Transcript Nutritional Requirements in Chronic Kidney Disease

Dietary
Approach To C
Kidney Disease
Dr Anita Saxena
MD, PhD, PhD
(Cambridge)
Associate Professor
Department of
Nephrology
SGPGIMS, Lucknow.
India
Nutrition In Renal Disease Is Complicated
• The term “Renal disease”
embraces a number of clinical
conditions whose common
feature is decrease in GFR.
• Another common feature that
these conditions share is
malnutrition but each condition
has a different approach in terms
of nutritional therapy.
Definition of Chronic Kidney Disease
• Chronic Kidney Disease is defined
as kidney damage for ≥ 3 months as
defined by structural or functional
abnormalities of the kidney, with or
without decreased GFR.
• GFR ≤ 60 ml/min/1.73m2 with or
without kidney damage.
• There are 5 stages of CKD
depending upon GFR (≥90, 60-89,
59-30, 29-15, <15) ml/minute.
Why Do We Need To 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 and water excretion.
• When diet exceeds daily protein
requirement, the excess protein is degraded
to urea and other nitrogenous wastes and
these products accumulate in the body.
• Because the severity of uremic syndrome is
proportional to the accumulation of these
waste products and ions, therefore, dietary
intake needs to be adjusted.
Why Modify Diets?
Cont..
• In kidney failure nutritional therapy allows good control
of several consequences of the disease.
Nausea /Vomiting Anorexia Initiation of dialysis
When Does Protein-Energy-Wasting
Set In?
The MDRD Study: Association Between Dietary Intake And
GFR and Serum Albumin and GFR
With GFR< 60 mL/min/1.73 m2 dietary protein and energy
intake decreases and serum also albumin decreases
(presence of inflammation).
Males, solid lines; Females, dashed lines
When Does Protein-Energy-Wasting Set In?
contd…..
• PEW most likely occurs during
CKD stage 3 or even earlier
partially due to inadequate
nutritional management in
predialysis phase and becomes
clinically evident when
GFR is < 15-10 ml/min.
• 20-70% patients on
Maintenance Dialysis show signs
of PEW.
Malnutrition is Multifactorial
Loss of Nutrients
& Water soluble
Vitamin in Dialysate
Uremic toxicity
Dietary protein
& energy intake
Inadequate
Dialysis dose
Anemia
loss of blood due to
GI bleed, frequent
blood sampling
Declining
Residual Renal
Function
level of counter
regulatory hormones
Glucagon, PTH
Anorexia
Loss of taste
Unpalatable diets
Malnutrition
Inflammation
Infection
Superimposed
illness
Presence of
Comorbidity
Hormonal disorders
Resistance to anabolic
hormones
Metabolic Acidosis
Markers of Protein-Energy Malnutrition
(Predictors of Morbidity And Mortality in CKD)

Progressive weight loss
BMI <22 kg m2 >60 years
 Wasting of fat and skeletal
muscle tissues
reduced muscle mass 5% in 3 m
Reduction in serum protein Serum
albumin level <3.8 g/dL
 Serum pre-albumin level <30 mg/dL
 Serum cholesterol level <100 mg/dL
 Low dietary protein intake <0.6 g/kg/d
or <0.8 g/kg/d on MHD and energy
intake <25kcal /kg/d for at least 2
months
What Problems Are Unique To
Patients with CKD?
Does CKD Have An Influence On Gastrointestinal Tract?
ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure
N. Canoa etal Clinical Nutrition (2006) 25, 295–310
1. Uraemic syndrome is associated with loss of appetite and a
variety of gastrointestinal adverse effects, which results in
reduced nutritional intake.
Anorexia 35% - 60% of MD Patients
14406
120
HDHD
pats
pats (DOPPS)
223 HD pats
34 HD pats
1846 HD pats (HEMO)
331 HD pats
307 HD pats
73 HD pats
106 PD pats
Merkus et al. 1999
66 CKD 5 predialysis pats
238 CKD 5 predialysis pats
0
Lopes et al. 2007
Carrero et al. 2007
Muscaritoli et al. 2007
Burrowes et al. 2005
Kalantar-Zadeh et al. 2004
Curtin et al. 2002
Virga et al. 1998
25
Murtagh et al. 2007
Curtis et al. 2002
50
75
100%
Does CRF Have An Influence On Gastrointestinal Tract?
ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure
N. Canoa etal Clinical Nutri(2006) 25, 295–310
2. Patients with CRF
Impaired gastric emptying
Impaired intestinal motility
Disturbances of digestive and absorptive
functions, and
Alterations in intestinal bacterial flora
(Kang JY. 1993. Dig Dis Sci 38:257–68)
Delayed intestinal fat absorption
(Drukker A Nephron 1982;30:154–60).
Gastroparesis is most pronounced in
patients with diabetic nephropathy.
What Problems Are Unique
To Patients with CKD?
3. Poor nutrition in general.
4. Lack of proper diet
counseling and poor
monitoring of nutritional
status.
Problems Are Unique To Patients
with CKD?
5. Hyperglycemia
6. Hyperlipidemia
7. Cardiovascular involvement
Problems Are Unique To Patients with
CKD?
8. High incidence of infections
9. Late initiation &
Inadequate dialysis.
Nutritional Requirements of
CKD Patients
CKD Stages 1-4
Low-protein diet (LPD) + Fluid Management
Low-protein diet (LPD) is a conservative treatment in
patients with chronic kidney disease (CKD) to
improve uremic symptoms and slow progression of
renal dysfunction.
(Brenner BM, Meyer TW, Hostetter TH N Engl J Med 307:652–659,
1982.)
Fluid Management
Input and Output Charting
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:
Previous 24 hour urine output + 500 ml if patient is dry
• If patient is edematous: 24 hour urine output + 300 ml
Nutrient Requirements for
Stage 1 Kidney Damage
(presence of protein in urine) normal GFR
GFR >90 mL/min/1.73 m2
Protein: 0.8 g/kg/d
Non Diabetics Energy: 30-35 kcal/kg/d
35 kcal/kg/d < 60 years
30 kcal/kg/d > 60 years
Diabetics : <30 kcal/kg/d
Water soluble Vitamins and minerals as per RDA
Principle Is Restrict Protein
Do Not Say No To Protein
Prescribe Low Potassium Diet
Potassium Intake in CKD 1 mEQ/kg/day
Hyperkalemia (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.
X
X
Avoid green leafy vegetables,
tomatoes, sweet lime, lemon,
carrots, raw salad, mango, dry fruits
fruit juice, vegetable soup,
X
X
coconut water.
X
X
X
Low Sodium Diet for better
control of blood pressure& 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
Nutrient Requirements for Predialysis Stages 2 ,3 4, 5
Kidney Damage With Mild Decrease in GFR To Severe
Reduction In GFR 60-89, 30-59; 15-<30mL/min/ 1.73 m2
Nutrient
Requirement (conservative management)
Low protein
0.6g/kg/d
Guideline 24
Those unable to accept 0.75 g/kg/d
Energy
30-35 kcal/kg/d
(35 < 60 years; 30 > 60 years; Guideline 25
Phosphorus
800-1000 mg to prevent hyperphosphatemia.
Non-calcium based phosphate binder with meals to
prevent soft tissue calcification.
Calcium
1000-1500 mg/d
Sodium
<2.4 g/d
Potassium
1 mEq/kg
Cholesterol
<200 mg/d. Avoid egg yolk
Water soluble Vitamins and minerals/ RDA
Anemia
Treat anemia with folic acid, B12,iron supplements and ESA
Do Not Advise Your Patients Not To Take Protein.
Put them on Low Protein 0.6g/kg/d
Weight of patient = 50 kg
50 x 0.6 = 30 g of protein
1
2
Milk 150 ml = 4.5 g/protein
3
Dal 1 bowl = 6 g protein
Chappati=2 g 8 chappaties = 16 g
Rice: 50 g raw = 3 g Total 29.5g
4
Protein intake in Children K/DOQI Guideline 6 2009
CKD stage 1-3 dietary protein
intake 100% to 140% of the DRI
for ideal body weight.
