Presentation on theme: "Dietary Approach To C Kidney Disease"— Presentation transcript:
1 Dietary Approach To C Kidney Disease Dr Anita SaxenaMD, PhD, PhD (Cambridge)Associate ProfessorDepartment of NephrologySGPGIMS, 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
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 earlierpartially due to inadequate nutritional management in predialysis phase and becomes clinically evident whenGFR is < ml/min.20-70% patients on Maintenance Dialysis show signs of PEW.
9 Malnutrition is Multifactorial Resistance to anabolic AnorexiaLoss of tasteUnpalatable dietsLoss of Nutrients& Water solubleVitamin in DialysateUremic toxicityDietary protein& energy intakeInadequateDialysis doseMalnutritionAnemialoss of blood due toGI bleed, frequentblood samplingInflammationInfectionSuperimposedillnessDecliningResidual RenalFunctionPresence ofComorbiditylevel of counterregulatory hormonesGlucagon, PTHHormonal disordersResistance to anabolichormonesMetabolic 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 tissuesreduced muscle mass 5% in 3 mReduction in serum protein Serum albumin level <3.8 g/dL Serum pre-albumin level <30 mg/dL Serum cholesterol level <100 mg/dLLow 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
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, 295–3101. 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 Patients255075100%307 HD patsCurtin et al. 2002238 CKD 5 predialysis patsCurtis et al. 2002106 PD patsMerkus et al. 199973 HD patsVirga et al. 199866 CKD 5 predialysis patsMurtagh et al. 20071846 HD pats (HEMO)Burrowes et al. 2005223 HD patsCarrero et al. 2007331 HD patsKalantar-Zadeh et al. 2004120 HD pats14406 HD pats (DOPPS)Lopes et al. 200734 HD patsMuscaritoli 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, 295–3102. Patients with CRFImpaired gastric emptyingImpaired intestinal motilityDisturbances of digestive and absorptivefunctions, andAlterations 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 infections9. Late initiation &Inadequate dialysis.
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 chartingFluid intake:Water taken with meals, medications or otherwiseTea, CoffeeMilkCurdAnd any other liquidFluid Prescription:Previous 24 hour urine output ml if patient is dryIf 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 m2Protein: 0.8 g/kg/dNon Diabetics Energy: kcal/kg/d35 kcal/kg/d < 60 years30 kcal/kg/d > 60 yearsDiabetics : <30 kcal/kg/dWater soluble Vitamins and minerals as per RDAPrinciple Is Restrict ProteinDo Not Say No To Protein
21 Prescribe Low Potassium Diet Potassium Intake in CKD 1 mEQ/kg/day Hyperkalemia (high serum K+)Can cause arrhythmiaPrescribe Low K foods:Foods containing <100 mg K /100gApple, 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.XXXXXXX
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 m2NutrientRequirement (conservative management)Low protein0.6g/kg/d Guideline 24Those unable to accept 0.75 g/kg/dEnergy30-35 kcal/kg/d(35 < 60 years; 30 > 60 years; Guideline 25Phosphorusmg to prevent hyperphosphatemia.Non-calcium based phosphate binder with meals to prevent soft tissue calcification.Calciummg/dSodium<2.4 g/dPotassium1 mEq/kgCholesterol<200 mg/d. Avoid egg yolkWater soluble Vitamins and minerals/ RDAAnemiaTreat 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 29.5g1234
26 Protein intake in Children K/DOQI Guideline 6 2009 CKD stage 1-3 dietary proteinintake 100% to 140% of the DRI for ideal body weight.CKD stages 4 to % to 120% of the DRIEnergy 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 symptomsPreserve residual renal functionDelay onset of dialysisPreserve nutritional status.Improve metabolic complications due to renalinsufficiencyEssential 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 edemaEnergy: 35 kcal/kg b.w./dProtein 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/dSoy protein is beneficial for kidneysAvoid 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 Normoglycemia2 Manage dyslipidemia3. Manage Weight4. 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 formanagement of hyperglycemia, hypertension, anddyslipidemia may be extrapolated from the recommendationsfor women with earlier stages ofCKD.Discontinue Treatment ofDKD with RAS inhibitorsHbA1C as close to normal aspossible (<1% above upper limit of normal)Use Insulin to control hyperglycemia if necessaryLiberalize dietary proteing/kg preconceptionWeight/dTreat High blood pressure > / mm HgTarget 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 ofwhich should be water)Continuous intake rather thanacute bursts of drinking willensure required urinary SG of <1.01.Take a glass of water before going to bed to maintain specific gravity < 1.01.Avoid hard tap waterIn adults, urine volume should be>2 L/dayLow salt dietLow protein dietPrefer 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 physicalactivity should be encouraged.XXCranberryJuiceXX
35 Gout (Hyper-Uricemia ) Avoid Foods Containing High Uric Acid Low protein dietPoultry and organ meatsFish Herring, Fish Roe, Salmon, SardineKidney, Liver, Meat Soup ExtractsLegumes (Dry PeasBeans, Soyabean)MushroomsAsparagus.
