-427
• 53 Madl C, Kranz A, Liebisch B et al. Lactic acidosis in thiamine deficiency. Clin Nutr 1993; 12: 108-111
• 54 Druml W, Schwarzenhofer M, Apsner R et al. Fat-soluble vitamins in patients with acute renal failure. Miner Electrolyte Metab 1998; 24: 220-226
• 55 Amrein K, Schnedl C, Holl A et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL-ICU randomized clinical trial. JAMA 2014; 312: 1520-1530
• 56 Lipkin AC, Lenssen P. Hypervitaminosis a in pediatric hematopoietic stem cell patients requiring renal replacement therapy. Nutr Clin Pract 2008; 23: 621-629
• 57 Berger MM, Shenkin A, Revelly JP et al. Copper, selenium, zinc, and thiamine balances during continuous venovenous hemodiafiltration in critically ill patients. Am J Clin Nutr 2004; 80: 410-416
• 58 Heidegger CP, Berger MM, Graf S et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2013; 381: 385-393
• 59 Gunst J, Vanhorebeek I, Casaer MP et al. Impact of early parenteral nutrition on metabolism and kidney injury. J Am Soc Nephrol 2013; 24: 995-1005
• 60 Doig GS, Simpson F, Sweetman EA et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309: 2130-2138
• 61 Griffiths RD, Jones C, Palmer TE. Six-month outcome of critically ill patients given glutamine-supplemented parenteral nutrition. Nutrition 1997; 13: 295-302
• 62 Majchrzak KM, Pupim LB, Flakoll PJ et al. Resistance exercise augments the acute anabolic effects of intradialytic oral nutritional supplementation. Nephrol Dial Transplant 2008; 23: 1362-1369
• 63 Johansen KL, Mulligan K, Schambelan M. Anabolic effects of nandrolone decanoate in patients receiving dialysis: a randomized controlled trial. JAMA 1999; 281: 1275-1281
• 64 Kuhlmann MK, Schmidt F, Kohler H. High protein/energy vs. standard protein/energy nutritional regimen in the treatment of malnourished hemodialysis patients. Miner Electrolyte Metab 1999; 25: 306-310
• 65 Weiner DE, Tighiouart H, Ladik V et al. Oral intradialytic nutritional supplement use and mortality in hemodialysis patients. Am J Kidney Dis 2014; 63: 276-285
• 66 Stratton RJ, Bircher G, Fouque D et al. Multinutrient oral supplements and tube feeding in maintenance dialysis: a systematic review and meta-analysis. Am J Kidney Dis 2005; 46: 387-405
• 67 Boudville N, Rangan A, Moody H. Oral nutritional supplementation increases caloric and protein intake in peritoneal dialysis patients. Am J Kidney Dis 2003; 41: 658-663
• 68 Kalantar-Zadeh K, Ikizler TA. Let them eat during dialysis: an overlooked opportunity to improve outcomes in maintenance hemodialysis patients. J Ren Nutr 2013; 23: 157-163
• 69 Pupim LB, Flakoll PJ, Brouillette JR et al. Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 2002; 110: 483-492
• 70 Fouque D, McKenzie J, de Mutsert R et al. Use of a renal-specific oral supplement by haemodialysis patients with low protein intake does not increase the need for phosphate binders and may prevent a decline in nutritional status and quality of life. Nephrol Dial Transplant 2008; 23: 2902-2910
• 71 Lacson Jr E, Wang W, Zebrowski B et al. Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report. Am J Kidney Dis 2012; 60: 591-600
• 72 Teixido-Planas J, Ortiz A, Coronel F et al. Oral protein-energy supplements in peritoneal dialysis: a multicenter study. Perit Dial Int 2005; 25: 163-172
• 73 Smolle KH, Kaufmann P, Holzer H et al. Intradialytic parenteral nutrition in malnourished patients on chronic haemodialysis therapy. Nephrol Dial Transplant 1995; 10: 1411-1416
• 74 Pupim LB, Majchrzak KM, Flakoll PJ et al. Intradialytic oral nutrition improves protein homeostasis in chronic hemodialysis patients with deranged nutritional status. J Am Soc Nephrol 2006; 17: 3149-3157
• 75 Dukkipati R, Kalantar-Zadeh K, Kopple JD. Is there a role for intradialytic parenteral nutrition? A review of the evidence. Am J Kidney Dis 2010; 55: 352-364
• 76 Cano NJ, Fouque D, Roth H et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol 2007; 18: 2583-2591
• 77 Lim VS, Yarasheski KE, Crowley JR et al. Insulin is protein-anabolic in chronic renal failure patients. J Am Soc Nephrol 2003; 14: 2297-2304