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Case Report


Managing Malnutrition in Peritonitis

1Dr Anita Saxena, 2Dr Amit Gupta, 3Dr Medhavi Gautam,

3Dr Manas Ranjan Behera

1Additional Professor, 2Professor, 3Fellow Department Of Nephrology, SGPGIMS, Lucknow 226014


Key words: CAPD, Peritonitis, protein, energy


Introduction

This is a case of 56 years old male, a known case of chronic kidney disease (CKD) since 2010 . He had diabetes mellitus (DM) for 15 years, diabetic retinopathy (DR), diabetic kidney disease (DKD), normal sized kidney and (hypertension) since 2009. Since 2010 patient had drop in urine output with rising creatinine coupled with vomiting and anorexia. His appetite worsened progressively and was moderately malnourished. In January 2011, patient was admitted with complaints of vomiting, breathlessness, generalized weakness and swelling. He was declared a case of end-stage-renal-disease (ESRD) and had first hemodialysis on Jan 19, 2011

Dietary History: Patient had inadequate (poor) nutritional Intake (true undernutrition) f for 4 months prior to January

2011 (September to December 2010). Diet prescription advised to him according to KDOQI Guidelines for conservative management was protein intake 0.6g/kgbw/d and energy intake of 30 kcal/kgbw/day since he was diabetic. On calculating his dietary intake based on recall (as told by his wife ), his actual intake was 0.4g/kg/d of protein and <20 kcal/kg/d energy.

Nutritional Status: The patient had chronic malnutrition or protein energy wasting (PEW) as was evident from his serum total protein 5.4 g/dL , serum albumin 3.3 g/dL and cholesterol 96 mg/dL (Table 1). His body weight was 65 kg and BMI 23 kg/m2 .


Table 1 Biochemical Profile of Patient


Parameter

119/1/11

22/1/11

6/2/11

6/5/11

9/7/11

8/8/11

5/5/12

25/8/12

24/11/12

HB

6.2

6.1

7.9

9.4

10.1

9.7

10.5

12

12.9

TLC

13.5

9.7

16.2

8.4

17.1

20.2

13.1

12.9

BUN

113

31

49

32

43.5

55.7

S. Creat.

12.0

11.0

6.4

12.6

9.3

10.8

12.35

11.04

Na

138

140

-

-

135

139

138

136

137

K

4.5

3.9

-

-

3.7

3.2

4.7

4.09

4.0

Ca

6.3

-

-

-

-

8.6

8.3

9.4

10.3

P

8.9

-

-

-

-

4.9

4.15

3.8

4.8

S Prot

5.4

5.0

5.4

-

6.6

-

7.0

6.5

7.6

S Album

3.3

1st HD

2.9

2.8

CAPD

3.2

4.16

3.43

3.8

4.4

Trigly

96

6/5/-11

3/8/11

5/5/12

25/8/12

24/11/12

Choles

131

-

Renal Replacement Therapy: The patient was initiated on HD twice/thrice weekly depending upon volume overload. He was anorexic. He was anuric (urine output was 30-40 ml/24 hours). Patient was planned for continuous ambulatory peritoneal dialysis (CAPD).

His food intake during hospital stay was 700-800 kcal/d of energy intake and protein intake 35-40 g/d. Blood sugars were uncontrolled

Fluid prescription: Fluid Intake was restricted to previous 24 hour urine output + 500 ml, including IV infusion.


Table 2 Biochemical profile after initiation of CAPD


Parameter

6/2/11

6/5/11

9/7/11

3/8/11

5/5/12

25/8/12

HB

7.9

9.4

10.1

9.7

10.5

12

TLC

16.2

8.4

17.1

20.2

13.1

12.9

BUN

31.0

49.0

32.0

43.5

S. Creat.

6.4

12.6

9.3

10.8

12.35

S. Na

135

139

138

136

S. K

3.7

3.2

4.7

4.09

S. Calcium

8.6

8.3

9.4

S.Phosphorus

4.9

4.15

3.8

S Protein

5.4

-

6.6

-

7.0

6.5

S Albumin

2.8

CAPD

3.2

3.6

4.16

3.43

3.8

S serum

When CAPD was initiated, the serum albumin was 2.8 g/ dL and serum protein was 5.4 which was much below recommended levels (KDOQI serum albumin 4.0g/dl). Six months after initiation of CAPD the serum albumin increased to 4.16 g/dL Recommended dietary intake was 83g protein/d (1.3 g/kg/d) along with 1900 kcal/d of energy. His food intake is given in Table 3. Patient was eating well. However, 6 months post CAPD, serum albumin stated declining because patient had two episodes of peritonitis which resolved on treatment in August and November 2012 respectively.


Table 3 Food Intake of Patient

On January 3rd , 2013, patient was admitted in the hospital with peritonitis (Figure 1) and his PD catheter was removed. Biochemical profile is given in Table 4. Patients was hypercatabolic and stated on MHD . His serum total protein was 5.9 g/dL and albumin was 3.3 which gradually declined to

2.2 within one month due to bacterial and fungal infection, inflammation and poor dietary intake (protein 30g/d and energy 600 kcals/d). Serum phosphates increased to 8.1 mg/ dL. Patient was advised to increase protein intake to 1.5g/ kg/d and energy intake 30 kcal/kg/d. However, the patient expired on 25th February, 2013 due to unresolving peritonitis and multiple organ failure.


