Dietary Approach To C Kidney Disease

Dr Anita SaxenaMD, PhD, PhD (Cambridge)

Associate ProfessorDepartment of Nephrology

SGPGIMS, Lucknow.India

Nutrition In Renal Disease Is Complicated

• The term “Renal disease” embraces a number of clinical conditions whose common feature is decrease in GFR.

• Another common feature that these conditions share is malnutrition but each condition has a different approach in terms of nutritional therapy.

Definition of Chronic Kidney Disease

• Chronic Kidney Disease is defined as kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR.

• GFR ≤ 60 ml/min/1.73m2 with or without kidney damage.

• There are 5 stages of CKD depending upon GFR (≥90, 60-89, 59-30, 29-15, <15) ml/minute.

Why Do We Need To 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 and water excretion.

• When diet exceeds daily protein requirement, the excess protein is degraded to urea and other nitrogenous wastes and these products accumulate in the body.

• Because the severity of uremic syndrome is proportional to the accumulation of these waste products and ions, therefore, dietary intake needs to be adjusted.

Why Modify Diets? Cont..

• In kidney failure nutritional therapy allows good control of several consequences of the disease.

Nausea /Vomiting Anorexia Initiation of dialysis

When Does Protein-Energy-Wasting Set In?

Males, solid lines; Females, dashed lines

The MDRD Study: Association Between Dietary Intake And GFR and Serum Albumin and GFRWith GFR< 60 mL/min/1.73 m2 dietary protein and energy intake decreases and serum also albumin decreases (presence of inflammation).

When Does Protein-Energy-Wasting Set In?contd…..

• PEW most likely occurs during CKD stage 3 or even earlier partially due to inadequate nutritional management in predialysis phase and becomes clinically evident when

GFR is < 15-10 ml/min.• 20-70% patients on

Maintenance Dialysis show signs of PEW.

Loss of Nutrients& Water soluble

Vitamin in Dialysate

Malnutrition

Uremic toxicityAnorexia

Loss of tasteUnpalatable diets

Dietary protein& energy intake

InflammationInfection

Superimposed illness

Presence of Comorbidity

Metabolic AcidosisHormonal disorders

Resistance to anabolichormones

level of counter regulatory hormones Glucagon, PTH

DecliningResidual Renal

Function

Anemia loss of blood due to GI bleed, frequent

blood sampling

InadequateDialysis dose

Malnutrition is Multifactorial

Markers of Protein-Energy Malnutrition (Predictors of Morbidity And Mortality in CKD)

Progressive weight loss BMI <22 kg m2 >60 years

Wasting of fat and skeletal muscle tissues

reduced muscle mass 5% in 3 m

Reduction in serum protein Serum albumin level <3.8 g/dL

Serum pre-albumin level <30 mg/dL

Serum cholesterol level <100 mg/dL Low dietary protein intake <0.6 g/kg/d

or <0.8 g/kg/d on MHD and energy intake <25kcal /kg/d for at least 2 months

What Problems Are Unique To Patients with CKD?

1. Uraemic syndrome is associated with loss of appetite and a variety of gastrointestinal adverse effects, which results in reduced nutritional intake.

Does CKD Have An Influence On Gastrointestinal Tract?

ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure

N. Canoa etal Clinical Nutrition (2006) 25, 295–310

0 25 50 75 100%

307 HD pats Curtin et al. 2002

238 CKD 5 predialysis pats Curtis et al. 2002

106 PD pats Merkus et al. 1999

73 HD pats Virga et al. 1998

66 CKD 5 predialysis pats Murtagh et al. 2007

1846 HD pats (HEMO) Burrowes et al. 2005

223 HD pats Carrero et al. 2007

331 HD pats Kalantar-Zadeh et al. 2004

120 HD pats14406 HD pats (DOPPS) Lopes et al. 2007

34 HD pats Muscaritoli et al. 2007

Anorexia 35% - 60% of MD Patients

Does CRF Have An Influence On Gastrointestinal Tract?

ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure N. Canoa etal Clinical Nutri(2006) 25, 295–310

2. Patients with CRF

Impaired gastric emptying

Impaired intestinal motility

Disturbances of digestive and absorptive

functions, and

Alterations in intestinal bacterial flora

(Kang JY. 1993. Dig Dis Sci 38:257–68)

Delayed intestinal fat absorption (Drukker A Nephron 1982;30:154–60).

Gastroparesis is most pronounced in patients with diabetic nephropathy.

What Problems Are Unique To Patients with CKD?

3. Poor nutrition in general.4. Lack of proper diet

counseling and poor monitoring of nutritional status.

Problems Are Unique To Patients with CKD?

5. Hyperglycemia

6. Hyperlipidemia

7. Cardiovascular involvement

Problems Are Unique To Patients with CKD?

8. High incidence of infections

9. Late initiation & Inadequate dialysis.

Nutritional Requirements of CKD Patients

CKD Stages 1-4

Low-protein diet (LPD) + Fluid Management

Low-protein diet (LPD) is a conservative treatment in patients with chronic kidney

disease (CKD) to improve uremic symptoms and slow progression of renal dysfunction.

(Brenner BM, Meyer TW, Hostetter TH N Engl J Med 307:652–659, 1982.)

Fluid Management Input and Output Charting

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:

Previous 24 hour urine output + 500 ml if patient is dry• If patient is edematous: 24 hour urine output + 300 ml

Nutrient Requirements for Stage 1 Kidney Damage (presence of protein in urine) normal GFRGFR >90 mL/min/1.73 m2

Protein: 0.8 g/kg/d

Non Diabetics Energy: 30-35 kcal/kg/d 35 kcal/kg/d < 60 years

30 kcal/kg/d > 60 years Diabetics : <30 kcal/kg/d

Water soluble Vitamins and minerals as per RDA

Principle Is Restrict Protein Do Not Say No To Protein

Prescribe Low Potassium Diet Potassium Intake in CKD 1 mEQ/kg/day

Hyperkalemia (high serum K+) Can cause arrhythmia

Prescribe Low K foods: • Foods containing <100 mg K /100g• 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 fruitsfruit juice, vegetable soup, coconut water.

X

X

X

XXX

X

Low Sodium Diet for better control of blood pressure& edema Sodium intake in CKD <2.4 g/d(AHA/KDOQI Guidelines for control of Hypertension)1 tsp=5g =2.5 g Na Avoid Foods containing Sodium>100 mg/100g Avoid canned foods/fruits/Pickles/fruit jam

Nutrient Requirements for Predialysis Stages 2 ,3 4, 5 Kidney Damage With Mild Decrease in GFR To Severe Reduction In GFR 60-89, 30-59; 15-<30mL/min/ 1.73 m2

Nutrient Requirement (conservative management)

Low protein 0.6g/kg/d Guideline 24 Those unable to accept 0.75 g/kg/d

Energy 30-35 kcal/kg/d(35 < 60 years; 30 > 60 years; Guideline 25

Phosphorus 800-1000 mg to prevent hyperphosphatemia. Non-calcium based phosphate binder with meals to prevent soft tissue calcification.

Calcium 1000-1500 mg/d

Sodium <2.4 g/d

Potassium 1 mEq/kg

Cholesterol <200 mg/d. Avoid egg yolkWater soluble Vitamins and minerals/ RDA

Anemia Treat anemia with folic acid, B12,iron supplements and ESA

Put them on Low Protein 0.6g/kg/d Weight of patient = 50 kg50 x 0.6 = 30 g of protein

Milk 150 ml = 4.5 g/protein Dal 1 bowl = 6 g proteinChappati=2 g 8 chappaties = 16 gRice: 50 g raw = 3 g Total 29.5g

Do Not Advise Your Patients Not To Take Protein.

1

4

3

2

CKD stage 1-3 dietary proteinintake 100% to 140% of the DRI for ideal body weight.CKD stages 4 to 5 100% to 120% of the DRI

Energy intake should exceed RDA for age at least initially.

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.

Protein intake in Children K/DOQI Guideline 6 2009

MDRD StudyLow Protein Diet + Keto Analogues

• Delay progression of kidney disease in the Predialysis period. Reduce uremic symptoms

Preserve residual renal function Delay onset of dialysis Preserve nutritional status.

