Importance of Diet In Peritoneal Dialysis Dr Anita

Importance of Diet In Peritoneal Dialysis. Dr Anita Saxena MD (AM), Ph. D (Cambridge) Department Of Nephrology Sanjay Gandhi Post Graduate Institute Of Medical Sciences Lucknow

In uremic patients anorexia and loss of taste cause imbalance between intake and nutritional requirement. What Is Malnutrition Imbalance Depletion of Body Stores Nutrient Requirement Disease Nutrient Intake 20 -70% patients on Maintenance Dialysis show signs of PEW. Malnutrition

Malnutrition Is Of Two Types FACTORS TYPE 1 Associated with uremic syndrome TYPE 2 Associated with MIA syndrome Serum albumin Comorbidity Normal/low Uncommon Low Common Presence of inflammation Food intake Resting energy expenditure Oxidative stress Protein catabolism Reversed by dialysis and Nutritional support No Yes Decreased Normal Low/Normal Elevated Increased Decreased Yes Markedly increased Increased No Stenvinkel P et al, NDT 15; 953, 2000

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 important Prevalence of protein energy wasting (PEW) in patients on PD patients is 40 -66% and HD therapy is 18– 75% and correlates with the risk of morbidity and mortality. Mehrotra R, Kopple JD Annu Rev Nutr. 2001; 21: 343 -79. Tapaiwala, Kopple JD 1996: Am J Clin Nutr 1997; 65: 1544– 57 Mehrotra R, Kopple JD. Annu Rev Nutr 2001; 21: 343– 79.

Nutritional Status • Signs of PEW increase as GFR declines. • CANUSA Study has shown that evidence of poor nutritional status in PD patients is associated with Ø Adverse outcomes Ø Poor patient and Ø Technique survival GOOD HEALTH Ø Increased hospitalization NUTRITION

When 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) 247 S 251 S) DPI (g/kg/day) As Renal Function Declines, Spontaneous Dietary Protein 1. 20 Occurs Restriction 1. 01 0. 850000001 1. 00 0. 70 0. 80 0. 54 0. 60 0. 40 0. 20 0. 00 >50 50 -25 24 -10 <10 Creatinine Clearance (ml/min) Ikizler, JASN 6: 1386 -1393, 1995 Prospective observational study of 90 patients

When Does Protein-Energy-Wasting Set In? • PEW becomes clinically evident when GFR is < 1510 ml/min.

The MDRD Study: Association Between Dietary Intake And GFR. With GFR< 60 m. L/min/1. 73 m 2 prevalence of reduced dietary protein and energy intake is High. Mean levels of protein and energy intake as a function of GFR based on 24 -hour urine collections and diet diaries. (males, solid lines; females, dashed lines).

MDRD Study. Association between Serum Albumin and GFR Serum albumin is lower at levels of GFR < 60 m. L/min/1. 73 m 2, 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/d. L (bromcresol green) method). males, solid lines; females, dashed lines

What Causes Decreased Protein And Energy Intake And Hence Malnutrition In PD Patients?

UREMIA LOW NUTRIENT INTAKE Malnutrition is Multifactorial INFLAMMATION HYPERCATABOLISM

Malnutrition Is Multi-Factorial Hypercatabolic State + Anorexia Inadequate Dietary Protein & Energy Intake Peritoneal transport Malnutrition Metabolic acidosis PD procedure per se Dialysis dose Underdialysis Causes Anorexia PD duration Acute & Chronic Illness Comorbidity Diabetes Endocrine Increased catabolism PD Inflammation Residual renal function Infectious Illness Uremia per se

Nutritional Management of PD Patient • Is challenging Not only includes what a patient should be eating but what is more important is the reason why patient is not eating?

Reason Why Patients Don’t Eat Anorexia/Loss of Appetite Guideline 6 • Kidney failure causes Retention of uremic toxins/anorexogenic substances due to uremia. Gastric problems Oral manifestations (lack of taste , dryness of mouth) Poor dental hygiene Impaired olfactory function Anorexia is evidenced by decreased dietary protein intake (DPI) and decreased dietary energy intake (DEI), which are hallmarks of kidney failure.

