Nutritional management of the dialysis patient with acquired immunodeficiency syndrome

Review

Nutritional Management of the Dialysis Patient With Acquired Immunodeficiency Syndrome Dodi Plourd, RD*

I Objective: To review the current literature so that appropriate nutritional guidelines, interventions, and management for the dialysis patient with acquired immunodeficiency syndrome (AIDS) can be determined. I Data: Relevant English language articles were identified via MEDLINE search (1980 to 1995). Relevant texts also were reviewed. Additional references were selected from bibliographies of identified articles and texts. n Study selection: All selected articles and texts related to the nutritional concerns, management, and intervention for patients (1) with AIDS, (2) with end-stage renal disease (ESRD), and (3) with ESRD and AIDS who are on dialysis. I Data synthesis: Human immunodeficiency virus infection, AIDS, and ESRD are all nutritionally debilitating. When a patient has AIDS and is dependent on dialysis, the nutritional consequences are compounded. Malnutrition results from a combination of many factors, and as it progresses, there is increased morbidity and mortality. Nutritional guidelines recommended for persons with AIDS are based on extrapolations of needs and allowances from other chronic diseases. I Conclusion: Information regarding the nutritional needs and management of the ESRD patient with AIDS who is on dialysis is not available at this time. Nutritional goals can be estimated based on the reported needs for each disease state separately. Intervention and management can be accomplished using tools and information available for the nutritional management of other chronic diseases. As the number of AIDS patients increases, there will be an increased number of dialysis patients with AIDS. Additional research is necessary to define the nutritional needs and management of this high-nutritional risk population. o 1995 by the National Kidney Foundation, Inc.

H

ELPING PATIENTS who have end stage renal disease (ESRD) attain or maintain the best nutritional status possible is difficult. Even for patients who have been on dialysis for years, maintaining the necessary balance of various nutrients is ardu*Renal Dietitian, Departments of Nephrology and Clinical Nutrition, University of Californ/a, San DlegoMedical Center, San Diego, CA. Address reprint requests to Dodl Plourd, RD, Departments of Nephrology and Clinical NutrlOon, lJnwers/ty of California, San Diego-MedIcal Center, 200 W Arbor Dr, San D/ego, CA 92103-8781. o 1995 by the National Kidney Foundation, Inc. 1051-2276/95/0504-0002$03.00/O

182

Journal

ous. The addition of any other chronic illness only adds to the challenge. Approximately one third to one half of dialysis patients have ESRD secondary to diabetic nephropathy.’ There are numerous other chronic and acute diseases that coexist with ESRD, such as Crohn’s disease, sickle cell disease, arthritis, obesity, hyperlipidemia, systemic lupus erythematosus, and various cancers. One of the newest chronic diseases coexisting with ESRD is acquired immunodeficiency syndrome (AIDS). AIDS is the final stage of an infection caused by the human immunodeficiency virus (HIV). HIV affects cell-mediated immunity by de-

of Rena/ Nutrition,

Vol5,

No 4 (October),

1995:

pp 182-l 93

MANAGEMENT

OF

THE

DIALYSIS

PATIENT

WITH

stroying the helper-inducer subsets of T lymphocytes.2 The hallmark of HIV infection is progressive depletion of T cells, eventually leading to immunodeficiency, secondary infections, and malignancies.3 These effects cause systemic disease with multisystem and multiorgan involvement, which may include the kidney.4 Nutritional problems related to opportunistic infections, malignancies, and therapy are reported at all stages of HIV infection. Inadequate intake, nutrient malabsorption, as well as physiological and metabolic changes all contnbute to nutritional compromise. AIDS can severely intensify the nutritional difficulties already commonly seen in the ESRD patient. Practitioners must focus on all nutritionally related diagnoses to accurately assess these patients

EPIDEMIOLOGY HIV-ASSOCIATED

AND CAUSES OF NEPHROPATHY

Approximately 170,000 Americans are currently on dialysis.1,5 Estimates by the Centers for Disease Control and Prevention in Atlanta, GA, suggest that approximately 1 million people In the United States are now infected with HIV.6,7 Limited epidemiological studies indicate that renal disease occurs in 2% to 10% of patients with HIV infection.* AIDS patients comprise slightly less than 1% of dialysis patients.gz10 However, there is disparity between individual dialysis centers in the numbers of AIDS patients. The difference in numbers of patients is in part a reflectron of different patient populations and risk factors in various locations. Epidemiologrcal features of HIV-associated renal disease are different than those of AIDS in general. The typical AIDS patient is young, white, male, and homosexual. The greatest risk factors for the development of HIV-associated renal failure are being young, black, and male and practicing intravenous (IV) drug abuse.8,1 l Of the ESRD seen in AIDS, the most frequently encountered renal pathology is caused by focal and segmental glomerulosclerosis (95%). This type of nephropathy is called HIV-associated nephropathy

