malnutrition in dialysis
Pathogenesis and treatment of malnutrition in maintenance dialysis
Malnutrition is a crucial problem in patients treated with chronic hemodialysis or peritoneal dialysis.
It occurs in 20 to 70 percent of patients (depending upon the strategy accustomed measure nutritional status), with an increasing length of your time on dialysis correlating with an increasing decline in nutritional parameters.
There could also be significant differences between countries with reference to some measures of nutritional status, like albumen concentration.
Based upon the Dialysis Outcomes and Practice Patterns Study (DOPPS), as an example, the subsequent mean albumen levels were reported in France (3.87 mg/dL), Germany (4.17 mg/dL), Italy (3.98 mg/dL), Spain (3.98 mg/dL), us (3.6 mg/dL), and also the uk (3.72 mg/dL).
However, since differences in measurement methods cause differences in results, the strategy used from laboratory to laboratory and country to country must be known to assess any true differences in albumin in a private patient or groups of patients.
Two important issues are discussed elsewhere:
• How is nutritional status evaluated
• What is that the relation between nutritional status and survival? Patients with malnutrition, as manifested partly by hypoalbuminemia, measured at the onset of or during maintenance dialysis, have an increased fatality rate ( figure 1A-B ).
• this is often true for patients treated with either maintenance hemodialysis or peritoneal dialysis.
• The pathogenesis, prevention, and treatment of malnutrition in these patients are discussed here.
• Most of the observations are made in patients treated with maintenance hemodialysis, but similar considerations apply in many respects to continuous peritoneal dialysis.
The most readily treatable reason for inadequate nutrition in many patients is underdialysis, which might result in anorexia and decreased taste acuity.
Patients with a minimally acceptable Kt/V and a coffee mid-week BUN may appear, initially glance, to be dialyzed.
However, many such patients are underdialyzed with poor protein intake being answerable for the low BUN.
This problem eventually led to the appreciation that protein intake must be considered when evaluating the adequacy of dialysis.
Thus, estimation of the normalized protein equivalence of nitrogen appearance (nPNA), as index of protein intake, may be a a part of the dialysis regimen.
This is also called the normalized protein catabolic rate (nPCR).
The PCR is simply valid as a measure of protein intake within the patient in neutral balance.
The relationship between the dose of dialysis and protein intake was demonstrated in a very small group of hemodialysis patients in whom the intensity of dialysis was increased by enhancing dialysis time, blood flow, and/or membrane extent.
As the Kt/V rose from 0.82 to 1.32 over a 3 month period, there was a concurrent elevation in PCR from 0.81 to 1.02 g/kg per day.
the increase in PCR was indicative of increased protein intake (and better nutrition) due, presumably, to improved appetite.
A second group during which the dialysis regimen was unchanged had no increase in either Kt/V or PCR.
Whether there’s a mathematical link between Kt/V and PCR because they’re both calculated from similar measures could be a subject of debate.
Further support for the observation of improved nutritional intake with increased dialysis dose was reported during a study during which improved weight was observed with more frequent daily hemodialysis.
An increased dialysis dose may additionally enhance nutritional status among malnourished peritoneal dialysis patients.
Even within the well-dialyzed patient, however, variety of things can impair nutrition:
• The presence of an acute, chronic, or occult systemic illness resulting in an inflammatory response may adversely impact nutritional status. Markedly increased energy expenditure, proinflammatory cytokine levels, and oxidative stress appear to produce a link between inflammation and malnutrition.
• Nutrients are lost into the dialysate.
• As an example, aminoalkanoic acid losses into dialysate can average 4 to eight g/day with peritoneal dialysis or hemodialysis.
• With peritoneal dialysis, losses rise much higher during episodes of peritonitis.
• With hemodialysis, certain reuse procedures lead to increased losses of protein into dialysate.
• Protein loss as high as 20 grams in one hemodialysis has been reported with polysulfone dialyzers reused with bleach.
• Dietary restrictions can make food less palatable.
• Furthermore, the encouragement to limit fluid intake to attenuate intradialytic weight gain may result in a concurrent decrease in caloric intake.
• Solid food contains a high fluid content and lots of beverages contain a considerable amount of calories.
• The dialysis procedure itself could also be catabolic, thanks to reduced protein synthesis and also the loss of amino acids in dialysate; this effect could also be more prominent with bioincompatible membranes.
• This may be overcome with appropriate nutritional intake.
