3RD POSTING: ---------- DIET

DIET
By: D2- Gil Legarda and Joanalyn Balino

Title: CHANGES IN TOTAL SODIUM INTAKE DO NOT LEAD TO PROPORTIONATE CHANGES IN TOTAL SODIUM REMOVAL IN CAPD PATIENTS
Li-Tao Cheng and Tao Wang

Wang and Cheng conducted a follow- up observational study to elucidate the relationship between total sodium intake (TSI) and total sodium removal (TSR) in Continuous Ambulatory Peritoneal Dialysis patients. 40 Patients were included into this study; Treatment group: 15 patients for group with increase salt intake (ISI) and 9 patients for group with decrease salt intake(DSI).A total of 16 patients with stable TSI (control group). The exclusion criteria: (1) less than 3 months duration on Peritoneal Dialysis; (2) having an occurrence of peritonitis in the previous month; (3) unable to endow with detailed dietary records; (4) using sodium-containing medications like bicarbonate.All these patients included in the study received glucose- based dialysis solutions. 132 mmol/L. was the sodium concentration in dialysis solutions. Those 40 patients were closely followed for 3 months. The demographic data of 40 patients, including gender, age, height, weight, blood pressure, primary diagnoses, and duration on Peritoneal dialysis were recorded at baseline. Weight and blood pressure were also measured after the follow-up.

The group with increase sodium intake (ISI), the total sodium intake (TSI) increased 1.57 ± 0.97g/day or 68.3 ± 42.2 mmol/day from 1.42 ± 0.66 g/day or 61.7 ± 28.7 mmol/ day at baseline to 2.99 ± 0.56 g/day or 130 ± 31.7 mmol/ day at the end of the study. For the group with decrease salt intake (DSI), TSI decreased 1.54 ± 0.86 g/day or 67.0 ± 37.4 mmol/day, from 3.21 ± 0.57 g/day or 139.6 ± 24.9 mmol/day at baseline to 1.67 ± 0.23 g/day or 72.6 ± 10.0 mmol/day at the end of the study. In both groups, the changes in TSI reached statistical significance (p < 0.001). There were no significant differences in changes in sum of urinary sodium removal (USR), dialysate sodium removal (DSR), or total sodium removal (TSR) between the two groups.There was a significantly difference regarding the change in serum sodium concentration between the two groups. It was increased in group ISI and decreased in group DSI. On the other hand Urinary and dialysate sodium concentrations did not change.The changes in weight, blood pressure, number of antihypertensive medications, urine volume, ultrafiltration, and small solute removal (Kt/V and creatinine clearance) were not statistically significant between the two groups. The weights of patients in group ISI increased significantly during the follow-up (p < 0.05). The evaluation of fluid status between the 2 groups were ECW and E/T increased in group ISI and decreased in group DSI and these changes were all statistically significant (p < 0.05). There was no relationship was found between the TSI and TSR p = 0.193 and r is equal to -0.275. There were no significant changes in body weight, blood pressure, numbers of antihypertensive medications, or fluid status.


Alteration of dietary sodium intake might affect the difference in sodium concentration between blood and dialysates by slightly changing blood sodium concentration. The slight change has minimal impact on sodium removal as by dialysis in which to a large extent depends on convective transport induced by ultrafiltration. The product of ECW times serum sodium concentration increased for those who ate more salt and decreased remarkably in those who ate less salt. The study found that there is no relationship between sodium intake and residual renal sodium excretion in peritoneal dialysis patients. Patients in continuous ambulatory peritoneal dialysis changes in total sodium intake were not reflected in changes in total sodium removal through dialysate. With this result, it’s very important to cautiously measure and monitor dietary salt intake in CAPD patients.


