Transcript Peritoneal Dialysis

Peritoneal Dialysis
Nutritional Considerations
in PD
Peritoneal Dialysis
Objectives
1. Discuss risks and importance of poor
nutrition
2. How to assess nutritional state
3. How to achieve good nutrition
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Nutrition
Peritoneal Dialysis
Alternatives to Avoid
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Nutrition in Patients with CRF
Classes of nutrients

- carbohydrates

- fats

- proteins

- vitamins

- minerals

- water
Essential nutrients

- amino-acids

- essential fatty acids

- vitamins, elements
•Without these, an individual
cannot function
•Dietary protein provide
amino acids - body proteins
•Without sufficient dietary
protein and energy, no growth
or repair
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Recommended Protein & Energy Intakes
Protein
(g/kg BW/day)
Healthy adults
> 0.75#
Energy
(kcal/kg BW/day)
>35
CRF patients (non-dialyzed) ? 0.60 (high quality)
>35
HD patients
> 1.2
>35
CAPD patients
> 1.2
>35
# safe for 97.5 % of the population (WHO 1985) CRF patients with GFR
30-20 ml/min reduce protein and energy intake (MDRD study) Protein and
energy intake lower than recommended in a large proportion (20-60%?) of
HD and CAPD patients
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Protein-Energy Malnutrition
A state of deficiency resulting from
inadequate intake of protein and/or
energy relative to physiological needs
leading to progressive changes in
body composition and function and
nutrition
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Nutrition is a balance between supply and
demand
INTAKE
SUPPLY
BODY
STORE
LOSSES
DEMAND
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Negative Feedback Loop
Anorexa nausea
vomiting
Accumulation of
uremic toxins
Low protein and
energy intake
Low serum
urea
Loss of renal function
J Bergström ASN -94
MALNUTRITiON
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Major Metabolic Steps in Nutritional
Deficiency Disease
Well nourished
individual
Inadequate intake
Dietary survey
Impaired absorption
Increased nutrient loss from body Nutrient intake
Depletion of Tissue
Levels and Body Stores
Individual at risk
Biochem and
Altered biological and physiological physiol studies
Functions
Deterioration in capacity
to function normally
Malnourished
individual
Signs & symptoms
Clinical symptoms
Morbidity
Mortality
Vital statistic
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Patients at Risk of Developing
Malnutrition
 Elderly
 Socially isolated
 Diabetes mellitus
 Recurrent peritonitis
 Active comorbid conditions
 Loss of RRF
 Inadequate solute removal
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Risk Factors for Poor Nutrition
 Late start of dialysis
- Use of low protein diet
 Poor appetite
 Social factors
 Protein loss through peritoneum
- Increased with peritonitis
 Catabolic state
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Effects of Renal Insufficiency
Protein and Amino Acid Metabolism
•
Altered metabolism of proteins & amino acids
•
Intravascular alb pool may be reduced, even
though serum albumin is normal
•
Transferrin levels low
•
Increased catabolism (higher levels of
glucagon, PTH, toxins, acidosis)
•
Changes in amino-acid profiles
•
Increased risk of developing protein
malnutrition
•
Major cause of morbidity and mortality
DPI also diminishes with declining GFR
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Protein-Calorie Malnutrition in CRF
Catabolic Factors
 Comorbid illness
 Physical inactivity
 Infections
 Metabolic acidosis
 Abnormal energy metabolism
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Protein intake and
GFR
DPI
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
10ml / minGFR = 4.4g in DPI
>50
Ikizler, JASN 1995
25-50
GFR
24-10
<10
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Protein Intake in Pre-dialysis
DPI
N = 1687
1.2
1.0
0.8
0.6
0.4
0.2
0.0
70
MDRD study ; JASN 1994
45
25
GFR (mls / min)
9
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Catabolic Effects of Dialysis
Loss of amino
acids
Loss of glucose
CAPD
HD
2-4 g/day
14-28 g/week
9-13 g/dialysis
27-39 g/week
uptake
~25 g/dialysis
(glucose free dialysate)
Loss of protein
5-15 g/day
0
(higher with peritonitis)
Inflammatory
stimuli
Low grade inflammation
(particles chemicals)
Blood membrane
contact
Cytokine release
Cytokine release
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Causes of Anorexia
 Underdialysis particularly with loss of residual
renal function
 Sensation of abdominal fullness
- Poor gastric emptying particularly in diabetics
 Hyperglycaemia and glucose absorption from
excessive use of hypertonic dextrose
 Depression
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Risk Factors for Obesity
 Use of hypertonic dialysate, particularly 3.86%
dextrose, to maintain fluid balance
 High caloric intake, but low protein intake
 Lack of physical activity
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Causes of Low Plasma Albumin
(Malnutrition vs. Malnourished)
 True malnutrition
 Co-morbid conditions
- Infection
- Generalised vascular disease
- Chronic inflammation
- Proteinuria
- Malignancy
 Old age
 Dietary preference
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Assessment of Nutritional Status
 History and physical examination looking for loss
of weight and muscle wasting
 Dietary history
 Plasma creatinine, urea, albumin, transferrin
-  creatinine can mean  muscle mass and not  dialysis
clearance
-  creatinine can mean  muscle mass and not  dialysis
clearance
 Anthropometry
 SGA (Subjective Global Assessment)
 Biochemical / laboratory tests
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Anthropometry
Mainly used as research tool
Wolfson 1984
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Subjective Global Assessment
 Four items assessed over 7 point scale
 Weight change
- What was weight change over last 6 months?
 Anorexia
- Has dietary intake changed?
 Subcutaneous tissue
- Fat and muscle wasting e.g., under eyes or shoulders
- Muscle mass and wasting
- Examining temporalis muscle, prominence of clavicles,
contour of shoulders etc
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Subjective Global Assessment
1. Weight Change
History
PE
- in last 6 mths
- % (<5, 5-10,>10)
- in last 2 weeks
2. Dietary Intake
- overall
- pattern
- duration
- type
3. GIT Symptoms
- > 6weeks
4. Functional Capacity - overall +change
1. Loss of subcutaneous fat
2. Loss of muscle mass
3. Oedema
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Subjective Global Assessment
 Severe malnutrition - ‘1 or 2’ ratings in most
categories
 Mild to moderate - ‘3, 4 or 5’ ratings in most
categories
 Mild to Well Nourished - ‘6 or 7’ ratings in most
categories or continued improvement
A - Well nourished
B - Mild-Mod malnourished
C - Severely malnourished
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There is No Single Magic Nutritional
Index
 Each has limitations
 Use of combinations gives
corroborating information
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Non-Nutritional Factors
Affecting Albumin
 Fluid balance
 Infection/inflammation
 Urinary losses
 High dialysate losses
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Non-Nutritional Factors
Affecting Albumin





