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Prog Health Sci 2015, Vol 5, No2 Nutrition peritoneal dialysis patients – a review Nutrition and peritoneal dialysis patients – a review 1* 2 3 Kourkouta L. , Monios A. , Frantzana E. , Iliadis Ch. 1. Professor of Nursing Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece 2. Biologist, Professor 7th High School of Athens, Athens, Greece 3. Graduate Nurse from Nursing Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece ABSTRACT ___________________________________________________________________________ Introduction: The Peritoneal Dialysis (PD) is a significant contribution to the field. The exclusion preferable treatment option of the renal replacement criteria for the articles were the languages except in patients with chronic renal failure (CRF) end from English and Greek. stage. Results: Patient’s diet must contain 1.3 g of protein Purpose: The purpose of this study was to review of per kilogram of body weight per day. Consumption articles published related to the contribution of of foods rich in carbohydrates should be limited. nutrition to health promotion of patients undergoing Patients should consume foods with the adequate haemodialysis. quantity of phosphorus and potassium. Finally, they Materials and methods: A review of the Greek and should have their sodium levels and fluid intake international literature on the subject was Performed checked because sodium causes severe thirst that can through the electronic databases Medline, Google lead to excessive fluid intake. As a result, the patient Scholar, Scopus and the Association of Greek experiences swelling, shortness of breath and high Academic Libraries Link (Heal-Link), using as key blood pressure. words the following terms: haemodialysis, renal Conclusion: Patients who undergo peritoneal failure, peritoneal dialysis, nutrition. Most of the dialysis must be checked regularly and pay special articles used in this literature review were recently attention to their diets. published. Only few old - dated articles were Key words: haemodialysis, renal failure, diet, included in the study and the reason was their peritoneal dialysis, nutrition ___________________________________________________________________________ *Corresponding author: Kourkouta Lambrini ATEI of Thessaloniki, Greece e-mail: laku1964@yahoo.gr Received: 21.11.2015 Accepted:14.12.2015 Progress in Health Sciences Vol. 5(2) 2015 pp 205-210 © Medical University of Białystok, Poland 205 Prog Health Sci 2015, Vol 5, No2 Nutrition peritoneal dialysis patients – a review INTRODUCTION used in this literature review were recently published. Only few old - dated articles were Chronic kidney failure is a disease which is included in the study and the reason was their increasingly recognized as a public health problem. significant contribution to the field. The exclusion It is usually characterized by an asymptomatic criteria for the articles were the languages except period which is potentially detectable [1]. Chronic from English and Greek. kidney disease is common, and its prevalence increases significantly with age, and particularly in Chronic kidney disease women. However, the classification of disease is not Chronic renal failure is defined as the gradual according to age and gender, as well as with damage of the kidneys. Proteinouria, haematouria or the level of proteinouria [2]. anatomic abnormality and the glomerular filtration Furthermore, it is more common in the rate (GFR) < 60 ml/min/1.73 m2 is at least present in elderly than in young people due to atheromatosis of cases for ≥ 3 months. The renal failure is irreversible renal vascular disease. Over 70% of patients’ cases and only a small number of people can follow a suffering from chronic kidney disease are due to conservative treatment. The disease is classified into diabetes mellitus, hypertension and atherosclerosis. 5 (five) stages that depend on the glomerular Patients who suffer from the disease have to filtration rate (GFR) and the presence of kidney maintain contact with a renal medicine specialist for damage (Table 1) [2]. their rehabilitation therapy of renal function in an early stage for, it is manifested that the final stage of Table 1. Stages of chronic kidney failure the disease is associated with increased mortality and morbidity [3]. GFR It is evident that in Greece there is a greater STAGE DESCRIPTIO frequency of new patients for haemodialysis per S N (ml/min/1.72m2 million populations compared to 24 European ) countries in 2004. It possessed the 3rd position 1 Kidney damage ≥ 90 worldwide for the corresponding frequency in renal with normal or replacement therapy after the USA and Japan. The increased GFR classification of Greece in the 8th place regarding the 2 Kidney damage 60-89 global comparison of the prevalence of renal with mild replacement therapy, although more favorable, it decrease in GFR remains very high and indicates the size of the 3 Moderate 30-59 increased number of 13 patients in end-stage chronic decrease in GFR renal failure in our country [4]. 