Reference
Cheng, L. and Wang, T.. (2006). Changes in Total Sodium Intake Do Not Lead to Proportionate Changes in Total Sodium Removal in CAPD Patients.Peritoneal Dialysis International, Vol. 26, pp. 218–223. Retrieved June 26, 2009 from http://www.pdiconnect.com/cgi/reprint/26/2/218?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=salt+intake&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Dyad 6 guomanman and chenya

The Hemodialysis Diet Versus The Peritoneal Dialysis Diet
By Maria Karalis, MBA, RD, LD


Nutrition is an important part of your dialysis treatment plan whether you are on hemodialysis (HD) or peritoneal dialysis (PD). To give forth your best in all aspects of your lifestyle, you need to make an effort to maintain yourself by eating enough of the right kinds of foods or less restricted foods.

If you are thinking about changing modalities or need to make an informed decision about which modality to begin, there are a lot of issues to consider. One thing to consider is what your diet will be like on HD versus PD. This article will give you a very brief overview of the differences in these diets.

Protein

Protein is needed to keep tissues healthy and replace old or damaged tissues. People on PD are advised to follow a diet higher in protein than those on HD because protein is lost through the peritoneal membrane with every dialysis exchange. Some proteins are also lost during HD, but not to the same degree as PD.

Protein is also important as an aid for the body in preventing infection. Since the potential for infection is always present with PD, it is important to maintain a protein-rich diet. During infection, people on PD are advised to eat 1 1/2 times more meat and meat substitutes than usual.

There are two kinds of protein. High quality (animal) comes from milk, meat, chicken, fish and eggs, and contains all the needed ingredients for tissue growth. Low quality (plant) comes from vegetables, breads, cereals, and lacks some ingredients that tissues need to grow. You need both proteins. Your renal dietitian will decide your protein needs.

In order for your body to use proteins for growth and repair, sufficient calories are needed. Calories are necessary for energy and for maintaining your body weight. Just as fuel gives power to cars, calories fuel your body and give you energy. If you are underweight, you may have to eat high-calorie foods. This is more of an issue with HD patients.

People on PD tend to gain weight over time from absorption of calories from the dextrose in the dialysate (some people absorb as much as 500-700 calories each day from their dialysate). To minimize unwanted weight gain, decrease calorie intake. This should be done by reducing concentrated sweets and fats. Exercise is also important in maintaining your body weight. As always, check with your doctor before starting any exercise program.

Potassium

Potassium is a mineral vital for regulating your heart. People on PD do not usually require a potassium restriction since they are receiving dialysis every day. In fact, some are usually advised to increase their potassium through diet or oral medication.

Most people on HD need to limit their intake of high potassium foods since potassium builds up in between dialysis treatments. Some foods high in potassium include bananas, tomatoes, oranges, exotic fruits and potatoes.

Phosphorous

As kidneys fail, they lose their ability to balance calcium and phosphorus. Phosphorus combines with calcium to keep teeth and bones strong. Unlike potassium, phosphorus is not removed well by HD or PD. High phosphorus levels can eventually lead to calcium and phosphorus deposits in the heart, skin, joints and blood vessels. As such, phosphorus must be controlled through diet and phosphate binders for HD and PD. Phosphorus is found in almost all foods but is especially high in dairy products, cheese, dried beans, liver, nuts and chocolate.

Sodium

The amount of sodium allowed in HD and PD is the same. Sodium is limited to control thirst and keep blood pressure under control. For both HD and PD, food can be cooked with a small amount of salt, but no additional salt should be added to foods at the table.

On PD, sudden weight gain from fluids, elevated blood pressure or excessive thirst, may signal the need to cut back on sodium and/or fluid intake. Additionally in PD, excess water weight requires stronger, or higher, dialysate concentrations and consequently more calories are absorbed. This can eventually lead to an increased body weight.

Fluids

Healthy kidneys maintain fluid balance and prevent swelling in feet, ankles, legs, hands or face. When the kidneys lose their ability to get rid of extra fluid, excess water can raise blood pressure, cause strain on the heart and make it hard to breathe.

