Journal of Renal Nutrition and Metabolism Vol 2 No 3 July-September- 2016


Nutritional Management CKD 18

Guidelines For Maintenance Dialysis And Post-Transplant Nutritional Management

Dr Anita Saxena

Additional Professor, Department Of Nephrology, Sanjay Gandhi Post Graduate Institute Of Medical Sciences, Lucknow.

Key Words : Malnutrition, Maintenance Dialysis, Post-Transplant, Nutritional Management

Malnutrition is common in patients with chronic kidney disease, and its prevalence before the initiation of dialysis is poorly characterized in these patients in developing countries. The term malnutrition implies an imbalance in nutrient intake and nutrient requirement. It is of two types Type 1 and Type 2. Type I malnutrition is reversible with nutritional support but Type 2 malnutrition is not reversible despite nutritional support because of presence of inflammation . Once chronic kidney disease sets in, vicious cycle of malnutrition, inflammation, infection, anemia, fluid imbalance, hormonal imbalance and other associated disorders begins which sets in malnutrition, affects quality of life, and survival. Maintenance hemodialysis (HD) patients who are frequently anorectic are more susceptible to malnutrition. Amino acid loss to the dialysate and cytokine-mediated proteolysis as a result of exposure to bio-incompatible membrane and endotoxin­ contaminated dialysate is an important cause of malnutrition . Peritoneal dialysis (PD) is protein catabolic primarily because of protein and amino acid losses through the peritoneal effluent. Hence, protein requirements in HD and PD patients are increased compared with nonuremicsl. Malnutrition is present in patients before initiation of dialysis. Studies have shown that that there significant difference in serum proteins and CRP levels between malnourished and non-malnourished patients. The CRP level is high and serum albumin and serum protein is low amongst malnourished patients2. Uraemic patients have lower plasma concentration of essential amino acids. Characteristically, the branched-chain amino acids valine, leucine and isoleucine are decreased in chronic renal failure. Uraemia is associated with some specific abnormality leading to a selective depletion of valine, which may have a negative effect on protein synthesis. Important independent nutritional risk factors for mortality in renal patients which reflect malnutrition are low serum albumin, low SGA scores, low normalized protein intake, and low BMI. Markers of protein energy wasting are 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 <0.8 g/kg/d on maintenance hemodialysis (MHD) and energy intake <25kcal /kg/d for at least 2 months. Decreased dietary protein intake and dialysis associated protein catabolism leads to further derangement of nutritional status. From metabolic point of view, each

dialysis session decreases plasma amino acid levels and as a consequence blunts intracellular protein synthesis. Problems unique to patients with CKD which affect nutritional status are . Poor nutrition in general, late initiation of dialysis and inadequate dialysis, lack of proper diet counseling and poor monitoring of nutritional status, high incidence of infections, hyperglycemia, hyperlipidemia and cardiovascular involvement.

Malnutrition at initiation of dialysis is a strong predictor of subsequent increase in relative risk of death3. KDOGI guidelines4,5 recommend that predialyzed

stabilized serum albumin should be maintained ;;:: 4 g/dL , hence the requirements of dietary protein intake are double compared to CKD patients not dependent on dialysis. The loss of protein during HD is 1-3g/ HD session and during PD is 5- l5g/24 hours. To reverse protein loss high protein diet should b prescribed to patients on dialysis and at least 50% of protein high biological value (HBV). A patient on hemodialysis requires 1.2 g/kg/d in order to maintain neutral nitrogen balance. A stable patient on peritoneal dialysis requires 1.2 g/kg/d, however, if patient is malnourished he should be prescribed 1.3 g/kg/d. Milk and milk products, poultry, fish and soya products are foods of HBV. Peritonitis is a hyper catabolic state. Patients suffering from peritonitis require 1.5 g/kg/ d of protein. Since patients are kept on high protein diet, renal specific oral supplements to increase protein and energy intake6.

The energy requirements of patients on dialysis are 35 kcal/kg bw for those < 60 y of age and 30-35 kcal/kg for those > 60 years. Dextrose based dialysates result in net positive calorie gain due to glucose absorption. Patients on PD often suffer from abdominal discomfort and suppression of appetite due to presence of dialysate in the peritoneal cavity and absorption of glucose (100 to 200g/d) . Peritoneal dialysate calorie load should be included in total energy intake. A patient can get 300-500 kcal/dfrom dialysate.

