What is an appropriate diet for an 18‑year‑old female with end‑stage renal disease (stage 5 chronic kidney disease) on peritoneal dialysis?

Dietary Recommendations for an 18-Year-Old Female with CKD Stage 5 on Peritoneal Dialysis

An 18-year-old female on peritoneal dialysis requires 1.2-1.3 g/kg/day of protein (with at least 50% from high biological value sources) and 35 kcal/kg/day of total energy intake, including calories absorbed from dialysate glucose. 1

Protein Requirements

Target protein intake should be 1.2-1.3 g/kg/day based on actual or adjusted body weight. 1

• At least 50% of protein must come from high biological value sources such as eggs, poultry, fish, lean meat, and dairy products 2, 3
• Peritoneal dialysis causes significant protein losses averaging 5-15 g per 24 hours into the dialysate, plus amino acid losses of approximately 3 g/day 4, 3
• Protein intake below 1.3 g/kg/day in peritoneal dialysis patients is associated with hypoalbuminemia, increased peritonitis incidence, and prolonged hospital stays 1
• Protein intakes up to 1.5 g/kg/day or greater appear well tolerated in peritoneal dialysis patients 1

Energy Requirements

Total daily energy intake should be 35 kcal/kg/day for this 18-year-old patient, which includes both dietary calories and glucose absorbed from peritoneal dialysate. 1

• Approximately 60% of dialysate glucose is absorbed in patients with normal peritoneal transport capacity, providing 100-200 g of glucose per 24 hours 1
• The glucose absorbed from dialysate must be counted toward total energy intake when calculating dietary needs 1
• Energy expenditure in peritoneal dialysis patients is similar to healthy individuals, supporting the 35 kcal/kg/day recommendation 1
• Adequate energy intake is essential to maintain neutral nitrogen balance and prevent protein catabolism 2

Specific Macronutrient Distribution

Carbohydrates should provide approximately 60% of total dietary energy, with adjustment for dialysate glucose absorption. 2

• The extensive carbohydrate absorption from peritoneal dialysate can cause hyperglycemia, hypercholesterolemia, and hypertriglyceridemia 1
• Anorexia from glucose absorption from dialysate commonly reduces dietary intake 4

Fat intake should be monitored, with emphasis on heart-healthy sources to manage lipid abnormalities. 1

Fluid and Electrolyte Management

Fluid intake should be individualized based on residual urine output plus approximately 500-800 mL daily. 5

• Peritoneal dialysis preserves residual renal function better than hemodialysis initially, making residual diuresis an important consideration 4
• Daily peritoneal dialysis sessions allow for less restrictive fluid management compared to hemodialysis 5

Sodium should be limited to 60-100 mEq/day (approximately 1,500-2,300 mg/day). 5

Potassium can be liberalized to 2,000-3,000 mg/day due to daily dialysis sessions. 5

• Peritoneal dialysis has lower restrictions on potassium compared to hemodialysis because of continuous daily clearance 5
• Monitor serum potassium levels regularly and adjust intake accordingly 2

Phosphorus intake requires careful monitoring, with emphasis on avoiding phosphorus additives in processed foods. 6

• Focus on whole foods low in sodium and phosphorus additives rather than severely restricting natural phosphorus sources 6
• Protein-rich foods are major sources of phosphorus, requiring careful balance with protein needs 2

Micronutrient Supplementation

Water-soluble B vitamins must be supplemented due to dialytic losses. 3

• Folic acid: 1 mg/day 3
• Pyridoxine (vitamin B6): 10-20 mg/day 3
• Water-soluble vitamin losses are lower in peritoneal dialysis compared to hemodialysis but still require supplementation 5

Monitoring Parameters

Regular nutritional assessment should include the following markers: 2, 3

• Serum albumin every 1-4 months (target: normal range) 2, 3
• Normalized protein nitrogen appearance (nPNA) with target ≥0.9 g/kg/day 2, 3
• Body mass index (BMI) with concern if <20 kg/m² 2, 3
• Assessment for >10% body weight loss over 6 months 2, 3
• Plasma electrolytes and phosphorus monitoring 2

Intervention Strategy for Poor Intake

If dietary intake is inadequate despite counseling, escalate nutritional support systematically. 2

• First-line: Intensive dietary counseling by a trained renal dietitian 1, 2
• Second-line: Oral nutritional supplements high in energy, given 2-3 hours after meals or late evening to avoid suppressing regular food intake 2
• Third-line: Enteral tube feeding if oral supplements fail and patient cannot tolerate adequate oral intake 1
• Fourth-line: Intraperitoneal amino acid (IPAA) administration for malnourished patients meeting specific criteria 1

IPAA may be considered for patients with: 1

• Evidence of protein malnutrition and inadequate dietary protein intake
• Inability to tolerate adequate oral protein nutrition or tube feeding
• The combination of oral/enteral intake with IPAA will meet nutritional goals
• Difficulty controlling hyperglycemia or hyperlipidemia related to dialysate glucose absorption

Critical Pitfalls to Avoid

Do not restrict protein below 1.2 g/kg/day in an attempt to reduce uremia—instead optimize dialysis adequacy. 2

Account for dialysate glucose absorption when calculating total energy intake to prevent overfeeding. 1

Monitor for refeeding syndrome when initiating nutritional support in malnourished patients. 2

Ensure dialysis prescription adequacy is maintained as protein intake increases to prevent uremic toxicity. 2

Avoid overly restrictive potassium and phosphorus limitations that compromise protein intake and quality of life. 6