• As shown in some, but not all, studies, persistent acidosis may enhance protein degradation and aminoalkanoic acid oxidation.
• Gastroparesis (by slowing gastric emptying) or, in peritoneal dialysis, the presence of dialysate within the abdomen may impart a sense of fullness.
• Some medications, like phosphate binders, can impair nutrient absorption.
• Adequate dialysis isn’t a whole substitute for the clearance functions of an intact kidney. specifically, the retention of middle molecules (1000 to 5000 Daltons) may partially contribute to anorexia, possibly by directly affecting the central systema nervosum.
• Serum concentrations of leptin, a hormone that induces satiety via effects upon the hypothalamus, could also be increased thanks to reduced renal or dialysis clearance.
• However, a job for leptin in malnutrition within the dialysis patient remains to be proven.
• Chronic volume overload could also be directly related to malnutrition, with improved fluid status increasing overall nutritional status.
• The presence of both malnutrition and intensely low levels of renal function at the time of dialysis initiation are directly related to subsequent poor nutritional status despite adequate dialysis.
• This observation suggests that dialysis should be begun before the onset of serious malnutrition.
• The commencement within the prevention of malnutrition is careful assessment of the patient’s nutritional status at the start of dialysis and each three to 6 months thereafter.
• Early diagnosis and correction can avoid clinical deterioration which will make the patient harder to treat, partially because malnutrition itself may cause anorexia.
• This relationship is recommended by studies within which improved nutritional status led to improved food intake.
• In one report, for instance, malnourished patients on hemodialysis received parenteral nutrition supplements during the dialysis procedure.
• This led to a rise in food intake, which began before any changes can be demonstrated in nutritional status.
Ingestion of an adequate diet is incredibly important if malnutrition is to be prevented. Patients previously on a low-protein diet might have to be reminded to extend protein intake once dialysis begins to counteract protein loss within the dialysate.
Although somewhat controversial, a diet providing 1.0 to 1.2 g/kg per day of high biologic value protein is usually recommended for patients on hemodialysis.
Continuous ambulatory peritoneal dialysis is related to a better level of dialysate protein loss; as a result, protein intake should be a minimum of 1.2 g/kg per day with this treatment modality.
One study demonstrated that the metabolic response to protein intake is normal in hemodialysis patients, further supporting the importance of maintaining adequate dietary protein intake.
Adequate caloric intake also must be emphasized, since it’s required for anabolism.
In one study, for instance, patients on maintenance hemodialysis were studied on different diets.
There was negative balance unless caloric intake was a minimum of 32 kcal/kg ideal weight
For patients treated with peritoneal dialysis, the calories provided by the dialysis solution should be taken under consideration.
The presence of malnutrition is sometimes suspected from anthropometry or the presence of hypoalbuminemia or decreased creatinine production.
Evaluation should begin with an intensive history to see whether the reduction in food intake is caused by unpalatable dietary restrictions or by changes within the patient’s sense of taste.
The dietary history should include personal or ethnic food preferences.
If limiting such preferences is interfering with food intake, the clinician or dietitian should work with the patient and family to feature more preferred foods to the diet. In cases of severe malnutrition, most or all dietary limitations may must be removed for a limited period of your time.
In general, if malnutrition is diagnosed, we advise the subsequent stepped treatment strategy:
• Evaluation of any source of inflammation should be sought and managed.
• Dietary intake should be assessed and dietary counseling should be undertaken.
• If the patient cannot improve nutrient intake by diet alone, intake should be improved in a very step-wise fashion, starting with oral supplements and ending with total parenteral nutrition if no other nutrient intake methodology is suitable.
Drugs that may impair appetite or make meals less palatable should be reduced or eliminated.
In severe cases, the patient may have the benefit of temporary cessation of oral phosphate binders.
Hyperphosphatemia may be a lesser risk during this setting, since the low protein intake itself will lower the plasma phosphate concentration.
In fact, hypophosphatemia is also an extra clue to the presence of malnutrition.
Gastroparesis may be contributing factor to decreased food intake by delaying gastric emptying, thereby increasing the sensation of fullness.
This complication is most typical in diabetics (possibly affecting as many as 20 to 30 percent of diabetics with end-stage renal disease), but can even occur in nondiabetics.
If gastroparesis is suspected from the history, the speed of gastric emptying may be accurately assessed by various methods, like ingestion of a radiolabeled test meal with simultaneous gastric scanning.