Patients with renal failure are at risk of developing hyperphosphatemia and hyperkalemia due to impared clearance of phosphates and potassium. Hence dietary phosphorus intake should be restricted to 800-1000 mg/d to prevent hyperphosphatemia and potassium intake should be 1 mEq/kg/d. High phosphorus foods are milk products, processed or spreadable cheese, meats, fish, dry fruits (almond, pistachio), chocolate, colas. Plant based protein should be preferred . High protein to phosphorus ratio foods should be avoided. Patients can take one small fruit a day like

Journal of Renal Nutrition and Metabolism Vol 2 No 3 July-September- 2016 Nutritional Management CKD 19


apple, banana, guava, pear, orange, or papaya. If serum potassium is > 5.0 mg/dL patients should be advised not to take fruits. The food items patients need to avoid routinely include green leafy vegetables, tomatoes, sweet lime, lemon, carrots, raw salad, mango, dry fruits, fruit juice, vegetable soup, coconut water, melons and watermelons. To reduce potassium intake leach/remove potassium from vegetables by soaking chopped vegetables in luke warm water for half an hour. Patients should avoid green leafy vegetables. However, a small helping of green leafy vegetable (sagg) can be taken occasionally.

Calcium intake should be <2 g/d, preferably 1000- 1500 mg/d including supplements. Salt intake should be restricted to prevent edema and deterioration of blood pressure control. Sodium intake should be <2 . g/d. Cholesterol intake should be less <200 mg/ d, hence patient should be advised not to take egg yolk and milk cream. If serum cholesterol is <100 mg/dL, egg yolk can be advised. Water soluble vitamins and minerals need to be supplemented . Zinc supplementation is advocated if zinc deficiency is documented in patients. Anemia cannot be corrected through diet therefore patients have to be advised folic acid, B12, iron supplements (after proper assessment of iron profile) and erythropoietin stimulating agents (ESA) .

Once patient u ndergoes successful renal transplantation, the uremic factors associated to malnutrition of dialysis period are reversed and there is significant increase in appetite after renal transplantation7 ,8. After transplant, patients face a lot of nutritional challenges because of side effects of immunosuppressive medications and corresponding metabolic abnormalities which impact on long term morbidity and quality of life of KTR and patients develop declining renal function . For nutritional management, the post transplant period is divided into three phases, first Month Post Surgery (0-30 days), second month (Day 31-90), and fourth Month onwards (Day 91 Onwards) but if graft function is impaired (Chronic Renal Allograft Injury ( CRAI) ) the patient's nutritional requirements are are set according to CKD predialysis nutritional regimen.

Transplanted patients develop acute PEM in the early post­ transplant period due to surgical trauma, short-term starvation, high-dose steroid therapy and acute rejection episodes, pre-existing protein-energy malnutrition (dialysis period), delay in restoration kidney function9. Since, the surgical trauma is generally mild, bowel function is rapidly restored . Spontaneous oral nutrient intake is resumed therefore enteral or parenteral nutrition are generally not required 10.

Phase 1 First Month of Surgery (0-30 days) : Protein requirement is 1.2-1.5 g/kg/d, energy requirement is 35 kcal/kg/ d and that of fat is 20g/dl. Restrict cholesterol to <200 mg/d

Salt intake should be 2.5/g/d or more depending upon blood pressure and urine output. Potassium intake should be liberal(3.5g/d or more) if urine output is more than 4-5 liters. If Tacrolimus (TAC) induced hyperkalemia ensues, restrict potassium intake Fluid intake during kidney transplant unit (KTU) stay should be liberal along with replacement with intravenous fluids if graft function is

normal and patient's urine output is high (:2::8.0 liters). In case of rejection and anuria/oliguria (<400 ml/d) fluid intake will have to be restricted. Magnesium supplementation ( 1g TID) if is required if hypomagnesemia occurs due to calcineurin inhibitors. Calcium intake should not exceed 1300 mg and it should not to be taken with meals. To treat anemia iron, folic acid, B6, B 12 supplements need to be added.