Fluid gain and fluid intake work the same for those on either modality. PD operates by putting 1-2 liters of fluid solution in the peritoneal membrane every few hours, depending on the dialysis. At the end of the exchange, the fluid is withdrawn. If more fluid is released than was put in, you will need to drink a little more. If less fluid is released than was put in, you will need to drink a little less.

One of the goals during HD is fluid removal. Less fluid gain between treatments results in better-tolerated treatments and is easier on the heart. Higher fluid gains can lead to cramping during dialysis and possibly longer treatment times (some people need extra treatment if all water weight is not removed). The goal for fluid gain should be no more than 1-2 pounds per day between treatments.

The fluid allowance for HD is determined by the amount of urine produced in a 24-hour period. Most people are limited to 700-1000 ml of fluid per day plus urine output. For example, if you urinate 500 cc, your total daily fluid allowance would be 1200 cc (500 + 700). Fluid allowances vary from person to person. Other considerations include how much the remaining kidney function is left and the person’s body size.

Hemodialysis Peritoneal Dialysis

Protein Based on needs Based on needs; protein needs higher than HD

Calories Based on needs Based on needs; focus is on less sweets/fats to

prevent unwanted weight gain from dextrose

in dialysate

Potassium Limited Not usually limited

Phosphorus Limited Limited

Sodium Limited Limited

Fluid Limited Limited but can be more liberal than HD

Summary

The table above provides a summary of the differences in PD and HD diets. For more specific and individualized advice about your diet, please consult with your physician and Registered Dietitian.

reference

http://www.aakp.org/aakp-library/hemodialysis-diet-versus-peritoneal-diet/

A Low-Protein Diet Does Not Necessarily Lead to Malnutrition in Peritoneal Dialysis Patients

Institute of Nephrology, First Hospital, Peking University, Beijing, China.

2005 National Kidney Foundation, Inc. Published by Elsevier Inc.

The Dialysis Outcomes Quality Initiative (DOQI) group guideline recommends that the dietary protein intake (DPI) for peritoneal dialysis patients should be more than 1.2 g/kg/d. However, this target is not realistic for many Chinese peritoneal dialysis patients. In the present study, we investigated the impact of a low-protein diet on patients’ nutritional status in a longitudinal cohort study in peritoneal dialysis patients.
Methods：Forty-seven peritoneal dialysis patients who had been on peritoneal dialysis for at least 3 months by the end of 2002 were included in the present study. All of the patients were followed up for 1 year. The patients were asked to collect their 3-day dietary record once every 3 months, and dialysis adequacy was evaluated once every 6 months. Subjective global assessment was performed at the beginning and by the end of the study. Comorbidities occurring during the follow-up were recorded. Fluid status was assessed once every 3 months. Patients were divided into three groups, with patients having a consistent DPI ≥ 0.8 g/kg/d in group 1, patients with a variable DPI in group 2, and patients with a consistent DPI < 0.8 g/kg/d in group 3.
Results：There were 12, 18, and 17 patients in groups 1, 2, and 3, respectively. At the beginning of the study, 53.2% of the patients were malnourished. During the follow-up, nutritional status had improved in 12 patients, did not change in 32 patients, and had worsened in 3 patients. By the end of the follow-up, 34% of the patients were malnourished with only one severely malnourished patient. Malnourished patients by the end of the study had a significantly higher incidence of new comorbidities, more inflammation, and a higher incidence of fluid overload. There were no significant differences in the dialysis adequacy index among the three groups.
Conclusions：Our study suggests that (1) many Chinese peritoneal dialysis patients did not achieve a high protein intake as recommended by the DOQI, but the low-protein diet does not necessarily lead to malnutrition in these patients, and (2) comorbidities occurring during the follow-up and volume overload may be the important risk factors for malnutrition in peritoneal dialysis patients.
Reference: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WKY-4GJ0D2C-7&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=941838742&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=833b6221dd53cb964a31fe701480e2f5

