Nutrition in Peritoneal Dialysis

NUTRITION IN PERITONEAL DIALYSIS (PD)TEENA GUPTA

Nutritionist

FUNCTIONS OF THE KIDNEY

Regulation of red blood cell production

Regulation of blood pressure

Elimination of metabolic toxins and excess water through urine

Regulation of the blood’s acid base

balance

Regulation of mineral levels

END STAGE RENAL DISEASE (ESRD)

Patients with ESRD display a variety of metabolic and nutritional abnormalities and a large proportion of patients demonstrate signs of protein- energy malnutrition (PEM).

Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R,

eds. 3rd Edn. NY: Springer, 2009: 611-647.

PEM and inflammation are

highly prevalent in PD and may contribute to the high mortality in

these patients.

Avram MM, Fein PA, Rafiq MA, Schloth T, Chattopadhyay J, Mittman N. Malnutrition and inflammation as predictors of mortality in peritoneal dialysis patients. Kidney International 2006; 70:S4-S7

DIALYSIS – TREATMENT OPTION IN ESRD

MALNUTRITION IS THE RESULT OF AN

IMBALANCE

BETWEEN NUTRIENT INTAKE

AND

NUTRIENT REQUIREMENT

*Kopple, NKF Press release 5/1/99

MALNUTRITION

Supply Demand

NUTRITION

INTAKE LOSSESBody Stores

MANIFESTATION OF MALNUTRITION IN PD PATIENTS

Low muscle massHypo – proteinaemia

Energy malnutrition

Decrease in body weightLow fat massLow carbohydrate stores

Combined Protein & Energy Malnutrition

Protein malnutrition

↓caloriesStarved appearance-↓weight-↓triceps skinfold-↓mid arm circumferenceSerum albumin may be lowered

↓protein +stressWell nourished appearance- Oedema- Loose hair↓serum albumin

Butterworth CE, Weinsier RL. Malnutrition in hospital patients: assessment and treatment. In: Goodhart RS, Shils ME, eds. Modern nutrition in health and disease. 2nd Ed. Philadelphia:Lea &

Febiger, 1980 :160-7

MANIFESTATION OF MALNUTRITION IN PD PATIENTS

PEM IN PD PATIENTS

Inflammation

Malnutritio

n

Cardiovascular disease

Resting Hypermetabolism

Loss of residual renal function

Increased mortality and cardiovascular death

Wang AYM. The heart of peritoneal dialysis. Perit Dial Int 2007; 27(Suppl_2): 228-232

PREVALENCE OF MALNUTRITION

Severe malnutrition ranges from 2-9% and mild – to – moderate malnutrition ranges from 33-45% in PD patients¹.

PD patients absorb a large amount of calories from the dialysate and may look “ over- nourished” in body weight but actually have low serum albumin and protein malnutrition².

¹Chung SH, Na MH, Lee SH, Park SJ, Chu WS, Lee HB. Nutritional status of Korean peritoneal dialysis patients. Perit Dial Int 1999; 19(Suppl 2):S517-22²National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure. New York, NY: National

Kidney Foundation; 2001.

.

CAUSES OF MALNUTRITION IN PD PATIENTS

MULTIFACTORIAL IN NATURE

Inadequate food intake

Dialysate losses of proteins, amino acids

Loss of blood

Endocrine disorders of uremia

Chronic Inflammation

Catabolic response to Co morbidity

Accumulation of uremic toxins

KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

MIA Syndrome

ASSESSMENT OF THE NUTRITIONAL STATUS OF PD PATIENTS IS IMPORTANT

EARLY ASSESSMENT IS IMPORTANT

To prevent, diagnose and treat uremic malnutrition because

malnutrition itself may lead to anorexia and vice versa

Reversibility may take years

Recovery is slow and often incomplete By early identification, use of optimal diet & dialysis will lead to an

improvement in nutritional status.

For evaluation of dietary requirementDevelopment of suitable nutritional strategy to prevent malnutrition.

THERE IS NO SINGLE MAGIC NUTRITIONAL INDEX

Each has limitations.

Combination of valid, complementary measures.

Even if patients have good nutritional status, they

should be monitored - every 6 months if <50 yrs

- every 3 months if > 50 yrs.

