Transcript Importance of Diet In Peritoneal Dialysis

Importance of Diet In
Peritoneal Dialysis.
Dr Anita Saxena
MD (AM), PhD, PhD
(Cambridge)
Department Of Nephrology
Sanjay Gandhi Post
Graduate Institute Of
Medical Sciences
Lucknow
In uremic patients
anorexia and
loss of taste
cause imbalance
between intake
and nutritional
requirement.
What Is Malnutrition
Imbalance
Depletion of Body Stores
Nutrient
Requirement
Disease
Nutrient
Intake
20-70% patients on
Maintenance Dialysis
show signs of PEW.
Malnutrition
Malnutrition Is Of Two Types
FACTORS
TYPE1
Associated with
uremic syndrome
TYPE 2
Associated with MIA
syndrome
Serum albumin
Comorbidity
Presence of
inflammation
Food intake
Resting energy
expenditure
Oxidative stress
Protein catabolism
Reversed by
dialysis and
Nutritional support
Normal/low
Uncommon
No
Low
Common
Yes
Decreased
Normal
Low/Normal
Elevated
Increased
Markedly increased
Decreased
Yes
Increased
No
Stenvinkel P et al, NDT
15;953,2000
Protein–Energy Wasting (PEW)
(refers to multiple nutritional and catabolic alterations)
• Malnutrition or Protein energy wasting (PEW) is highly
prevalent in peritoneal dialysis (PD) and is associated with
poor outcomes, including hospitalization and mortality.
• Recognizing and diagnosing PEW in PD is important
Prevalence of protein energy wasting (PEW) in patients on
PD patients is 40-66% and
HD therapy is 18–75% and
correlates with the risk of morbidity and mortality.
Mehrotra R, Kopple JD Annu Rev Nutr. 2001;21:343-79.
Tapaiwala, Kopple JD 1996: Am J Clin Nutr 1997;65:1544–57
Mehrotra R, Kopple JD. Annu Rev Nutr 2001; 21:343–79.
Kalantar-Zadeh K, AJKD 2003;42:864–81.
Nutritional Status
• Signs of PEW
increase as GFR declines.
• CANUSA Study has shown that evidence of poor
nutritional status in PD patients is associated with
 Adverse outcomes
 Poor patient and
 Technique survival
GOOD HEALTH
 Increased hospitalization
NUTRITION
When Does Protein-Energy-Wasting Set In?
• Dietary protein and energy intake diminish long before endstage renal disease develops most likely during CKD stage 3
or even earlier. (Kopple 1989,1997 Nutr. 1, 1999 vol.1(29) 247S-251S)
As Renal Function Declines, Spontaneous Dietary Protein
Restriction Occurs
DPI (g/kg/day)
1.20
1.00
1.01
0.85
0.70
0.80
0.54
0.60
0.40
0.20
0.00
>50
50-25
24-10
<10
Creatinine Clearance (ml/min)
Ikizler, JASN 6:1386-1393, 1995
Prospective observational study of 90 patients
When Does Protein-Energy-Wasting Set In?
• PEW becomes clinically evident when GFR is < 1510 ml/min.
The MDRD Study: Association Between Dietary Intake And
GFR.
With GFR< 60 mL/min/1.73 m2 prevalence of reduced dietary
protein and energy intake is High.
Mean levels of protein and energy intake as a function of GFR
based on 24-hour urine collections and diet diaries.
(males, solid lines;
females, dashed lines).
MDRD Study. Association between Serum Albumin
and GFR
Serum albumin is lower at levels of GFR < 60 mL/min/1.73 m2, indicating a
decline in circulating protein levels or serum protein concentrations,
protein losses or inflammation.
An acceptable goal level for albumin is >4.0 g/dL (bromcresol green)
method).
males, solid lines;
females, dashed lines
What Causes Decreased Protein And
Energy Intake And Hence Malnutrition
In PD Patients?
UREMIA
LOW
NUTRIENT
INTAKE
Malnutrition is Multifactorial
INFLAMMATION
HYPERCATABOLISM
Malnutrition Is Multi-Factorial
Hypercatabolic State + Anorexia
Inadequate
Dietary Protein
& Energy Intake
Peritoneal transport
Malnutrition
PD procedure per se
Dialysis dose
Underdialysis
Causes Anorexia
Metabolic acidosis
PD duration
Acute & Chronic Illness
Comorbidity
Diabetes
Endocrine
Increased catabolism
PD
Inflammation
Residual renal
function
Infectious Illness
Uremia per se
Nutritional Management of PD Patient
• Is challenging
Not only includes what a patient should be
eating but
what is more important is
the reason why patient
is not eating?
Reason Why Patients Don’t Eat
Anorexia/Loss of Appetite
Guideline 6
• Kidney failure causes
Retention of uremic toxins/anorexogenic
substances due to uremia.
Gastric problems
Oral manifestations (lack of taste , dryness of
mouth)
Poor dental hygiene
Impaired olfactory function
Anorexia is evidenced by decreased dietary protein
intake (DPI) and decreased dietary energy intake
(DEI), which are hallmarks of kidney failure.