Improve metabolic complications due to renal insufficiency

• Essential amino acid tablet contain all amino acids essential

for uremic patients (50 mg /tablet; dose 5 mg/kg/d). (Barsotti G, etal . Kidney Int 24:Suppl 16, S278–S284, 1983.

Gretz N, Korb E, Strauch M Kidney Int 24:Suppl 16, S263–S267, 1983)

COST

Nephrotic SyndromeDietary Recommendations: Low fat, Low salt diet+ Fluid restriction

• Restrict Fluid: depending upon presence of edema

• Energy: 35 kcal/kg b.w./d• Protein 0.6-0.8 g/kg b.w. with 1 g for each

gram of albumin lost in urine. • In children protein - according to RDA for

chronological age.• Restrict Sodium to 2.4 g/d. • Low Fat diet: Fat <30% of total calories

(PUFA 10%)• Cholesterol < 200mg/d• Soy protein is beneficial for kidneys• Avoid egg yolk, cream, red meat, fried

foods

Diabetic NephropathyDietary Recommendations (Up-To-Date, 2006)

1. Protein intake of 0.8 g/kg/d reduces albuminuria and stabilizes kidney function (Egg white HBV for protenuria).

2. As GFR decreases restrict protein 0.6 g/kg/d.

3. Energy: <30 kcal/kg/d for weight management.

4. Total fat should be restricted: 30% total Kcals.

(<10% calories from SFA; <10% calories from PUFA; 10-15% calories from MUFA)

5. Dietary cholesterol <200 mg daily along with n-3 polyunsaturated fats.

1. Achieve Normoglycemia 2 Manage dyslipidemia 3. Manage Weight4. Good Blood Pressure control (<130/80 mmHg) 5. Bring down Proteinuria with use of ACE/ARB

Diabetic NephropathyDietary Recommendations

(Up-To-Date, 2006)

1. Advise small meals at frequent intervals that consist of low-fat and complex carbohydrates.

2. 3 meals and 2 snacks

3. Avoid meals with high-fiber content.

BF/Dinner

Pregnancy, Diabetes and CKDDiscontinue Treatment of DKD with RAS inhibitors

HbA1C as close to normal as possible (<1% above upper limit of normal) Use Insulin to control hyperglycemia if necessaryLiberalize dietary protein 1.0-1.2g/kg preconception Weight/dTreat High blood pressure >140-160/90-105 mm Hg Target BP <130/80 mm Hg because of CKD. Avoid hypotension

No studies on Preg Diabetics CKD Stage 5. Strategies for management of hyperglycemia, hypertension, anddyslipidemia may be extrapolated from the recommendationsfor women with earlier stages ofCKD.

RENAL STONE DISEASE

Drink plenty of fluid: 3-4 litres/day (half of

which should be water)• Continuous intake rather than

acute bursts of drinking will

ensure required urinary SG of <1.01.• Take a glass of water before going to bed to

maintain specific gravity < 1.01.• Avoid hard tap water• In adults, urine volume should be>2 L/day• Low salt diet• Low protein diet• Prefer vegetarian diet. • If urine pH >6.0 avoid citrate supplements.• Prefer refined cereals and flours.

RENAL STONE DISEASE Composition: calcium, oxalate, phosphate, uric acid

RENAL STONE DISEASE Composition Calcium, Oxalate, Phosphate, Uric acid

• Patients can take a total of 1000-1200 mg of calcium/day from natural foods.

• Milk intake should not exceed 2 glasses/day.• Avoid calcium supplements as tablets.• Allow lemon juice.• Avoid orange juice as it raises oxalate level. • Avoid cola beverages. • Avoid Cranberry juice. • Calcium phosphate stones are treated

successfully with high-phosphate diets. In this case prefer whole grains.

• Weight reduction and all forms of physical

activity should be encouraged.

CranberryJuice

X

X

X

X

Gout (Hyper-Uricemia ) Avoid Foods Containing High Uric Acid

Low protein diet Poultry and organ meats• Fish Herring, Fish Roe, Salmon,

Sardine

• Kidney, Liver, Meat Soup Extracts • Legumes (Dry Peas Beans, Soyabean) Mushrooms Asparagus.