2. Dialysis Dose Inadequate Dialysis Dose Causes Uremic Symptoms and patient is unable to eat Give adequate dialysis Maintain Kt/V urea of 1. 7/week CAPD ADEMEX Trial (2001) If patient is on dialysis individualize dialysis prescription.

Nutritional Effects Of Increasing Delivered Dialysis Dose In Malnourished PD Patients had evidence of declining nutrition over 12 months With 25% increase in delivered PD dose for 6 months Total Kt/V 1. 67 1. 93 ( 18%) Wt, kg -6 m 0 +2 m +4 m +6 m p - 12 m 67. 4 68. 2 66. 6 65. 1 65. 3 66. 4 0. 18 27. 9 0. 94 27. 7 0. 85 27. 2 0. 81 26. 7 26. 8 27. 4 0. 84 0. 19 0. 23 1. 06 31. 6 1. 04 31. 2 0. 83 26. 7 0. 92 28. 7 0. 17 0. 03 P. albumin, g/L 35. 6 34. 3 31. 4 32. 8 0. 05 SGA 5. 7 5. 2 4. 0 4. 4 0. 15 MAC, cm n. PNA, g/kg/d DPI, g/kg/d Oral calories, cal/kg/d 30. 8 31. 7 Open, prospective, longitudinal intervention: Davies et al K Int 57: 1743, 2000

3. 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 upsets Discontinue calcium supplements if bowel movements are irregular Reduce salt intake for better control of blood pressure to minimize requirement of antihypertensive medication.

4. Glucose Absorption From Dialysate Anorexia can Causes Loss Of Appetite Peritoneal Dialysate In patients on Peritoneal Dialysis Glucose Absorption from dialysate may cause Suppression of Appetite and induce abdominal discomfort Patient absorbs 100 -200 g/d of glucose which is equivalent to 300 -500 kcal/d Encourage patient to take small but frequent meals. � � �

Comorbid conditions like diabetes, gastrointestinal disorders, and infection 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.

Metabolic Acidosis Causes Protein Catabolism Decrease Protein Catabolism Increase Albumin Synthesis Serum Bicarbonate level at 22 mmol/L Evaluate Monthly NKF/KOQI Guideline 13/14 Supplement 1 g TID

Diabetic Gastroparesis causes decreased food intake Ajumobi AB , Griffin RA , Hospital Physician March 2008 • Characterized by Delayed gastric emptying & associated upper gastrointestinal (GI) symptoms • 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 hypoglycemia • Electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) have roles in the pathogenesis of DGP. • Dysfunction of NO neurons in the myenteric plexus may be responsible for DGP

Metabolic Acidosis Causes malnutrition by Increasing Protein Catabolism. Bicarb Therapy Decrease Protein Catabolism Increase Albumin Synthesis Serum Bicarbonate level at 22 mmol/L Evaluate Monthly NKF/KOQI Guideline 13/14

By the time CAPD is initiated patient is already malnourished.

Aims 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 wasting • Prevent protein energy malnutrition • Prevent Hyperglycemia • Dyslipidemia • Maintain adequate nutritional status. • Build up body stores for good transplant outcome (if planned) • Improve quality of life

Monitor 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 n. PNA Every 3 -4 months Anthropometry As needed

Percentage of individuals Why is the Protein Target Higher for PD Patients? Normals PD Protein and amino acid losses and catabolic factors shift the curve to the right for PD patients low high Protein Requirement

Loss Of Protein CAPD/Day 5 -15 g Peritonitis/24 h 15. 1 gm • Protein intake should be increased from 1. 3 - 1. 5 g/kg/d Estimating energy, protein & fluid requirements for adult clinical conditions June 2012 Qeensland Govt

Decreased Protein Intake May Lead To Protein-energy Wasting And Poor Survival In PD patients, Dietary Protein Intake <0. 73 g/kg/day is associated with proteinenergy wasting and worst outcome. • 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): 3715 -21