2. Dialysis Dose
Inadequate Dialysis Dose
Causes Uremic Symptoms and
patient is unable to eat
Give adequate dialysis
Maintain Kt/V urea of
1.7/week CAPD
ADEMEX Trial (2001)
If patient is on dialysis
individualize dialysis prescription.
Nutritional Effects Of Increasing Delivered Dialysis
Dose In Malnourished PD Patients
Patients had evidence of declining nutrition over 12 months
With 25% increase in delivered PD dose for 6 months
Total Kt/V 1.67  1.93 ( 18%)
Wt, kg
-6m
0
+2m
+4m
+6m
p
- 12 m
67.4
68.2
66.6
65.1
65.3
66.4
0.18
27.7
0.85
27.2
0.81
26.7
26.8
nPNA, g/kg/d
27.9
0.94
27.4
0.84
0.19
0.23
DPI, g/kg/d
Oral calories,
cal/kg/d
1.06
31.6
1.04
31.2
0.83
26.7
0.92
28.7
0.17
0.03
P. albumin, g/L
35.6
34.3
31.4
32.8
0.05
SGA
5.7
5.2
4.0
4.4
0.15
MAC, cm
30.8
31.7
Open, prospective, longitudinal intervention: Davies et al K Int 57:1743, 2000
3. Medications Can Cause Anorexia
Eliminate/Treat any potentially reversible or treatable
condition or medication that might interfere with appetite
or cause malnutrition.
Phosphate binders may induce loss of appetite.
Discontinue use of phosphate binders for 2 weeks
to see if appetite improves.
Discontinue use of iron supplements if there are
repeated GI upsets
Discontinue calcium supplements if bowel
movements are irregular
Reduce salt intake for better control of blood
pressure to minimize requirement of
antihypertensive medication.
4. Glucose Absorption From Dialysate Anorexia can
Causes Loss Of Appetite
Peritoneal
Dialysate
In patients on Peritoneal Dialysis
Glucose Absorption from dialysate may
cause Suppression of Appetite and
induce abdominal discomfort
Patient absorbs 100-200g/d of glucose
which is equivalent to 300-500 kcal/d
Encourage patient to take small but
frequent meals.





Comorbid conditions like diabetes,
gastrointestinal disorders, and infection
can cause malnutrition.
Combined presence of co-morbidities such as
cardiovascular disease and vascular complications
in diabetic CAPD patients along with malnutrition
increases mortality of PD patients.
Dong J, Wang T, Wang HY. Blood Purif 2006; 24:517–23 The Impact Of New
Comorbidities On Nutritional Status In CAPD Patients.
Metabolic Acidosis Causes Protein Catabolism
Decrease Protein Catabolism Increase Albumin Synthesis
Serum Bicarbonate
level at  22 mmol/L
Evaluate Monthly
NKF/KOQI
Guideline 13/14
Supplement
1g TID
Diabetic Gastroparesis causes decreased food intake
Ajumobi AB , Griffin RA ,Hospital Physician March 2008
• Characterized by Delayed gastric
emptying & associated upper
gastrointestinal (GI) symptoms
• DGP result in poor glycemic control, poor
nutrition, and dehydration, which in turn
may lead to poor quality of life & frequent
hospitalizations.
• Gastric emptying is slower during
hyperglycemia and accelerated during
hypoglycemia
• Electrolyte abnormalities (eg,
hypokalemia, hypomagnesemia) have
roles in the pathogenesis of DGP.
• Dysfunction of NO neurons in the
myenteric plexus may be responsible for
DGP
Metabolic Acidosis Causes malnutrition by Increasing
Protein Catabolism. Bicarb Therapy Decrease Protein Catabolism
Increase Albumin Synthesis
Serum Bicarbonate
level at  22 mmol/L
Evaluate Monthly
NKF/KOQI
Guideline 13/14
By the time CAPD is initiated patient is
already malnourished.
Aims of Nutritional Intervention In PD
• To diminish accumulation of nitrogenous wastes to
prevent appearance of uremic symptoms.
• To limit metabolic disturbances characteristic of
uremia.
• To prevent uremic sarcopenia/muscle wasting
• Prevent protein energy malnutrition
• Prevent Hyperglycemia
• Dyslipidemia
• Maintain adequate nutritional status.
• Build up body stores for good transplant outcome (if
planned)
• Improve quality of life
Monitor Nutritional Status
(Dialysis Dependent Patients)
Measure
Frequency of Measurement
Total protein
Monthly**
Serum albumin
Monthly**
Na
Monthly**
K
Monthly**
Ca
Monthly**
P
Monthly**
% of usual post-drain body weight
Monthly**
% of standard (NHANES II) body weight
Monthly**
Subjective Global Assessment
Every 6 months
Dietary interview and/or diary
Monthly
nPNA
Every 3-4 months
Anthropometry
As needed
Percentage of individuals
Why is the Protein Target Higher for
PD Patients?