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

LOW SALT

RESTRICT FLUID

CONTROL

BLOOD PRESSURE

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

• Low Protein 0.8g/kg/d• As creatinine increases reduce it to 0.6 g/kg/d • Low SALT diet • Restrict Fluid intake• Good control of Blood pressure • Long Term Coverage With Antibiotics if infected • Soy protein (slows progression of PKD inanimals) (Aukema, et al. J Am Soc Nephrol .10:300-308, 1999)• Avoid foods with higher amounts of oxalic acid.

(spinach, rhubarb, beets, eggplants,cocoa, and chocolate)

• Omega-3-fatty acids (Flax seeds/oil ): anti-hypertensive, lipid-lowering and anti-inflammatory effects.

SOY

Management Of Patients On Maintenance Dialysis

Hemodialysis CAPD

Malnutrition At Initiation Of Dialysis Is A Strong Predictor Of Subsequent Increase In Relative

Risk Of Death 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.

Chung SH Peritoneal Dialysis International, Vol. 20, pp. 19–26

Malnutrition was present in 45% of 91 patients commencing CAPD as assessed by SGA.

Initial nutritional status appears to exert a powerful influence on CAPD patient survival.

By Kaplan–Meier analysis, patient survival rate is significantly lower in malnourished patients than in normal patients (67.1% vs 91.7% p = 0.02)

Relative risk of death increases with 1. Lower serum albumin and

2. Worse nutritional status

as assessed by SGA and %LBM

CANUSA Study NDT1998; 13 (Suppl 6):158–63.

Loss Of Protein

• Protein intake should be increased to > 1.3 1.5g/kg/dEstimating energy, protein & fluid requirements

for adult clinical conditions June 2012 Qeensland Govt

• Krediet RT, Zuyderhoudt FM, Boeschoten EW, Arisz L: Peritoneal

• permeability to proteins in diabetic and non-diabetic continuous ambulatory peritoneal dialysis patients. Nephron

• 42: 133–140, 1982. Imholz AL, Koomen

Peritonitis/24 h15.1 gm

CAPD/Day5-15 g/24h4 g of which is

albumin

HD/session1-3 g/session

The loss of serum proteins in stable continuous ambulatoryperitoneal dialysis (CAPD) patients averages5 g per 24 hours, 4 g of which is albumin

Dietary Protein & Energy Intake for Patients on MHD NKF-K/DOQI Guideline 15, 16

S Albumin ≥ 4.0g/dL Guidelines 3 S Prealbumin ≥30 mg/dL Guidelines 4 Prescribe 1.2g/kgbw/d protein to clinically stable

patients on HD Guideline 15 Prescribe 1.3g/kgbw/d protein to patients on PD

necessary to ensure neutral or positive nitrogen balance. Guideline 16

Energy 30-35 Kcal/kg/d depending upon age <60 or >60 y

At least 50% of protein should be of HBV

Increasing Protein Intake in Dialysis: The Phosphate Paradigm

Mortality decreases when protein intake increases up to 1.4 g/kg/day (lower panel) despite a slight increase in serum phosphate (Shinaberger JH et al.,1982). nPNA, appearance.

Protein has linear relation with phosphate

1 g protein brings 13–15 mg phosphate

(of which 30–70% is absorbed through the intestinal lumen).

Increasing Protein Intake in Dialysis: The Phosphate Paradigm

• Mean peritoneal phosphate clearance (L/wk/1.73 m2 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, high-average 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 a patient.

Patients on Maintenance Dialysis Require Extra Protein Supplement Insufficient Protein Intake

• Renal Specific Protein Supplements in powder or biscuit form.

• Peptide based supplements for sick patients.

