1. Nutritional Considerations in PD

2. Objectives Discuss risks and importance of poor nutrition
How to assess nutritional state
How to achieve good nutrition

3. Nutrition

4. Alternatives to Avoid

5. Nutrition in Patients with CRF
Classes of nutrients
- carbohydrates
- fats
- proteins
- vitamins
- minerals
- water
Essential nutrients
- amino-acids
- essential fatty acids
- vitamins, elements
Without these, an individual
cannot function
Dietary protein provide
amino acids - body proteins
Without sufficient dietary
protein and energy, no growth
or repair

6. Recommended Protein & Energy Intakes
(g/kg BW/day) (kcal/kg BW/day)
Healthy adults > 0.75# >35
CRF patients (non-dialyzed) ? 0.60 (high quality) >35
HD patients > >35
CAPD patients > >35
# safe for 97.5 % of the population (WHO 1985) CRF patients with GFR ml/min reduce protein and energy intake (MDRD study) Protein and energy intake lower than recommended in a large proportion (20-60%?) of HD and CAPD patients

7. Protein-Energy Malnutrition
A state of deficiency resulting from inadequate intake of protein and/or
energy relative to physiological needs leading to progressive changes in
body composition and function and nutrition

8. Nutrition is a balance between supply and demand

9. Accumulation of uremic toxins
Negative Feedback Loop
MALNUTRITiON
Anorexa nausea
vomiting
Low protein and
energy intake
Low serum
urea
Accumulation of uremic toxins
Loss of renal function
J Bergström ASN -94

10. Major Metabolic Steps in Nutritional Deficiency Disease
Well nourished
individual
Dietary survey
Nutrient intake
Biochem and
physiol studies
Individual at risk
Signs & symptoms
Malnourished
individual
Vital statistic

11. Patients at Risk of Developing Malnutrition
Elderly
Socially isolated
Diabetes mellitus
Recurrent peritonitis
Active comorbid conditions
Loss of RRF
Inadequate solute removal

12. Risk Factors for Poor Nutrition
Late start of dialysis
Use of low protein diet
Poor appetite
Social factors
Protein loss through peritoneum
Increased with peritonitis
Catabolic state

13. Effects of Renal Insufficiency
Protein and Amino Acid Metabolism
Altered metabolism of proteins & amino acids
Intravascular alb pool may be reduced, even though serum albumin is normal
Transferrin levels low
Increased catabolism (higher levels of glucagon, PTH, toxins, acidosis)
Changes in amino-acid profiles
Increased risk of developing protein malnutrition
Major cause of morbidity and mortality
DPI also diminishes with declining GFR

14. Protein-Calorie Malnutrition in CRF
Catabolic Factors
Comorbid illness
Physical inactivity
Infections
Metabolic acidosis
Abnormal energy metabolism

15. Protein intake and GFR 10ml / min¯ GFR = ¯ 4.4g in DPI 0.3 0.4 0.5 0.6
0.7
0.8
0.9
1.0
1.1
1.2
1.3
DPI
>50
25-50
24-10
<10
Ikizler, JASN 1995
GFR

16. Protein Intake in Pre-dialysis
DPI
N = 1687
0.0
0.2
0.4
0.6
0.8
1.0
1.2 70 45 25 9
GFR (mls / min)
MDRD study ; JASN 1994

17. Catabolic Effects of Dialysis
CAPD HD
Loss of amino acids
2-4 g/day
14-28 g/week
9-13 g/dialysis
27-39 g/week
Loss of glucose
uptake
~25 g/dialysis
(glucose free dialysate)
Loss of protein
5-15 g/day
(higher with peritonitis)
Inflammatory stimuli
Low grade inflammation (particles chemicals)
Cytokine release
Blood membrane contact

18. Causes of Anorexia
Underdialysis particularly with loss of residual renal function
Sensation of abdominal fullness
Poor gastric emptying particularly in diabetics
Hyperglycaemia and glucose absorption from excessive use of hypertonic dextrose
Depression

19. Risk Factors for Obesity
Use of hypertonic dialysate, particularly 3.86% dextrose, to maintain fluid balance
High caloric intake, but low protein intake
Lack of physical activity

20. Causes of Low Plasma Albumin (Malnutrition vs. Malnourished)
True malnutrition
Co-morbid conditions
- Infection
- Generalised vascular disease
- Chronic inflammation
- Proteinuria
- Malignancy
Old age
Dietary preference

21. Assessment of Nutritional Status
History and physical examination looking for loss of weight and muscle wasting
Dietary history
Plasma creatinine, urea, albumin, transferrin
-  creatinine can mean  muscle mass and not  dialysis clearance
-  creatinine can mean  muscle mass and not  dialysis clearance
Anthropometry
SGA (Subjective Global Assessment)
Biochemical / laboratory tests

22. Anthropometry
Mainly used as research tool
Wolfson 1984

23. Subjective Global Assessment
Four items assessed over 7 point scale
Weight change
What was weight change over last 6 months?
Anorexia
Has dietary intake changed?
Subcutaneous tissue
Fat and muscle wasting e.g., under eyes or shoulders
Muscle mass and wasting
- Examining temporalis muscle, prominence of clavicles, contour of shoulders etc

24. Subjective Global Assessment
1. Weight Change - in last 6 mths
- % (<5, 5-10,>10)
- in last 2 weeks
2. Dietary Intake - overall
- pattern
- duration
- type
3. GIT Symptoms - > 6weeks
4. Functional Capacity - overall +change
1. Loss of subcutaneous fat
2. Loss of muscle mass
3. Oedema
History PE