Normals PD
Protein and amino
acid losses and
catabolic factors
shift the curve to
the right for PD
patients
low
high
Protein Requirement
Loss Of Protein
CAPD/Day
5-15 g
Peritonitis/24 h
15.1 gm
• Protein intake should be increased from 1.3 - 1.5g/kg/d
Estimating energy, protein & fluid requirements
for adult clinical conditions June 2012 Qeensland Govt
Decreased Protein Intake May Lead To
Protein-energy Wasting And Poor Survival
In PD patients, Dietary Protein Intake
<0.73 g/kg/day is associated with proteinenergy wasting and worst outcome.
• DPI >0.94 g/kg/day favours better nutritional status
and long-term outcome in this population.
Dong J etal Daily protein intake and survival in patients on
peritoneal dialysis. NDT 2011 Nov;26(11):3715-21
Predictors Of Survival In Anuric Peritoneal Dialysis
Patients
Jansen MM Kidney International (2005) 68, 1199–1205
• Daily protein loss is a significant negative prognostic factor
and may be one of the factors that predisposes to
malnutrition, and increased peritoneal protein loss.
• Factors associated with worse patient survival & mortality
Higher Age
Nutritional status : CNI scores
(SGA, 6 anthrop measure: SKF, body weight,
BMI) and S.Albumin)
nPCR
Daily protein loss
Daily fluid output (UF + urine) and
Cholesterol level
Diabetes (comorbidity)
Presence of Malnutrition At
Initiation Of Dialysis Is A Strong
Predictor Of Subsequent
Increase In Relative Risk Of
Death.
Among PD patients prevalence
of protein energy wasting is
40-66%.
Carrero JJ, J Renal Nutr 2013 Vol 23, issue 2, Pages
77-90
Hakim RM and Lazarus JM. JASN 1995; 6:1319–28
Abdu A et al Afr J Clin Nutr 2011;24(3):150-153
Flanigan MJ. Perit Dial Int. 1998;18:489-496.
Initial nutritional status exerts a powerful influence on
CAPD patient survival Chung SH Perit Dial Inter Vol. 20, pp. 19–26
Kaplan–Meier analysis, patient survival rate was significantly
lower in malnourished patients than in normal patients
(67.1% vs 91.7% p = 0.02) N=91 54% Diabetic patients
Initial FFEF body mass was a
determinant of SGA score and
predicted death
Malnutrition was present in 45% of patients commencing CAPD
as assessed by SGA.
CANUSA Study
NDT1998; 13 (Suppl 6):158–63.
Relative risk of
death increases
with
1. Lower serum
albumin and
2. Worse
nutritional status
as
assessed by
SGA and %LBM
Reverse Protein Loss
Give High Protein Diet to
Patients on Peritoneal Dialysis
NKF-K/DOQI Guideline 3 & 4
Guidelines 3
S Albumin ≥ 4.0g/dL
Guidelines 4
S Prealbumin ≥30 mg/dL
Dietary Protein Intake for Patients on
PD NKF-K/DOQI
Guideline 16


For patients on CAPD unless a patient has demonstrated
an adequate nutritional status on 1.2 g/kgbw/d diet,
prescribe 1.3g/kgbw/d necessary to ensure neutral or
positive nitrogen balance
Guideline 16
Patients with high peritoneal membrane transport
characteristics have low serum albumin due to
excessive protein loss. Perl etal 2009 Clin JASN 4: 1201-1206
At least 50% of protein should be of HBV
YOGURT 3.1g/60/100g
3
MILK WITHOUT CREAM
6.4/135calories /200ml
4
SOY
NUGGETS
TOFU
SOYA PRODUCTS 43g/100G
1 helping 50g=21g/216
MILK
PANEER 13 /240/100
To Increase Protein and Energy
Intake Oral Supplements Are
Essential For Patients On
Maintenance Dialysis
For sick patients, use energy and protein
dense ONS.
ONS can provide approx 10 kcal/kg/d
Phillis ME Clin Nephro 1978 9: 241-8 Caglar et al Kidney Intrn
2002 62 1054-9
Patients on Maintenance Dialysis Require Extra Protein
Supplement Insufficient Protein Intake
• Protein Supplements powder or biscuit form
Proseventy 70 % protein
Renourish 60% Protein (10g/16g sachet)
NeproHP
Pentasure 35%
Lamino Bix 1.6 g protein/disc
Threptin Biscuits 1.5g/disc
• Alpha Keto Analogues (affordability)
• Peptide based supplements PEPTAMEN
Protein Requirement = 1.3g/kg/d x Wt.
60 kg x 1.3 = 78 g of protein
Milk 150 ml =
4.5 g/protein
Dal 1 bowl
=
6 g protein
Curd = 100g =
3g
Chappati=1.5 g 8 chappaties = 12 g
Rice: 50 g raw =
3.4 g 3
Paneer/Tofu 100g
13 g/21g
Egg white 2 =
8g
5
Fish50g/chicken35g =7.5 g
Total 57.5g
Supplement 30 g/d = 20g
7
Total 77.5
1
2
4
6
Protein supplementation can improve the catabolic state of
CAPD patients.
Significant improvement in protein intake
(p < 0.05) from baseline at each study month.
Caloric intake increased from baseline
throughout the supplementation period
Change in nitrogen
balance during months 1
and 3 of supplementation.
