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Dietary Approach To C Kidney Disease

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1 Dietary Approach To C Kidney Disease
Dr Anita Saxena MD, PhD, PhD (Cambridge) Associate Professor Department of Nephrology SGPGIMS, Lucknow. India

2 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.

3 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.

4 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.

5 Why Modify Diets? Cont.. In kidney failure nutritional therapy allows good control of several consequences of the disease. Nausea /Vomiting Anorexia Initiation of dialysis

6 When Does Protein-Energy-Wasting Set In?

7 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

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

9 Malnutrition is Multifactorial Resistance to anabolic
Anorexia Loss of taste Unpalatable diets Loss of Nutrients & Water soluble Vitamin in Dialysate Uremic toxicity Dietary protein & energy intake Inadequate Dialysis dose Malnutrition Anemia loss of blood due to GI bleed, frequent blood sampling Inflammation Infection Superimposed illness Declining Residual Renal Function Presence of Comorbidity level of counter regulatory hormones Glucagon, PTH Hormonal disorders Resistance to anabolic hormones Metabolic Acidosis

10 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

11 What Problems Are Unique To Patients with CKD?

12 Does CKD Have An Influence On Gastrointestinal Tract
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 25 50 75 100% 307 HD pats Curtin et al. 2002 238 CKD 5 predialysis pats Curtis et al. 2002 106 PD pats Merkus et al. 1999 73 HD pats Virga et al. 1998 66 CKD 5 predialysis pats Murtagh et al. 2007 1846 HD pats (HEMO) Burrowes et al. 2005 223 HD pats Carrero et al. 2007 331 HD pats Kalantar-Zadeh et al. 2004 120 HD pats 14406 HD pats (DOPPS) Lopes et al. 2007 34 HD pats Muscaritoli et al. 2007

13 Does CRF Have An Influence On Gastrointestinal Tract
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 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.

14 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.

15 Problems Are Unique To Patients with CKD?
5. Hyperglycemia 6. Hyperlipidemia 7. Cardiovascular involvement

16 Problems Are Unique To Patients with CKD?
8. High incidence of infections 9. Late initiation & Inadequate dialysis.

17 Nutritional Requirements of CKD Patients

18 CKD Stages 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.)

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

20 Principle Is Restrict Protein
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: 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

21 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

22 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. X X X X X X X

23 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

24 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 mg to prevent hyperphosphatemia. Non-calcium based phosphate binder with meals to prevent soft tissue calcification. Calcium 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

25 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 Milk 150 ml = 4.5 g/protein Dal 1 bowl = 6 g protein Chappati=2 g 8 chappaties = 16 g Rice: 50 g raw = 3 g Total 29.5g 1 2 3 4

26 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 % 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.

27 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

28 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 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

29 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). 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. 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

30 Diabetic Nephropathy Dietary Recommendations (Up-To-Date, 2006)
1. Advise small meals at frequent intervals that consist of low-fat and complex carbohydrates meals and 2 snacks 3. Avoid meals with high-fiber content. BF/Dinner

31 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 recommendations 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 g/kg preconception Weight/d Treat High blood pressure > / mm Hg Target BP <130/80 mm Hg because of CKD. Avoid hypotension


33 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.

34 RENAL STONE DISEASE Composition Calcium, Oxalate, Phosphate, Uric acid
Patients can take a total of mg of calcium/day from natural foods. Milk intake should not exceed 2 glasses/day. 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 activity should be encouraged. X X CranberryJuice X X

35 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.

36 Autosomal Dominant Polycystic Kidney Disease (ADPKD)

37 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: , 1999) Avoid foods with higher amounts of oxalic acid. (spinach, rhubarb, beets, eggplants, cocoa, and chocolate) Omega-3-fatty acids (Flax seeds/oil ): anti-hypertensive, lipid-lowering and anti-inflammatory effects. SOY

38 Management Of Patients On Maintenance Dialysis Hemodialysis CAPD

39 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 Hakim RM and Lazarus JM. JASN 1995; 6:1319– Abdu A et al Afr J Clin Nutr 2011;24(3): Flanigan MJ. Perit Dial Int. 1998;18:

40 Chung SH Peritoneal Dialysis International, Vol. 20, pp. 19–26
 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. 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)

41 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

42 Loss Of Protein CAPD/Day HD/session 5-15 g/24h 1-3 g/session
Protein intake should be increased to > g/kg/d Estimating energy, protein & fluid requirements for adult clinical conditions June 2012 Qeensland Govt Krediet RT, Zuyderhoudt FM, Boeschoten EW, Arisz L: Peritoneal permeability to proteins in diabetic and non-diabetic continuous ambulatory peritoneal dialysis patients. Nephron 42: 133–140, Imholz AL, Koomen HD/session 1-3 g/session CAPD/Day 5-15 g/24h 4 g of which is albumin Peritonitis/24 h 15.1 gm The loss of serum proteins in stable continuous ambulatory peritoneal dialysis (CAPD) patients averages 5 g per 24 hours, 4 g of which is albumin

43 At least 50% of protein should be of HBV
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 Energy Kcal/kg/d depending upon age <60 or >60 y At least 50% of protein should be of HBV

44 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.

45 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 a patient.

46 Patients on Maintenance Dialysis Require Extra Protein Supplement Insufficient Protein Intake
Renal Specific Protein Supplements in powder or biscuit form. Peptide based supplements for sick patients. The Renilon Multicentre Trial: Use of a renal-specific 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 Sep;23(9): )

47 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

48 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 well-being. Bolus feeding: Start ml feed, then increase to ml per feeding. Continuous feeding: Start with 20-50ml/hr, then increase 20ml every 2-8 hrs until requirement is met. Guideline 19 – Indications for Nutrition Support in dialysis dependent patients

49 Practical Rules For Preventing Protein En Energy Wasting/ Malnutrition

50 1. Monitor Nutritional Status
Identify Nutritional deficiencies before they become clinically evident. (K/DOQI,AJKD.2000;35:S1-140. Enia G, etal. NDT ;8:

51 Monitor Nutritional Status (Predialysis. and Dialysis Depenedent
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 Body composition DEXA As needed

52 Prevent Monitor Treat Complications

53 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).

54 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.

55 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)

56 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)

57 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

58 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.

59 Anorexia cont.. Induces abdominal discomfort Suppression of Appetite
In patients on Peritoneal Dialysis Glucose Absorption from dialysate Induces abdominal discomfort Suppression of Appetite (patient absorbs g/d kcal/d ) Encourage patient to take small but frequent meals. Peritoneal Dialysate

60 Serum Bicarbonate level at  22 mmol/L
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

61 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.

62 Maintain Glucose levels below 180 mg/dL
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.

63 6. Prevent Infections especially in PD To Maintain Good Nutritional Status Infections lead to ed appetite Impart Intense training to patient & attendant for maintaining hygiene. Exit site infection Peritonitis

64 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) ) Every 1ml/min/1.73m2 increase in GFR associated with fold increase in DPI and fold increase in DCI. (Cross sectional study on 242 CAPD patients Caravaca etal 1999, Per Dial Int. Vol )

65 Avoid Contrast and Other Toxins Worsen renal function
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.

66 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.

67 9. Reverse Protein Loss Give High Protein Diet to Patients on Dialysis

68 Daily Hemodialysis Increases Protein and Energy Intake
: Rule 10. Practical Rules For Preventing PEW Galland et al. Kidney Int 2001

69 TAKE HOME MESSAGE Prevent Malnutrition From Setting In

70 2. Monitor closely nutritional status and nutrient intake.
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. Protein of High Biological Value

71 Thank you

72 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

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