Perez VO, Heranandez EB, Bustillo GG, Penie JB, Porben SS, Borras AE, Gonzalez CM, Martinez AA. Nutritional status in chronic renal failure patients assisted at the hemodialysis program of the Hermanos Ameijeiras

Hospital. Nutr Hosp 2007; 22:677-94.

ASSESSMENT OF NUTRITIONAL STATUS

1. Measurements to be performed routinely in all patients

Predialysis or stabilized serum albumin

% of usual post dialysis or post drain weight

% of standard body weight

Subjective Global Assessment (SGA)

24-hr dietary recall/ Diet diary

nPNAKDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

ASSESSMENT OF NUTRITIONAL STATUS

2. Measures to confirm the data obtained from Category 1

Predialysis or stabilized serum prealbumin

Skinfold thickness Mid-arm muscle area,

circumference, or diameter

Dual energy x-ray absorptiometry

ASSESSMENT OF NUTRITIONAL STATUS

3. Clinically useful measures

Predialysis or stabilized serum

CreatinineUrea nitrogenCholesterol

Creatinine index

ANTHROPOMETRIC MEASUREMENTS

Skin Fold Thickness - Body fat stores

Mid Arm circumference - Muscle mass

Low % IBW and BMI are of concern

At present, anthropometry is the only method that can be readily performed in most units.

•Weight (kg)

•Body mass Index – BMI

•Mid Upper Arm Circumference - MUAC

•Height (cms)

•Ideal Body Weight – IBW

•Skin Fold Thickness – SFT

Skin fold thickness is measured by lightly pinching the skin and subcutaneous fat layers to separate them from the underlying muscle tissue (figure 2). Pinching the fat fold too firmly will change the result, so the initial grasp of the skin and subcutaneous tissue is critical to an accurate measure. The spring-loaded pressure calipers are applied until the needle on the dial comes to a stop.

MUAC

Skin fold Thickness

PATIENT HISTORY & DIETARY RECALLValid & clinically useful for measuring dietary protein and energy intake.

3 day diet dairy preferred to 24 hr dietary recall

Symptoms of anorexia, nausea ,vomiting, weight loss ,dietary habits and pattern, quantity & quality of food ingested and fluid balance should be properly and carefully evaluated and compared with the recommended intake.

KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

NUTRITIONAL MANAGEMENT

RECOMMENDED NUTRITIONAL INTAKES FOR PD PATIENTS¹

Nutrients Recommended intakes per day

Energy 35 Kcal/ kg IBW - <60 yrs30-35Kcal/ kg IBW - ≥60 yrs

Protein KDOQI recommends 1.2-1.3g/kg IBW/ day(=50% of High Biological Value). Some nitrogen balance studies indicate that protein intake of ≥ 1.0 g/ kg IBW may be enough.

Fats 30% of total energy supply

Water and sodium

As per residual diuresis

Potassium 40-80mmol. Individualized depending on serum levels

Calcium Individualized, usually not <1000mg/ day

Phosphorous 8-17 mg/ kg or 800-1000 mg/ day (adjusted to higher protein needs), when serum phosphorous is > 5.5 mg/ dl²

¹Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd Edn. NY: Springer, 2009: 611-647.

²National Kidney Foundation. K/DOQI clinical practice guidelines for managing bone metabolism in chronic kidney disease. Am J Kidney Dis2003; 42(suppl 1):S1-S92

PROTEINS

EAT MORE - CLASS I PROTEINS Egg White Fish & Chicken Low Fat/ Skim milk/Soymilk Skim Milk Products Soya bean EAT MODERATELY - CLASS II

PROTEINS Pulses & legumes Mixed Cereals

EAT LESS/AVOID Red Meat Egg Yolk Organ Meat Full fat milk Full fat milk pdts Shell fish

To compensate the protein loss (5-15g/ day) through dialysis in PD

ENERGY

o Carbohydrates (CHOs) are the main source of energy (1 gm=4Kcal)o They also provide calcium, Iron and B vitamins. o In PD diet at least 50% calories should be from

CHOso Excess calories from CHOs, stored as fats

Carbohydrates Fatso An essential nutrient

that provides concentrated

energy. (1gm Fat = 9 Kcal)

o Contributes to the palatability of food.o Carriers of fat soluble vitaminso Supplies essential fatty acids.