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Figure1 : Peritonitis


Parameter

3/1/13

16/1/13

3/2/13

16/2/13

18/2/13

Hb

10.5

13.5

9.3

7.4

TLC

11,800

38,000

17.400

20,520

Platelets

190

2.2

2.48

2.31

S Creatinine

9.2

6.1

6.8

6.6

Na

133

130

132

130

118

K

3.7

3.6

5.2

5.0

5.7

Ca

8.8

8.8

8.6

7.8

P

6.1

6.1

2.1

8.1

anuric

S. Protein

5.9

5.2

4.7

S . Albumin

3.3

2.3

2.1

2.2

Alk Phos

105

176

93

230

Amylase

206

HCO3

16/1/13

17

19

Parameter

3/1/13

16/1/13

3/2/13

16/2/13

18/2/13

Hb

10.5

13.5

9.3

7.4

TLC

11,800

38,000

17.400

20,520

Platelets

190

2.2

2.48

2.31

S Creatinine

9.2

6.1

6.8

6.6

Na

133

130

132

130

118

K

3.7

3.6

5.2

5.0

5.7

Ca

8.8

8.8

8.6

7.8

P

6.1

6.1

2.1

8.1

anuric

S. Protein

5.9

5.2

4.7

S . Albumin

3.3

2.3

2.1

2.2

Alk Phos

105

176

93

230

Amylase

206

HCO3

16/1/13

17

19

Table 4. Biochemical profile of the Patient


FOOD ITEM

PROTEIN

ENERGY

Chappati 6 small (10 g= 60g flour)

6.0

210

Dal 1 bowl 25 g raw

6.0

112

Ommellette 2 eggs

13.0

240

Chicken or fish 2 pieces 60 g

13.0

130

Soyabean 50 g

21.0

216

Paneer + curd 250g

13.0

270

Proseventy powder

20.0

102

2.5% Glucose Dialysate

-

480

Total

92

1760

Discussion:

Thiscaseillustratesacommonscenarioinwhichapatientwith CKD progresses to ESRD, is initiated on maintenance HD, switches over to CAPD, and endures several complications associated with peritoneal dialysis like peritonitis, loss of appetite and inadequate dietary intake which cause progressive deterioration of nutritional status. CKD leads to a state of metabolic and nutritional derangements, more aptly called protein energy wasting (PEW). PEW is a major risk factor for adverse clinical outcomes, such as increased rates of hospitalization and death, in patients with ESRD. Nutritional assessment should be done when patients presents as CKD and should be periodically monitored in follow up visits. For nutritional assessment, a combination of clinically valid tools like SGA score, anthropometry, serum albumin, pre albumin, cholesterol, sodium, potassium, phosphorus calcium, dietary interviews and dietary diaries should be combined to get comprehensive information in order to make a nutritional diagnosis and use suitable aids for intervention and monitoring. Loss of muscle mass, low serum albumin and obvious loss of subcutaneous fat tissue; even in the absence of a formal nutritional assessment, is eveidence enough to classify patient as having PEW. Prevention and treatment of PEW in ESRD patient should involve an integrated approach to reduce protein and energy depletion, avoid further losses, and replenish already wasted stores.

What Causes Decreased Protein And Energy Intake And Hence Malnutrition In PD Patients? The illustrated case exemplifies several factors that can be identified and prevented before development of PEW. Malnutrition, in this patient was multifactorial. It was caused by anorexia, inadequate dietary and protein intake, PD procedure per se which causes loss of amino acids and nutrients in the

peritoneal dialysate, loss of residual renal function, bacterial and fungal peritonitis, metabolic acidosis, comorbid conditions like diabetes mellitus and hypertension and peritoneal transport characteristics (Figure 2). Although markers like IL-6 and IL1 and TNF- were not measured in this patient, elevated levels of IL-6 are associated with increased muscle proteolysis, an effect that can be blocked with administration of IL-6 receptor antibodies. IL-1 and TNF- cause anorexia through effects on the satiety center in the central nervous system.


Treatmenting PEW: Oral and Enteral Nutritional Supplementation.

Transperitoneal energy intake compensates for the lower oral dietary energy, protein and fat intake in CAPD patients. Estimated uptake of the intraperitoneal energy load is 70% which is equivalent to 19% of total energy intake. Peritonitis is a hypercatabolic procedure. In peritonitis, intraperitoneal loss of protein can go upto 15 g in 24 hours compared to 5-15 g of protein loss of every day when the patient is on CAPD, therefore, protein intake should be increased from 1.3 g/ kg/d to 1.5 g/kg/d. Fifty percent of protein should be of high biological value. Dialysis dose should be adjusted according to requirements. In such patients once PD catheter is removed, and if dietary intake is poor, nutritional support in the form of tube feeding or intradialytic parenteral nutrition (IDPN) or total parenteral nutrition (TPN) should be considered. Studies have demonstrated a direct correlation between response to nutritional supplementation and the severity of PEW and the amount of nutrients received, with diabetic patients showing a reduced response to nutritional support. Inflammatory status does not significantly affect the response to nutritional support. The high cost of IDPN is a barrier for use of IDPN, however it should be considered in patients in whom oral or enteral supplements are not feasible


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due to gut edema, recurrent vomiting and gastroparesis. Other studies using amino acids in dialysate (AAD) as a nutritional intervention in PD patients with PEW have provided conflicting results. Overall, AAD remains a viable option in PD patients with PEW who cannot tolerate or are not suitable for oral and other enteral supplements. However, overnight tube feeding can dramatically increase energy and protein intake. Multivitamins should be administered through IV route. Renal specific nutritional supplements should be used in dialysis patients to ensure recommended intake of protein and energy in order to reverse protein losses. Metabolic acidosis should be treated and bicarbonate level should be maintained 22.0mmol/L.


Conclusion:

Providing intradialytic meals, IDPN or oral nutritional supplements to dialysis patients are the interventions to increase serum albumin and to improve longevity and quality of life in this patient.


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References

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