183

AIDS

(HIVAN).” Usually HIVAN produces rapid deterioration in renal function. Within a few weeks of presentation, most patients have manifested ESRD.12 Nephropathy may occur before any other clinical diagnoses to define AIDS are determined. The term “HIVAN” is a comprehensive label that includes renal disease in individuals irrespective of the clinical stage of their disease.4 Other causes of ESRD in the patient with HIV infection are minimal change disease, glomerular mesangial hyperplasia, membranous and membranoproliferative glomerulonephritis, and immunoglobulin nephropathy.13

MALNUTRITION Malnutrition is common in dialysis patients and has been shown by numerous studies to be associated with increased morbidity and mortality.14-l6 It has been estimated that approximately 33% of maintenance dialysis patients have mild to moderate malnutrition and that in 6% to 8% of the patients, the malnutrition is severe.‘6 Serum albumin levels less than 35 g/L (3.5 mg/dL), depressed serum cholesterol levels, body weight less than 80% of ideal body weight (IBW), reduction In anthropometrics, low serum creatinine levels, normalized protein catabolic rate less than 0.8 g/kg/d, continued decrease in dry weight, and low predialysis potassium or phosphorus levels are all indices of malnutrition in the dialysis patient population.14 Many of these indices also are indicative of malnutrition in the AIDS population 17,18 The importance of albumin level as a predictive test for survival in the ESRD population cannot be overstated. It has been reported that morbidity and mortality increase significantly with only small decreases in serum albumin levels in the hemodialysrs population.lg Albumin level as test of baseline nutritional status in relationship to survival in the AIDS population also has been noted as predictive. Mortality is highly correlated with decreasing serum albumin levels in AIDS patients 20 In the AIDS population, malnutrition plays a remarkable and independent role in mor-

184

DOD1

bidity and mortality as well as severely reduced quality of life.21 Various studies have defined malnutrition or “wasting” in AIDS patients. It has been shown that the depletion of body cell mass is frequent and occurs out of proportion to the loss of weight and loss of fat. This situation is more consistent with the hypermetabolism of chronic sepsis rather than starvation, which in assessing nutrient goals is a significant point to note.21-24 The preservation of fat mass in AIDS patients may be explained in part by a process of futile cycling of the free fatty acids and triacylglycerols, resulting in increased lipolysis.25 It has been shown that the loss of lean body mass in patients with AIDS is related directly to mortality. Once a patient’s weight approaches approximately 66% of IBW or the total body cell mass (lean tissue) approaches 54% of normal, death occurs.21 The development of malnutrition in the AIDS population is multifactorial as is the development of malnutrition in the ESRD population. Factors that influence nutritional intake and affect nutritional requireTABLE 1. Factors Influencing

Nutritional

Physical Anorexia related to uremra, fever, malaise, or treatments Esophageal and oral lesions Alcohol and drug abuse Malabsorptron and diarrhea Nausea and vomiting related to chemotherapy, gastrttis, esophagitrs, reduced peristalsis, uremia, or gastroparesrs Altered mental status related to dementia, central nervous system pathology, narcotics to control pain or diarrhea, or nutritional deficits Weakness and fatigue Drug-nutrient rnteractrons Low-calorie or unpalatable diet Other chronic disease Increased energy and protein needs Effects of other dietary constrtuents Chemrcal and brologrcal form of nutrient Decreased physical activity

PLOURD

ments and status can be classified as physical, environmental, or psychological (Table 1) .26-28 The challenge is to provide optimal nutritional care and support so that the patient will have an acceptable quality of life and a sense of well-being. The dialysis patient with AIDS can be supported nutritionally by the provision of nutritional and appealing meals, by appropriate education regarding their special needs, through the use of special modifications in the provision or planning of meals, by addressing the symptoms and contributrng factors of malnutrition, and by providing interaction with caring individuals. When provided appropriately, adequate nutrition can preserve lean body mass, prevent weight loss, preserve normal growth, provide adequate levels of all nutrients to prevent deficiencies, and optimize nutritional stores. Improved strength, increased ability to fight infection, reduced fatigue, better toleration of medications and/or treatments, alleviation of symptoms, and improved quality of life all result from improved nutritional status.2g-31