If slow or delayed gastric emptying is documented, several therapeutic modalities is also beneficial:
• Metoclopramide are often given, but the dose must be limited in patients with end-stage renal disease.
• Patients are successfully treated with erythromycin
• Patients not awake to erythromycin may answer other agents, like cisapride.
• However, the utilization of cisapride is now restricted per the manufacturer’s and Federal Drug Administration’s recommendations thanks to the chance of arrhythmias.
• As of August 2000, prescriptions for the drug can only be filled directly through the manufacturer after providing documentation on need for the drug and assessment of risk factors for cardiac arrhythmias within the individual patient (including a protracted QTc on the EKG or use of medicines known to change the drug’s metabolism like macrolide antibiotics, antifungals and phenothiazines).
If gastroparesis is detected via gastric emptying scans, the optimal therapeutic agent is also chosen based upon the prokinetic response to an intravenous test dose.
As an example, the gastric emptying response to intravenous doses of metoclopramide (5 mg) and erythromycin (200 mg) was assessed in 6 dialysis patients with hypoalbuminemia and occult gastroparesis.
Subsequent oral therapy based upon a successful gastric response significantly improved albumen levels (from 3.3 to 3.7 g/dL).
If attention to the preceding problems doesn’t improve appetite and food intake, then nutritional supplementation could also be necessary.
Oral supplementation, enteral tube feeding, and parenteral nutrition are all possibilities.
A 2005 systematic review and meta-analysis of 18 studies (including five randomized controlled trials) found that enteral nutritional support increased total intake and albumin concentration (0.23 g/dL).
Clinical outcomes were evaluated in precisely some studies, while data was inadequate to check both disease-specific versus standard formulae and enteral versus parenteral nutrition.
Oral supplements are the simplest and cheapest to use.
Several supplements are intended primarily for the patient with end-stage renal disease.
They are low in potassium and fairly dense in nutrients, thereby providing adequate calories and protein, while minimizing the danger of hyperkalemia and fluid overload.
However, these supplements have the disadvantage of being more costly than less specific preparations, thereby making compliance a difficulty.
Oral supplements provided at the time of dialysis treatments could also be an efficient therapy.
This was suggested by a matched cohort study of maintenance hemodialysis patients with albumin concentrations ≤3.5 g/dL who were given oral nutritional supplements at the time of dialysis.
By 15 months of follow-up, improved survival was demonstrated among patients given oral nutritional supplements compared with untreated matched control patients by both as-treated and intention-to-treat analysis. the best advantage of oral supplements was observed among patients with rock bottom baseline albumen concentration (≤3.2 g/dL).
These observations, although potentially clinically significant, are limited by the absence of random allocation of patients; although control patients were matched by propensity score, residual confounding remains possible.
Another study analyzed the effect of providing oral supplements (taken at non-dialysis times) to patients with albumin ≤3.8 mg/dL.
This was a retrospective analysis of knowledge provided by Fresinius Medical Health Care Plan’s disease management program, during which eligible patients (ie, defined as those with albumin ≤3.8 mg/dL for 2 or more months) were given 24 cans of oral supplement per month.
Among eligible patients, 276 received supplements and 194 failed to, either because it absolutely was deemed inappropriate for unspecified reasons, or because they refused.
After multiple adjustments, compared with no supplements, the employment of oral supplements was related to a lower rate of hospitalization (89 versus 68 percent respectively), and with a nonsignificant trend toward improved survival at one year (p = 0.09).
This study was limited by the possible presence of unadjusted differences within the patient populations.
Despite the constraints related to both studies cited above, oral nutritional supplements administered during the dialysis treatment is also a useful intervention for a few patients with very low albumen.
Compared with intravenous nutritional supplementation, oral supplementation has fewer side effects, is cheaper, and appears to be an affordable start within the nutrition management of those patients.
The general supplements will be tried in patients ready to tolerate the rise in potassium and fluid intake.
We limit the precise “renal failure” supplements to patients with preexisting hyperkalemia or fluid overload due, for instance, to failure. Although some evidence suggests that oral essential amino acids is also modestly beneficial to patients with significant hypoalbuminemia, further study is required before any recommendation concerning their use.
Patient compliance is vital to the success of oral nutrient supplements.
A different regimen is required in patients with severe anorexia who are unable to extend their oral intake.
Overnight supplementation by nasoenteral feeding tube could also be effective during this setting.