Predictors Of Survival In Anuric Peritoneal Dialysis Patients Jansen MM Kidney International (2005) 68, 1199– 1205 • Daily 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 & mortality Higher Age Nutritional status : CNI scores (SGA, 6 anthrop measure: SKF, body weight, BMI) and S. Albumin) n. PCR Daily protein loss Daily fluid output (UF + urine) and Cholesterol level Diabetes (comorbidity)

Presence 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 40 -66%. Carrero JJ, J Renal Nutr 2013 Vol 23, issue 2, Pages 77 -90 Hakim RM and Lazarus JM. JASN 1995; 6: 1319– 28 Abdu A et al Afr J Clin Nutr 2011; 24(3): 150 -153 Flanigan MJ. Perit Dial Int. 1998; 18: 489 -496.

Initial nutritional status exerts a powerful influence on CAPD patient survival Chung SH Perit Dial Inter Vol. 20, pp. 19– 26 Kaplan–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 patients Initial FFEF body mass was a determinant of SGA score and predicted death Malnutrition was present in 45% of patients commencing CAPD as assessed by SGA.

CANUSA Study NDT 1998; 13 (Suppl 6): 158– 63. Relative risk of death increases with 1. Lower serum albumin and 2. Worse nutritional status as assessed by SGA and %LBM

Reverse Protein Loss Give High Protein Diet to Patients on Peritoneal Dialysis

NKF-K/DOQI Guideline 3 & 4 Guidelines 3 S Albumin ≥ 4. 0 g/d. L Guidelines 4 S Prealbumin ≥ 30 mg/d. L

Dietary Protein Intake for Patients on PD NKF-K/DOQI Guideline 16 n n For patients on CAPD unless a patient has demonstrated an adequate nutritional status on 1. 2 g/kgbw/d diet, prescribe 1. 3 g/kgbw/d necessary to ensure neutral or positive nitrogen balance Guideline 16 Patients with high peritoneal membrane transport characteristics have low serum albumin due to excessive protein loss. Perl etal 2009 Clin JASN 4: 1201 -1206 At least 50% of protein should be of HBV

e u l a 3 V PANEER 13 /240/100 YOGURT 3. 1 g/60/100 g al ic MILK WITHOUT CREAM g o l 6. 4/135 calories /200 ml o i 4 B h g i H f o n i e ot r P SOY NUGGETS TOFU SOYA PRODUCTS 43 g/100 G 1 helping 50 g=21 g/216 MILK

To Increase Protein and Energy Intake Oral Supplements Are Essential For Patients On Maintenance Dialysis For sick patients, use energy and protein dense ONS can provide approx 10 kcal/kg/d Phillis ME Clin Nephro 1978 9: 241 -8 Caglar et al Kidney Intrn 2002 62 1054 -9

Patients on Maintenance Dialysis Require Extra Protein Supplement Insufficient Protein Intake • Protein Supplements powder or biscuit form Proseventy 70 % protein Renourish 60% Protein (10 g/16 g sachet) Nepro. HP Pentasure 35% Lamino Bix 1. 6 g protein/disc Threptin Biscuits 1. 5 g/disc • Alpha Keto Analogues (affordability) • Peptide based supplements PEPTAMEN

Protein Requirement = 1. 3 g/kg/d x Wt. 60 kg x 1. 3 = 78 g of protein Milk 150 ml = 4. 5 g/protein Dal 1 bowl = 6 g protein Curd = 100 g = 3 g Chappati=1. 5 g 8 chappaties = 12 g Rice: 50 g raw = 3. 4 g 3 Paneer/Tofu 100 g 13 g/21 g Egg white 2 = 8 g 5 Fish 50 g/chicken 35 g =7. 5 g Total 57. 5 g Supplement 30 g/d = 20 g 7 Total 77. 5 1 2 4 6

Protein 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 period Change in nitrogen balance during months 1 and 3 of supplementation. Effectiveness of Protein S supplementation …CAPD RA Elias, A etal

Foods Permitted • Fruits permitted: one fruit in a day (approx 50 m. Eq) 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 fruits • Vegetable 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).