Status Environmental Poverty Inadequate cooking facilittes No caregrver Socral Isolation Unacceptable or unavailable meal delivery program Poor sanitary conditions Culturally preferred food unavailable Unsuitable housrng Inadequate knowledge and education

Psychological Depression Desire for death Food aversions related to alterations in taste, texture, and smell Altered perception of food value. fad diets, junk food, megadosrng nutrients, usrng “special foods,” eating nonfood substances Fear of somatic problems leading to anticipatory nausea and vomrtrng or fear of diarrhea lndrvidual dietary habits Unable to take medications as prescrrbed

MANAGEMENT

DETERMINING

OF

THE

DIALYSIS

NUTRIENT

PATIENT

WITH

NEEDS

Determining nutrient needs for the dialysis patient with AIDS can be attempted by comparing the established nutrient goals for the disease states separately and monitoring various indices (laboratory values, clinical symptoms, and diet histortes) carefully and frequently.31 Estimates of energy requirements are based on predictions of expenditures for various conditions above what is considered basal. Protein requrrements are determined by measuring the amount of dietary protein that balances the losses of nitrogen from the body (for children and pregnant women this includes the amount necessary for the deposition of tissue and growth).26 In an outpatient dialysis unit, the adequacy of calories and protein are monitored by patient changes in weight, laboratory values, normalized protein catabolic rate, and diet recalls and histories. Nitrogen balance is seldom performed in the outpatient setting, and more exact determrnation of caloric needs (indirect calorimetry) IS most often done for research purposes only. The calorie and protein determination IS not as exact as it could be and has not been specifically studied in this population. The determination of mrcronutrient needs also is poorly defined. Agreement on needs for the ESRD and the AIDS populations separately IS not always easy to obtain when discussing vitamin, mineral, and trace element requirements. Thus far, research on micronutrient needs for the dialysis patient with AIDS has not been reported. Nutrient considerations for the healthy individual,32-34 the AIDS patient,17s31 ,353 and the patient on dialysis,37-39 as well as an estimate of nutrient goals for the dialysis patient with AIDS, are shown In Table 2. Goals are simply guidelines that are used in the assessment, education, counseling, and monrtoring process to help patients achieve optimal nutritional status. In determining nutrient goals, the standard tool used for assessment of body weight is IBW. In the AIDS population, a usual body weight (UBW) or actual body

185

AIDS

weight (ABW) is used most often. Many AIDS patients present with a UBW or ABW that is less than the lBW.40,41

MACRONUTRIENT THE DIALYSIS AIDS

NEEDS FOR PATIENT WITH

Protein and calorie needs are particularly high for the dialysis patient with AIDS. Their needs are increased because of the effect of dialysis and also because of the increase in basal metabolism and common malabsorption seen In the AIDS patient.17,22.26 Patients with AIDS often experience metabolic Increases or decreases secondary to frequent opportunistic infections. The resultant fluctuating needs for nutrients can make determination of goals difficult. The final amount of protein recommended might be excessive when compared with the standard dialysis patient. Rather than suggest a lesser amount of protein, it may be prudent to increase dialysis time or change the dialysis procedure itself so that nutritional stores can be maintained. Some of the calories necessary for the peritoneal dialysis patient with AIDS may be met In part by the calories provided by the dextrose in the dialysate. Although this might be viewed as beneficial, this assumed benefit may ‘be cancelled out because of the increased protein losses that can result in peritoneal dialysis.* Fat intake is encouraged because of its caloric density. Often in the AIDS population there IS a problem with malabsorption of fat.25 If a patient has symptoms of fat malabsorption (abdominal bloating, diarrhea, excess flatus) the amount or type of fat consumed may need to be limited or changed. Increased amounts of fats that are easier to digest and absorb, such as medium chain triglycerides (MCT), often are prescribed and better tolerated. MCTs do not contain the essential fatty acid, linoleic acid, and cannot be used as the sole source of fat.22,42 Fluid allowance varies in the dialysis patient In the dialysis patient with AIDS, fluids often are liberalized secondary to increased

