Presentation on theme: "Importance of Diet In Peritoneal Dialysis."— Presentation transcript:
1Importance of Diet In Peritoneal Dialysis. Dr Anita SaxenaMD (AM), PhD, PhD (Cambridge)Department Of NephrologySanjay Gandhi Post Graduate Institute Of Medical SciencesLucknow
2Malnutrition What Is Malnutrition Imbalance Nutrient Intake In uremic patients anorexia and loss of taste cause imbalance between intake and nutritional requirement.What Is MalnutritionImbalanceDepletion of Body StoresNutrient RequirementDiseaseNutrient Intake20-70% patients on Maintenance Dialysis show signs of PEW.Malnutrition
3Malnutrition Is Of Two Types FACTORSTYPE1Associated with uremic syndromeTYPE 2Associated with MIA syndromeSerum albuminNormal/lowLowComorbidityUncommonCommonPresence of inflammationNoYesFood intakeDecreasedLow/NormalResting energy expenditureNormalElevatedOxidative stressIncreasedMarkedly increasedProtein catabolismReversed by dialysis and Nutritional supportStenvinkel P et al, NDT 15;953,2000
4Recognizing 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 importantPrevalence of protein energy wasting (PEW) in patients onPD patients is 40-66% andHD therapy is 18–75% andcorrelates 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;65:1544–57Mehrotra R, Kopple JD. Annu Rev Nutr 2001; 21:343–79.Kalantar-Zadeh K, AJKD 2003;42:864–81.
5increase as GFR declines. Signs of PEWincrease as GFR declines.CANUSA Study has shown that evidence of poor nutritional status in PD patients is associated withAdverse outcomesPoor patient andTechnique survivalIncreased hospitalizationNutritional StatusGOOD HEALTHNUTRITION
6When 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 OccursDPI (g/kg/day)Creatinine Clearance (ml/min)Ikizler, JASN 6: , 1995Prospective observational study of 90 patients
7When Does Protein-Energy-Wasting Set In? PEW becomes clinically evident when GFR is < ml/min.
8The 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 GFRbased on 24-hour urine collections and diet diaries.(males, solid lines;females, dashed lines).
9MDRD 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 GFRmales, solid lines;females, dashed lines
10What Causes Decreased Protein And Energy Intake And Hence Malnutrition In PD Patients?
11Malnutrition is Multifactorial UREMIALOW NUTRIENT INTAKEINFLAMMATIONHYPERCATABOLISM
12Malnutrition Is Multi-Factorial Hypercatabolic State + AnorexiaInadequateDietary Protein& Energy IntakePD procedure per seDialysis doseUnderdialysisCauses AnorexiaPeritoneal transportMalnutritionMetabolic acidosisPD durationAcute & Chronic IllnessResidual renalfunctionComorbidityDiabetesEndocrinePDInfectious IllnessIncreased catabolismInflammationUremia per se
13Nutritional Management of PD Patient Is challengingNot only includes what a patient should be eating butwhat is more important isthe reason why patientis not eating?
14Reason Why Patients Don’t Eat Anorexia/Loss of Appetite Guideline 6Kidney failure causesRetention of uremic toxins/anorexogenicsubstances due to uremia.Gastric problemsOral manifestations (lack of taste , dryness of mouth)Poor dental hygieneImpaired olfactory functionAnorexia is evidenced by decreased dietary protein intake (DPI) and decreased dietary energy intake (DEI), which are hallmarks of kidney failure.
152. Dialysis DoseInadequate Dialysis Dose Causes Uremic Symptoms andpatient is unable to eatGive adequate dialysisMaintain Kt/V urea of1.7/week CAPDADEMEX Trial (2001)If patient is on dialysis individualize dialysis prescription.
16Nutritional 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/LSGA67.427.90.941.0631.635.65.7220.127.116.111.0418.104.22.1686.627.20.810.8326.731.44.065.126.730.865.326.831.766.427.40.840.9228.722.214.171.124.190.230.170.030.050.15Open, prospective, longitudinal intervention: Davies et al K Int 57:1743, 2000
173. 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 upsetsDiscontinue calcium supplements if bowel movements are irregularReduce salt intake for better control of blood pressure to minimize requirement of antihypertensive medication.