Foods Permitted • Use refined flour (sieve flour/atta before cooking) • Use tamarind pulp instead of tomatoes to enhance taste • Use, garlic, heeng, methi dana, and turmeric in cooking. • Use coriander powder (dhania), cumin seeds (zeera) and red chlli powder in small quantity.

High Protein Food For Dialysis Patients • Curd with 3 tsp of Proseventy powder • High Protein Chappati. Add 1 Tb 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).

Protein intake in Children K/DOQI Guideline 6 2009 CKD stage 3 dietary protein intake 100% to 140% of the DRI for ideal body weight. CKD stages 4 to 5 100% to 120% of the DRI If patient is on hemodialysis, then an additional increment on anticipated losses 0. 4 g/kg/d and peritoneal losses 0. 80. 9 g/kg/d should be followed. 100 -120% + 0. 4 or 0. 8 -0. 9 g /kg/d (2000)

Newer 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, 2002 • Over 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.

Guideline 17 – Daily Energy Intake (DEI) Major source: Carbohydrates and Fat Recommended: 35 kcal/kg bw for those < 60 y of age 30 -35 kcal/kg for those > 60 years. n 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 (300 -500 kcal/day) n Fernstrom A, etal. J Inter Medicine 1996 Oct; 240(4): 211 -8 n n PD 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.

Energy Intake From Peritoneal Dialysate Absorption 1 week of PD: 500 -2100 g of glucose absorbed 1. 5% (2 L) ~ 76 kcal CAPD 4 x 2 L = 302 kcal 3 x 2 L 1. 5% + 1 x 2 L 2. 5% = 410 kcal 2. 5% (2 L) ~ 182 kcal 4. 25% (2 L)~ 308 kcal 3 x 2 L 1. 5% +1 x 4. 25% = 536 kcal

Energy Intake in Children K/DOQI Guideline 5 n Energy intake should exceed RDA for age at least initially. n Peritoneal dialysate glucose absorption increases total calorie intake by 7 -10 kcal/kg/d n Prescribe “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. n

Indications 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.

In Very Malnourished PD patients n Plan hemodialysis as a temporary measure in very malnourished patients while either enteral or parenteral nutrition is given. n Once good steady state of nutrition is obtained a return to PD can be made.

SIDE EFFECT Icodextrin-based PD Solution METABOLIC ACIDOSIS Conventional Glucose Dialysis Solutions can lead Skin Rashes Vesicular Rashes 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

Hyperkalemia Low urine output 1 Gram protein= 1 me. Q Potassium Intake in CKD 1 m. EQ/kg/day Prescribe Low Potassium Diet • High serum K+ Can cause arrhythmia • Prescribe Low K foods: • Foods containing <100 mg K /100 g • Apple, banana, guava, pear, orange, papaya

Reduce 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.

Low 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=5 g =2. 5 g Na Avoid Foods containing Sodium>100 mg/100 g Avoid canned foods/ fruits/ Pickles/ fruit jam

Phosphorus • Hyperphosphatemia implies increased concentration of inorganic phosphates in the blood (>4. 5 mg/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 hyperphosphatemia • Hyperphosphatemia 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.

PTH FGF 23 3 mg/kg/d 20 mg/kg/d 60% and 70% of dietary P absorbed by the GI tract Two third excreted in urine 600 -800 mg Phosphorus 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% is

KDOQI 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/d. L ) at Stages 3 and 4 of CKD, and >5. 5 mg/d. L 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.

1. Calculate Phosphate Content Of Diet • 1 g protein brings 13– 15 mg phosphate • Total protein x 14 = phosphate content • 60 kg 0. 6 g/kg/d= 36 g protein • Total phosphorus= 36 x 14= 504 mg • If patient is on dietary supplement add phosphorus content of supplement to dietary phosphorus intake.