Effectiveness of Protein S
supplementation …CAPD
RA Elias, A etal
Foods Permitted
• Fruits permitted: one fruit in a day (approx 50 mEq) if serum
potassium is <5.0,
• Apple, banana (diabetic to avoid banana), orange, pineaaple,
rosapple, guava, papaya, pear.
• If serum potassium is >5.0 stop taking fruits
• Vegetable permitted:
• Potato, turai (ridge gourd), lauki (bottle gourd), bhidi (ladies
finger), tinda (giloda), parwal (snake gaurd), methi saag
(fenugreek leaves), kaddu (pumpkin), cabbage, simla mirch
(green pepper), green peas.
• Dehusked Lentil (Dal) Permitted, dhuli moong (green gram),
arhar (tur dal), urad dhuli (black gram), dhuli masoor(lentil),
kidney beans, choley (once a month).
Foods Permitted
• Use refined flour (sieve flour/atta before cooking)
• Use tamarind pulp instead of tomatoes to enhance
taste
• Use, garlic, heeng, methi dana, and turmeric in
cooking.
• Use coriander powder (dhania), cumin seeds (zeera)
and red chlli powder in small quantity.
High Protein Food For Dialysis Patients
• Curd with 3 tsp of Proseventy powder
• High Protein Chappati. Add 1Tb sp of soyabean
flour to wheat flour (atta) or Mix Proseventy
powder to wheat flour (atta).
• Sandesh diabetic patients can use sugarfree powder
to make sandesh, chenney ka rasgulla (not for
diabetics), rice pudding/kheer (diabetics can use
sugar free powder), paneer ki kheer (diabetics can
use sugar free powder), Moon dal kebabs, egg
white, soyabean and soyaben products (Tofu,
nuggets and milk).
Protein intake in Children K/DOQI Guideline 6 2009
CKD stage 3 dietary protein
intake 100% to 140% of the DRI
for ideal body weight.
CKD stages 4 to 5 100% to 120%
of the DRI
If patient is on hemodialysis, then
an additional increment on
anticipated losses 0.4g/kg/d
and peritoneal losses 0.80.9g/kg/d should be followed.
100-120% + 0.4 or 0.8-0.9g
/kg/d (2000)
Newer PD solutions with lower
GDPs preserve RRF better
•
Use of 1.1% AA solution showed an
anabolic response with increase in
IGF and lower phosphorous and
potassium levels (randomized study)
• Study of 22 CAPD patients with
serum albumin levels of less than 3.5
g/dl, use of AA dialysate improved
their nutritional status, rate Taylor G etal
Clin Nephrol 58: 445–450, 2002
• Over 3 years Chinese study : one
daily exchange of AA-based solution
showed better nutritional parameters,
Li FK, Chan etal Am J Kidney Dis 42: 173–183, 2003.
Guideline 17 – Daily Energy Intake (DEI)
Major source: Carbohydrates and Fat


Recommended: 35 kcal/kg bw for those < 60 y of age
30-35 kcal/kg for those > 60 years.
Dextrose based solutions result in net positive calorie
gain due to glucose absorption. (results in decreased
intake of protein and fat)
Patients get 19% of total energy intake dialysate
glucose absorption (300-500 kcal/day)
Fernstrom A, etal. J Inter Medicine1996 Oct;240(4):211-8


PD calorie load should be included in total Kcal intake.
Calorie load provided from absorption of lactate =
calorie load lost from proteins (8.75 ±0.27 g/d) lost in
dialysate.
Energy Intake From Peritoneal
Dialysate Absorption
1 week of PD: 500-2100g of glucose absorbed
1.5% (2L)
~ 76 kcal CAPD 4 x 2L = 302 kcal
3 x 2L 1.5% + 1 x 2L 2.5% = 410 kcal
2.5% (2L) ~ 182 kcal
4.25% (2L)~ 308 kcal 3 x 2L 1.5% +1 x 4.25% = 536 kcal
Energy Intake in Children
K/DOQI Guideline 5

Energy intake should exceed
RDA for age at least initially.

Peritoneal dialysate glucose
absorption increases total calorie
intake by 7-10 kcal/kg/d

Prescribe “catch up” energy
supplements to achieve RDA or
Higher as per chronol age for
children who demonstrate energy
malnutrition .
If patient does not gain weight
recommend Energy intake based
on height age.

Indications for Nutrition Support
NKF/KDOQI Guideline 19
• Patients who are unable to meet protein/energy requirements
with food for an extended period of time should receive
nutrition support.
Extended period is defined as days to 2 weeks.
Complete assessment is needed before intervention.
• Eliminate/treat any potentially reversible or treatable condition
or medication that might interfere with appetite or cause
malnutrition.
Use progressive therapies like counseling, supplements, tube
feeding, IDPN/IPN, TPN.
In Very Malnourished PD patients
 Plan hemodialysis as a temporary measure in very
malnourished patients while either enteral or
parenteral nutrition is given.

Once good steady state of nutrition is obtained a
return to PD can be made.
SIDE EFFECT
Icodextrin-based PD Solution
METABOLIC ACIDOSIS
Conventional Glucose Dialysis Solutions can lead Skin Rashes
Vesicular Rashes
to ultrafiltration failure.