Analytical method
Gender
Age
Pregnancy
Fluid balance




Infection/inflammation
Cardiac disease
Malignancy
Protein losses
(urine, dialysate)
•Infection/inflammation related
albumin is like an ‘negative’ acute phase protein
•Association between cardiac disease and
hypoalbuminaemia (Foley 1996)
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Albumin as a Negative Acute
Phase Reactant
Qureshi et al., 1995
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Albumin as a Predictor
 Strong predictor of morbidity and mortality
(CANUSA study)
 Albumin may be affected by protein intake
However,
 Albumin is affected by non-nutritional factors
 Albumin may not increase in response to
nutritional intervention
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Serum albumin alone is
neither necessary nor
sufficient to indicate
malnutrition
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Relative Death Risk
Serum Albumin and Death Risk
Haemodialysis Patients
20
10
0
<=2.5
2.5-3.0 3.0-3.5 3.5-4.0 4.0-4.5
Serum Albumin (mg/dl)
Lowrie et al, 1990
>4.5
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Target Protein Intake for PD
 Nitrogen balance is the reference method for
determining adequacy of protein intake
 N Balance studies by Blumenkrantz and
Bergstrom indicate that at 1.2 g protein/kg/day no
patients were in negative nitrogen balance
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Nitrogen balance, g/day
Malnutrition in ESRD
Target Intake for PD
5
4
3
2
1
0
1
2
0.9
1.0
1.1
1.2
1.3
1.4
Protein intake, g/kg body wt/day
Blumenkrantz et al, KI 1982
1.5
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How Can This Target Be Achieved?
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Methods for Nutritional Support in PD