CKD stages 4 to 5 100% to 120%
of the DRI
Energy intake should exceed
RDA for age at least initially.
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.
MDRD Study
Low Protein Diet + Keto Analogues
• Delay progression of kidney disease in the Predialysis period.
Reduce uremic symptoms
Preserve residual renal function
Delay onset of dialysis
Preserve nutritional status.
Improve metabolic complications due to renal
insufficiency
• Essential amino acid tablet contain all amino acids essential for
uremic patients (50 mg /tablet; dose 5 mg/kg/d).
(Barsotti G, etal . Kidney Int 24:Suppl 16, S278–S284, 1983.
Gretz N, Korb E, Strauch M Kidney Int 24:Suppl 16, S263–S267, 1983)
COST
Nephrotic Syndrome
Dietary Recommendations:
Low fat, Low salt diet+ Fluid restriction
• Restrict Fluid: depending upon presence
of edema
• Energy: 35 kcal/kg b.w./d
• Protein 0.6-0.8 g/kg b.w. with 1 g for
each gram of albumin lost in urine.
• In children protein - according to RDA
for chronological age.
• Restrict Sodium to 2.4 g/d.
• Low Fat diet: Fat <30% of total calories
(PUFA 10%)
• Cholesterol
< 200mg/d
• Soy protein is beneficial for kidneys
• Avoid egg yolk, cream, red meat, fried
foods
Diabetic Nephropathy
Dietary Recommendations (Up-To-Date, 2006)
1. Protein intake of 0.8 g/kg/d reduces
albuminuria and stabilizes kidney
function (Egg white HBV for
protenuria).
1. Achieve Normoglycemia
2 Manage dyslipidemia
3. Manage Weight
4. Good Blood Pressure
control (<130/80 mmHg)
5. Bring down Proteinuria
with use of ACE/ARB
2. As GFR decreases restrict protein
0.6 g/kg/d.
3. Energy: <30 kcal/kg/d for weight
management.
4. Total fat should be restricted: 30%
total Kcals.
(<10% calories from SFA; <10% calories
from PUFA; 10-15% calories from
MUFA)
5. Dietary cholesterol <200 mg daily
along with n-3 polyunsaturated fats.
Diabetic Nephropathy
Dietary Recommendations
(Up-To-Date, 2006)
1. Advise small meals
at frequent intervals
that consist of low-fat
and complex
carbohydrates.
2. 3 meals and 2 snacks
3. Avoid meals with
high-fiber content.
BF/Dinner
Pregnancy, Diabetes and CKD
No studies on
Preg Diabetics
CKD Stage 5.
Strategies for
management
of
hyperglycemia,
hypertension,
and
dyslipidemia
may be
extrapolated
from the
recommendati
ons
for women
with earlier
stages of
CKD.
Discontinue Treatment of
DKD with RAS inhibitors
HbA1C as close to normal as
possible (<1% above upper
limit of normal)
Use Insulin to control
hyperglycemia if necessary
Liberalize dietary protein
1.0-1.2g/kg preconception
Weight/d
Treat High blood pressure
>140-160/90-105 mm Hg
Target BP <130/80 mm Hg
because of CKD.
Avoid hypotension
RENAL STONE DISEASE
RENAL STONE DISEASE
Composition: calcium, oxalate, phosphate, uric acid
•
•
•
•
•
•
•
•
•
Drink plenty of fluid: 3-4 litres/day (half of
which should be water)
Continuous intake rather than
acute bursts of drinking will
ensure required urinary SG of <1.01.
Take a glass of water before going to bed
to maintain specific gravity < 1.01.
Avoid hard tap water
In adults, urine volume should be>2 L/day
Low salt diet
Low protein diet
Prefer vegetarian diet.
If urine pH >6.0 avoid citrate supplements.
Prefer refined cereals and flours.
RENAL STONE DISEASE
Composition Calcium, Oxalate, Phosphate, Uric acid
• Patients can take a total of 1000-1200 mg of
calcium/day from natural foods.
