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Nutritional aspects of peritoneal dialysis

  • C. A. Pollock
  • B. A. Cooper
  • L. S. Ibels
  • E. De Kantzow

Abstract

Maintaining the nutritional status of the patient is recognized as an important aspect of peritoneal dialysis therapy. Patients commencing dialytic therapy are at risk of malnutrition due to factors inherent in progressive renal failure including the metabolic and hormonal effects of uraemia, comorbid disease, the effects of drugs prescribed, and psychosocial factors associated with chronic disease. It has been estimated that up to two-thirds of patients on peritoneal dialysis may be malnourished, and this group has a higher risk of both morbidity and mortality. Several groups of patients appear to be a higher risk of complications of malnutrition, in particular the elderly and patients with renovascular disease, where the risk of vascular disease may be magnified. Once dialysis is commenced additional mechanisms which promote progressive malnutrition occur. In peritoneal dialysis these include inadequate dialysis, loss of protein and amino acids during dialysis, which may be more marked in patients with increased peritoneal permeability, and the catabolic efects of peritonitis. Glucose-based dialysate may displace other food sources and amplify abnormalities in carbohydrate metabolism. Bioincompatible dialysate and peritonitis may stimulate cytokine production and promote malnutrition. Nutritional adequacy is not easy to assess in peritoneal dialysis, largely due to dependence of traditional markers of nutrition on body water content, which varies in end-stage renal failure. Total body nitrogen (TBN) provides the most accurate means of measuring protein stores and has significant and predictable prognostic value. In the absence of access to measurement of TBN, several parameters should be considered in parallel to achieve an overall assessment of nutrition, as all other methods may be variably affected by the presence of renal failure, the mode and adequacy of dialysis delivery and fluid status at the time of assessment. Serum albumin is the visceral protein marker most well established as having important prognostic value and should be regularly assessed, but both its sensitivity and specificity in detecting nutritional impairment prior to severe malnutrition are poor. However, no single alternative serum protein measure confers improved sensitivity in detecting malnutrition in dialysis patients. Alternative measures of lean body mass, such as bioelectrical impedance and dual-energy X-ray absorptiometry when measured with an accurate determination of total body water may well prove to be useful, but as yet their prognostic usefulness is unclear. The subjective global assessment is a useful prognostic tool, but is not specific for nutritional adequacy and is likely to be significantly affected by comorbid illness. Nutritional supplementation in small studies with either oral, intravenous intradialytic parenteral nutrition or intraperitoneal amino acids has been shown to improve several nutritional markers, provided the profile of the supplemental solution is appropriate to the deficiencies observed in renal failure and adequate energy is concurrently supplied. However, the impact of improving nutrition in benefiting prognosis awaits confirmation.

Keywords

Peritoneal Dialysis Protein Intake Dialysis Patient Lean Body Mass Total Body Water 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer Science+Business Media Dordrecht 2000

Authors and Affiliations

  • C. A. Pollock
  • B. A. Cooper
  • L. S. Ibels
  • E. De Kantzow

There are no affiliations available

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