184. Glucose Absorption From Dialysate Anorexia can Causes Loss Of Appetite Peritoneal DialysateIn patients on Peritoneal Dialysis Glucose Absorption from dialysate may cause Suppression of Appetite and induce abdominal discomfortPatient absorbs g/d of glucosewhich is equivalent to kcal/dEncourage patient to take small but frequent meals.
19Comorbid 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.
20Serum Bicarbonate level at 22 mmol/L Metabolic Acidosis Causes Protein Catabolism Decrease Protein Catabolism Increase Albumin SynthesisSerum Bicarbonate level at 22 mmol/LEvaluate MonthlyNKF/KOQIGuideline 13/14Supplement1g TID
21Diabetic Gastroparesis causes decreased food intake Ajumobi AB , Griffin RA ,Hospital Physician March 2008Characterized by Delayed gastric emptying & associated upper gastrointestinal (GI) symptomsDGP 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 hypoglycemiaElectrolyte abnormalities (eg, hypokalemia, hypomagnesemia) have roles in the pathogenesis of DGP.Dysfunction of NO neurons in the myenteric plexus may be responsible for DGP
22Serum Bicarbonate level at 22 mmol/L Metabolic Acidosis Causes malnutrition by Increasing Protein Catabolism. Bicarb Therapy Decrease Protein Catabolism Increase Albumin SynthesisSerum Bicarbonate level at 22 mmol/LEvaluate MonthlyNKF/KOQIGuideline 13/14
23By the time CAPD is initiated patient is already malnourished.
24Aims 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 wastingPrevent protein energy malnutritionPrevent HyperglycemiaDyslipidemiaMaintain adequate nutritional status.Build up body stores for good transplant outcome (if planned)Improve quality of life
25Monitor 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
26Why is the Protein Target Higher for PD Patients? NormalsPDProtein and amino acid losses and catabolic factors shift the curve tothe right for PD patientsPercentage of individualslowhighProtein Requirement
27Loss Of Protein CAPD/Day 5-15 g Peritonitis/24 h 15.1 gm Protein intake should be increased from g/kg/dEstimating energy, protein & fluid requirementsfor adult clinical conditions June 2012 Qeensland GovtCAPD/Day5-15 gPeritonitis/24 h15.1 gm
28Decreased 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.
29Predictors Of Survival In Anuric Peritoneal Dialysis Patients Jansen MM Kidney International (2005) 68, 1199–1205Daily 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 & mortalityHigher AgeNutritional status : CNI scores(SGA, 6 anthrop measure: SKF, body weight, BMI) and S.Albumin)nPCRDaily protein lossDaily fluid output (UF + urine) and Cholesterol levelDiabetes (comorbidity)
30Presence 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:
31Malnutrition 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. 19–26Kaplan–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 patientsInitial FFEF body mass was a determinant of SGA score and predicted death
32CANUSA Study NDT1998; 13 (Suppl 6):158–63. Relative risk of death increases with1. Lower serum albumin and2. Worsenutritional status as assessed bySGA and %LBM
33Reverse Protein Loss Give High Protein Diet to Patients on Peritoneal Dialysis
35Dietary 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 16Patients 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
36MILK WITHOUT CREAM 6.4/135calories /200ml PANEER 13 /240/100gYOGURT 3.1g/60/100gMILK WITHOUT CREAM 6.4/135calories /200mlProtein of High Biological Value4TOFUSOY NUGGETSMILKSOYA PRODUCTS 43g/100G1 helping 50g=21g/216
37To Increase Protein and Energy Intake Oral Supplements Are Essential For Patients On Maintenance DialysisFor sick patients, use energy and protein dense ONS.ONS can provide approx 10 kcal/kg/dPhillis ME Clin Nephro : Caglar et al Kidney Intrn
38Protein Supplements powder or biscuit form Proseventy 70 % protein Patients on Maintenance Dialysis Require Extra Protein Supplement Insufficient Protein IntakeProtein Supplements powder or biscuit formProseventy 70 % proteinRenourish 60% Protein (10g/16g sachet)NeproHPPentasure 35%Lamino Bix 1.6 g protein/discThreptin Biscuits 1.5g/discAlpha Keto Analogues (affordability)Peptide based supplements PEPTAMEN
39Protein 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 77.51234567
40Protein 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 periodChange in nitrogen balance during months 1 and 3 of supplementation.Effectiveness of Protein S supplementation …CAPDRA Elias, A etal
41Foods PermittedFruits 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 fruitsVegetable 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).