The Renilon Multicentre Trial: Use of a renal-specific oral supplement by HD patients who have low protein intake does not increase need for phosphate binders and prevents decline in nutritional status and quality of life.Serum albumin and prealbumin changes associate positively with the increment in protein intake (The Renilon Multicentre Trial Fouque D etal NDT. 2008 Sep;23(9):2902-10)

Serum albumin (SA) levels before, during, and after the nutrition supplement in hemodialysis (HD) and peritoneal dialysis (PD) patients. Daily Supplement: 20 – 30 g protein and approx 500 caloriesSignificant improvement in albumin level during months 4 – 6 in HD patients but not in PD Patients. It takes 3months of supplementaion to show improvement in S albuminIn PD patients s albumin levels declined after supplementation was stopped

Nutrition Supplements in Dialysis Patients: Use in Peritoneal Dialysis Patients and Diabetic Patients R Poole Adv Peritoneal Dial, Vol. 24, 2008

• If oral supplements are not tolerated or effective and malnutrition is present (<20 Kcal/kg/d and Protein intake is <0.8 kg/g/d) consider tube feeding to increase protein intake.

• Overnight supplement can improve nutritional status and overall well-being.

• Bolus feeding: Start 50-100 ml feed, then increase to 300-400ml per feeding.

• Continuous feeding: Start with 20-50ml/hr, then increase 20ml every

2-8 hrs until requirement is met.

Guideline 19 – Indications for Nutrition Support in dialysis dependent patients

Practical Rules For Preventing Protein

En Energy Wasting/ Malnutrition

1. Monitor Nutritional Status

Identify Nutritional deficiencies before they become clinically evident.

(K/DOQI,AJKD.2000;35:S1-140.Enia G, etal. NDT. 1993;8:1094-1098

Monitor Nutritional Status(Predialysis* and Dialysis Depenedent** Patients)

Measure Frequency of MeasurementTotal protein 3 monthly* Monthly**Serum albumin 3 monthly* Monthly**Na 3 monthly* Monthly**K 3 monthly* Monthly**Ca 3 monthly* Monthly**P 3 monthly* Monthly**% of usual post-drain body weight Monthly**% of standard (NHANES II) body weight Monthly**Subjective Global Assessment Every 6 monthsDietary interview and/or diary MonthlynPNA Every 3-4 monthsAnthropometry As neededBody composition DEXA As needed

Prevent Monitor Treat Complications

Slow Progression of CKD

• Reduce Albuminuria to slow progression of CKD, particularly in diabetics.

• Supplement with vitamin B complex (AHA)

• Folic Acid, Vitamin B6 and B12 supplements to prevent hyperhomocystenemia

• Serum albumin < 4.0 g/dL, prior to initiation of dialysis, predict morbidity and mortal(Kaysen et al, 2008).

Slow Progression of CKD

• Control Blood Pressure to slow progression of CKD and lower CVD risk.

• Target BP ≤130/80 mmHG • Limit sodium intake. • Prescribe diuretics to treat fluid

overload• Advise Weight reduction if

required. • Monitor serum potassium in

patients on renin angiotensin aldosterone system (RAAS) antagonists.

• Limit dietary potassium intake.

Slow Progression of CKD

Manage Diabetes • Target HbA1c should be

<7.0% (ADA Guidelines 2007).

• Good control of newly diagnosed diabetes may slow progression of CKD.

• Blood glucose control may help slow progression of CKD

(DCCT,1993; UKPDS,1998)

2. Correct Uremic Symptoms

If patient is on dialysis individualize dialysis prescription. Give adequate dialysis Maintain Kt/V urea of 1.2 for HD 1.7/week CAPD ADEMEX Trial (2001)

Nutritional Effects Of Increasing Delivered Dialysis Dose In Malnourished PD Patients

- 12 m - 6 m 0 + 2 m + 4 m + 6 m

p

Wt, kg

MAC, cm

nPNA, g/kg/d

DPI, g/kg/dOral calories, cal/kg/d

P. albumin, g/L

SGA

67.4

27.90.94

1.0631.6

35.6

5.7

68.2

27.70.85

1.0431.2

34.3

5.2

66.6

27.20.81

0.8326.7

31.4

4.0

65.1

26.7

30.8

65.3

26.8

31.7

66.4

27.40.84

0.9228.7

32.8

4.4

0.18

0.190.23

0.170.03

0.05

0.15

Open, prospective, longitudinal intervention: Davies et al K Int 57:1743, 2000

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%)

3. Treat 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.

Anorexia cont..