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Nutritional counseling
Pharmacologic appetite stimulation
Oral supplements
Enteral formulas (nasogastric, PEG)
Intravenous
Intraperitoneal (nutritional dialysis)
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Prevalence of Malnutrition is
Similar in HD and PD*
Mode #Studies
#Pts
% Malnourished
HD
3
502
21-53 (28%)
PD
3
401
26-56 (36%)
* Evaluated by the same method
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Nutrition: Guidelines 2002
 All patients should undergo regular screening for
undernutrition using as a minimum SGA, height
weight and albumin
 Diagnosis of undernutrition should be considered
if any of following are met:
- BMI < 18.5
- unintentional loss of oedema free weight of > 10% in last
6 mths
- plasma albumin below normal (value depends on assay)
- Low SGA scores
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Nutrition: Guidelines 2002
 If undernutrition suspected
- refer to dietitian to assess dietary intake
- measure CRP, plasma bicarbonate, dialysis adequacy
and residual renal function
 Correct low dietary intake
 If intake adequate, look for infection if CRP high,
and other catabolic factors such as acidosis,
thyrotoxicosis and poorly controlled diabetes
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What is Nutrineal™?
Nutrineal™ is a peritoneal dialysis solution with
amino acids instead of glucose which integrates
dialysis and nutritional supplementation
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Nutrineal™ Characteristics
Amino acids as osmotic agent
No glucose
No change in dialysis procedures
More physiologic pH
Osmolality equivalent to 1.5% glucose
Clearance equivalent to 1.5% glucose
40 mEq/L lactate
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Amino Acid Content of Nutrineal™ (2.0 L)
Essential
Nonessential
Histidine
Isoleucine
Leucine
Lysine
Methionine
Phenylalanine
Threonine
Tryptophan
Valine
Alanine
Arginine
Glycine
Proline
Serine
Tyrosine
14.1g (64%)
7.9 g (36%)
Conditionally essential in renal patients
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Bioavailability and Utilization Nutrineal™
• How much is absorbed?
• How is it utilized (Anabolic?)
- Nitrogen balance
- IGF-1
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Delivering 25% of daily protein intake
In just one exchange Nutrineal can deliver
25% of the target Daily Protein Intake*
With an absorption rate of 70-80% over 4-6 hours, one exchange of 2L Nutrineal
provides approximately 18g of AAs to an average, stable, 60kg patient: that is
0.3 g/kg body weight/day, which represents 25% of the
1.2 g/kg body weight/day target intake1
Target DPI
* Recommended dosage for adults: one 2L or 2.5L bag/day
Jones MR, et al., PDI, 1998;18(2):210-216
25%
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Bioavailability
For 60 kg
patient
AAs
Day 1 Protein and
AA Losses
0.16g/kg
Jones et al, PDI 1998;18:210-216
Day 2 AA gains
0.3 g/kg
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The Therapy
Before Prescription:
1. Check adequacy (Kt/V > 2; Cr.Cl. > 50 L./week)
2. Correct possible acidosis (bicarbonate > 23
mmol/L.)
3. Verify protein intake
4. Review comorbid conditions
5. Assess nutritional status
Therapeutic Target:
Protein intake of around 1.2 g/kg/day
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Nutrineal® : an efficient and compliant way of
delivering AA’s whilst providing dialysis
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Managing Protein Needs with Nutrineal
 Target protein intake* = 1.2 g/kg/day
 One exchange with Nutrineal contributes the
equivalent of 0.3 g/kg in an average patient
(20-25% of daily target)
*Kopple, 1997
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Conclusion
 Poor nutrition common in PD patients and is
adverse risk factor
 Important to assess nutritional status
 In malnourished patients
- correct identifiable comorbidities
- assess dialysis adequacy and increase dose if near or
below target
- maximise oral intake
 Nutrineal