Icodextrin: Effectively clear small solutes.
Increases ultrafiltration rates.
Improves the sodium and fluid balance in
high-transporters who have poor UF
Better control of blood pressure.
. Long dwell can help some anuric patients
to be maintained on PD because of better
fluid balance.
Improve cardiovascular parameters&
Improve lipid profile in patients and
Better blood sugar: lowers insulin level &
improve insulin sensitivity
Hyperkalemia Low urine output
1 Gram protein= 1meQ Potassium
Potassium Intake in CKD 1 mEQ/kg/day
Prescribe Low Potassium Diet
• High serum K+ Can cause arrhythmia
• Prescribe Low K foods:
• Foods containing <100 mg K /100g
• Apple, banana, guava, pear, orange, papaya
Reduce Potassium intake
Leach/remove potassium from vegetables by soaking
chopped vegetables in
luke warm water for half an hour.
Avoid green leafy vegetables,
tomatoes, sweet lime, lemon,
carrots, raw salad, mango, dry fruits
fruit juice, vegetable soup,
coconut water.
Low Sodium Diet for Renal Patients for
better control of blood pressure and
to prevent edema
Sodium intake in CKD <2.4 g/d
(AHA/KDOQI Guidelines for control of Hypertension)
1 tsp=5g =2.5 g Na Avoid Foods containing
Sodium>100 mg/100g Avoid canned foods/ fruits/
Pickles/ fruit jam
Phosphorus
• Hyperphosphatemia implies increased concentration of inorganic
phosphates in the blood (>4.5mg/dl).
• Primary source of P is food and its is absorbed in intestine.
• In healthy individuals >95% of P is excreted through urine.
• Only small amounts of P are excreted into the feces, sweat, and
saliva.
• Protein has linear relationship with phosphorus.
• In predialysis stage, high protein intake causes hyperphosphatemia
• Hyperphosphatemia is well known risk factor for cardiovascular
mortality in CKD especially in patients on dialysis.
• It is associated with secondary hyperparathyroidism, renal
osteodystrophy, and development of vascular calcification.
PTH
FGF23 
3 mg/kg/d
20mg/kg/d
60% and 70% of dietary P
absorbed by the GI tract
Two third
excreted in
urine
600-800 mg
Phosphorus balance in normal physiology. Adult body store of phosphorus is approximately 700
g, of which 85% is contained in bone 14% is intracellular, and only 1% is extracellular. Of the
extracellular phosphorus Kidney injury impairs the ability to maintain phosphorus balance,
phosphorus homeostasis is lost and positive phosphate balance occurs in the later stages (4 and
5) of kidney diseases. 70% is organic (phosphate) and contained within phospholipids and 30% is
KDOQI GUIDELINE
4. RESTRICT DIETARY PHOSPHORUS
IN PATIENTS WITH CKD
• Restrict Dietary phosphorus to 800 to 1,000 mg/day
(adjusted for dietary protein needs) when the serum
phosphorus levels are elevated (>4.6 mg/dL ) at Stages
3 and 4 of CKD, and
>5.5 mg/dL in those with kidney failure (Stage 5).
• Restrict Dietary phosphorus to 800 to 1,000 mg/day
(adjusted to dietary protein needs) when the plasma
levels of intact PTH are elevated above target range of
the CKD stage.
• The serum phosphorus levels should be monitored
every month following the initiation of dietary
phosphorus restriction.
1. Calculate Phosphate Content Of Diet
• 1 g protein brings 13–15 mg
phosphate
• Total protein x 14 = phosphate
content
• 60 kg 0.6g/kg/d= 36 g protein
• Total phosphorus= 36x14= 504
mg
• If patient is on dietary
supplement add phosphorus
content of supplement to
dietary phosphorus intake.
Pi level in CKD patients should be <5.0 mg/dl. Relative risk of
mortality increases with serum phosphorus levels >6.5 mg/dL
Very low levels of Pi (< 2.5 mg/dl) are associated with osteomalacia
and bone disease, and can even induce rhabdomyolysis.
Association between all-cause mortality and serum phosphorus concentration, stratified by
country and adjusted for serum concentrations of calcium and PTH, dialysate calcium
concentration, age, gender, race, duration of ESRD, hemoglobin,
albumin, Kt/V, and 14 summary comorbid conditions. ** 0.001% significance level
KDOQI: Advise Low Phosphorus Containing Foods.
Recommended Daily Allowance (RDA) For Phosphorus 800 mg/day
Foods High in protein and dairy products contain the
most P
High (> 200 mg P per 100 g)
Milk products
Meats
Fish
Dry fruits
Chocolate
Medium (> 100 but < 200 mg P per 100 g)
Cereals
Legumes
Minimum in vegetables and fruits
Low (< 100 g P per 100 g)
Vegetables
Fruits
Avoid Foods With Phosphorus-based
Additives.
SAY NO TO
• Cola beverages
• Enhanced or restructured
meats
• Frozen meals
• Cereals
• Snack bars
• Processed or spreadable
cheeses
• Instant products
• Refrigerated bakery
products

4. Prescribe Phosphate
Binders With Meals
Purpose of therapy with phosphate binders is to limit
intestinal absorption of dietary phosphorous and to
maintain phosphates in normal range.