Cholecalciferol (Vitamin D3) Therapy and Vitamin D Insufficiency in Patients with Chronic Kidney Disease: A Randomized Controlled Pilot Study
Prakash Chandra, MD; José Nilo G. Binongo, PhD; Thomas R. Ziegler, MD; Lynn E. Schlanger, MD; Wenli Wang, MD; James T. Someren, MD; Vin Tangpricha, MD, PhD, FACE
Published: 05/28/2008

To maintain optimal bone health and calcium homeostasis, vitamin D is important to be incorporated in the diet. The parathyroid gland secretes hormones in order to maintain calcium in the blood. However, in patients with chronic renal disease, activation of the compensatory mechanism will increase the PTH secretion in order to maintain normal levels of vitamine D. In due time, chronic elevation of PTH will lead to secondary hyperparathyroidism which can lead to renal osteodystrophy. This double-blind, placebo-controlled research study is conducted in order to determine the effectiveness of weekly supplementation of cholecalciferol to reduce PTH levels and correct the vitamin D deficiency among patients with stage 3-4 CKD. 45 eligible participants were gathered upon screening based on the criteria established. The chemical blood component of the participants, which includes serum calcium, phosphate, albumin, AST and creatinine, will be assessed using the standard methods established by Emory University Hospital Chemistry Laboratory. The primary outcomes will be measured by week 6 and week 12 at a baseline data. The change in the primary and secondary outcomes will be examined using unstructured variance-covariance matrix. Confidence intervals were determined using a confidence level of 95%; statistical tests were 2-sided and performed at a 5% level of significance.

Findings from the clinical study revealed that weekly supplementation of cholcalciferol within 12 weeks duration can effectively correct the level of vitamin D in the serum of patients with CKD stage 3 and 4. After the 12 weeks therapy, the participants who received supplementation demonstrated an increase of 185% serum concentrations of vitamin D compared with a 5% increase in the placebo group.

Through the findings of the study, patients having stages 3 and 4 CKD will be able to have an optimal vitamin D status along with the cholecalciferol supplementation once a week for 12 weeks. It is assured to the clients that this dietary supplementation is safe as well as inexpensive. The awareness of deficiency in vitamin D followed by correction of vitamin D status will result in decreased risk of developing secondary hyperparathyroidism among CKD patients. The long term effects will also result in optimum bone health, better cardiovascular status and decreased mortality in CKD patients.

References:
Authors and Disclosures
Prakash Chandra, MD,1 José Nilo G. Binongo, PhD,2 Thomas R. Ziegler, MD,1,3 Lynn E. Schlanger, MD,3 Wenli Wang, MD,3 James T. Someren, MD,3 and Vin Tangpricha, MD, PhD, FACE,1,3 from the 1Graduate Program in Nutrition and Health Sciences and the Departments of 2Biostatistics and 3Medicine, Emory University, Atlanta, Georgia.

Dyad 6 guomanman and chenya


Diet on peritoneal dialysis
Peritoneal dialysis (PD) only became a common treatment for end stage renal disease in the 1980s. APD and CAPD are types of peritoneal dialysis (more info about peritoneal dialysis). It is usually a continuous or daily treatment, which means that diet is generally a little easier than it is for most patients on 3-times weekly haemodialysis.

Individual patients have different needs, so what is written here may not be exactly right for you. Renal dietitians will give advice according to your own blood test results and nutritional needs.




Protein

Patients on PD have some extra protein loss into the PD fluid, and this can add up to quite a lot each day. A higher protein intake is often recommended, e.g. an intake of 1.2-1.5 g/kg ideal body weight each day.

More information about protein in food.



Sodium (salt)

As for all renal patients, avoiding excessive salt is important. Too much salt will raise blood pressure, cause fluid retention and fluid overload, and it will make you thirsty so that you cannot keep your fluid intake down. We recommend a 'no added salt' diet. Do not use salt substitutes such as Lo-salt, which contain large amounts of potassium.

More info about avoiding excessive salt.



Potassium

The frequent or continuous dialysis that patients on PD have means that potassium is usually easier to control than on haemodialysis. Many patients do not need to restrict potassium at all, and some may need to deliberately eat foods containing potassium. However others do need to restrict their potassium.