Phase 2 : After Ist Month (31-90 days): Protein intake should be reduced to 1.0 g/kg/d energy 35 kcal/kg/d, fat 20g/. Phosphate supplementation may be considered if hypophosphatemia persists despite adequate dietary intake. Advise phosphorus rich foods (protein) with organic phosphorus and high bioavailability (milk , cheese yogurt , poultry, colas) . In case of patient develops hyperglycemia, i.e., new onset diabetes after transplantation (NODAT), restricting energy intake to 30 kcal/kg/d (Insulin therapy as per requirement)is important. Target HbAlc at 7.0-7.5%, although <7.0% is recommended . Fluid intake should be liberal if graft function is normal. In case of rejection and anuria/oliguria (<400 ml/d) fluid intake should be reduced according to urine output. Potassium intake should be liberal if urine output is more than 4-5 liters and but restrict potassium intake If patient has tacrolimus induced hyperkalemia . In the immediate post-kidney transplant period a rapid decline in bone mineral density (BMD) can occur because of high immunosuppressive doses and may continue during 1st 2 years. Calcium deficiency, low weight, low BMI, and low 25 hydroxy Vitamin D levels which correlate with BMD reflect poor nutritional status. Calcium intake should be 1000-1300 mg/d and that of Vitamin D should be 5-15 µg/d. Intervention with vitamin D (0.25-0.5

µg/d) or analogues (calcitonin) with or without calcium (500-1500mg/d), or bisphosphonates are effective in preventing bone loss

Phase 3: Third Month Onwards Maintenance Phase: Once the patient has stabilized after transplant (3rd month post transplant onwards) and the immunosuppressive medication trough levels have stabilized, the patient should gradually start reducing his water intake from 6-7 liters to approximately no more than 3 liters. Blood pressure is a good guide for water intake. If patient is requiring too many antihypertensive medications, it is possible that his total body water may be more than required . Bioimpedance technique can measure water compartments and also estimate dry weight. Ifthere is difference between actual weight and dry weight, this would imply expanded water compartments and so water intake will have to be reduced. Patients should be advised not to indulge in excessive water drinking. Water intake should be thirst driven. High dose of corticosteroids also cause retention of salt and water. Restrict protein intake t o O . Sg/ k g / d . D i e t a r y re com m e n d a t i on s for hyperdyslipidaemia are changes in life-style, a diet rich in wholegrain with 25 g fibre for females and 30g for males , low glycemic index foods along with avoidance of simple sugars. Patients should eat more fresh and high-fiber foods (carbohydrates) and fats no more than 30% of total energy and rich in vitamin E . Monounsaturated fat should be restricted to 20%. Olive oil, canola oil, soft tub margarine should be recommended along with sunflower oil. Saturated (7%) and trans fats (< 1%) no more than 8% of total energy. n6 PUFA should provide 8-10% of total energy.

Journal of Renal Nutrition and Metabolism Vol 2 No 3 July-September- 2016 Nutritional Management CKD 20


Omega 3 PUFA intake should be 2-3 g/d. Control weight gain to prevent obesity.

General Precaution: During early post-transplant period and in periods of acute illness, the likelihood of food­ borne infection is high due to significant suppression of the immune system. Patients should be advised to drink boiled water, maintain hygiene and wash vegetables thoroughly. They should eat freshly cooked food. In case the skin of the fruit is oily it should be washed with warm water.Patients with normal graft function can take fish/chicken twice a week. Patients on antihypertensive medication should be advised not to add extra salt to food. Remove salt shaker from the table. Patients on Tacrolimus should not take grapefruit juice . Nutritional status of the patient should be monitored every three months.

Chronic Renal Allograft Injury (CRAI) : In case of graft dysfunction and progressive decrease in GFR, restricting dietary protein might be beneficial with respect to kidney function . This is generally associated with proteinuria and arterial hypertension . Dietary prescription should be protein 0.6-0.75 /kg/d to reduce proteinuria and stabilize renal function; salt 2.5-5.0 g/d or sodium 2000 mg, potassium 3,500-4000 mg, calcium > l200mg/ d to prevent osteoporosis, phosphorus 800-1000 mg/d and Vitamin D supplementation if required .

Correct Metabolic Acidosis Sodium baicarbonate 0.9g/kg/d in three divided doses can be advised. Check bicarbonate level monthly. Maintain it at 22.0mmol/dL Phosphate binders to be taken with meals if serum creatinine is >2.0 mg%. fluid intake will have to be monitored! 1.


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