Pi level in CKD patients should be <5. 0 mg/dl. Relative risk of mortality increases with serum phosphorus levels >6. 5 mg/d. L 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

KDOQI: Advise Low Phosphorus Containing Foods. Recommended Daily Allowance (RDA) For Phosphorus 800 mg/day Foods High in protein and dairy products contain the most P High (> 200 mg P per 100 g) Milk products Meats Fish Dry fruits Chocolate Medium (> 100 but < 200 mg P per 100 g) Cereals Legumes Minimum in vegetables and fruits Low (< 100 g P per 100 g) Vegetables Fruits

Avoid Foods With Phosphorus-based Additives. SAY NO TO • Cola beverages • Enhanced or restructured meats • Frozen meals • Cereals • Snack bars • Processed or spreadable cheeses • Instant products • Refrigerated bakery products �

4. Prescribe Phosphate Binders With Meals Purpose of therapy with phosphate binders is to limit intestinal absorption of dietary phosphorous and to maintain phosphates in normal range. Protein has linear relation with phosphate 1 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). n. PNA, appearance.

Increasing Protein Intake in Dialysis: The Phosphate Paradigm • Mean peritoneal phosphate clearance (L/wk/1. 73 m 2 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, highaverage 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 phosphate • This results in a net balance of 1800 mg every other day in HD pateints, an amount that cannot be eliminated through dialysis • Phosphate binders are a must for such patients.

6. 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 phosphatebinders is less. • This may contribute to improved quality of life and reduce treatment costs.

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 J Am Soc Nephrol. 2011 Feb; 6(2): 281– 289. Percentage of patients below, within, or above phosphate treatment targets by GFR category

Percenta. 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 25 th and 75 th percentiles by the bottom and top of the box, respectively. P for univariable linear trend = 0. 008. 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

per. Protein 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. 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

Management of DGP • Maintain adequate glycemic control, control upper GI symptoms, ensure adequate hydration and nutrition, prevent malnutrition. • Maintain Glucose levels below 180 mg/d. L and above 110 mg/d. L to avoid hypoglycemia 1. Avoid inhibiting gastric myoelectric control and motility. 2. Hyperglycemia inhibits the action of prokinetic drugs such as erythromycin.

Management of DGP • Carbohydrates and substances with high osmolarity increase gastric emptying, therefore avoid meals have a high-fiber content • Medium-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 Overlod • Parenteral nutrition may be needed to supply dietary requirements temporarily in severe cases

Restrict Fat: Emphasize On Reduction of Saturated & Trans Fatty Acids of Dyslipidemia • Fatty acid intake can be modified easily. Management by substituting canola oil, a blend that includes both omega-3 and monounsaturated fats, for vegetable oils • AHA Recommendations: Prefer monounsaturated fats /oils: corn, safflower , soyabean , olive , peanut and canola oils Total fat: 25 -35% of total calories: <10% PUFA Saturated Fat <7% Trans Fats <1% Dietary cholesterol <200 mg daily along with n-3 polyunsaturated fats.

Fluid Management Input and Output Charting Ultrafiltration + Urine Output+ Edema Oral Intake + IV infusions & Urine Output charting Fluid intake: Water taken with meals, medications or otherwise Tea, Coffee Milk Curd And any other liquid Fluid Prescription: UF+ Previous 24 hour urine output + 500 ml if patient is dry • If patient is edematous: 24 hour urine output + 300 ml

Conclusion: How Do We Handle PD Patients with Signs of Malnutrition/Wasting? Provide adequate nutrition, adequate dialysis and treat co-morbidities Evaluate and treat potential dialysis related causes of wasting Nutritional supplements Others • Infectious complications • Exit site infections • Nutritional intervention • Silent ischemic heart disease • Other infectious complications • Physical training • Intercurrent clinical events • Reduce pre-meal exhanges • Pharmacological • Peridontal disease • Bioincompatible membranes intervention • Failed kidney transplant • Use biocompatible PD fluids • Volume overload • Icodextrin based PD fluid • Inflammatory diseases • Amino acid based PD fluid Modified after Carrero et al Blood Purif 2008; 26: 291– 299

T h a nk y o u

1. Prevent malnutrition from setting in. 2. Correct uremia and metabolic acidosis. 4. Individualize diet prescriptions. 5. Replenish plasma amino acid and protein pool, prescribe High Protein Diet along with oral protein supplements. P ro te in of H ig h B io lo gi c al V al ue 3. Monitor closely nutritional status and nutrient intake. 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.