TABLE 2. Estimating Nutritional Nutrient

Goals for the Dialysis Patient With AIDS RDA

Protein

0.8 g/kg

Calories

25-30 cal/ IBW

AIDS IBW

kg

Fat

5 30%

Fluid

Approximately 35 mLf kg

Calcium

800-l

,200

mg

Phosphorus

800-l

,200

mg

Potassium

Iron

No RDA, estimated safe and adequate amount 1,8755,625 mg No RDA. estrmated safe and adequate amount 1,l OO3,300 mg 18mg

Zinc

15mg

Magnesium Fiber

400 mg 20-25 g

Ascorbic acid (vitamin C) Thiamin (61) Rrboflavin (B2) Pyridoxrne (B6) Cobalamine

60 mg

Sodium

of cal

1.5 mg 1.7 mg 2.9 mg

HDIPD

1.5-2.0 g/kg ABW/UBW (t s to 2.0-2 5 WI J d albumin and rnfection) 35-45 Cal/kg ABW/UBW (t cal = 500 for weight wn)

30-35 Cal/kg IBW (HD) 25-35 Cal/kg IBW (PD) (includes dialysate cal)

30%

30%-40%

of cal, might need & or change in type of fat if patient has fat malabsorption Same as RDA*

2 x RDA (1,600-2, 400 mg) 2 x RDA (1,600-2, 400 mg) Estimated safe and adequate amount 1,875-5,625 mg, often supplemented* Estimated safe and adequate amount 1 ,lOO-3,300 mg*

Supplementation individualrzed 2 x RDA (30 mg)* 2 x RDA (800 mg)* Same as RDA (may need ? In soluble and J in insoluble fiber) 2 x RDA* (120 mg)

6w

2 2 2 2

x x x x

RDA* RDA* RDA* RDA*

(3 0 (3.4 (5.8 (12

mg) mg) mg) pg)

Pantothnrc acid Biotrn Niacin Folic acid Vitamrn E Vitamin A Vitamin D

10mg

2 x RDA*

0.3 mg 20 mg 400 &I 30 IU 5,000 IU 400 IU

2 2 2 2 2 2

Vitamin

70-l

Supplementatron necessary If on chronic antibiotrc therapy*

1 O-l 4g/kg IBW 1.2-1.5 g/kg IBW (260% HBV)

HD/PD (HD) (PD)

of cal

Urine output + 1 OOO1200 mL (HD) 2000 mL (PD) 1,000-l ,500 mg

With

1 4-2.0 g/kg ABW/UBW (260% HBV)

45-50

Cal/kg

ABWIUBW

W) 40-45 Cal/kg ABWIUBW (PD) (includes dralysate cal) 30%-40% of cal, might need & or change In type of fat if patient has fat malabsorptron Same as HD/PD*

Same

as HD/PD

12-l 5 mg/g of protein or 17 mg/kg IBW (with phosphate binder) 1 mEq/kg IBW (HD) May need supplementation (PD)

Same

as HD/PD

Same

as HD/PD*

2,000-4,000 mg, often more liberalized in peritoneal dialysis

Same

as HD/PD*

Same

Same

as AIDS

Same

as HD/PD*

as AIDS

Not routrnely supplemented Not supplemented Same as RDA

Same

AIDS

Not supplemented* Same as RDA (may t in soluble and insoluble fiber)

as RDA

Same

need J In

as RDA*

Same as RDA Same as RDA 5-10 mg Same as RDA

Same as RDA* Same as RDA* 5-10 mg* Same as RDA*

Same

Same

as RDA*

Same Same Same Same Same Same

as as as as as as

Same

as AIDS

0312)

K

40 t.J,g

x x x x x x

(20 mg)

RDA* (0.6 mg) RDA* (40 mg) RDA* (800 Fg) RDA* (60 IU) RDA* (10,000 IU) RDA (800 IU)

as RDA

Same as RDA Same as RDA 800-l ,000 pg No supplementation No supplementation Supplementation vidualized No supplementation

Abbreviations. RDA, Recommended Dietary Allowance; IBW, ideal peritoneal dialysis, ABW, actual body weight; UBW, usual body weight; increase, J, , decrease, cal, calones, = , approximately *Might need supplementation If patient has chronic diarrhea

body HBV,

rndr-

werght; HD, high biological

RDA* RDA* HD/PD* HD/PD* HD/PD* HD/PD

hemodialysis; value protein,

PD, ? ,

MANAGEMENT

OF

THE

losses from diarrhea, and other infections.

