NUTRITION FOR DIALYSIS PATIENTSBy

Khairatul Azwa Binti Mohd Shamsuddin

A115851

AIMS

Understand the nutritional needs of ESRD patients.

Systematically break down the nutritional needs of ESRD patients.

Gain an understanding of the seriousness of malnutrition in ESRD patients.

OBJECTIVES

At the end of this session, students will be able to:

Describe in detail the nutritional needs of ESRD patients.

Draw a food pyramid guide on nutrition for ESRD patients.

Be motivated to educate ESRD patients on their dietary intake.

INTRODUCTION

Global picture of malnutrition 10 to 70% in HD patients 18 to 51% in CAPD patients

Mostly protein deficiency Hypoalbuminemia 25 – 50%

Malnutrition indicators are powerful predictors of morbidity and mortality in ESRD.

NUTRITION PRESCRIPTION FOR DIALYSIS

CHALLENGES TO ACHIEVEMENT

Achieving energy adequacy Replacing protein losses Educational needs Other nutrients to manage

PROTEINDietary protein

Pi, H+, K+, Na+, SO4, N

Ess & Non-Ess Amino AcidsBody protein stores

Urea

Renal excretion

WHY IS PROTEIN IMPORTANT?

PROTEIN METABOLISM IN ACIDOSIS

Uremia imposes anorexia and indicates abnormal protein and amino acid metabolism. Altered essential amino acid concentrations Metabolic acidosis accelerates protein

degradation Amino acids from proteolysis increasingly

oxidised

PROTEIN LOSSES IN HEMODIALYSATES

8 – 12g per treatment with conventional membranes.

10 – 30% higher with porous synthetic membranes.

Cellulosic membranes increase amino acid losses from skeletal muscle.

Reprocessed dialyzers consume more.

PROTEIN LOSSES DURING PD

Types of proteins lost (5 – 15g daily) Carrier proteins, hormones, coagulation/fibrinolytic

hormones, immune system, enzymes, lipoprotein, etc. (including albumin)

Amino acid losses from 1.7 – 3g/day.

• CAPD peritonitis increases losses by > 15g/day.

• IPD peritonitis have recorded up to 100g/day.• Appetite suppressed from dextrose

absorption.

HOW MUCH PROTEIN DO THESE PATIENTS NEED?

PROTEIN REQUIREMENTS

Increased for ESRD Between 1.1 – 1.2g/kg/day for HD Between 1.2 – 1.4g/kg/day for PD Between 1.4 – 1.6g/kg/day for PD with peritonitis

INTAKE RECOMMENDATIONS

Limit total fat to less than 30% energy. Saturated fat to less than 10% energy. Increasing polyunsaturated fat (PUFA). Limiting cholesterol intake to less than

300mg.

Fat also supplies energy 1g = 9 kcal

CHECKPOINT!

What have we learnt so far? Protein

Increase intake to avoid malnutrition. Recover lost proteins Altered metabolism

Recommendations range from 1.1 – 1.6g/kg/day Lipids

Increase PUFA intake. Important to maintain energy.

HIGH SODIUM FOODS

Calcium levels progressively fall.

Recommended intake is 1000 – 1500mg

Low protein/phosphorus diet will also result in low calcium. Need supplement

Supplementation may cause hypercalcemia.

Phosphate levels rise as renal function is 25% or less.

Bone abnormalities rise with 50% GFR or less.

Restrict phosphate to 12 – 15mg/g dietary protein Use phosphate binders Individualize dose

Calcium Phosphate

PHOSPHATE

Food content Meat : 7 – 8mg/g protein Shellfish/tinned fish/ offal : 15 – 20mg/g protein Dairy foods : 25mg/g protein

Lowering phosphate requires protein reduction.

Binders is a must with high phosphate foods. Calcitriol increases gut absorption.

HIGH PHOSPHATE FOODS

CHECKPOINT!

What have we learnt so far? Protein

Increase intake to avoid malnutrition. Recover lost proteins Altered metabolism

Recommendations range from 1.1 – 1.6g/kg/day Lipids

Increase PUFA intake. Important to maintain energy.

Sodium & Fluid Reduce salt intake and maintain fluid restriction as

recommended. Phosphate

Restrict to avoid bone abnormalities Phosphate binders a must!

POTASSIUM

Serum potassium > 6.0 – 6.5 if GFR below 5ml/min.

Consider non-dietary causes of hyperkalemia.

Restrict to 1 mmol/kg body weight. 2.0 – 3.0g for HD 3.0 – 4.0g for PD

HIGH POTASSIUM FOODS

VITAMIN REPLACEMENT THERAPY Needed to support carbo, protein, lipid,

and nucleic acid metabolism. Absorption, retention, and activity affected

because :Restricted dietsUremic toxinsGI effectsDialysis process

Supplement & restrainReplace losses of water-soluble vitamins.Vit A retention causes toxicity.Excessive Vit C supplementation aids oxalate

formation.

CHECKPOINT! What have we learnt so far?

Protein Increase intake to avoid malnutrition.

Recover lost proteins Altered metabolism

Recommendations range from 1.1 – 1.6g/kg/day

Lipids Increase PUFA intake. Important to maintain energy.

Sodium & Fluid Reduce salt intake and maintain fluid restriction as recommended.

Phosphate Restrict to avoid bone abnormalities Phosphate binders a must!

Potassium To avoid heart problems. Decrease intake.

Vitamins Moderate intake.

PATIENT EDUCATION

Value of early education intervention on knowledge retention and practice.

INCREASE STAFFING & TIME REQUIREMENTS

Nutrition screening Monitoring of nutritional status Patient counseling

CONCLUSION

HAVE THE OBJECTIVES BEEN ACHIEVED?

Describe in detail the nutritional needs of ESRD patients.

Draw a food pyramid guide on nutrition for ESRD patients.

Be motivated to educate ESRD patients on their dietary intake.

Eat freely

Eat moderately

Eat with caution

Protein & Calories

Potassium

Phosphate Sodium : Eat moderately

Fluid : Drink moderately