4 Severe decrease 15-29 Patients who suffer from kidney failure in GFR have great chances to be malnourished or develop 5 Kidney failure < 15 or dialysis malnutrition, which contributes to the patients’ morbidity and mortality. Due to this fact, the present All patients, regardless of their age, gender study attempts to show the contribution of nutrition and proteinouria or albuminouria, when the GFR 60 in the health promotion of patients undergoing ml/min 1.72 m2, are considered to have at least haemodialysis. The assessment of their nutritional moderately severe chronic failure. status may be particularly difficult in this population The number of proteinouria is a major risk on account of the changes as regards the metabolism factor for both the evolution of chronic kidney of proteins and carbohydrates, disturbances of salt failure and cardiovascular disease. It is known that and water balance and other factors in comparison many other risk factors play a role in the with the general population [5]. development of the atherosclerotic lesion, which is The purpose of this study was to review of responsible for the appearance and growth of many articles published related to the contribution of cardiovascular diseases [4,5]. Adverse health effects nutrition to health promotion of patients undergoing are linked with the effects that exist in a reduced haemodialysis. glomerular filtration rate and in particular if it does not change with the passage of time [6]. MATERIALS AND METHODS The early stages of kidney failure are often asymptomatic, despite the accumulation of several A review of the Greek and international metabolites. Some symptoms include: malaise, loss literature on the subject was performed through the of energy, loss of appetite, insomnia, noctouria and electronic databases Medline, Google Scholar, polyouria due to reduced ability to concentrate, Scopus and the Association of Greek Academic itching, nausea, vomiting and diarrhea, Libraries Link (Heal-Link), using as key words the hallucinations due to, polyneuropathy, restless legs following terms: haemodialysis, renal failure, syndrome, bone pain due to bone metabolism peritoneal dialysis, nutrition. Most of the articles disease, hallucinations and tetany due to 206 Prog Health Sci 2015, Vol 5, No2 Nutrition peritoneal dialysis patients – a review hypocalcaemia, symptoms due to salt and water o increased nutritional needs or losses due to retention (distal or pulmonary edema), and protein degradation process, inflammation symptoms caused due to anemia are amenorrhea in in the process of hemodialysis and women, erectile dysfunction in men [7]. shortage of acid during dialysis o changes in metabolism and endocrine Haemodialysis disorders (increased catabolism, reduced Haemodialysis is a sustained vital process anabolism). for the treatment of patients suffering from end-stage Except for losses that are obvious, energy renal disease. Its objective is to restore the kidney requirements are greater in CRF end-stage (up to 35- function by reversing the dramatic uremic symptoms 40 kcal/kg) due to the increased basic metabolism and also help patients’ functional condition to affected by the sympathetic nervous system. When increase the chances of their survival [6]. calories are inadequate, amino acids are used to meet This is mainly achieved by the formation of a the needs. As a result, increased protein levels are haemodialysis system whose ingredients and required [9, 11]. concentrations are formed approximately close to Last but not least, vegetable sources of normal values that need the body. Particular proteins that exceed the daily requirements are emphasis is placed on individual adaptation of deprived in urea, other nitrogenous bases, phosphate, haemodialysis. A method of calculating the amount and sulfuric acid. These waste products accumulate of dialysis is to calculate the Kt/V. Kt/V is an initial in patients with uremia and lead to muscle value that is indicative of the dose of the dialysis. catabolism, bone loss, and vascular calcification. The Kt/V is best described as the fractional clearance Health and nutritional status improvement are the of urea as a function of volume distribution [8]. main objectives for patients undergoing The link for the haemodialysis of artificial haemodialysis. Their nutrition status must be kidney during the first days of dialysis along with the assessed. Regularly by their medical expert with the concentration of sodium is set deliberately low to cooperation of the dietician [12]. avoid volume overload problems such as Obviously, if energy consumption is either hypertension and cardiovascular failure. Much above or below the needs of the individual in the evidence indicates that the correction of chronic long run, then, obesity or marasmus may appear. acidosis is a clinical benefit regarding the bone Protein intake should be sufficient for maintaining metabolism and nutrition [7]. the structural integrity of the human organism. The Therefore, a major risk factor for patients on laboratory measurements of serum proteins are vital dialysis is malnutrition. The mortality is affected by for the patients’ nutritional status. Similarly, the serum albumin levels. The lower the serum albumin vitamin and mineral intake must be sufficient to meet level is, lesser than 4.5 g/dl, the higher the risk of the needs of the enzymatic function of the human mortality is [8]. body [13]. Vitamins are important cofactors that Nutritional assessment regulate the metabolic pathways, by which lipids, Patients that suffer from kidney failure proteins and carbohydrates are produced and have great chances to be malnourished or develop processed. Patients in peritoneal dialysis are more malnutrition, which contributes to their morbidity liable to disturbances of water-soluble vitamins. So, and mortality [9]. they often need to take vitamin supplements. Malnutrition in conjunction with age, Vitamin E as well, which is a fat-soluble vitamin is gender, and the respective functional disorders plays associated with various degenerative conditions an important role in the progress of patients’ [14]. These failures are caused by inadequate dietary situation [10]. intake, decreased absorption due to certain drugs, The assessment of their nutritional status metabolic changes that differentiate the needs and may be particularly difficult in this population on increased losses through the solution of peritoneal account of the changes as regards the metabolism of dialysis [15]. proteins and carbohydrates, disturbances of salt and water balance and other factors in comparison with Peritoneal dialysis diet the general population Most of the factors that lead In 2000, the National Kidney Foundation to malnutrition in patients undergoing peritoneal revealed results as (KDOQI) Kidney Disease dialysis involve one or a combination of the Outcomes Quality Initiative for kidney disease following ones [9]: with clinical practice guidelines regarding nutrition o decreased food intake, either due to in chronic kidney disease. These guidelines continue psychological factors (depression) or to form the basis of nutrition care in adults with physical factors (inadequate treatment of chronic kidney disease. However, if need be, the uremia, side effects from drug use, doctor along with the dietitian will discuss with the infections, changes in the sense of taste), patient about some changes in his diet. In addition and even financial reasons. 