MICRONUTRIENT THE DIALYSIS AIDS

DIALYSIS

PATIENT

WITH

fever, night sweats,

NEEDS FOR PATIENT WITH

In 1989, a Task Force on Nutrition Support for AIDS reported Nutritional Guidelines for the /-W/nfected Patient.31 The guidelines recommended by the Task Force were based on extrapolations of needs and allowances from other chronic diseases. The Task Force set primary goals for the nutritional management of AIDS patients, including specific micronutrient recommendations. Two times the recommended dietary allowance (RDA) for various micronutrients is generally recommended for AIDS patients. Some researchers are now promoting certain micronutrients to be supplemented, in addition to the diet, in amounts up to five times the RDA for AIDS patients.43 A number of studies of AIDS patients have indicated that low serum levels of various vitamins and minerals are common.24,44,45 Zinc; selenium; vitamins A, E, and C; folic acid; pyridoxine (B6), and cobalamrne (B12) are nutrients often described as deficient in AIDS patients.45,46 The pathogenesis of decreased serum levels of various nutrients is uncertain.47 Supplementation in high doses for all, without careful monitoring, may result in complications, particularly in a patient with coexisting chronic illness, such as ESRD. Some of the deficiencies noted in AIDS patients were in part nutritional in origin. Dietary intake was strongly correlated with blood levels of water-soluble vitamins.44 It may be beneficial to encourage dialysis patients with AIDS to increase their intake of foods high in the various B vitamins to decrease the risk of deficiencies Food sources of the B vitamins are abundant, although somewhat limited, in many dialysis diets. Specific recommendations will depend on the individual patient’s laboratory values and dietary vitamin and mineral allowances. Without question, micronutrients play an important role in the proper functioning of

AIDS

187

the immune system. Paradoxically a nutrient deficiency impairs immune function, and an excess also can impair immune function.45 Researchers are looking at the manipulation of specific individual nutrients to help maintain or improve the function of the immune system in the AIDS patient. At this time, no conclusive immune-enhancing recommendations have been made. Persons with AIDS are at risk for oversupplementation of nutrients and are likely to use special diet regimens or unconventional therapies secondary to a search for a “cure” or simply because they are feeling panicky about the progress of their disease. Lack of controlled nutrition studies, as well as lack of adequate amounts of safe and effective treatments or vaccines to fight AIDS, have resulted in widely diverse beliefs and nutrition practices in this group of patients.4*,4g Thirty-eight percent of alternative therapy users do not routinely tell their conventional practitioners about their use of alternative treatments.48 Many AIDS patients obtain the majority of their nutrition information from friends, relatives, and salespeople. 4QIt is important to obtain information regarding these practices to adequately and accurately assess a patient’s needs and how they might be helped effectively. For dialysis patients, it is generally recommended to supplement the diet with various B vitamins; the same recommendation might be made for the dialysis patient with AIDS. Pyridoxine is recommended in higher doses for patients who are on antituberculosis medications. Drug-nutrient interactions must be monitored.37,38,50 In addition to the standard dialysis supplementation, if a patient exhibits symptoms of any vitamin or mineral deficiency, serum levels should be determined and supplementatron started along with careful monitoring. Unfortunately, monitoring serum levels does not always give an accurate guide to the deficiency, and the process is costly. Patient compliance with the standard supplementation often is poor. Dialysis patients with AIDS should be encouraged to comply with standard prescriptions and be discouraged