In patients on Peritoneal Dialysis Glucose Absorption from dialysate

Induces abdominal discomfort

Suppression of Appetite

(patient absorbs 100-200g/d 300-500 kcal/d )

Encourage patient to take small but frequent meals.

Peritoneal Dialysate

Rule 4 Correct Of Metabolic Acidosis Reduce Protein Catabolism, Increase Albumin Synthesis Degradation Of Essential BCAA.

Serum Bicarbonate level at 22 mmol/L

Evaluate Monthly

NKF/KOQI

Guideline 13/14

Replace Sevelamer HCL With Sevelamer Carbonate To Prevent Acidosis

Treat comorbid conditions like diabetes, gastrointestinal disorders, and

infection which increase 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.

Rule 5. Practical Rules For Preventing PEW

Treat Diabetic Gastroparesis: characterized by delayed gastric emptying & Upper GI symptoms Ajumobi AB , Griffin RA ,Hospital Physician March 2008

Maintain Glucose levels below 180 mg/dLAverage blood glucose should not exceed 150 mg/dl (Use Insulin therapy)Prevent Hypoglycemia: Blood glucose should not be less than 110 mg/dl (to).

Prescribe Medium-chain triglycerides. Avoid meals containing Fat to avoid delayed gastric emptying.

Give high-calorie liquid supplements if patient is not in Volume Overload. if patient is sick consider parenteral nutrition.

6. Prevent Infections especially in PD To Maintain Good Nutritional Status

Infections lead to ed appetite

Impart Intense training to patient & attendant for maintaining hygiene.

Peritonitis

Exit site infection

• Anorexia is more common in patients

who have lost RRF and has significant

independent effect on dietary protein

intake.

• Patients with RRF have higher mean DPI

and nPNA than patients without RRF

(1.08 ±0.31vs 0.89 ± 0.31g/kg/d and

62.1 ±12.4 vs 54.9 ±15.3g.d). ( Wang etal JASN 2001 Nov 12 (11) 2450-7)

Every 1ml/min/1.73m2 increase in GFR associated with 0.041-fold increase in DPI and 0.838-fold increase in DCI. (Cross sectional study on 242 CAPD patients Caravaca etal 1999, Per Dial Int. Vol 19 350-6 )

7. Preserve Residual Renal Function for Proper clearance

of middle molecules Anorexia In PD

Avoid Contrast and Other Toxins

Worsen renal function Avoid Nonsteroidal anti-inflammatory drugs, aminoglycoside antibiotics, andoral phosphate solutions.

Aminoglycoside antibiotics used for treatment of peritonitisand catheter infections should be used with caution (ISPD).

Prevent peritonitis, because peritonitis is also associated with a decline in RRF.

STATEGIES FOR PRESERVING RRF cont..

8. Anemia also causes generalized weakness & loss of appetite

• Correct Iron Profile

• Supplement Folic Acid

• Correct Vitamin B12 deficiency

• Treat chronic infections and secondary hyperparathyrpoidism

• Prescribe optimal dose of ESA/EPO

• Use L-Carnitine in EPO resistant anemia.

9. Reverse Protein Loss Give High Protein Diet to

Patients on Dialysis

:

Galland et al. Kidney Int 2001

Daily Hemodialysis Increases Protein and Energy Intake

Rule 10. Practical Rules For Preventing PEW

TAKE HOME MESSAGE Prevent Malnutrition From Setting In

1. Correct uremia and metabolic acidosis to prevent protein catabolism.

2. Monitor closely nutritional status and nutrient intake.

3. Individualize diet prescriptions.

4. Do not completely stop protein intake.

• Restrict Protein intake to 0.6 g/kg/d in predialysis patients.

5. Ensure high protein diet for patients on Maintenance Dialysis.

6. Eliminate drugs which cause GI upset and anorexia.

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Foods With High Phosphorus Content Useful In Treating Stone Disease

• Milk and milk products, khoa • liver, egg yolk, fish, meat products,

soft drinks, whole grain cereals and flours, Mustard leaves cauliflower,

• carrot peanut, • Kidney beans, soyabean, til water chestnut, .Chocolate dry fruits dry coconut