42Foods Permitted Use refined flour (sieve flour/atta before cooking) Use tamarind pulp instead of tomatoes to enhance tasteUse, garlic, heeng, methi dana, and turmeric in cooking.Use coriander powder (dhania), cumin seeds (zeera) and red chlli powder in small quantity.
43High Protein Food For Dialysis Patients Curd with 3 tsp of Proseventy powderHigh 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).
44Protein intake in Children K/DOQI Guideline 6 2009 CKD stage 3 dietary proteinintake 100% to 140% of the DRI for ideal body weight.CKD stages 4 to % to 120% of the DRIIf 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)
45Newer 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, 2002Over 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.
46Guideline 17 – Daily Energy Intake (DEI) Major source: Carbohydrates and FatRecommended: 35 kcal/kg bw for those < 60 y of age30-35 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):211-8PD 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.
47Energy Intake From Peritoneal Dialysate Absorption 1 week of PD: g of glucose absorbed1.5% (2L) ~ 76 kcal CAPD 4 x 2L = 302 kcal3 x 2L 1.5% + 1 x 2L 2.5% = 410 kcal2.5% (2L) ~ 182 kcal4.25% (2L)~ 308 kcal 3 x 2L 1.5% +1 x 4.25% = 536 kcal
48Energy 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/dPrescribe “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.
49Indications 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.
50In 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.
51Icodextrin-based PD Solution SIDE EFFECTMETABOLIC ACIDOSISSkin RashesVesicular RashesConventional 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.
52High 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 DietHigh serum K+ Can cause arrhythmiaPrescribe Low K foods:Foods containing <100 mg K /100gApple, banana, guava, pear, orange, papaya
53Reduce 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.
54Low 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
55PhosphorusHyperphosphatemia 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 hyperphosphatemiaHyperphosphatemia 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.
56FGF23 PTH3 mg/kg/d20mg/kg/d60% and 70% of dietary P absorbed by the GI tractTwo third excreted in urinemgPhosphorus 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% isinorganic .
57KDOQI 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.
581. Calculate Phosphate Content Of Diet 1 g protein brings 13–15 mg phosphateTotal protein x 14 = phosphate content60 kg 0.6g/kg/d= 36 g proteinTotal phosphorus= 36x14= 504 mgIf patient is on dietary supplement add phosphorus content of supplement to dietary phosphorus intake.
59Pi 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
60KDOQI: Advise Low Phosphorus Containing Foods KDOQI: Advise Low Phosphorus Containing Foods. Recommended Daily Allowance (RDA) For Phosphorus 800 mg/dayFoods High in protein and dairy products contain the most P High (> 200 mg P per 100 g)Milk productsMeatsFishDry fruitsChocolateMedium (> 100 but < 200 mg P per 100 g)CerealsLegumesMinimum in vegetables and fruitsLow (< 100 g P per 100 g)VegetablesFruits
61Avoid Foods With Phosphorus-based Additives. SAY NO TOCola beveragesEnhanced or restructured meatsFrozen mealsCerealsSnack barsProcessed or spreadable cheesesInstant productsRefrigerated bakery products
624. Prescribe Phosphate Binders With Meals Purpose of therapy with phosphate binders is to limitintestinal absorption of dietary phosphorous and tomaintain phosphates in normal range.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 et al.,82). nPNA, appearance.
63Increasing 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 patients.
64Relationship 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.
65Role 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.
67Protein 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). SplineCubic 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.
