5.2 Peritoneal Dialysis and Diet Modifications

Peritoneal dialysis offers unique nutritional challenges. Patients need more protein to offset losses, but must balance this with glucose absorption from dialysate. Careful management of nutrients like phosphorus and potassium is crucial for long-term health.

Optimizing nutrition for peritoneal dialysis patients requires a team approach. Dietitians work closely with doctors, nurses, and pharmacists to tailor recommendations, manage deficiencies, and educate patients on making smart food choices that support their treatment.

Nutritional Considerations for Dialysis

Peritoneal Dialysis vs. Hemodialysis

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• Peritoneal dialysis (PD) removes waste products and excess fluid continuously through the peritoneal membrane, while hemodialysis (HD) occurs intermittently through an external filter
• PD patients typically have fewer dietary restrictions due to the continuous nature of the treatment (potassium, fluid)
• Protein losses in PD are generally higher than in HD, necessitating increased protein intake for PD patients
• Fluid restrictions are often less stringent in PD compared to HD due to the daily removal of fluid through dialysate exchanges
• Potassium restrictions are usually less strict in PD patients due to continuous removal
• Phosphorus control may be more challenging in PD patients due to absorption from dialysate, requiring careful management of dietary phosphorus and use of phosphate binders
• Glucose absorption from dialysate in PD can contribute to weight gain and altered lipid profiles, necessitating careful monitoring of carbohydrate intake and overall calorie balance
  • Example: A PD patient may need to limit high-carbohydrate snacks to prevent excessive weight gain
  • Example: HD patients might need to avoid high-potassium foods (bananas, oranges) more strictly than PD patients

Protein, Carbohydrate, and Fat Intake for Peritoneal Dialysis

Macronutrient Recommendations

• Protein recommendations for PD patients typically range from 1.2-1.5 g/kg of body weight per day to compensate for dialysate protein losses and maintain nitrogen balance
  • Example: A 70 kg patient would need 84-105 g of protein daily
• Carbohydrate intake should be monitored due to glucose absorption from dialysate, with recommendations typically ranging from 50-60% of total energy intake
  • Example: For a 2000 kcal diet, carbohydrate intake would be 250-300 g per day
• Fat intake should be limited to 25-35% of total energy intake, with emphasis on sources of unsaturated fats to help manage cardiovascular risk
  • Example: Incorporating olive oil, avocados, and fatty fish (salmon) into the diet
• Calorie recommendations for PD patients generally range from 25-35 kcal/kg/day, adjusted based on individual factors such as age, activity level, and body composition
  • Example: A 70 kg patient might need 1750-2450 kcal per day

Individualization and Monitoring

• Fiber intake of 20-25 grams per day promotes bowel regularity and helps manage blood glucose and lipid levels
  • Example: Including whole grains, vegetables, and fruits (within potassium restrictions) in the diet
• Individualization of macronutrient recommendations considers factors such as residual renal function, comorbidities, and nutritional status
  • Example: A diabetic PD patient might need stricter carbohydrate control
• Regular assessment of dietary intake and adjustment of recommendations accounts for changes in dialysis prescription, residual renal function, and overall health status
  • Example: Increasing protein recommendations if laboratory values show declining nutritional status

Nutrient Deficiencies in Peritoneal Dialysis

Common Deficiencies and Their Impact

• Water-soluble vitamin deficiencies, particularly vitamin C, B6, and folate, occur due to losses in dialysate and dietary restrictions
  • Example: Vitamin C deficiency can lead to impaired wound healing and increased susceptibility to infections
• Vitamin D deficiency prevalence in PD patients requires careful monitoring and supplementation to maintain bone health and mineral metabolism
  • Example: Low vitamin D levels can contribute to secondary hyperparathyroidism and bone disease
• Iron deficiency emerges due to frequent blood tests, residual blood loss, and decreased absorption, necessitating regular assessment and supplementation
  • Example: Iron deficiency anemia can cause fatigue and reduced quality of life
• Zinc deficiency may occur due to losses in dialysate and decreased dietary intake, potentially affecting taste perception and wound healing
  • Example: Zinc deficiency can lead to altered taste sensation (dysgeusia) and poor appetite

Management Strategies

• Selenium deficiency can develop over time, potentially impacting thyroid function and antioxidant status
  • Example: Low selenium levels may contribute to increased oxidative stress
• Carnitine deficiency may occur in long-term PD patients, potentially affecting energy metabolism and muscle function
  • Example: Carnitine deficiency can lead to muscle weakness and fatigue
• Management strategies include targeted supplementation, dietary counseling to increase intake of nutrient-rich foods, and regular monitoring of nutrient status through biochemical markers and clinical assessment
  • Example: Prescribing a renal-specific multivitamin and providing education on food sources of key nutrients

Optimizing Nutrition for Peritoneal Dialysis Patients

Interdisciplinary Collaboration

• Regular communication with nephrologists aligns nutritional interventions with changes in dialysis prescription and overall medical management
  • Example: Adjusting protein recommendations based on changes in residual renal function
• Coordination with pharmacists manages drug-nutrient interactions and optimizes the timing of medications and supplements relative to meals and dialysis exchanges
  • Example: Advising patients to take phosphate binders with meals for maximum effectiveness
• Collaboration with nurses monitors fluid status, catheter site care, and provides patient education on diet and lifestyle modifications
  • Example: Developing strategies to manage fluid intake based on ultrafiltration rates

Patient Education and Monitoring

• Engagement with social workers addresses psychosocial factors affecting nutritional status, such as food insecurity or depression
  • Example: Connecting patients with community resources for meal delivery services
• Participation in interdisciplinary team meetings allows for comprehensive care planning and ensures that nutritional interventions are integrated with overall treatment goals
  • Example: Discussing nutritional strategies to support wound healing for a patient with a non-healing ulcer
• Development and implementation of patient education programs in collaboration with the healthcare team improves adherence to dietary recommendations and self-management skills
  • Example: Creating a hands-on cooking class for PD patients to learn low-sodium, kidney-friendly recipes
• Regular assessment and documentation of nutritional status, interventions, and outcomes informs ongoing care and treatment decisions
  • Example: Tracking changes in serum albumin levels to evaluate the effectiveness of nutritional interventions