Protein has linear relation with phosphate
1 g protein brings 13–15 mg phosphate, of which 30–70%
is absorbed through the intestinal lumen.
Mortality decreases when protein intake increases up to 1.4 g/kg/day (lower panel) despite a
slight increase in serum phosphate (Shinaberger et al.,82). nPNA, appearance.
Increasing Protein Intake in Dialysis: The
Phosphate Paradigm
•
Mean peritoneal phosphate clearance (L/wk/1.73 m2 BSA) according to peritoneal membrane
transport category and peritoneal dialysis modality. CAPD, continuous ambulatory peritoneal
dialysis; CCPD, continuous cyclic peritoneal dialysis; H, high transport category; HA, highaverage transport category, LA & L: combined low-average and low transport category.
1-day peritoneal dialysis clears ~300 mg phosphate.
• 1 regular hemodialysis session clears 500–600 mg phosphate
• This results in a net balance of 1800 mg every other day in HD
pateints, an amount that cannot be eliminated through dialysis
• Phosphate binders are a must for such patients.
6.
Preserved Residual Renal Function Removal of
Phosphates is more effective
(Study conducted on a cohort consisting of HD and PD patients)
• Relationship between phosphate levels and RRF.
• The presence of residual renal function (RRF) in
chronic dialysis patients contributes to improved
clearance of uremic toxins, in particular the
clearance of middle molecules and protein-bound
solutes.
• In patients with RRF requirement of phosphatebinders is less.
• This may contribute to improved quality of life and
reduce treatment costs.
Role of Residual Renal Function in Phosphate Control and Anemia
Management in Chronic Hemodialysis Patients
E. Lars Penne,*† Neelke C. van der Weerd,*† etal
Clin J Am Soc Nephrol. 2011 Feb; 6(2): 281–289.
Percentage of patients below, within, or above phosphate treatment targets by GFR
category
.
Relationship between RRF and use of phosphate-binding agents. Each box shows the
distribution of phosphate-binding agent use in DDD for the range of RRF as indicated on
the horizontal axis. The mean dose is shown by the black circle, the median by the middle
horizontal line, and the 25th and 75th percentiles by the bottom and top of the box,
respectively. P for univariable linear trend = 0.008.
Anuric patients used on average six tablets (3 to 9.5) of phosphate-binding agents per
day, as compared with 3 (1 to 6.3) in patients in the upper tertile (P = 0.001). The dose
of phosphate-binding agents, expressed as DDD, was lower in patients within the higher
GFR tertiles Role of Residual Renal Function in Phosphate Control and Anemia
Management in Chronic Hemodialysis Patients
.
Protein To Phosphorus Ratio
Dietary phosphorus was divided into protein ratio into four a priori selected increments of <12,
12 to <14 (reference), 14 to <16 and ≥16 mg/g. The MHD patients whose daily food intake
contained >16 mg of dietary phosphorus per gram of food protein, exhibited almost two
increased death risk compared with the 12 to <14 mg/g group in the fully adjusted model.
Cubic spline models of the Cox proportional regression analyses reflecting adjusted mortality
predictability (with 95% CI) according to the percentile of the patient’s dietary phosphorus
intake. A trend toward increased risk of death in the MHD patients with higher dietary
phosphorus intakes.
Nazanin Noori Association of Dietary Phosphorus Intake and Phosphorus to Protein Ratio
times with Mortality in HD Patients Clin JASN. 2010 Apr; 5(4): 683–692.
Management of DGP
• Maintain adequate glycemic
control, control upper GI
symptoms, ensure adequate
hydration and nutrition, prevent
malnutrition.
• Maintain Glucose levels below
180 mg/dL and above 110
mg/dL to avoid hypoglycemia
1. Avoid inhibiting gastric
myoelectric control and motility.
2. Hyperglycemia inhibits the
action of prokinetic drugs such
as erythromycin.
Management of DGP
• Carbohydrates and substances with high
osmolarity increase gastric emptying,
therefore avoid meals have a high-fiber
content
• Medium-chain triglycerides do not delay
gastric emptying to the same extent as
common fat therefore avoid meals
containing.
• Advise small meals at frequent intervals
that consist of low-fat and complex
carbohydrates.
• Give high-calorie liquid supplements if
patent is not in Volume Overlod
• Parenteral nutrition may be needed to
supply dietary requirements temporarily
in severe cases
Restrict Fat: Emphasize On Reduction of
Saturated & Trans Fatty Acids
of Dyslipidemia
• Fatty acid intake can be modified easilyManagement
by substituting
canola
oil, a blend that includes both omega-3 and monounsaturated
fats, for vegetable oils
• AHA Recommendations:
Prefer monounsaturated fats /oils:
corn, safflower , soyabean , olive , peanut
and canola oils
Total fat: 25-35% of total calories: <10% PUFA
Saturated Fat <7%
Trans Fats <1%
Dietary cholesterol <200 mg daily along with
n-3 polyunsaturated fats.