A short course of overnight tube feeding can result in a sufficient improvement in nutritional status and overall well-being that adequate dietary oral is resumed.
Patients with severe gastroparesis could also be unable to tolerate any kind of oral supplementation.
Intradialytic parenteral nutrition (IDPN) could also be beneficial during this setting if the malnutrition isn’t too severe. IDPN solutions are similar those used for total parenteral nutrition : a typical solution contains 10 percent amino acids and 40 to 50 percent glucose, 10 to twenty percent lipids, or a mix of carbohydrate or lipids depending upon the wants of the patient.
However, IDPN has certain limitations:
• It is that the costliest and least efficient nutritional supplement. IDPN often costs twice the maximum amount as dialysis itself, and only 70 percent of the nutrients are literally delivered to the patient due to loss into the dialysate.
• Malnutrition may persist, since IDPN is run only three days per week for roughly 4 hours.
• It could also be related to a below expected delivered dose of dialysis, due possibly to increased urea generation.
Despite these shortcomings, IDPN is convenient (because it’s delivered during dialysis) and is probably going to be beneficial in some patients.
However, although variety of studies suggest that IDPN provides substantial benefit, most were case reports, retrospective, or poorly designed.
To better assess the consequences of IDPN, 186 malnourished hemodialysis patients were randomly assigned to oral nutritional supplements, with or without one year of IDPN.
At two years, there was no difference in mortality, hospitalization rate, and nutritional status between the 2 groups.
With statistical procedure, however, improved nutrition defined as a rise in prealbumin level of greater than 30 mg/L within the primary three months correlated with an approximately 50 percent decrease in mortality at two years.
The optimal indications for IDPN haven’t been established.
We consider use of this modality within the malnourished dialysis patient who cannot tolerate oral supplements but who can consume a minimum of 50 percent of the prescribed caloric intake.
This is in step with the 2007 European best practice guidelines for hemodialysis.
If this degree of oral intake can not be reached, we first try a nasoenteral feeding tube with nighttime enteral nutrition or, if oral intake isn’t tolerated, the institution of total parenteral nutrition should be considered.
Total parenteral nutrition (TPN) is required within the rare patient with severe malabsorption, severe malnutrition, or severe intolerance of oral supplements. Although generally well tolerated, TPN solutions typically contain added potassium, phosphorus, and magnesium.
Thus, patients with end-stage renal disease receiving TPN are in danger for the event of hyperkalemia, hyperphosphatemia, and hypermagnesemia. Elimination of the added electrolytes can prevent these problems but carries the reverse risk of electrolyte deficiencies with prolonged therapy.
We generally recommend that TPN be started with solutions containing little or no added electrolytes.
The patient should then be carefully monitored, and electrolytes should be added if the plasma levels fall below the conventional range.
The dialysis prescription should be reassessed in terms of Kt/V and also the protein catabolic rate.
In a trial to handle the question of optimal dialysis dose and membrane flux for hemodialysis patients, an oversized test, called the Hemodialysis (HEMO) Study, was performed.
Patients were randomly assigned to a regular (single-pool Kt/V of 1.25) or high dose of dialysis (single-pool Kt/V of 1.65) and a low- or high-flux dialyzer.
Similar outcomes in terms of survival were observed with high and standard dialysis doses likewise as dialysis using high and low flux membranes.
Subsequent analysis of the HEMO trial also found that nutritional parameters, like albumin and anthropometric measures, were the identical with the various dose and flux interventions.
Current minimum recommendations are 1.3 to 1.4 for Kt/V in hemodialysis, at least 1.7 for weekly Kt/V in continuous ambulatory peritoneal dialysis, and 1.0 to 1.2 g/kg per day for the nPNA.
there’s also some preliminary evidence that, compared with Kt/V, Kt alone (which is that the non-normalized dialysis dose) could also be more closely related to albumen levels.
Although further study is required, daily in center and nocturnal hemodialysis are used as a rescue therapy for patients with severe malnutrition complicating uremia, with patients generally reporting increased appetite after switching from conventional to daily dialysis.
The effects on nutrition of short daily and nocturnal hemodialysis are presented separately.
Recombinant human STH
Some studies suggest that administration of recombinant human somatotropic hormone can reduce wasting and catabolism, improve nutritional status, and lower the BUN in hemodialysis patients, even within the elderly.
• In one study, 139 adult dialysis patients with albumin levels but 4 g/dL were randomly assigned to 6 months of therapy with different doses of recombinant somatotrophin or placebo.