25. Subjective Global Assessment
Severe malnutrition - ‘1 or 2’ ratings in most categories
Mild to moderate - ‘3, 4 or 5’ ratings in most categories
Mild to Well Nourished - ‘6 or 7’ ratings in most categories or continued improvement
A - Well nourished
B - Mild-Mod malnourished
C - Severely malnourished

26. There is No Single Magic Nutritional Index
Each has limitations
Use of combinations gives corroborating information

27. Non-Nutritional Factors Affecting Albumin
Fluid balance
Infection/inflammation
Urinary losses
High dialysate losses

28. Non-Nutritional Factors Affecting Albumin
Analytical method
Gender
Age
Pregnancy
Fluid balance
Infection/inflammation
Cardiac disease
Malignancy
Protein losses
(urine, dialysate)
Infection/inflammation related
albumin is like an ‘negative’ acute phase protein
Association between cardiac disease and
hypoalbuminaemia (Foley 1996)

29. Albumin as a Negative Acute Phase Reactant
Qureshi et al., 1995

30. Albumin as a Predictor However,
Strong predictor of morbidity and mortality (CANUSA study)
Albumin may be affected by protein intake
However,
Albumin is affected by non-nutritional factors
Albumin may not increase in response to nutritional intervention

31. Serum albumin alone is neither necessary nor sufficient to indicate malnutrition

32. Serum Albumin and Death Risk Haemodialysis Patients
<=2.5
>4.5 10 20
Serum Albumin (mg/dl)
Relative Death Risk
Lowrie et al, 1990

33. Target Protein Intake for PD
Nitrogen balance is the reference method for determining adequacy of protein intake
N Balance studies by Blumenkrantz and Bergstrom indicate that at 1.2 g protein/kg/day no patients were in negative nitrogen balance

34. Malnutrition in ESRD Target Intake for PD4 5 3 2 1
0.9
1.0
1.1
1.2
1.3
1.4
1.5
Protein intake, g/kg body wt/day
Nitrogen balance, g/day
Blumenkrantz et al, KI 1982

35. How Can This Target Be Achieved?

36. Methods for Nutritional Support in PD
Nutritional counseling
Pharmacologic appetite stimulation
Oral supplements
Enteral formulas (nasogastric, PEG)
Intravenous
Intraperitoneal (nutritional dialysis)

37. Prevalence of Malnutrition is Similar in HD and PD*
Mode #Studies #Pts % Malnourished
HD (28%)
PD (36%)
* Evaluated by the same method

38. Nutrition: Guidelines 2002
All patients should undergo regular screening for undernutrition using as a minimum SGA, height weight and albumin
Diagnosis of undernutrition should be considered if any of following are met:
- BMI < 18.5
- unintentional loss of oedema free weight of > 10% in last 6 mths
- plasma albumin below normal (value depends on assay)
- Low SGA scores

39. Nutrition: Guidelines 2002
If undernutrition suspected
- refer to dietitian to assess dietary intake
measure CRP, plasma bicarbonate, dialysis adequacy and residual renal function
Correct low dietary intake
If intake adequate, look for infection if CRP high, and other catabolic factors such as acidosis, thyrotoxicosis and poorly controlled diabetes

40. What is Nutrineal™?
Nutrineal™ is a peritoneal dialysis solution with amino acids instead of glucose which integrates dialysis and nutritional supplementation

41. Nutrineal™ Characteristics
Amino acids as osmotic agent
No glucose
No change in dialysis procedures
More physiologic pH
Osmolality equivalent to 1.5% glucose
Clearance equivalent to 1.5% glucose
40 mEq/L lactate

42. Amino Acid Content of Nutrineal™ (2.0 L)
Essential Nonessential
Histidine Alanine
Isoleucine Arginine
Leucine Glycine
Lysine Proline
Methionine Serine
Phenylalanine Tyrosine
Threonine
Tryptophan
Valine
14.1g (64%) 7.9 g (36%)
Conditionally essential in renal patients

43. Bioavailability and Utilization Nutrineal™
How much is absorbed?
How is it utilized (Anabolic?)
- Nitrogen balance
- IGF-1

44. Delivering 25% of daily protein intake
In just one exchange Nutrineal can deliver
25% of the target Daily Protein Intake*
With an absorption rate of 70-80% over 4-6 hours, one exchange of 2L Nutrineal provides approximately 18g of AAs to an average, stable, 60kg patient: that is 0.3 g/kg body weight/day, which represents 25% of the 1.2 g/kg body weight/day target intake1
* Recommended dosage for adults: one 2L or 2.5L bag/day
25%
Target DPI
Jones MR, et al., PDI, 1998;18(2):

45. Bioavailability For 60 kg patient AAs Day 1 Protein and AA Losses
Day 2 AA gains
0.3 g/kg
0.16g/kg
Jones et al, PDI 1998;18:

46. The Therapy Before Prescription:
Check adequacy (Kt/V > 2; Cr.Cl. > 50 L./week)
Correct possible acidosis (bicarbonate > 23 mmol/L.)
Verify protein intake
Review comorbid conditions
Assess nutritional status
Therapeutic Target:
Protein intake of around 1.2 g/kg/day

47. Nutrineal® : an efficient and compliant way of delivering AA’s whilst providing dialysis

48. Managing Protein Needs with Nutrineal
Target protein intake* = 1.2 g/kg/day
One exchange with Nutrineal contributes the equivalent of 0.3 g/kg in an average patient (20-25% of daily target)
*Kopple, 1997

49. Conclusion
Poor nutrition common in PD patients and is adverse risk factor
Important to assess nutritional status
In malnourished patients
- correct identifiable comorbidities
- assess dialysis adequacy and increase dose if near or below target
maximise oral intake
Nutrineal