The Role of Specific Enteral Nutrition for 
                        CKD  Predialysis Patients 
                    for  Prevent Disease Progression
              RIA BANDIARA
              Dept/KSM I. Penyakit Dalam
              FK UNPAD/ RS Hasan SadikinBandung
                   Complications of CKD
               Associated with Level of GFR
                        Hypertension
                        Anemia
                        Malnutrition
                        Bone Disease
                        Neurological Changes
                        Functioning & Well-being
 Ko G.J. Curr Opin Clin Nutr Metab Care. 2017
                                                              Low protein  diet
                                                               0.6-0.8 g/kg/day
                                                      Benefit                   Risks
                                                                                                • Inadequate calorie intake 
                                                                                                  (<30 Cal/kg/d)
                           Glomerular                                Uremic                     • Protein loss and 
                          hyperfiltration     Proteinuria            toxins                       hypercatabolism
                                                                                                • Inflammation
                                                                                                • Worsening  acidemia
                            Oxidative           Metabolic         Phosphorus                    • Altered glucosa
                              stress            acidosis              PTH                         homeostasis
                                       Insulin            Blood                                               Protein
                                    resistance           pressure                                             energy
                                                                                                              wasting
                       Nutritional status derangement is essentially characterized by loss of muscle mass and 
                       visceral proteins (wasting/cachexia), and eventually by a loss of fat mass (the concept of 
                                        Better uremia control                            Worse clinical outcomes ?
                                     Delaying dialysis initiation
                       protein-energy wasting or PEW, as compared to simple malnutrition)
                         Diagram of the role of low-protein diet in the management of chronic kidney disease. 
   Ko G.J. Curr Opin Clin Nutr Metab Care. 2017