188 from taking supplements that are known to be harmful. Ascorbic acid (vitamin C) is a watersoluble vitamin that is generally prescribed to the dialysis patient at 60 mg/day (in addition to dietary sources).51 This vitamin often is overprescribed and self-prescribed in the AIDS population. Excess vitamin C can interfere with the absorption of vitamin B12, can cause the depletion of copper stores, osmotic diarrhea, hypoglycemia, and oxaluria, and when discontinued can cause rebound scurvy.52 Based on the information available at this time, vitamin C in the dialysis patient with AIDS should only be supplemented at the standard dialysis recommendation. Calcium and phosphorus allowances for the dialysis patient with AIDS are the same as those for the dialysis patient. In the dialysis patient with AIDS, if intake is good and protein needs are met, phosphorus restriction is necessary along with phosphate binders. When appetite and intake are poor, or when a patient has symptoms of malabsorption, serum phosphorus levels often are low, and dietary restriction and binders are not necessary. Potassium and sodium allowances should be individualized to meet the patient’s needs while maintaining normal serum levels and hydration. Iron supplementation is individualized in the dialysis patient. Recombinant human erythropoietin often is used to correct anemia by increasing red blood cell formation, and adequate iron stores are necessary.53,54 Inadequate iron intake, as well as excess intake, can contribute to an increased risk of infection.55 In the AIDS population, iron often is self-prescribed in amounts larger than medically advised.56 Supplementation of oral or IV active vitamin D on an individual basis in the dialysis patient with AIDS, using the same guidelines formulated for the general dialysis population, is necessary.57 Vitamin A toxicity in the dialysis patient has been documented. Supplementation of vitamin A is contraindicated unless a deficiency has been documented. Vitamins D, A, E, and K are fat soluble and may need to be supple-

DOD1

PLOURD

mented in a water-miscible form if the patient is experiencing fat malabsorption. For patients who receive chronic antibiotic therapy, supplementation of vitamin K should be considered.56 Zinc supplementation is not consistently prescribed in the general dialysis patient. Symptoms of zinc deficiency include changes in taste acuity, anorexia, impaired wound healing, and hypogeusia,26 all common complaints of AIDS patients. If a deficiency is suspected, zinc supplementation for a specific length of time, along with appropriate monitoring of deficiency symptoms and serum levels, is appropriate.51 AIDS patients who have severe diarrhea could lose up to 20 mg of zinc/L of stool, and supplementation is necessary.25 Zinc in amounts as little as 25 mg/day can cause gastrointestinal distress and impaired immune function.5g Hypomagnesemia is rare in ESRD. It may be necessary to supplement magnesium in the dialysis patient with AIDS if absorption is impaired or if vomiting occurs.37

INTERVENTIONS After nutritional goals and guidelines are determined, it is necessary to make the appropriate interventions to help the patient meet those goals. Guidelines for successful nutrition interventions for the person with AIDS are shown in Table 3.2g-31,36 The suggestions for intervention could be made for anyone with any of the complications noted. In many instances, the suggestions made for the dialysis patrent with AIDS will not need to be modified for lower potassium, sodium, phosphorus, etc, because of other symptoms that the patient may have and because of nutrient losses that occur. The modifications necessary will depend on the patient’s present intake and nutritional status. Each list of suggestions can be rndividualized depending on what the patient needs and can tolerate. Food safety in the immunocompromised patient cannot be overlooked. A slight food poisoning in a healthy individual may become a life-threatening illness for the AIDS patient. Recovery from food-borne illness in

