Nutrition in haemodialysis

1. Nutrition in Hemodialysis
BY
Dr / Abouelsoued mahmoud

2. • Patients on dialysis are commonly depleted of protein and
energy stores. The degree to which protein and energy depletion
is the result of deficient nutrition or, alternatively, protein and
energy wasting.
• The terminology protein-energy wasting (PEW) syndrome to
describe the loss of body protein mass and fuel reserves in
patients with end-stage kidney disease (ESKD) .

4. Assessment of nutritional status in patients on
hemodialysis:-
• Dietary assessment .
• Physical assessment .
• Laboratory assessment .

5. • Dietary assessment
 We question patients monthly about loss of appetite, loss of weight,
weight, or development of gastrointestinal symptoms such as nausea
or vomiting.
 We inquire as to psychosocial issues such as access and affordability
of food, ability to prepare meals, and the role of family members in
food preparation

6. • Physical assessment
We measure post dialysis edema-free weight every month. We use the
the weight to calculate the body mass index (BMI) and to monitor for
weight loss.In some patients who cannot achieve post dialysis
euvolemia for a variety of reasons, we monitor the trend of their
weight with simultaneous assessment of interdialytic weight gain and
volume.
 Loss of 5 %of non edematous weight within three months or an
unintentional loss of 10 % of nonedematous weight over six months
should be considered an indicator of PEW independently of weight-
for-height measures. A decline in BMI over time may be associated
with increased mortality

7. • Laboratory assessment:-
Serum albumin A serum albumin <3.8 g/dL is a suggested
diagnostic criterion for PEW syndrome.
( not very specific as serum albumin levels may also fall due to non-nutritional factors including
including inflammation, acute or chronic stress, overhydration, urinary or peritoneal losses, and
acidemia)
BUN:-Malnourished patients often show a gradual reduction in BUN. Low
predialysis BUN levels have been associated with increased mortality
( non Specific ).

8. • PNA (protein nitrogen appearance ) :-
The PNA is calculated from the post- and predialysis BUN
concentrations of two consecutive hemodialysis sessions. The rate of
increase in serum urea nitrogen between two consecutive
hemodialysis sessions reflects dietary nitrogen intake.
National guidelines (based on opinion) recommend maintaining a
PNA >1.2 g/kg/day.

9. Copyrights apply

10. Causes of PEW (protein energy wasting):-
Decreased intake and anorexia .
Hypercatabolic state.
Insulin resistance.
Metabolic acidosis
The dialysis procedure .
Dietary restrictions .
Medications (such as phosphate
binders, can impair nutrient
absorption.)

11. DIETARY RECOMMENDATIONS TO PREVENT PROTEIN-ENERGY
WASTING
• Kidney Foundation Kidney Disease Outcomes Quality Initiative
(KDOQI) recommends as follow :-
• 1.2 g/kg protein per day; at least 50 percent should be of high biologic
value
• 30 to 35 kcal/kg of calories per day.
• higher than the recommended daily allowance for healthy adults
(which is 0.8 g/kg/day).
• It is important to closely follow metabolic parameters (including urea)
if a high protein diet is prescribed to dialysis patients.

12. If The patient cannot take protein by diet ?
• Nutritional supplement :-
Indications for treatment:-
An unintentional loss of 5 percent of nonedematous weight within three
months or 10 percent of nonedematous weight over six months
Or
An albumin <3.8 g/dL

13. • Oral supplements :-For most patients selected for treatment with
dietary supplements, we use oral supplements.
o formulated specifically for end-stage kidney disease (ESKD)
patients and are low in potassium and dense in nutrients, which
provides adequate calories and protein and minimizes the risk of
hyperkalemia and fluid overload. However, these supplements are
more costly

14. • Intradialytic parenteral nutrition For patients who continue to lose
weight or have very low serum albumin (<3.2 g/dL) despite oral
supplementation and for patients such as those with severe
gastroparesis who may be unable to tolerate oral
supplementation, we use IDPN.
• IDPN is convenient because it is delivered during dialysis and is
likely to be beneficial in some patients