• Lean body mass significantly increased in the least dose levels (2.5 kg versus –0.4 kg) for placebo, while albumen levels attended increase.
• In another prospective, cross-over study, improvements in protein metabolism were observed with administration of recombinant human somatotropin in comparison to no hormone therapy, as shown by a decrease in BUN (55 versus 40 mg/dL [19.6 versus 14.3 mmol/L]) and a decrease in protein catabolic rate (0.82 versus 0.67 g/kg per day). Follow-up evaluation of those patients revealed that the improved protein metabolism resulted from the increased ability to utilize essential amino acids. Similar improvements in protein metabolism were noted in other studies during which the like recombinant human STH could largely be explained by a rise in free insulin-like growth factor-1 levels.
Recombinant human endocrine has also been reported to boost nutritional status in malnourished patients on hemodialysis treated with IDPN; the latter was ineffective when given alone.
Recombinant insulin-like growth factor-1 (IGF-1) has also been shown to markedly increase balance in patients treated with CAPD.
Despite evidence suggesting that recombinant human somatotrophic hormone provides short term benefits ,significant long-term nutritional benefits with this agent aren’t consistently observed.
additionally, the consequences of recombinant human human growth hormone on malnutrition associated morbidity and mortality are unclear.
One additional major limitation of the utilization of recombinant therapy for the treatment of malnutrition in patients with ESRD is its very high cost.
To best assess the advantages and adverse effects related to recombinant human somatotropic hormone , the chance trial will assess the effect of this hormone on survival in hypoalbuminemic dialysis patients and its effect upon morbidity, markers of body protein mass, inflammation, exercise capacity, and quality of life.
Correction of acidosis
Uremic acidosis can increase muscle breakdown and diminish albumin synthesis, resulting in muscle wasting and muscle weakness.
Recommendations concerning correction of acidosis are presented separately.
Androgenic anabolic steroids and anti inflammatory drugs are utilized in dialysis patients with malnutrition.
• Only limited data have evaluated the efficacy and adverse effects of androgenic anabolic steroids in dialysis patients.
• Although a rise in weight, muscle mass, and albumin are reported, the long-term efficacy and risk for adverse effects with these agents is unclear. These agents therefore can not be recommended during this setting.
• The use of anti-inflammatory agents in patients with malnutrition-inflammation syndrome complex is reviewed separately.
• Dialysis patients often have decreased taste acuity, which is controversially related to deficiency disease.
• If present, diminished taste acuity can result in decreased intake and anorexia.
• The role of deficiency disease has never been established and that we don’t routinely measure plasma zinc levels or administer zinc supplements.
MALNUTRITION IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS
Much of the foregoing discussion applies to both hemodialysis and peritoneal dialysis.
As previously noted, however, there are several problems unique to peritoneal dialysis, including increased dialysate protein losses and a sense of fullness because of dialysate within the abdomen.
Gastroparesis is additionally more common, since many CAPD patients are diabetic.
The management of malnutrition in these patients again focuses on prevention and treatment.
The approach is comparable thereto noted above, but there are variety of specific recommendations:
• Patients with loss of appetite should drain the dialysate just before meals in order that the abdomen is empty at mealtime.
• They may additionally tolerate frequent, small meals better than the standard three large meals.
• Peritoneal dialysis patients generally have fewer dietary restrictions than those treated with hemodialysis, since they’re continuously dialyzed. However, some patients consume excessive amounts of fluid that are removed by the utilization of high-dextrose dialysate. the following increase in glucose absorption can, in susceptible subjects, cause hyperglycemia, which might directly suppress appetite.
• Avoidance of excess fluid intake is therefore desirable, since it limits the requirement to be used of hypertonic dialysis solutions.
• Persistent malnutrition is treated with oral supplements or TPN. Limited data, however, have reported mixed results with oral nutritional supplementation; this can be possibly the results of poor compliance, small sample size, and reliance upon albumen concentration because the principal outcome measure.
• Clearly, IDPN isn’t feasible thanks to continuous dialysis.
Amino acid dialysate
Dialysate containing amino acids because the osmotic agent, instead of glucose, may minimize a number of these above problems, increasing net protein intake, allowing the attainment of positive balance and net anabolism and improving the plasma albumin concentration and overall nutrition.
