1. 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

2. Malnutrition What Is Malnutrition Imbalance Nutrient Intake
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

3. Malnutrition Is Of Two Types
FACTORS
TYPE1
Associated with uremic syndrome
TYPE 2
Associated with MIA syndrome
Serum albumin
Normal/low
Low
Comorbidity
Uncommon
Common
Presence of inflammation No
Yes
Food intake
Decreased
Low/Normal
Resting energy expenditure
Normal
Elevated
Oxidative stress
Increased
Markedly increased
Protein catabolism
Reversed by dialysis and Nutritional support
Stenvinkel P et al, NDT 15;953,2000

4. Recognizing and diagnosing PEW in PD is important
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:
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.

5. increase as GFR declines.
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
Increased hospitalization
Nutritional Status
GOOD HEALTH
NUTRITION

6. When Does Protein-Energy-Wasting Set In?
Dietary protein and energy intake diminish long before end-stage 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)
Creatinine Clearance (ml/min)
Ikizler, JASN 6: , 1995
Prospective observational study of 90 patients

7. When Does Protein-Energy-Wasting Set In?
PEW becomes clinically evident when GFR is < ml/min.

8. 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).

9. 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).
MDRD Study. Association between Serum Albumin and GFR
males, solid lines;
females, dashed lines

10. What Causes Decreased Protein And Energy Intake And Hence Malnutrition In PD Patients?

11. Malnutrition is Multifactorial
UREMIA
LOW NUTRIENT INTAKE
INFLAMMATION
HYPERCATABOLISM

12. Malnutrition Is Multi-Factorial
Hypercatabolic State + Anorexia
Inadequate
Dietary Protein
& Energy Intake
PD procedure per se
Dialysis dose
Underdialysis
Causes Anorexia
Peritoneal transport
Malnutrition
Metabolic acidosis
PD duration
Acute & Chronic Illness
Residual renal
function
Comorbidity
Diabetes
Endocrine PD
Infectious Illness
Increased catabolism
Inflammation
Uremia per se

13. 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?

14. 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.

15. 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.

16. 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  1.93 ( 18%)
+ 2 m
+ 4 m
+ 6 m p
- 12 m
- 6 m
Wt, kg
MAC, cm
nPNA, g/kg/d
DPI, g/kg/d
Oral calories,
cal/kg/d
P. albumin, g/L
SGA
67.4
27.9
0.94
1.06
31.6
35.6
5.7
68.2
27.7
0.85
1.04
31.2
34.3
5.2
66.6
27.2
0.81
0.83
26.7
31.4
4.0
65.1
26.7
30.8
65.3
26.8
31.7
66.4
27.4
0.84
0.92
28.7
32.8
4.4
0.18
0.19
0.23
0.17
0.03
0.05
0.15
Open, prospective, longitudinal intervention: Davies et al K Int 57:1743, 2000

17. 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.

18. 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 g/d of glucose
which is equivalent to kcal/d
Encourage patient to take small but frequent meals.     

19. 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.

20. Serum Bicarbonate level at  22 mmol/L
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

21. 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

22. Serum Bicarbonate level at  22 mmol/L
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

23. By the time CAPD is initiated patient is already malnourished.

24. 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

25. 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 Body composition DEXA As needed

26. 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
Percentage of individuals
low
high
Protein Requirement

27. Loss Of Protein CAPD/Day 5-15 g Peritonitis/24 h 15.1 gm
Protein intake should be increased from g/kg/d
Estimating energy, protein & fluid requirements
for adult clinical conditions June 2012 Qeensland Govt
CAPD/Day
5-15 g
Peritonitis/24 h
15.1 gm

28. Decreased Protein Intake May Lead To Protein-energy Wasting And Poor Survival
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):
In PD patients, Dietary Protein Intake <0.73 g/kg/day is associated with protein-energy wasting and worst outcome.

29. 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)

30. 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 %. Carrero JJ, J Renal Nutr 2013 Vol 23, issue 2, Pages Hakim RM and Lazarus JM. JASN 1995; 6:1319–28 Abdu A et al Afr J Clin Nutr 2011;24(3): Flanigan MJ. Perit Dial Int. 1998;18:

31. Malnutrition was present in 45% of patients commencing CAPD as assessed by SGA.
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

32. 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

33. Reverse Protein Loss Give High Protein Diet to Patients on Peritoneal Dialysis

34. NKF-K/DOQI Guideline 3 & 4
Guidelines 3
S Albumin ≥ 4.0g/dL
Guidelines 4
S Prealbumin ≥30 mg/dL

35. 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:
At least 50% of protein should be of HBV

36. MILK WITHOUT CREAM 6.4/135calories /200ml
PANEER 13 /240/100g
YOGURT 3.1g/60/100g
MILK WITHOUT CREAM 6.4/135calories /200ml
Protein of High Biological Value 4
TOFU
SOY NUGGETS
MILK
SOYA PRODUCTS 43g/100G
1 helping 50g=21g/216

37. 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 : Caglar et al Kidney Intrn

38. Protein Supplements powder or biscuit form Proseventy 70 % protein
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

39. Protein Requirement = 1.3g/kg/d x Wt.
60 kg x 1.3 = 78 g of protein Milk 150 ml = g/protein Dal 1 bowl = 6 g protein Curd = 100g = 3 g Chappati=1.5 g 8 chappaties = 12 g Rice: 50 g raw = g Paneer/Tofu 100g 13 g/21g Egg white = 8g Fish50g/chicken35g = 7.5 g Total 57.5g Supplement 30 g/d = 20g Total 77.5 1 2 3 4 5 6 7

40. 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

41. 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).