Why 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.

Why 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.

What Causes Malnutrition t Nutrien t n e m e r i Requ Disease t n e i r t u N Intake Malnutrition

Protein 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 important • although 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.

Conventional Glucose Dialysis Solutions PD solutions may also affect RRF • Many current PD solutions are bioincompatible, with low p. H • The 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 RRF • These changes are presumed to lead to ultrafiltration failure. Kim SG, et al. (Balnet Study). Perit Dial Int 2008; 28(suppl 3): S 117– 22. Kunal Chaudhary*† and Ramesh Khanna† JASN 2010

Icodextrin-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.

Newer 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, 2002 • Over 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.

Guideline 17 – Recommended Daily Energy Intake Major source: Carbohydrates and Fat n 35 kcal/kg/bw of energy for those < 60 y of age 30 -35 kcal/kg/d for those > 60 years. Patients get 19% of total energy intake dialysate glucose absorption. () Fernstrom A, etal. J Inter Medicine 1996 Oct; 240(4): 211 -8 (300 -500 kcal/day from PD) This causes decreased intake of protein and fat. This intake should be included in total energy intake prescribed by dietician.

Control Serum Phosphorus In Diet • Educate patient on phosphorus targets <4. 5 mg/dl • Provide 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.

The Renilon Multicentre Trial Denis Fouque D, Mc. Kenzie J, de Mutsert R, etal Nephrol Dial Transplant. 2008 Sep; 23(9): 2902 -10 • Use of a renal-specific oral supplement by HD patients with low protein intake does not increase the need for phosphate binders • Serum 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.

Treat Diabetic Gastroparesis Ajumobi AB , Griffin RA , Hospital Physician March 2008 • Characterized by Delayed gastric emptying & associated upper gastrointestinal (GI) symptoms • Symptoms 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 hypoglycemia • Electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) have roles inthe pathogenesis of DGP. • Dysfunction of NO neurons in the myenteric plexus may be responsible for DGP

Management of DGP • Maintain adequate glycemic control, control • • • upper GI symptoms, ensure adequate hydration and nutrition, prevent malnutrition. Maintain Glucose levels below 180 mg/d. L to: 1. Avoid inhibiting gastric myoelectric control and motility. 2. Hyperglycemia inhibits the action of prokinetic drugs such as erythromycin Carbohydrates and substances with high osmolarity increase gastric emptying, therefore avoid meals have a high-fiber content Medium-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 Overlod Parenteral nutrition may be needed to supply dietary requirements temporarily in severe cases

• Use prokinetic drugs, antiemetic agents like metoclopramide, domperidone, erythromycin, and cisapride , pyloric injection of botulinum toxin (potent inhibitor of neuromuscular transmission) to control symptoms of DGP • Domperidone: doses between 10 and 30 mg taken orally a half hour before meals and at bedtime, domperidone has been shown to reduce GI symptoms • Oral erythromycin between 50 and 100 mg taken 3 times daily in combination with a low-bulk diet • Cisapride is a potent prokinetic drug that acceleratesgastric emptying of solids and improves dyspeptic (can cause fatal cardiac arrhythmias. )

When 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. 1 247 S-251 S) • 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 < 1510 ml/min. • 20 -70% patients on Maintenance Dialysis show signs of PEW.

Sources of Selenium

5. Emphasize Merits Of Plant-based Proteins Rather Than Those From Meat Or Dairy Sources • • P Intake from Plant Foods: The Role of Phytate Many 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 PO 4 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.