Chronic kidney disease (CKD), a major global public health problem, has been recognized as one of the eleven important causes of death (WHO, 2009). This review explores wide range of barriers related to patients and health systems involved in controlling the prevalence of CKD at the primary health care level.

2. Efficacy of Dietary
Intervention in ESRD
Patients
Dr. Ch. M. Junaid Nazar
Senior Medical Officer/Research Associate
MBBS, MPH, M.Sc. Nephrology, MD Internal Medicine, FRSPH
Nephrology Department,
Pakistan Kidney Institute,
Shifa International Hospital,
Pakistan

3. Content
• Introduction
• Prevalence
• Pathophysiology
• Risk Factor
• Association of Nutrition and outcome of Kidney Disease
• Extent of malnutrition in ESRD patients
• Methodology
• Discussion
• Conclusion

4. Introduction
 Chronic Kidney is a internationally recognized
epidemic.
 The Third National Health and Nutrition Examination
Survey has noted that more than 20 million American
have chronic renal kidney disease
 One study suggests that 40 to 70 % of patients with
end-stage renal disease are malnourished
 It is very common and latest data suggest that it
affects about 8 % of the UK adult population. The
incidence of end stage renal disease (ESRD) patients
joining renal replacement therapy (RRT) program in
the UK is about 125/million each year

5. Prevalence
 The incidence of end stage renal disease (ESRD)
patients joining renal replacement therapy (RRT)
program in the UK is about 125/million each year
 The figure is almost 300/million in parts of the
USA (because of racial factors and increased
population prevalence of diabetes and
hypertension
 In United Kingdom, the number of patients on
RRT is around 600/million.

6. Pathophysiology
keys
1.Adaptive changes to nephron injury promote various effects the ultimately contributes
to progression of CKD.
2.Hypertension, hyperfilteration, hyperglycemia, high grade proteinuria, and over
activation of RAAS cause renal injury and progression of kidney to ESRD
3.CKD patients with high levels of proteinuria are at highest risk to progress to ESRD.
4.Therapies that reduce blood pressure to appropriate goals, reduce proreinuria, and
inhibit the RAAS provide the most benefit to slow loss of renal function in diabetic and
non- diabetic patients with proteinuria kidney disease.
5.ACE inhibitors and ARBs provides renoprotection in CKD patients: combination
therapy with these drugs and aldosterone antagonist may provide further kidney
protection but needs further validation.

7. Risk Factors
Decreased protein and caloric intake
 Anorexia, Frequent Hospitalization, Inadequate dialysis dose
Comorbidities
 hypertension, Diabetes mellitus, gastrointestinal diseases, on-
going inflammatory response autoimmune disorders
 Increased protein and energy requirement
 Losses of nutrients
 Increased resting energy expenditure
 Older age
 Family history of chronic kidney disease

8. Association of Nutrition and outcome of
Kidney Disease
• A number of studies have evaluated the nutritional
status of advance CKD stage (3-5) has reported
some degree of poor nutritional status. The
prevalence of abnormalities has been estimated to
range from approximately 20 % to 60 % using
various nutritional parameters.
• Similarly in stage 4-5, mild to severe malnutrition
by subjective global assessment is reported in 44
% of patients and for patients on HD it was 30 %
and for PD patients it was 40 patients

9. Indices of Nutritional Status
 The parameters which have been proposed to
assess the nutritional status are albumin,
cholesterol and creatinine as well more complex
and not yet readily available parameters such as
plasma and muscle amino acid profiles, pre
albumin and insulin growth factor (IGF)
 Analysis of body composition there will be
different body techniques such as anthropometric,
bioelectrical impedance.
 Serum albumin is most extensively used method
to measure malnutrition in CKD patients

10. Extent of malnutrition in
ESRD patients
 Pre -dialysis patients
 Dialysis dependent patients
 Transplant patient

11. Dialysis
• Hemodialysis
• Peritoneal dialysis

12. Predialysis
• Malnutrition is not specific to any stage of end
stage renal disease but it is evident that it is
present even before the starting RRT.
• Report which is published by MDRD study
indicated that early signs of malnutrition such as
reduction in body mass index (BMI), weight,
anthropometric measurements and notable
decline in urinary biochemistry parameters
including urinary creatinine excretion were
observed in the chronic renal failure were noted.

13. Transplant
 The extent of malnutrition in transplant is still
under process and little is known about its effects
 However, the treatment and prevention of
malnutrition has not been discussed in these
patients.
 Malnutrition in pre-dialysis, dialysis, and post
dialysis stage is related to multiple factors.

14. Methodology

15. Outcomes Related with
Diet
• Hypertension
• Diabetes Mellitus
• Cardiovascular Diseases
• Obesity
• Protein
• Protein Calorie malnutrition (PCM)
• Potassium
• Vitamins

16. Different risk factor effecting
Nutrition in ESRD
• Education and Understanding
• Late Referrals
• Mistakes in Prescription
• Low immune status and Lack of
donors
• Poor Diagnostic Methods

17. Findings
Environmental Physiological
Anorexia related to uremia, fever,
or treatments
Malabsorption and diarrhea,
Nausea and vomiting related to
chemotherapy, gastritis,
esophagitis, reduced peristalsis,
Low calorie or palatable diet,
altered mental status related to
dementia etc
Depression
Desire for death
Food aversions related to
alteration in taste, texture, and
smell
Altered perception of food value:
fat diet, junk food, mega dosing
nutrition’s, using special food.

18. Target for Future
Research
 The development of new practice guidelines,
particularly for fluid management,
 Special attention needs to be focused on the
additional impact of immunosuppressive
medications
 Clinical research efforts using interventional
dietary trials for multiple post transplant
complications

19. Conclusion
• Life style, particularly diet is a critical component
of treatment for these conditions.
• Registered dietitians paly a key role in bridging the
gap between the science of nutrition and the
empowerment of individuals to alter their lifestyles
in a healthy manner
• Diet intervention in relation with end stage renal
disease is really complicated topic

20. References
• Available on Request

22. Contact
Please send me email in order you got any questions
 Email Address: dr.cmjnazar@live.co.uk
 Mobile Number:0092_3331491063
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