Dr. Kopple made this statement at an NKF meeting. “ Malnutrition is a high predictor of mortality in maintenance dialysis patients.” Malnutrition is the result of an imbalance between nutrient intake and nutrient requirement.
In normal population protein and water are correlated. Measurement of body water is reflected in the body’s resistance to an alternating electric current Swept frequency bioimpedence monitor allows measurement of intra- and extracellular water compartments. Intracellular water correlates more with protein stores In normal population protein and water are correlated BIA measures the impedance or opposition to the flow of an electric current thru body fluids,contained mainly in lean &fat tissue.Impedance is directly proportional to TBW. In overweight CAPD patients LBM may be masked by fat gain and thereby missed in serial body weight measurement, so BEI is helpful. (R.Schmidt et al Advances in PD, 1992) Demonstrated BEI as very sensitive and effective clinical measure of LBW in CAPD pts. Based on measurement of resistance and reactance when a constant alternating electric current is applied to patient. Empirical equations are used to calculate TBW from resistance and total body mass from ratio of resistance to reactance is called as “phase angle”( Range0º-90º) . Values < 25 th percentile indicate malnutrition
Nutrition in Peritoneal Dialysis
NUTRITION IN PERITONEALDIALYSIS (PD)TEENA GUPTANutritionist
FUNCTIONS OF THE KIDNEY Regulation of red blood Regulation of the cell production blood’s acid base balance Regulation of Regulation of mineral blood pressure levels Elimination of metabolic toxins and excess water through urine
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.
DIALYSIS – TREATMENT OPTIONIN ESRD 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
MALNUTRITION MALNUTRITION IS THE RESULT OF AN IMBALANCE BETWEEN NUTRIENT INTAKE AND NUTRIENT REQUIREMENT Supply Demand NUTRITIONINTAKE Body Stores LOSSES *Kopple, NKF Press release 5/1/99
MANIFESTATION OFMALNUTRITION IN PD PATIENTS Protein Energy malnutrition malnutrition Decrease in body weight Low muscle mass Low fat mass Hypo – proteinaemia Low carbohydrate stores Combined Protein & Energy Malnutrition
MANIFESTATION OFMALNUTRITION IN PD PATIENTS ↓calories ↓protein +stress Starved appearance Well nourished -↓weight -↓triceps skinfold appearance -↓mid arm - Oedema circumference - Loose hair Serum albumin ↓serum may albumin be lowered 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
PEM IN PD PATIENTS Increased mortality and cardiovascular death Cardiovascul Inflammati ar disease Malnutritio on n Resting Hypermetabolism Loss of residual renal function 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):S517-22 ²National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure. New York, NY: National Kidney Foundation; 2001.
MULTIFACTORIAL IN NATURE Dialysate losses of proteins, amino acids Accumulation of Inadequate uremic toxins food intake Chronic Loss of bloodInflammation MIA Syndrome Endocrine disorders Catabolic response of uremia to Co morbidity KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.
ASSESSMENT OF THENUTRITIONAL STATUS OF PDPATIENTS IS IMPORTANT
EARLY ASSESSMENT ISIMPORTANT 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 MAGICNUTRITIONAL 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 NUTRITIONALSTATUS1. Measurements to be Predialysis or stabilized performed routinely in all serum albumin patients % of usual post dialysis or post drain weight % of standard body weight Subjective Global Assessment (SGA) 24-hr dietary recall/ Diet diary nPNA KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.
ASSESSMENT OF NUTRITIONAL STATUS2. Measures to confirm the Predialysis or stabilized data obtained from Category serum prealbumin 1 Skinfold thickness Mid-arm muscle area, circumference, or diameter Dual energy x-ray absorptiometry
ASSESSMENT OF NUTRITIONAL STATUS3. Clinically useful measures Predialysis or stabilized serum Creatinine Urea nitrogen Cholesterol Creatinine index
ANTHROPOMETRICMEASUREMENTS •Weight (kg) •Height (cms) •Body mass Index – BMI •Ideal Body Weight – IBW •Mid Upper Arm Circumference - MUAC •Skin Fold Thickness – SFT 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.
MUAC Skin fold ThicknessSkin 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 iscritical to an accurate measure. The spring-loaded pressure calipers are applied until the needle on the dial comes to a stop.
PATIENT HISTORY & DIETARYRECALLValid & clinically useful for measuring dietary protein and energy intake.3 day diet dairy preferred to 24 hr dietary recallSymptoms of anorexia, nausea ,vomiting, weight loss ,dietary habits andpattern, quantity & quality of food ingested and fluid balance should beproperly and carefully evaluated and compared with the recommendedintake. KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.
RECOMMENDED NUTRITIONAL INTAKES FOR PD PATIENTS¹Nutrients Recommended intakes per dayEnergy 35 Kcal/ kg IBW - <60 yrs 30-35Kcal/ kg IBW - ≥60 yrsProtein 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 supplyWater and As per residual diuresissodiumPotassium 40-80mmol. Individualized depending on serum levelsCalcium Individualized, usually not <1000mg/ dayPhosphorous 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 To compensate the protein loss (5-15g/ day) through dialysis in PD EAT MORE - CLASS I PROTEINS EAT LESS/AVOID Egg White Red Meat Fish & Chicken Egg Yolk Low Fat/ Skim milk/Soymilk Organ Meat Skim Milk Products Full fat milk Soya bean Full fat milk pdtsEAT MODERATELY - CLASS II Shell fish PROTEINS Pulses & legumes Mixed Cereals
ENERGY Carbohydrates Fatso Carbohydrates (CHOs) are o An essential nutrient that the main source of energy provides concentrated (1 gm=4Kcal) energy. (1gm Fat = 9 Kcal)o They also provide calcium, o Contributes to the Iron and B vitamins. palatability of food.o In PD diet at least 50% o Carriers of fat soluble calories should be from vitamins CHOs o Supplies essential fattyo Excess calories from CHOs, acids. stored as fats
FATS Unsaturated fats Saturated Fats (Eat Less/ (Eat in moderation) Avoid ) Oils high in PUFA like Butter & Ghee sunflower, soya, Cream, processed cheese safflower, corn Coconut & palm oil Oils high in MUFA like Egg yolk, Red meat, mustard, groundnut oil, shellfish olive oil, corn & sesame oil Fundamentals of Food and Nutrition III edition Sumati R, Mudambi. Et al
APPROXIMATE ENERGYABSORPTION FROM DIALYSATE 60-70% of the energy is absorbed from the dialysate*. Energy absorption from : 1.5% / 2L solution = 78 Kcal 2.5% / 2L solution = 130 Kcal 4.25% / 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
PICKLES, PAPAD, CHUTNEY ,ADDED SALT PROCESSED & FAST FOODS SODIUM Salt = sodium chloride 1 teaspoon of salt contains 2g – 2.4 g of sodiumSALTED SNACKS SEASONINGS & SAUCES
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
FLUIDSFluid 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
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