207 Prog Health Sci 2015, Vol 5, No2 Nutrition peritoneal dialysis patients – a review to the nutrients, the patient's needs in vitamins and Potassium iron ought to be covered [16]. Patients who undergo haemodialysis must pay particular attention to the consumption Proteins of fruit and vegetables for, they are high in The Diet KDOQI guidelines recommend potassium. Hyperkalemia (High Potassium in 1.2 g protein/kg/day for adult maintenance for blood) occurs suddenly without warning signs patients that undergo haemodialysis and 1.2-1.3 leading to the onset of cardiac arrest, if the value g/kg/day for adults under chronic peritoneal dialysis. of potassium in the blood plasma is greater than These Nutritional guidelines KDOQI recommend an 9mEq/L. For this reason, biochemical levels of energy intake of 35 kcal/kg/day to maintain nitrogen potassium and dietary intakes must be closely balance. For this reason, it is essential that the checked. The patient under haemodialysis three Agency and the body be strong and this will be times per week is able to receive up to 1.5-2, 5g achieved by increasing the daily dietary protein and an uric patients 2g (= 51mEq) of potassium intake [17,18]. a day [24,25]. Lean meat, oily fish, eggs and dairy products are some of the food rich in protein. Phosphorus and calcium However, they contain phosphorus and their Phosphorus intake should be limited. High consumption should be regulated by the dietician levels of phosphorous in patients undergoing [19]. peritoneal dialysis can cause heart problems, bone The presence of the dialysis fluid in the and joint disorders and skin ulcers [26]. body causes satiety resulting in decreasing the Furthermore, the level of phosphorus in patient’s appetite. It is essential the patient blood must remain at low levels in order increase the frequency of meals and consume osteodystrofy to be avoided. Phosphorus increases small amounts of food more often. This is more while calcium decreases in blood with the passage of preferable than two or more heavy meals per time. As a result, the calcium is removed from bones. day. Moreover, decrease in appetite may be As a consequence, bones become more fragile and noticed in cases of infections or anemia. For this susceptible to fractures. This imbalance of reason, the contribution of dietician is very phosphorus-calcium occurs from the first stages of important in order these needs to be met [20]. kidney disease, long before some form of dialysis is required. Nevertheless, symptoms usually become Carbohydrates apparent much later [24]. It is manifested that patients under Dialysis along with phosphorus-binding haemodialysis may often experience glucose agents removes more phosphorus from the blood and tolerance resulting in hypoglycemic or can provide extra calcium. The patient might need to hyperglycemic episodes. One of the causes can reduce the amount of phosphorus intake which is be either the delayed action of insulin due to the difficult because plenty of foods rich in phosphorus resistance of tissues in it, or insulin resistance in are very good quality protein sources. The patient uremia. This glucose tolerance rarely requires the should understand that the more adjusted the level of administration of insulin. Thus, the patient phosphorus intake is, the greater the benefit to bone should have the carbohydrates in his diet health will be [26, 27]. controlled. The recommended dietary regimen Foods high in phosphorus are dairy for patients is 50-60% of their total calorie-intake products, cheese, eggs, small fish and beverages like and it ought to be high in fiber [15]. What’s more, coca - cola [28,29]. a conducted survey revealed that diet low in carbohydrates and high in fat improves glycemic Vitamins and minerals control and prevents the progression of kidney Vitamins and minerals are essential for failure [21]. normal body function and development. Studies in However, food rich in carbohydrates such adults under haemodialysis provided clues for low as bread, cereals and sugar consumption should be blood concentrations of water-soluble vitamins and limited by the patient to avoid gaining excessive minerals. That was because of the inadequate intake, weight and calorie intake in the body [22]. increased losses and needs [30]. The recommended dietary intake should Fats achieve the 100% of the dietary reference intake Special attention must be given in amount of thiamine (B1), riboflavin (B2), uremic patients regarding dietary fat intake Pyridoxine (B6), vitamin B12 and folic acid. Also, because the main cause of death is the dietary intake of 100% of the recommended atherosclerosis. The recommended dietary Dietary intake should be the goal for vitamins A, C, intake of fats is approximately 30% of total E and K, copper and zinc [27,29]. calories. Saturated fats must be less than 10% It is recommended that the intake of these and cholesterol 250-300mg/day [21,23]. metals must be checked every 4 to 6 months, because 208
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