Fluid Management
Input and Output Charting
Ultrafiltration + Urine Output+ Edema
Oral Intake + IV infusions & Urine Output charting
Fluid intake:
Water taken with meals, medications or otherwise
Tea, Coffee
Milk
Curd
And any other liquid
Fluid Prescription:
UF+ Previous 24 hour urine output + 500 ml if patient is dry
• If patient is edematous: 24 hour urine output + 300 ml
Conclusion: How Do We Handle PD Patients with
Signs of Malnutrition/Wasting?
Provide adequate
nutrition, adequate
dialysis and treat
co-morbidities
Evaluate and treat
potential dialysis
related causes of
wasting
Nutritional
supplements
Others
• Infectious complications
• Exit site infections
• Nutritional intervention
• Silent ischemic heart disease
• Other infectious complications
• Physical training
• Intercurrent clinical events
• Reduce pre-meal exhanges
• Pharmacological
• Peridontal disease
• Bioincompatible membranes
intervention
• Failed kidney transplant
• Use biocompatible PD fluids
• Volume overload
• Icodextrin based PD fluid
• Inflammatory diseases
• Amino acid based PD fluid
Modified after Carrero et al Blood Purif 2008;26:291–299
T
h
a
n
k
y
o
1. Prevent malnutrition from setting in.
2. Correct uremia and metabolic acidosis.
3. Monitor closely nutritional status and
nutrient intake.
4. Individualize diet prescriptions.
5. Replenish plasma amino acid and protein
pool, prescribe High Protein Diet along with
oral protein supplements.
6. Oral supplements should be administered
in between meals and before bed time.
7. Treat Metabolic Acidosis and superimposed
illness to prevent protein catabolism.
8. Eliminate drugs which cause GI upset and
cause anorexia.
Why Modify Diets?
• As kidney disease progresses, the capacity to respond
to changes in intake of nutrients and water becomes
less flexible.
• Solute and water excretion per nephron increases, but
the fewer number of functional nephrons leads to a more
restricted range of solute or water excretion.
• Therefore, in kidney failure nutritional therapy allows
good control of several consequences of the disease.
Why Modify Diets?
Cont..
• When diet exceeds daily protein requirement, the
excess protein is degraded to urea and other
nitrogenous wastes and these products
accumulate.
• Because the severity of uremic syndrome is
proportional to the accumulation of these waste
products and ions.
• Therefore dietary intake needs to be adjusted.
What Causes Malnutrition
Malnutrition
Protein energy wasting (PEW) or
Malnutrition
• Malnutrition or Protein energy wasting (PEW) is highly prevalent in
peritoneal dialysis (PD) and is associated with poor outcomes,
including hospitalization and mortality.
• Recognizing and diagnosing PEW in PD is important
• although studies are limited, there are interventions that may be
associated with improved outcomes.
• important causes of PEW and explore the current diagnostic tools
that are used to assess PEW.
• when patient is on dialysis, diet can play a big role in how patient
feels.
• PD uses a fluid that contains carbohydrates to help filter out the
toxins in the blood, dietary requirement change in order to
maintain body weight and prevent excess weight gain in patients
choosing this therapy.
Conventional Glucose Dialysis Solutions
PD solutions may also affect RRF
• Many current PD solutions are bioincompatible, with low pH
• The conventional glucose dialysis solutions cause mesothelial
cell injury concurrent with sustained regeneration Advanced
glycation end products (AGEs).
• AGE formation in the peritoneum causes severe interstitial
fibrosis and microvascular sclerosis causing apoptosis of renal
tubular epithelial cells and resultant loss of RRF
• These changes are presumed to lead to ultrafiltration failure.
Kim SG, et al. (Balnet Study). Perit Dial Int 2008;28(suppl 3):S117–22.
Kunal Chaudhary*† and Ramesh Khanna† JASN 2010
Icodextrin-based PD Solution Studies
Effectively clear small solutes.
Increases ultrafiltration rates.
Better fluid balance in high-transport
ers who have poor UF
Better BP control.
. Long dwell can help some anuric
patients to be maintained on PD
because of better fluid balance.
Improve cardiovascular parameters&
Improve lipid profile in patients and
Better blood sugar: lowers insulin level
& improve insulin sensitivity
Lower levels of AGEs with the use of
icodextrin better preserve peritoneal
membrane and prolong the use of PD.
Newer PD solutions with lower
GDPs preserve RRF better
•
Use of 1.1% AA solution showed an
anabolic response with increase in
IGF and lower phosphorous and
potassium levels (randomized study)
• Study of 22 CAPD patients with
serum albumin levels of less than 3.5
g/dl, use of AA dialysate improved
their nutritional status, rate Taylor G etal
Clin Nephrol 58: 445–450, 2002
• Over 3 years Chinese study : one
daily exchange of AA-based solution
showed better nutritional parameters,
Li FK, Chan etal Am J Kidney Dis 42: 173–183, 2003.
Guideline 17 – Recommended Daily Energy Intake
Major source: Carbohydrates and Fat

35 kcal/kg/bw of energy for those < 60 y of age
30-35 kcal/kg/d for those > 60 years.
