1. NUTRITION IN PERITONEAL
DIALYSIS (PD)
TEENA GUPTA
Nutritionist

2. FUNCTIONS OF THE KIDNEY
Regulation of red blood Regulation of the
cell production blood’s acid base
balance
Regulation of Regulation of mineral
blood pressure levels
Elimination of metabolic
toxins and excess water
through urine

3. END STAGE RENAL DISEASE
(ESRD)
Patients with ESRD display a variety of metabolic and
nutritional abnormalities and a large proportion of
patients demonstrate signs of protein- energy
malnutrition (PEM).
Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting
during peritoneal dialysis. In: Nolph and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd Edn.
NY: Springer, 2009: 611-647.

4. DIALYSIS – TREATMENT OPTION
IN ESRD
PEM and inflammation
are highly prevalent in
PD and may contribute
to the high mortality in
these patients.
Avram MM, Fein PA, Rafiq MA, Schloth T, Chattopadhyay J, Mittman N. Malnutrition and inflammation as predictors of
mortality in peritoneal dialysis patients. Kidney International 2006; 70:S4-S7

5. MALNUTRITION
MALNUTRITION IS THE RESULT OF AN
IMBALANCE
BETWEEN NUTRIENT INTAKE
AND
NUTRIENT REQUIREMENT
Supply Demand
NUTRITION
INTAKE
Body Stores
LOSSES
*Kopple, NKF Press release 5/1/99

6. MANIFESTATION OF
MALNUTRITION IN PD PATIENTS
Protein Energy
malnutrition malnutrition
Decrease in body weight
Low muscle mass
Low fat mass
Hypo – proteinaemia
Low carbohydrate stores
Combined Protein &
Energy Malnutrition

7. MANIFESTATION OF
MALNUTRITION IN PD PATIENTS
↓calories
↓protein +stress Starved appearance
Well nourished -↓weight
-↓triceps skinfold
appearance -↓mid arm
- Oedema circumference
- Loose hair Serum albumin
↓serum may
albumin be lowered
Butterworth CE, Weinsier RL. Malnutrition in hospital patients: assessment and treatment. In:
Goodhart RS, Shils ME, eds. Modern nutrition in health and disease. 2nd Ed. Philadelphia:Lea &
Febiger, 1980 :160-7

8. PEM IN PD PATIENTS
Increased mortality and cardiovascular
death
Cardiovascul
Inflammati ar disease
Malnutritio
on n
Resting
Hypermetabolism
Loss of residual renal function
Wang AYM. The heart of peritoneal dialysis. Perit Dial Int 2007; 27(Suppl_2): 228-232

9. .
PREVALENCE OF
MALNUTRITION
Severe malnutrition ranges from 2-9% and mild – to –
moderate malnutrition ranges from 33-45% in PD
patients¹.
PD patients absorb a large amount of calories from the
dialysate and may look “ over- nourished” in body
weight but actually have low serum albumin and
protein malnutrition².
¹Chung SH, Na MH, Lee SH, Park SJ, Chu WS, Lee HB. Nutritional status of Korean peritoneal dialysis patients. Perit Dial Int 1999; 19(Suppl 2):S517-22
²National Kidney Foundation. K/DOQI Clinical practice guidelines for nutrition in chronic renal failure. New York, NY: National Kidney
Foundation; 2001.

10. CAUSES OF MALNUTRITION
IN PD PATIENTS

11. MULTIFACTORIAL IN NATURE
Dialysate losses of
proteins, amino acids
Accumulation of Inadequate
uremic toxins food intake
Chronic Loss of blood
Inflammation
MIA Syndrome Endocrine disorders
Catabolic response of uremia
to Co morbidity
KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

12. ASSESSMENT OF THE
NUTRITIONAL STATUS OF PD
PATIENTS IS IMPORTANT

13. EARLY ASSESSMENT IS
IMPORTANT
 To prevent, diagnose and treat uremic malnutrition because
malnutrition itself may lead to anorexia and vice versa
Reversibility may take years
Recovery is slow and often incomplete
 By early identification, use of optimal diet & dialysis will lead to an
improvement in nutritional status.
For evaluation of dietary requirement
Development of suitable nutritional strategy to prevent malnutrition.

14. THERE IS NO SINGLE MAGIC
NUTRITIONAL INDEX
 Each has limitations.
Combination of valid, complementary measures.
 Even if patients have good nutritional status, they
should be monitored - every 6 months if <50 yrs
- every 3 months if > 50 yrs.
Perez VO, Heranandez EB, Bustillo GG, Penie JB, Porben SS, Borras AE, Gonzalez CM, Martinez AA. Nutritional
status in chronic renal failure patients assisted at the hemodialysis program of the Hermanos Ameijeiras Hospital.
Nutr Hosp 2007; 22:677-94.