• Milk intake should not exceed 2 glasses/day.
X
• Avoid calcium supplements as tablets.
• Allow lemon juice.
• Avoid orange juice as it raises oxalate level.
• Avoid cola beverages.
• Avoid Cranberry juice.
• Calcium phosphate stones are treated
successfully with high-phosphate diets. In this
case prefer whole grains.
• Weight reduction and all forms of physical CranberryJuice
activity should be encouraged.


X
X
X
Gout (Hyper-Uricemia )
Avoid Foods Containing High Uric Acid
Low protein diet
Poultry and organ meats
• Fish Herring, Fish Roe, Salmon,
Sardine
• Kidney, Liver, Meat Soup Extracts
• Legumes (Dry Peas
Beans, Soyabean)
Mushrooms
Asparagus.
Autosomal Dominant Polycystic
Kidney Disease (ADPKD)
LOW
SALT
RESTRICT
FLUID
CONTROL
BLOOD
PRESSURE
Autosomal Dominant Polycystic Kidney
Disease (ADPKD)
•
•
•
•
•
•
•
Low Protein 0.8g/kg/d
As creatinine increases reduce it to 0.6 g/kg/d
Low SALT diet
Restrict Fluid intake
Good control of Blood pressure
Long Term Coverage With Antibiotics if infected
Soy protein (slows progression of PKD inanimals)
(Aukema, et al. J Am Soc Nephrol .10:300-308,
1999)
• Avoid foods with higher amounts of oxalic acid.
(spinach, rhubarb, beets, eggplants,
cocoa, and chocolate)
• Omega-3-fatty acids (Flax seeds/oil ): antihypertensive, lipid-lowering and antiinflammatory effects.
SOY
Management Of Patients On
Maintenance Dialysis
Hemodialysis
CAPD
Malnutrition At Initiation Of
Dialysis Is A Strong Predictor Of
Subsequent Increase In Relative
Risk Of Death
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.
Chung SH Peritoneal Dialysis International, Vol. 20, pp. 19–26
By Kaplan–Meier analysis, patient survival rate is
significantly lower in malnourished patients than in normal
patients (67.1% vs 91.7% p = 0.02)
 Malnutrition was present in 45% of 91 patients
commencing CAPD as assessed by SGA.
 Initial nutritional status appears to exert a powerful
influence on CAPD patient survival.
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
Loss Of Protein
HD/session
1-3 g/session
•
CAPD/Day
5-15 g/24h
4 g of which is
albumin
Peritonitis/24 h
15.1 gm
Protein intake should be increased
to > 1.3 1.5g/kg/d
• Krediet
The
loss of serum
influid
stable
continuous ambulatory
Estimating
energy,proteins
protein &
requirements
peritoneal
dialysisconditions
(CAPD) patients
averages
for adult clinical
June 2012
Qeensland Govt
per 24 hours, 4 g FM,
of which
is albumin EW, Arisz L:
RT,5 gZuyderhoudt
Boeschoten
Peritoneal
• permeability to proteins in diabetic and non-diabetic continuous
ambulatory peritoneal dialysis patients. Nephron
• 42: 133–140, 1982. Imholz AL, Koomen
Dietary Protein & Energy Intake for Patients on
MHD NKF-K/DOQI Guideline 15, 16




S Albumin ≥ 4.0g/dL
Guidelines 3
S Prealbumin ≥30 mg/dL
Guidelines 4
Prescribe 1.2g/kgbw/d protein to clinically stable
patients on HD
Guideline 15
Prescribe 1.3g/kgbw/d protein to patients on PD
necessary to ensure neutral or positive nitrogen
balance.
Guideline 16
At least 50% of protein should be of HBV
Energy 30-35 Kcal/kg/d depending upon age <60
or >60 y
Increasing Protein Intake in Dialysis: The Phosphate
Paradigm
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 JH et al.,1982). 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 a patient.
Patients on Maintenance Dialysis Require Extra Protein
Supplement Insufficient Protein Intake
• Renal Specific Protein Supplements in powder or biscuit form.