Patients get 19% of total energy
intake dialysate glucose absorption. ()
Fernstrom A, etal. J Inter Medicine1996 Oct;240(4):211-8
(300-500 kcal/day from PD)
This causes decreased intake
of protein and fat.
This intake should be included in total
energy intake prescribed by dietician.
Control Serum
Phosphorus In Diet
• Educate patient on phosphorus targets <4.5 mg/dl
• Provide consistent instruction and regular follow-up
during prescription of dietary phosphate restriction.
• Make sure patient is compliant to prescription and
is taking phosphate binder with meals.
The Renilon Multicentre Trial
Denis Fouque Fouque D, McKenzie J, de Mutsert R, etal
Nephrol Dial Transplant. 2008 Sep;23(9):2902-10
• Use of a renal-specific oral supplement by
HD patients with low protein intake does not
increase the need for phosphate binders
• Serum albumin and prealbumin positively
increase with the increment in protein intake
(r = 0.29, P = 0.01 and r = 0.27, P = 0.02,
respectively).
• and may prevent a decline in nutritional
status and quality of life.
Treat Diabetic Gastroparesis
Ajumobi AB , Griffin RA ,Hospital Physician March 2008
• Characterized by Delayed gastric emptying &
associated upper gastrointestinal (GI)
symptoms
• Symptoms include nausea, vomiting, early
satiety, postprandial fullness, belching,
abdominal pains, bloating, anorexia, and
weight loss.
• DGP result in poor glycemic control, poor
nutrition, and dehydration, which in turn may
lead to poor quality of life & frequent
hospitalizations.
• Gastric emptying is slower during
hyperglycemia and accelerated during
hypoglycemia
• Electrolyte abnormalities (eg, hypokalemia,
hypomagnesemia) have roles inthe
pathogenesis of DGP.
• Dysfunction of NO neurons in the myenteric
plexus may be responsible for DGP
Management of DGP
• Maintain adequate glycemic control, control
•
•
•
•
•
•
upper GI symptoms, ensure adequate hydration
and nutrition, prevent malnutrition.
Maintain Glucose levels below 180 mg/dL to:
1. Avoid inhibiting gastric myoelectric control
and motility.
2. Hyperglycemia inhibits the action of
prokinetic drugs such as erythromycin
Carbohydrates and substances with high
osmolarity increase gastric emptying, therefore
avoid meals have a high-fiber content
Medium-chain triglycerides do not delay gastric
emptying to the same extent as common fat
therefore avoid meals containing.
Advise small meals at frequent intervals that
consist of low-fat and complex carbohydrates.
Give high-calorie liquid supplements if patent
is not in Volume Overlod
Parenteral nutrition may be needed to supply
dietary requirements temporarily in severe
cases
• Use prokinetic drugs, antiemetic agents
like metoclopramide, domperidone,
erythromycin,and cisapride , pyloric
injection of botulinum toxin (potent
inhibitor of neuromuscular transmission)
to control symptoms of DGP
• Domperidone: doses between 10 and 30
mg taken orally a half hour before meals
and at bedtime, domperidone has been
shown to reduce GI symptoms
• Oral erythromycin between 50 and 100 mg
taken 3 times daily in combination with a
low-bulk diet
• Cisapride is a potent prokinetic drug that
acceleratesgastric emptying of solids and
improves dyspeptic (can cause fatal cardiac
arrhythmias.)
When Does Protein-Energy-Wasting Set In?
• Dietary protein and energy intake diminish long
before end-stage renal disease develops
(Kopple 1989,and 1997 Nutr. January 1, 1999 vol. 129 no. 1 247S-251S)
• PEW is partially caused by inadequate nutritional
management in predialysis phase, most likely
during CKD stage 3 or even earlier.
• PEW becomes clinically evident when GFR is < 1510 ml/min.
• 20-70% patients on Maintenance Dialysis show
signs of PEW.
Sources of Selenium
Vitamin B Foods | Vitamin B12 Deficiency Symptoms
Vitamin
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Sources
Outer layers of
grain
Whole Grains
Fruits and
Vegetables
Liver (beef, pork
and chicken),
Milk
Eggs
Meat and poultry.
Selenium
Functions
Good Brain
Function
Healthy Nerves
Good Memory
Healthy Red
Blood Cells
Strong Muscles
5. Emphasize Merits Of Plant-based Proteins
Rather
Than Those From Meat Or Dairy Sources
•
•
•
•
•
•
•
P Intake from Plant Foods: The Role of Phytate
Many fruits and vegetables contain only small amounts of P.
In plants P is mostly in the form of phytic acid or phytate
(beans, peas, cereals, and nuts)
Because humans do not express the degrading enzyme phytase,
the bioavailability of P from plant-derived food is relatively low,
usually <50%.
Hence, despite “apparently” higher P content of some plants
there is lower rate of intestinal P absorption /gram of plant protein
than animal-based protein.
Organic PO4 is found naturally and abundantly in some plant
seeds, nuts, and legumes hence can worsen hyperphosphatemia .
P in meat is present as organic phosphates and is easily hydrolyzed
and readily absorbed.
Restrict meat in diet.