MANAGEMENT

TABLE Nutrition

OF

THE

DIALYSIS

PATIENT

WITH

189

AIDS

3. Interventions

for Persons

With

AIDS

Problem: Loss of appetite Eat frequent, small meals and snacks between meals Keep favorite, readrly available foods on hand, and put those foods rn a convenient place. If possible, avoid fluids with meals. Do mild exercise before meals Avoid stress around mealtimes. Avoid strong cooking odors, keep home well ventilated Serve food attractively Try eating in different locations Ask someone to prepare meals for you; use a meal delivery program Get together with other people for any event that may spark Interest In eating. On days that you are not feeling well, a liquid or powder nutntronal supplement may be necessary Note You might consider the use of an appetite strmulant; ask your physrcran. Problem. Diarrhea (loss of vitamins, minerals, other nutrients and fluid) Continue to eat and drink plenty of flurds to prevent dehydration and weakness Sip drinks throughout the day that will provide calories Instead of plain water Dilute pectin-contarnrng furces (apple, pear, peach, nectarine, or grape) or commercral drinks, such as Pedialyte (Ross Laboratories, Columbus, OH) Consume foods with sodrum and potassium Avoid caffernated drinks and alcoholrc beverages Minimize insoluble fiber whole wheat and other whole-grain bread, cornmeal, bran-type cereals, granola, wheat germ, nuts, seeds, vegetables, and fruits with skin Increase soluble fiber; oatmeal, strawberries, apples, grapes, apricots, pears, cranberries, potatoes, peaches, and bananas Avoid gas-forming foods cauliflower, broccoli, cabbage, brussels sprouts, beans, carbonated beverages, and sorbrtol-sweetened or other chewing gum Eat frequent small meals served at room temperature Avoid hot beverages Decrease or avoid fatty foods. Decrease or avoid lactose-rich foods Note If the cause of diarrhea is treatable, medical Intervention is always desirable Problem. Nausea and vomrtrng Eat small meals throughout the day to keep from feelrng too full and to prevent a prolonged empty stomach Avoid drinking lrqurds at mealtimes to prevent feeling full, restrict fluids to 1 hour before or after eatrng Avoid eating sweets or fried or fatty foods Eat slowly Drink all fluids slowly Relax and chew your food well Eat dry foods, such as toast, crackers or, dry cereal, to ease an upset stomach, especially In the morning or before actrvrty Do not Ire down flat for at least 2 hours after eating Rest after eatrng Salty foods, such as pretzels or salted crackers, may help control nausea Tart foods, such as lemons, may help control nausea Try to avoid the smell of foods when you are not eating: ventrlate your home, especrally the kitchen Ask your doctor for an antiemetic and take it on schedule so that you do not experience nausea Problem. Bloating/fullness/heartburn Eat small, frequent meals Avoid gas-forming foods, cauliflower, broccolr, cabbage, brussels sprouts, beans, carbonated beverages, and sorbitol-sweetened or regular chewing gum Avoid greasy or fried foods. Take an antacid 1 hour after eatrng (check with your physrcran regarding the specific type of antacrd best for you) Allow 1 or 2 hours after a meal before you go to bed (wtth your head elevated) Frnd ways to distract yourself and/or relax. Problem. Increased need for calories and protein Add dry milk powder to milk, shakes, hot or cold cereal, scrambled eggs, soups, casseroles, and desserts Use milk, mrlk substitutes, or creamers Instead of water when making soup, cereal, instant cocoa, pudding, and sauces. (Contmued

on next

page)

190

DOD1 PLOURD

TABLE Nutrition

3. Interventions

for Persons

With

AIDS

(Cont’d)

Add

diced, ground, or pureed meat, or grated cheese or chunks of cheese to soups, vegetables, casseroles, pasta, rice, and salads, Add peanut butter to sauces, sandwich fillings, cookie frostrngs, and milkshakes or use on celery, fresh fruit, crackers, Snack on nuts and add chopped nuts to desserts, salads, and sandwiches. Top crackers or vegetables with chicken, tuna, or egg salad. Add rarsrns or other dried frurt to cereals, salads, puddings, and cookies. Add extra butter or margarine to soups, hot cereals, vegetables, potatoes, rice, and pasta, Use sour cream or yogurt as a dip for fruit and vegetables Add whopped cream topping to hot and cold beverages, puddings, gelatin, and fruit salad Try various commercially prepared nutritional supplements (liquids, powders, or bars). Eat small, frequent meals supplemented with high-calorie, high-protein snacks. Problem: Food safety Meat Cook all meats poultry, and fish thoroughly, precook all types of meat before grilling: use a meat thermometer. Heat leftovers thoroughly to an internal temperature of 165°F. Avoid all raw or undercooked meats, poultry, fish, and shellfish. Eggs Do not use eggs with cracked shells. Boil eggs for at least 7 minutes; fry eggs for at least 3 minutes on each side; scramble eggs to a dry, not runny, consrstency. Avoid raw eggs unless they are commercially pasteurized. Avoid foods with raw or partially cooked eggs, such as homemade mayonnaise, homemade ice cream, homemade eggnog, Caesar salad, and hollandarse sauce. Dairy products Use only pasteurized milk products Use only pasteurized processed cheese Avoid soft-ripened cheese, such as Brie and Camembert, and aged cheese. Fruits and vegetables Wash all fruits and vegetables well; If your T cell count is low, you can mix 2 tablespoons bleach/l gallon of water to use in cleaning fruits and vegetables. Avoid moldy fruit and vegetables. Preparation and clean up If you microwave food, use a rotating turntable, or turn the foods by hand frequently to assure even cookrng. Avoid wooden utensils and cutting boards. After prepanng raw meats, poultry, and eggs, wash cutting boards and utensils with a solution of one part bleach and eight parts water before preparing other foods. Use dish rags and towels only once before laundering or disposrng of them. Food storage Thaw frozen foods in the refrigerator, and keep them well covered. lmmedrately refrigerate or freeze cooked food that is to be saved. Do not save leftovers for more than 2 to 3 days in the refrigerator and 30 days in the freezer; when in doubt, throw it out. Keep foods below 40°F or above 140°F. Note: Call the USDA Food Safety Hot Line at (800)~5354555 for more Information on food safety Problem. Fatigue Make sure you are getting sufficient rest, including breaks and naps Try doing some mild to moderate exercise on a regular basis. Make sure you have a well-balanced diet Place a stool in the kitchen so that you can sit while preparing food. Accept offers of help with meal preparation. Investigate meal delivery programs and congregate meal programs. Make cleanup easy Order takeout food Keep easy-to-prepare foods on hand, such as frozen or microwave meals, canned soups and stews, Instant cereals, canned meat and fish, packaged noodle or rice dishes, peanut butter, cottage cheese, dried fruit, nuts, instant breakfast drinks or bars, and nutritional supplements. (Continued