37 Autosomal Dominant Polycystic Kidney Disease (ADPKD) Low Protein 0.8g/kg/dAs creatinine increases reduce it to 0.6 g/kg/dLow SALT dietRestrict Fluid intakeGood control of Blood pressureLong Term Coverage With Antibiotics if infectedSoy 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 with1. Lower serum albumin and2. Worsenutritional status as assessed bySGA 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/dEstimating energy, protein & fluid requirementsfor adult clinical conditions June 2012 Qeensland GovtKrediet RT, Zuyderhoudt FM, Boeschoten EW, Arisz L: Peritonealpermeability to proteins in diabetic and non-diabetic continuous ambulatory peritoneal dialysis patients. Nephron42: 133–140, Imholz AL, KoomenHD/session1-3 g/sessionCAPD/Day5-15 g/24h4 g of which is albuminPeritonitis/24 h15.1 gmThe loss of serum proteins in stable continuous ambulatoryperitoneal dialysis (CAPD) patients averages5 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, 16S Albumin ≥ 4.0g/dL Guidelines 3S Prealbumin ≥30 mg/dL Guidelines 4Prescribe 1.2g/kgbw/d protein to clinically stable patients on HD Guideline 15Prescribe 1.3g/kgbw/d protein to patients on PD necessary to ensure neutral or positive nitrogen balance Guideline 16Energy Kcal/kg/d depending upon age <60 or >60 yAt least 50% of protein should be of HBV
44 Increasing Protein Intake in Dialysis: The Phosphate Paradigm Protein has linear relation with phosphate1 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 phosphateThis results in a net balance of 1800 mg every other day in HD pateints, an amount that cannot be eliminated through dialysisPhosphate 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 proteinintake (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, 2008Serum 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 caloriesSignificant 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 albuminIn 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 every2-8 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
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 hyperhomocystenemiaSerum 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 mmHGLimit sodium intake.Prescribe diuretics to treat fluid overloadAdvise 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 DiabetesTarget 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 UremicSymptomsIf patient is on dialysis individualize dialysis prescription.Give adequatedialysisMaintain Kt/V urea of1.2 for HD1.7/week CAPDADEMEX Trial (2001)
57 Nutritional Effects Of Increasing Delivered Dialysis Dose In Malnourished PD Patients Patients had evidence of declining nutrition over 12 monthsWith 25% increase in delivered PD dose for 6 monthsTotal Kt/V 1.93 ( 18%)+ 2 m+ 4 m+ 6 mp- 12 m- 6 mWt, kgMAC, cmnPNA, g/kg/dDPI, g/kg/dOral calories,cal/kg/dP. albumin, g/LSGA67.427.90.941.0631.635.65.722.214.171.1241.04126.96.36.1996.627.20.810.8326.731.44.065.126.730.865.326.831.766.427.40.840.9228.7188.8.131.52.190.230.170.030.050.15Open, 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 upsetsDiscontinue calcium supplements if bowel movements are irregularReduce 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 dialysateInduces abdominal discomfortSuppression 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/LEvaluate MonthlyNKF/KOQIGuideline 13/14Replace Sevelamer HCL With SevelamerCarbonate 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 2008Maintain Glucose levels below 180 mg/dLAverage 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 parenteralnutrition.
63 6. Prevent Infections especially in PD To Maintain Good Nutritional Status Infections lead to ed appetiteImpart Intense training to patient & attendant for maintaining hygiene.Exit site infectionPeritonitis
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 and62.1 ±12.4 vs 54.9 ±15.3g.d).( Wang etal JASN 2001 Nov 12 (11) )Every 1ml/min/1.73m2 increase inGFR associated with fold increasein 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 ToxinsWorsen renal functionAvoid Nonsteroidalanti-inflammatory drugs, aminoglycoside antibiotics, andoral phosphate solutions.Aminoglycoside antibioticsused for treatment of peritonitisand catheter infections shouldbe used with caution (ISPD).Prevent peritonitis, because peritonitis is also associatedwith a decline in RRF.
66 8. Anemia also causes generalized weakness & loss of appetite Correct Iron ProfileSupplement Folic AcidCorrect Vitamin B12 deficiencyTreat chronic infections and secondary hyperparathyrpoidismPrescribe optimal dose of ESA/EPOUse 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 PEWGalland 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