TYPES OF CHOS

Simple

sugar

Complex

FATS1 g Fat = 9 kcal

FATS

Oils high in PUFA like sunflower, soya, safflower, corn

Oils high in MUFA like mustard, groundnut oil, olive oil, corn & sesame oil

Butter & Ghee Cream, processed

cheese Coconut & palm oil Egg yolk, Red meat,

shellfish

Unsaturated fats

(Eat in moderation) Saturated Fats (Eat Less/ Avoid )

Fundamentals of Food and Nutrition III edition Sumati R, Mudambi. Et al

APPROXIMATE ENERGY ABSORPTION FROM DIALYSATE

60-70% of the energy is absorbed from the dialysate*.

Energy absorption from :1.5% / 2L solution = 78 Kcal2.5% / 2L solution = 130 Kcal4.25% / 2L solution = 221 Kcal

* Heimburger O, Waniewski J, Werynski A, Lindholm B. A quantitative description of solute and fluid transport during peritoneal dialysis. Kidney Int 1992; 41:1320-1332

SODIUM

SALTED SNACKS

PICKLES, PAPAD, CHUTNEY ,ADDED SALTPROCESSED & FAST FOODS

SEASONINGS & SAUCES

Salt = sodium chloride1 teaspoon of salt contains 2g – 2.4 g of sodium

FLUID OVERLOAD AND PD

Clinical features of over hydration are observed in roughly ¼ of the patients on CAPD, in addition to the cumulative

appreciation of the risk for cardiovascular mortality that chronic

fluid overload presents¹·². Fluid overload is an important contributor for a high dropout rate in PD³.

¹Lameire N, Van Biesen W.The impact of residual renal function on the adequacy of peritoneal dialysis. Perit Dial Int 1997 ;( 17 Suppl 2):S102-10. ²Bergstrom J, Lindholm B. Malnutrition, cardiac diseases and mortality: An integrated point of view. Am J Kidney Dis 1998; 32:834-841. ³Gan HB, Chen MH, Lindholm B, Wang T. Volume control in diabetic and non diabetic peritoneal dialysis patients. International Urology and Nephrology 2005; 37:575-579.

FLUID OVERLOAD EVALUATION Detailed history from the patient about urine output,

UF, fluid intake, compliance with exchanges, and pattern of weight gain

Inspect patient’s PD records comparing patient weight, solution tonicity and UF achieved

Do a physical examination looking for extent of fluid overload.

Bioelectrical Impedance Analysis (BIA) of total body water

FLUIDS

Fluid input = Food + Drink*Fluid output = Amount of ultrafiltrate + urine output + insensible losses*Fluid includes everything that melts at room

temperature. FLUID SOURCES: Water, tea, coffee, milk, lassi. juice, soups, cold drinks, vegetable gravies, curries, dals, etc. and other liquids present in food.

* Varies from patient to patient

HOW TO CONTROL FLUID OVERLOAD

Avoid excess of fluid Control salt intake Daily weight and BP

monitoring Adequate dialysis Adequate Glycemic Control Decrease dietary sodium

Intake

POTASSIUM

FRUITS ALLOWED Potassium level : 3.5-5.5

mEq/L

PHOSPHORUSMILK & MILK PRODUCTS

NUTS,PULSES & LEGUMES EGGS & POULTRY

CHOCOLATE, SOFT DRINKS

The net absorption of phosphorus from a mixed diet has been reported to be in the range of 55–70% in adults.*

Ca x P < 55 mg²/ dL² or else it can cause metastatic calcification

* Rufino M,Bonis ED,Martin M, et al., Is it possible to control hyperphosphataemia with diet, without inducing protein malnutrtion?, Nephrol Dial Transplant, 1998;13 (Suppl. 3):65–7.

SUMMARY

Prophylaxis is better than treatment Malnutrition once established, is always difficult to

treat Malnutrition at the start of PD is a poor prognostic

sign Pay attention to nutrition in PD patients before start of therapy Proper nutrition counseling Monitor nutritional parameters

Eat Eat Well Well

THANK YOU