The Renilon Multicentre Trial: Use of a renalspecific oral supplement by HD patients who
have low protein intake does not increase
need for phosphate binders and prevents
decline in nutritional status and quality of
life.
Serum albumin and prealbumin changes
associate positively with the increment in protein
intake (The Renilon Multicentre Trial Fouque D etal NDT. 2008
Sep;23(9):2902-10)
• Peptide based supplements for sick patients.
Nutrition Supplements in Dialysis Patients: Use in Peritoneal Dialysis
Patients and Diabetic Patients R Poole Adv Peritoneal Dial, Vol. 24, 2008
Serum albumin (SA) levels before, during, and after the nutrition supplement
in hemodialysis (HD) and peritoneal dialysis (PD) patients.
Daily Supplement: 20 – 30 g protein and approx 500 calories
Significant improvement in albumin level during months 4 – 6 in HD patients but
not in PD Patients.
It takes 3months of supplementaion to show improvement in S albumin
In PD patients s albumin levels declined after supplementation was
stopped
Guideline 19 – Indications for Nutrition
Support in dialysis dependent patients
• If oral supplements are not tolerated
or effective and malnutrition is
present (<20 Kcal/kg/d and Protein
intake is <0.8 kg/g/d) consider tube
feeding to increase protein intake.
• Overnight supplement can improve
nutritional status and overall wellbeing.
• Bolus feeding: Start 50-100 ml feed,
then increase to 300-400ml per
feeding.
• Continuous feeding: Start with 2050ml/hr, then increase 20ml every
2-8 hrs until requirement is met.
En
Practical Rules For
Preventing Protein
Energy Wasting/
Malnutrition
1. Monitor Nutritional
Status
Identify Nutritional
deficiencies before they
become clinically evident.
(K/DOQI,AJKD.2000;35:S1-140.
Enia G, etal. NDT. 1993;8:1094-1098
Monitor Nutritional Status
(Predialysis* and Dialysis Depenedent** Patients)
Measure
Frequency of Measurement
Total protein
3 monthly* Monthly**
Serum albumin
3 monthly* Monthly**
Na
3 monthly* Monthly**
K
3 monthly* Monthly**
Ca
3 monthly* Monthly**
P
3 monthly* 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
Prevent
Monitor
Treat Complications
Slow Progression of CKD
• Reduce Albuminuria to slow
progression of CKD, particularly in
diabetics.
• Supplement with vitamin B complex
(AHA)
• Folic Acid, Vitamin B6 and B12
supplements to prevent
hyperhomocystenemia
• Serum albumin < 4.0 g/dL, prior to
initiation of dialysis, predict morbidity
and mortal(Kaysen et al, 2008).
Slow Progression of CKD
• Control Blood Pressure to
•
•
•
•
•
•
slow progression of CKD and
lower CVD risk.
Target BP ≤130/80 mmHG
Limit sodium intake.
Prescribe diuretics to treat fluid
overload
Advise Weight reduction if
required.
Monitor serum potassium in
patients on renin angiotensin
aldosterone system (RAAS)
antagonists.
Limit dietary potassium intake.
Slow Progression of CKD
Manage Diabetes
• Target HbA1c should be
<7.0% (ADA Guidelines 2007).
• Good control of newly
diagnosed diabetes may slow
progression of CKD.
• Blood glucose control may help
slow progression of CKD
(DCCT,1993; UKPDS,1998)
2. Correct Uremic
Symptoms
If patient is on dialysis
individualize dialysis
prescription.
Give adequate
dialysis
Maintain Kt/V urea of
1.2 for HD
1.7/week CAPD
ADEMEX Trial (2001)
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. Treat 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.
Anorexia cont..
In patients on
Peritoneal Dialysis
Glucose Absorption
from dialysate
Induces abdominal
discomfort
Suppression of
Appetite
(patient absorbs 100-200g/d
300-500 kcal/d )
Encourage patient to
take small but frequent
meals.