More info on foods that contain high levels of potassium.



Fluid (liquids including water)

You can safely drink an amount equal to the volume of urine that you pass each day, plus usually 750ml. The amount of fluid removed by dialysis usually allows you more flexibility in the volume you can drink than haemodialysis, as the fluid is removed every day. This needs to be judged for you individually. If you eat too much salt, you will not be able to keep your fluid intake down and will accumulate fluid.

More info on fluids



Phosphate

Eating a diet higher in protein means that phosphate intake is higher. Most patients need to follow a phosphate restriction, and to take phosphate binders with food. The aim is to keep the phosphate level in the blood below 1.8mmol/l.

More info on controlling phosphate.



Energy (calories)

PD fluid contains sugar (glucose, also called dextrose), and some of this goes into the blood. It can contribute up to 500 calories per day in some patients. Some patients may therefore need to reduce the calories that they eat. However under-nutrition can be a problem in dialysis patients, so advice on this depends on your own needs.

More info about undernutrition and energy intake.



Fibre

Constipation can cause problems with peritoneal dialysis, so most patients are encouraged to eat enough fibre to keep things moving.



A healthy diet

All renal patients are at extra risk of developing heart disease. It is important to live and eat healthily, eating a varied diet and avoiding fatty foods.

DYAD 4
BALAJADIA, BOND
ZANO, ALEXIS

Knowledge of Phosphorus Compared with Other Nutrients in Maintenance Dialysis Patients

This study aims to assess knowledge of phosphorus compared with other nutrients in patient undergoing maintenance dialysis (MD). It compared knowledge of phosphorus versus other nutrients important to the MD diet (potassium, sodium, protein) in hemodialysis (HD) and peritoneal dialysis (PD) patients. It further measured gender, age, education level and functional health literacy to assess correlations in patient nutrient knowledge. Nutrient knowledge was measured using a 25-item chronic kidney disease knowledge assessment tool for nutrition (CKDKAT-N), and functional health literacy was measured using the short-form of the test of functional health literacy in adults (STOFHLA). Patients receiving maintenance outpatient HD or PD at the University of Wisconsin Hospital and Clinics Kidney Clinic, Wisconsin Dialysis Incorporated.
Main outcome measure: Phosphorus knowledge versus knowledge of potassium, sodium and protein.

Forty-seven MD patients participated in the study (29 HD, 18 PD, 30 males and 17 females, average age 58.6 (SD 13.8 ) years, average grade level 1.4 (SD 2.6) years of post-secondary education). 35 participants had adequate, 4 marginal and 8 inadequate health literacy. CKDKAT-N scores ranged from 6 to 21 of 25 items, mean score of 13 (SD 2.91). Knowledge of phosphorus compared with knowledge of other nutrients was poor (0.38 versus 0.72, p = 0.003). Comparing HD to PD patient knowledge, both phosphorus (0.37 versus 0.42, p=0.231) and other nutrients (0.69 versus 0.80, p=0.115) were the same.

Despite regular dietary instruction, patients undergoing MD have a poor knowledge of dietary phosphorus content, compared with knowledge of other nutrients important in chronic kidney disease. Interestingly, there was no difference in nutrition knowledge when comparing PD and HD patients, despite differences in education level and health literacy between the groups.