42. 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.

43. 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).

44. 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 % to 120% of the DRI
If patient is on hemodialysis, then an additional increment on anticipated losses 0.4g/kg/d and peritoneal losses g/kg/d should be followed.
% or g
/kg/d (2000)

45. 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.

46. 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 ( 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.

47. Energy Intake From Peritoneal Dialysate Absorption
1 week of PD: g 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

48. 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.

49. 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.

50. 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.

51. Icodextrin-based PD Solution
SIDE EFFECT
METABOLIC ACIDOSIS
Skin Rashes
Vesicular Rashes
Conventional Glucose Dialysis Solutions can lead 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 Lower levels of AGEs with the use of icodextrin better preserve peritoneal membrane and prolong the use of PD.

52. High serum K+ Can cause arrhythmia Prescribe Low K foods:
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

53. 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.

54. 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

55. 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.

56. FGF23 
PTH
3 mg/kg/d
20mg/kg/d
60% and 70% of dietary P absorbed by the GI tract
Two third excreted in urine 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
inorganic .

57. 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.

58. 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.

59. Pi level in CKD patients should be <5. 0 mg/dl
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

60. KDOQI: Advise Low Phosphorus Containing Foods
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

61. 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 

62. 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.

63. 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, high-average 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.

64. Relationship between phosphate levels and RRF.
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 phosphate-binders is less.
This may contribute to improved quality of life and reduce treatment costs.

65. 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 Feb; 6(2): 281–289.
Percentage of patients below, within, or above phosphate treatment targets by GFR category

66. .
Percentage of patients below, within, or above phosphate treatment targets by GFR category.
Percentage of patients below, within, or above phosphate treatment targets by GFR category.
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 =
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 E. Lars Penne,*† Neelke C. van der Weerd,*† etal Clin JASN Feb; 6(2): 281–289.

67. 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 in the entire cohort of 224 MHD patients over 5 years (from October 2001 to January 2007). Spline .
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 in the entire cohort of 224 MHD patients over 5 years (from October 2001 to January 2007). Spline
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 Apr; 5(4): 683–692.

68. 1. Avoid inhibiting gastric myoelectric control and motility.
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.

69. 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

70. Restrict Fat: Emphasize On Reduction of Saturated & Trans Fatty Acids Management of Dyslipidemia
Fatty acid intake can be modified easily by substituting canola oil, a blend that includes both omega-3 and monounsaturated fats, for vegetable oils
AHA Recommendations:
Total fat: % of total calories: <10% PUFA
Saturated Fat <7%
Trans Fats <1%
Dietary cholesterol <200 mg daily along with
n-3 polyunsaturated fats.
Prefer monounsaturated fats /oils:
corn, safflower , soyabean , olive , peanut
and canola oils

71. 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 ml if patient is dry
If patient is edematous: 24 hour urine output ml

72. Conclusion: How Do We Handle PD Patients with Signs of Malnutrition/Wasting?
Provide adequate nutrition, adequate dialysis and treat co-morbidities
• Infectious complications
• Silent ischemic heart disease
• Intercurrent clinical events
• Peridontal disease
• Failed kidney transplant
• Volume overload
• Inflammatory diseases 1
Evaluate and treat potential dialysis related causes of wasting
• Exit site infections
• Other infectious complications
• Reduce pre-meal exhanges
• Bioincompatible membranes
• Use biocompatible PD fluids
• Icodextrin based PD fluid
• Amino acid based PD fluid 2
Nutritional supplements Others
• Nutritional intervention
• Physical training
• Pharmacological
intervention 3
Modified after Carrero et al Blood Purif 2008;26:291–299 72

73. Thank
you

74. 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.
Protein of High Biological Value

75. 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.

76. 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.

77. Malnutrition What Causes Malnutrition Nutrient Intake
Nutrient Requirement
Disease
Nutrient Intake
Malnutrition

78. 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.

79. 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

80. 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.

81. 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.

82. 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
( kcal/day from PD)
This causes decreased intake
of protein and fat.
This intake should be included in total
energy intake prescribed by dietician.

83. 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.

84. The Renilon Multicentre Trial Denis Fouque Fouque D, McKenzie J, de Mutsert R, etal Nephrol Dial Transplant Sep;23(9):
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.

85. 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

86. 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

87. 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.)

88. 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 S-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 < ml/min.
20-70% patients on Maintenance Dialysis show signs of PEW.

89. Sources of Selenium
Selenium

90. P Intake from Plant Foods: The Role of Phytate
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.