15. ASSESSMENT OF NUTRITIONAL
STATUS
1. Measurements to be  Predialysis or stabilized
performed routinely in all serum albumin
patients  % of usual post dialysis or
post drain weight
 % of standard body weight
 Subjective Global
Assessment (SGA)
 24-hr dietary recall/ Diet
diary
 nPNA
KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

16. ASSESSMENT OF
NUTRITIONAL STATUS
2. Measures to confirm the  Predialysis or stabilized
data obtained from Category serum prealbumin
1  Skinfold thickness
 Mid-arm muscle area,
circumference, or diameter
 Dual energy x-ray
absorptiometry

17. ASSESSMENT OF
NUTRITIONAL STATUS
3. Clinically useful measures  Predialysis or stabilized
serum
 Creatinine
 Urea nitrogen
 Cholesterol
 Creatinine index

18. ANTHROPOMETRIC
MEASUREMENTS
•Weight (kg) •Height (cms)
•Body mass Index – BMI •Ideal Body Weight – IBW
•Mid Upper Arm Circumference - MUAC •Skin Fold Thickness – SFT
Skin Fold Thickness - Body fat
stores
Mid Arm circumference - Muscle mass
Low % IBW and BMI are of concern
At present, anthropometry is the only method that can be readily performed in
most units.

19. MUAC
Skin fold
Thickness
Skin fold thickness is measured by lightly pinching the skin and subcutaneous fat layers to separate them from the underlying muscle tissue (figure 2).
Pinching the fat fold too firmly will change the result, so the initial grasp of the skin and subcutaneous tissue is
critical to an accurate measure. The spring-loaded pressure calipers are applied until the needle on the dial comes to a stop.

20. PATIENT HISTORY & DIETARY
RECALL
Valid & clinically useful for measuring dietary protein and energy intake.
3 day diet dairy preferred to 24 hr dietary recall
Symptoms of anorexia, nausea ,vomiting, weight loss ,dietary habits and
pattern, quantity & quality of food ingested and fluid balance should be
properly and carefully evaluated and compared with the recommended
intake.
KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;35(6) (S2):S1-S104.

21. NUTRITIONAL
MANAGEMENT

22. RECOMMENDED
NUTRITIONAL INTAKES FOR
PD PATIENTS¹
Nutrients Recommended intakes per day
Energy 35 Kcal/ kg IBW - <60 yrs
30-35Kcal/ kg IBW - ≥60 yrs
Protein KDOQI recommends 1.2-1.3g/kg IBW/ day(=50% of High
Biological Value). Some nitrogen balance studies indicate
that protein intake of ≥ 1.0 g/ kg IBW may be enough.
Fats 30% of total energy supply
Water and As per residual diuresis
sodium
Potassium 40-80mmol. Individualized depending on serum levels
Calcium Individualized, usually not <1000mg/ day
Phosphorous 8-17 mg/ kg or 800-1000 mg/ day (adjusted to higher protein
needs), when serum phosphorous is > 5.5 mg/ dl²
¹Carrero JJ, Heimburger O, Chan M, Axelsson J, Stenvinkel P and Lindholm B. Protein energy malnutrition/ wasting during peritoneal dialysis. In: Nolph
and Gokal’s textbook of Peritoneal Dialysis. Krediet RT, Khanna R, eds. 3rd Edn. NY: Springer, 2009: 611-647.
²National Kidney Foundation. K/DOQI clinical practice guidelines for managing bone metabolism in chronic kidney disease. Am J Kidney Dis2003; 42(suppl
1):S1-S92

23. PROTEINS
To compensate the protein loss (5-15g/ day) through dialysis in PD
EAT MORE - CLASS I PROTEINS EAT LESS/AVOID
 Egg White
 Red Meat
 Fish & Chicken
 Egg Yolk
 Low Fat/ Skim milk/Soymilk
 Organ Meat
 Skim Milk Products
 Full fat milk
 Soya bean
 Full fat milk pdts
EAT MODERATELY - CLASS II  Shell fish
PROTEINS
 Pulses & legumes
 Mixed Cereals