Reference: Pollock J et. al. Knowledge of Phosphorus Compared with Other Nutrients in Maintenance Dialysis Patients. PMC. September 2007

Dyad 3
Byron Webb A. Romero
Von Deneb H. Vitto
Raymond C. Ursal

RESPONSE: DIET OF PERITONEAL DIALYSIS PATIENTS

Numerous patients on peritoneal dialysis develop protein-energy malnutrition. Tjiong (2006) conducted a study which involved a dialysate solution with increased amount of Amino Acids (AA) with Glucose (G) to prevent malnutrition in patients undergoing Peritoneal Dialysis. The study compared 12 CAPD patients, one group received a mixture of AA (Nutrineal 1.1%) plus G (Physioneal l.36 - 3.86%) and the other group received G only as control dialysate. Results showed that even in a fed state, dialysis solution with AAG improves protein synthesis in CAPD patients. In conclusion, dialysate with AA plus G also improves protein synthesis in fed CAPD patients. Using such mixture may contribute to long-term improvement of the nutritional status of malnourished CAPD patients with deficient food intake. It could be a nutritional supplement that may help in improving the nutritional state of CAPD patients with poor ingestion of both proteins and calories.

Reference:

Tjiong, H.L., Rietveld, T., Wattimena, J.L., van den Berg, J.W., Kahriman, D., van der Steen, J., Hop, W.C., Swart, R., Fieren, M.W. (2006), Peritoneal Dialysis with Solutions Containing Amino Acids Plus Glucose Promotes Protein Synthesis during Oral Feeding, Clinical Journal of American Society of Nephrology (2007) 2: 74-80. Retrieved July 6, 2009 from http://cjasn.asnjournals.org/cgi/content/full/2/1/74

DYAD THREE (3)
Byron Webb A. Romero
Von Deneb H. Vitto
Raymond C. Ursal

ADDITIONAL RESPONSE TO: DIET FOR PERITONEAL DIALYSIS

Patients’ nutrition while on peritoneal dialysis is of utmost importance. It is essential to maintain good nutritional habits that conform with the requisites of our body for survival while uncompromising or worsening the current condition or illness. Because protein is much needed to keep tissues healthy and replace old or damaged ones, patients on PD are advised by their health care provider to follow a diet higher in protein especially that protein is lost through the peritoneal membrane with every dialysis exchange. Although some proteins are also lost during hemodialysis, it is not to the same degree as of those on PD. The potential for infection is also always present in patients on PD, which is why it is important to maintain a protein-rich diet as protein is also important as an aid for the body in preventing infection. Patients who are on PD are not usually required to be on potassium restriction since they are receiving dialysis every day. Some health care providers may even advise their patients to increase their potassium intake as it is vital for regulating heart function (Karalis, 2005). Phosphorus, unlike potassium is not well removed by PD thereby attributing to calcium and phosphorus deposits in some vital parts of the body resulting from the inability of the kidneys to balance calcium and phosphorus. As such, patients’ intake of phosphorus must be controlled through their dietary intake and use of phosphate binders. Sodium intake for patients in HD or PD is basically the same. It is limited so as to control the thirst mechanism and maintain controlled BP. For patients on PD, a sudden weight gain from fluids, elevated BP or excessive thirst, may signal the need to cut back on sodium and/or fluid intake of the patient. In addition, excess water weight would require a stronger, or higher dialysate concentration and consequently more calories are absorbed which can eventually lear to an increased body weight. Fluid gain and fluid intake work the same way for those on either HD or PD. Peritoneal dialysis operates by putting 1000 to 2000 mL of fluid solution in the peritoneal membrane every few hours but depending on the dialysis. At the end of the exchange, the fluid is then withdrawn. If more fluid is released than what was put in, the patient will need to drink a little more. If less fluid is released than was put in, the patient will need to drink a little less.

As diet is an important aspect of care for patients on peritoneal dialysis, our role as nurses is to promote a healthy behavior towards diet among our patients. We must also work collaboratively with other members of the health care team so as to deliver safe and quality care to our patients. It is also our role to conduct health teachings involving the patients and their families. We must continually utilize evidence-based researches on nutrition for patients on peritoneal dialysis to make ourselves up-to-date and maintain currency of practice.

Reference:
Karalis, M. (2005). Hemodialysis Diet versus Peritoneal Dialysis Diet. American Association of Kidney Patients. January 2005, 20 (4). Retrieved July 6, 2009 from http://www.aakp.org/aakp-library/hemodialysis-diet-versus-peritoneal-diet/.