681. Avoid inhibiting gastric myoelectric control and motility. Management of DGPMaintain 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 hypoglycemia1. Avoid inhibiting gastric myoelectric control and motility.2. Hyperglycemia inhibits the action of prokinetic drugs such as erythromycin.
69Management of DGPCarbohydrates and substances with high osmolarity increase gastric emptying, therefore avoid meals have a high-fiber contentMedium-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 OverlodParenteral nutrition may be needed to supply dietary requirements temporarily in severe cases
70Restrict 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 oilsAHA Recommendations:Total fat: % of total calories: <10% PUFASaturated Fat <7%Trans Fats <1%Dietary cholesterol <200 mg daily along withn-3 polyunsaturated fats.Prefer monounsaturated fats /oils:corn, safflower , soyabean , olive , peanutand canola oils
71Fluid Management Input and Output Charting Ultrafiltration + Urine Output+ EdemaOral Intake + IV infusions & Urine Output chartingFluid intake:Water taken with meals, medications or otherwiseTea, CoffeeMilkCurdAnd any other liquidFluid Prescription:UF+ Previous 24 hour urine output ml if patient is dryIf patient is edematous: 24 hour urine output ml
72Conclusion: 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 diseases1Evaluate 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 fluid2Nutritional supplements Others• Nutritional intervention• Physical training• Pharmacologicalintervention3Modified after Carrero et al Blood Purif 2008;26:291–29972
741. 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
75Why 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.
76Why 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.
77Malnutrition What Causes Malnutrition Nutrient Intake Nutrient RequirementDiseaseNutrient IntakeMalnutrition
78Protein 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 importantalthough 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.
79Conventional Glucose Dialysis Solutions PD solutions may also affect RRF Many current PD solutions are bioincompatible, with low pHThe 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 RRFThese 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
80Icodextrin-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.
81Newer 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, 2002Over 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.
82Guideline 17 – Recommended Daily Energy Intake Major source: Carbohydrates and Fat35 kcal/kg/bw of energy for those < 60 y of age30-35 kcal/kg/d for those > 60 years.Patients get 19% of total energyintake dialysate glucose absorption. ()Fernstrom A, etal. J Inter Medicine1996 Oct;240(4):211-8( kcal/day from PD)This causes decreased intakeof protein and fat.This intake should be included in totalenergy intake prescribed by dietician.
83Control Serum Phosphorus In Diet Educate patient on phosphorus targets <4.5 mg/dlProvide 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.
84The 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 bindersSerum 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.
85Treat Diabetic Gastroparesis Ajumobi AB , Griffin RA ,Hospital Physician March 2008 Characterized by Delayed gastric emptying & associated upper gastrointestinal (GI) symptomsSymptoms 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 hypoglycemiaElectrolyte abnormalities (eg, hypokalemia, hypomagnesemia) have roles inthe pathogenesis of DGP.Dysfunction of NO neurons in the myenteric plexus may be responsible for DGP
86Management of DGPMaintain 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 controland motility.2. Hyperglycemia inhibits the action ofprokinetic drugs such as erythromycinCarbohydrates and substances with high osmolarity increase gastric emptying, therefore avoid meals have a high-fiber contentMedium-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 OverlodParenteral nutrition may be needed to supply dietary requirements temporarily in severe cases
87Use prokinetic drugs, antiemetic agents like metoclopramide, domperidone, erythromycin,and cisapride , pyloric injection of botulinum toxin (potent inhibitor of neuromuscular transmission) to control symptoms of DGPDomperidone: doses between 10 and 30 mg taken orally a half hour before meals and at bedtime, domperidone has been shown to reduce GI symptomsOral erythromycin between 50 and 100 mg taken 3 times daily in combination with a low-bulk dietCisapride is a potent prokinetic drug that acceleratesgastric emptying of solids and improves dyspeptic (can cause fatal cardiac arrhythmias.)
88When 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.
90P Intake from Plant Foods: The Role of Phytate 5. Emphasize Merits Of Plant-based Proteins Rather Than Those From Meat Or Dairy SourcesP Intake from Plant Foods: The Role of PhytateMany 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.