In a prospective three month study, 105 malnourished peritoneal dialysis patients were randomly assigned to 1 or two exchanges per day with a 1.1 percent organic compound dialysate, or to usual therapy.
Benefits observed within the group receiving the protein dialysate included increases in insulin-like growth factor-1, and reduces in serum potassium and inorganic phosphorus, findings indicative of a general anabolic response.
The combination of organic compound plus glucose dialysate might also improve the nutritional status of malnourished patients. in a very random order crossover study of eight patients undergoing nocturnal automated peritoneal dialysis, protein kinetics was markedly superior over a 1 week period with dialysate containing organic compound plus glucose versus that observed during every week with the control dialysate.
Further study in a very larger number of patients is required to adequately evaluate this approach.
Dialysate containing amino acids because the osmotic agent is now commercially available in Europe, Canada and other regions, although they’re not commercially available within the us.
Patients who are treated with aminoalkanoic acid containing dialysate should be monitored closely for the subsequent reasons:
• To avoid aminoalkanoic acid imbalance, organic compound dialysate mustn’t be used for over one or at the most two exchanges per day.
• As the osmotic agent, a 1.1 percent solution of amino acids has an ultrafiltration profile kind of like dialysis solutions containing 1.5 percent dextrose.
• Thus, aminoalkanoic acid dialysate mustn’t be used for the overnight dwell because most of the amino acids are absorbed, thereby limiting the degree of fluid removal.
• There is concern that amino acids will raise urea nitrogen appearance and urea production if they’re not used for anabolism.
• organic compound dialysate may result in acidosis which is primarily thanks to the proton contained in cationic amino acids (such as lysine).
• Thus, both the BUN, and plasma bicarbonate concentration should be monitored.
The European Best Practice Guidelines suggest that an aminoalkanoic acid containing solution should be considered in malnourished patients.
They also state that this solution should only be used once daily.
Malnourished patients who don’t tolerate oral supplements are possibly to profit.
A response — improved appetite, increased plasma albumin concentration, weight gain — should be seen within three months; at now, we switch back to traditional dialysate.
Enteral tube feeding
Some PD patients with malnutrition who are unable to ingest adequate amounts of nutrition are successfully treated with enteral tube feedings, particularly with gastrostomy or gastrojejunostomy tubes.
A paucity of knowledge exists concerning the utilization of this method of feeding in adults, but it appears to end in improved nutrition in malnourished children.
Limited evidence suggests that improved control of acidosis may enhance the nutritional status in peritoneal dialysis patients.
In one study, 200 consecutive patients initiating peritoneal dialysis were randomized to high (lactate of 40 meq/L) or low (35 meq/L) alkali dialysate for one year.
Correction of acidosis with carbonate and sodium hydrogen carbonate was also utilized within the high alkali group.
At one year, the serum bicarbonate within the high alkali group was 27 meq/L versus 23 meq/L within the low alkali group.
Compared to the low alkali group, benefits observed with high alkali therapy included a greater increase in weight (6.1 versus 3.7 kg, P<0.05) and lower morbidity (16.4 versus 21.2 days spent within the hospital, P<0.05).
A preliminary study found that administration of ghrelin, a hormone that functions as an appetite enhancer, may enhance food intake acutely in malnourished patients undergoing peritoneal dialysis.
Longer term study is required to higher characterize the consequences of ghrelin during this setting.
INFORMATION FOR PATIENTS
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• Basics topic
• SUMMARY and proposals
• Malnutrition is common in patients treated with maintenance dialysis. Principal causes include inadequate dialysis dose, inflammation, dietary restrictions, nutrients lost via dialysate, catabolic properties of dialysis, and other factors.
• The beginning within the prevention of malnutrition is careful assessment of the patient’s nutritional status at the start of dialysis and each three to 6 months thereafter.
• Ingestion of an adequate diet is incredibly important if malnutrition is to be prevented.
• If malnutrition is diagnosed, it’s important to undertake treatment strategies as follows:
• Evaluation of any source of inflammation should be sought and managed.
• Dietary intake should be assessed and dietary counseling should be undertaken.
• If the patient cannot improve nutrient intake by diet alone, intake should be improved during a step-wise fashion, starting with oral supplements and ending with total parenteral nutrition if no other nutrient intake methodology is acceptable.
• Much of the discussion associated with malnutrition during this topic review applies to both hemodialysis and peritoneal dialysis.
• However, since there are several problems unique to peritoneal dialysis, variety of specific recommendations may be made in these patients.
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