Peritoneal
Dialysate
Rule 4 Correct Of Metabolic Acidosis Reduce Protein Catabolism,
Increase Albumin Synthesis Degradation Of Essential BCAA.
Serum Bicarbonate
level at  22 mmol/L
Evaluate Monthly
NKF/KOQI
Guideline 13/14
Replace
Sevelamer HCL
With Sevelamer
Carbonate To
Prevent Acidosis
Rule 5.
Practical Rules For Preventing PEW
Treat comorbid conditions
like diabetes, gastrointestinal
disorders, and infection which
increase 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.
Treat Diabetic Gastroparesis: characterized by
delayed gastric emptying & Upper GI symptoms
Ajumobi AB , Griffin RA ,Hospital Physician March 2008
Maintain Glucose levels below 180 mg/dL
Average blood glucose should not exceed
150 mg/dl (Use Insulin therapy)
Prevent Hypoglycemia: Blood glucose
should not be less than 110 mg/dl (to).
Prescribe Medium-chain triglycerides.
 Avoid meals containing Fat to avoid
delayed gastric emptying.
Give high-calorie liquid supplements if
patient is not in Volume Overload.
 if patient is sick consider parenteral
nutrition.
6. Prevent Infections especially in
PD To Maintain Good Nutritional Status
Infections lead to ed appetite
Impart Intense Exit site infection
training to patient
& attendant for
maintaining
hygiene.
Peritonitis
7. Preserve Residual Renal
Function for Proper clearance of
middle molecules
Anorexia In PD
• Anorexia is more common in patients
who have lost RRF and has significant
independent effect on dietary protein
intake.
• Patients with RRF have higher mean
DPI and nPNA than patients without
RRF (1.08 ±0.31vs 0.89 ± 0.31g/kg/d
and
62.1 ±12.4 vs 54.9 ±15.3g.d).
( Wang etal JASN 2001 Nov 12 (11) 2450-7)
Every
1ml/min/1.73m2
increase in
GFR
associated with
0.041-fold
increase
in DPI and
0.838-fold
increase in DCI.
(Cross sectional study on 242
CAPD patients Caravaca etal
1999, Per Dial Int. Vol 19 350-6 )
STATEGIES FOR PRESERVING RRF cont..
Avoid Contrast and Other Toxins
Worsen renal function
Avoid Nonsteroidal
anti-inflammatory drugs,
aminoglycoside antibiotics, and
oral phosphate solutions.
Aminoglycoside antibiotics
used for treatment of peritonitis
and catheter infections should
be used with caution (ISPD).
Prevent peritonitis, because
peritonitis is also associated
with a decline in RRF.
8. Anemia also causes generalized
weakness & loss of appetite
• Correct Iron Profile
• Supplement Folic Acid
•
Correct Vitamin B12 deficiency
• Treat chronic infections and secondary
hyperparathyrpoidism
• Prescribe optimal dose of ESA/EPO
• Use L-Carnitine in EPO resistant anemia.
9. Reverse Protein Loss
Give High Protein Diet to
Patients on Dialysis
:
Rule 10. Practical Rules For Preventing PEW
Daily Hemodialysis Increases
Protein and Energy Intake
Galland et al. Kidney Int 2001
TAKE HOME MESSAGE
Prevent Malnutrition From Setting In
1. Correct uremia and metabolic acidosis
to prevent protein catabolism.
2. Monitor closely nutritional status and
nutrient intake.
3. Individualize diet prescriptions.
4. Do not completely stop protein
intake.
• Restrict Protein intake to 0.6 g/kg/d
in predialysis patients.
5. Ensure high protein diet for patients
on Maintenance Dialysis.
6. Eliminate drugs which cause GI upset
and anorexia.
T
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Foods With High Phosphorus Content
Useful In Treating Stone Disease
• Milk and milk products, khoa
• liver, egg yolk, fish, meat products,
soft drinks, whole grain cereals and
flours, Mustard leaves cauliflower,
• carrot peanut,
• Kidney beans, soyabean, til
water chestnut,
.
Chocolate
dry fruits dry coconut