24. ENERGY
Carbohydrates Fats
o Carbohydrates (CHOs) are
o An essential nutrient that
the main source of energy
provides concentrated
(1 gm=4Kcal)
energy. (1gm Fat = 9 Kcal)
o They also provide calcium, o Contributes to the
Iron and B vitamins.
palatability of food.
o In PD diet at least 50% o Carriers of fat soluble
calories should be from
vitamins
CHOs
o Supplies essential fatty
o Excess calories from CHOs,
acids.
stored as fats

25. TYPES OF CHOS
Simple Complex
sugar

26. FATS
1 g Fat = 9 kcal

27. FATS
Unsaturated fats Saturated Fats (Eat Less/
(Eat in moderation) Avoid )
 Oils high in PUFA like  Butter & Ghee
sunflower, soya,  Cream, processed cheese
safflower, corn  Coconut & palm oil
 Oils high in MUFA like
 Egg yolk, Red meat,
mustard, groundnut oil, shellfish
olive oil, corn & sesame
oil
Fundamentals of Food and Nutrition III edition Sumati R, Mudambi. Et al

28. APPROXIMATE ENERGY
ABSORPTION FROM DIALYSATE
 60-70% of the energy is absorbed from the dialysate*.
 Energy absorption from :
 1.5% / 2L solution = 78 Kcal
 2.5% / 2L solution = 130 Kcal
 4.25% / 2L solution = 221 Kcal
* Heimburger O, Waniewski J, Werynski A, Lindholm B. A quantitative description of solute and
fluid transport during peritoneal dialysis. Kidney Int 1992; 41:1320-1332

29. PICKLES, PAPAD, CHUTNEY ,ADDED SALT
PROCESSED & FAST FOODS
SODIUM
Salt = sodium chloride
1 teaspoon of salt contains
2g – 2.4 g of sodium
SALTED SNACKS SEASONINGS & SAUCES

31. FLUID OVERLOAD AND PD
 Clinical features of over hydration are observed in roughly
¼ of the patients on CAPD, in addition to the cumulative
appreciation of the risk for cardiovascular mortality that chronic
fluid overload presents¹·². Fluid overload is an important
contributor for a high dropout rate in PD³.
¹Lameire N, Van Biesen W.The impact of residual renal function on the adequacy of peritoneal dialysis. Perit Dial Int 1997 ;( 17 Suppl
2):S102-10.
²Bergstrom J, Lindholm B. Malnutrition, cardiac diseases and mortality: An integrated point of view. Am J Kidney Dis 1998; 32:834-841.
³Gan HB, Chen MH, Lindholm B, Wang T. Volume control in diabetic and non diabetic peritoneal dialysis patients. International Urology
and Nephrology 2005; 37:575-579.

32. FLUID OVERLOAD EVALUATION
 Detailed history from the patient about urine output, UF,
fluid intake, compliance with exchanges, and pattern of
weight gain
 Inspect patient’s PD records comparing patient weight,
solution tonicity and UF achieved
 Do a physical examination looking for extent of fluid
overload.
 Bioelectrical Impedance Analysis (BIA) of total body water

33. FLUIDS
Fluid input = Food + Drink*
Fluid output = Amount of ultrafiltrate + urine output +
insensible losses*
Fluid includes everything that melts at room
temperature.
FLUID SOURCES: Water, tea, coffee, milk, lassi. juice,
soups, cold drinks, vegetable gravies, curries, dals, etc.
and other liquids present in food.
* Varies from patient to patient

34. HOW TO CONTROL FLUID
OVERLOAD
 Avoid excess of fluid
 Control salt intake
 Daily weight and BP
monitoring
 Adequate dialysis
 Adequate Glycemic Control
 Decrease dietary sodium
Intake

35. POTASSIUM

36. FRUITS ALLOWED
Potassium level : 3.5-5.5 mEq/L

37. MILK & MILK
PRODUCTS
PHOSPHORUS
CHOCOLATE, SOFT DRINKS
EGGS & POULTRY
NUTS,PULSES & LEGUMES

38.  The net absorption of phosphorus from a mixed
diet has been reported to be in the range of 55–
70% in adults.*
 Ca x P < 55 mg²/ dL² or else it can cause
metastatic calcification
* Rufino M,Bonis ED,Martin M, et al., Is it possible to control hyperphosphataemia with diet, without inducing protein
malnutrtion?, Nephrol Dial Transplant, 1998;13 (Suppl. 3):65–7.

39. SUMMARY
 Prophylaxis is better than treatment
 Malnutrition once established, is always difficult to
treat
 Malnutrition at the start of PD is a poor prognostic
sign
 Pay attention to nutrition in PD patients before start
of therapy
 Proper nutrition counseling
 Monitor nutritional parameters

40. Eat
Well

41. THANK YOU