on next

page)

MANAGEMENT

TABLE Nutrition

OF

THE

DIALYSIS

PATIENT

WITH

AIDS

191

3. interventions

for Persons

With

AIDS

(Cont’d)

Problem, Mouth soreness/swallomng dlfflcultles/taste changes Use a straw to drink Keep your mouth clean by nnslng it often Use a cotton swab instead of a toothbrush If brushing is painful or causes bleeding; avoid water-shooting hygiene devices and commercial mouthwash. If you use a toothbrush, use a soft one Eat cold or room-temperature foods. Eat foods that are soft (mashed potatoes, scrambled eggs, pudding, custard, ripe fruits) Avoid fried, spicy, hard (chips, nuts, seeds), salty, sticky, and sour foods. Avoid alcoholic beverages Cut foods Into small pieces. Tilt your head forward or backward to ease swallowing Find ways to increase aroma in foods using different spices, including sugar, lemon, vinegar, salt, and herbs Marinate meats. Use the trial-and-error approach to find out which foods taste good and which are not acceptable (remember that taste changes often are temporary) Drink small amounts of fluids with solid foods Eat protein foods at cold or moderate temperature.

this patient population is more difficult, and often the offending organism recurs with resulting illness. 60,61 Food safety issues are easily over looked by dietitians who are not used to working with immunocompromlsed persons. Diarrhea is common in patients with AIDS. Fifty percent to 60% of AIDS patients will have diarrhea at some time during their illness. Approximately 50% to 85% of these patients will have an infectious cause for their diarrhea identified, but only half of those are currently treatable.z5 It is extremely important to treat the cause of any infection if treatment is available Untreated Infection contributes to wasting and makes nutritional rehabilitation difficult to impossible to achieve. Nutritional modifications to treat diarrhea should be used as one of the first lines of nutritional support. The avoidance of caffeine, alcohol, fatty foods, insoluble fibers, and lactose may alleviate diarrhea in some dialysis patients with AIDS. Medications to decrease intestinal transit time, along with the addition of a stoolbulking agent, also may be useful rn the treatment of diarrhea. In some instances, elemental feeding or parenteral support will be necessary.17,i8 The loss of appetite may be seen as the result of infection, weakness, psychosocial problems, or it may occur secondary to medications or treatments.31 For patients

who are unable to meet their nutritional needs by eating small, frequent, nutrientdense meals; eating with their family and friends; eating favorite foods; or using liquid nutritional supplements, etc (Table 3), an appetite stimulant can be considered. A number of different products have been studied in the AIDS population that might be suitable in the dialysis patient with AIDS. Dronabinol (Marinol; Roxane Laboratones, Columbus, OH) or megestrol acetate (Megace; Bristol Myers Oncology Division, Princeton, NJ) are medications that may offer some appetite stimulation and associated weight gain for these patients.62,63 There has been some interest in using growth hormone to stimulate appetite in dialysis patients without AIDS, with relatively good results reported.64 All medications, as well as side effects and benefits, need to be considered on an individual basis. Meal delivery programs, the “Share” food program, AIDS foundations, churches and other food banks, buddy programs to assist with meal preparation and to provide social contact at meal times, and financial support are all available, at various degrees, for most patients. Familiarity with the available community assistance and nutrition programs makes it easier to guide patients to appropriate services from which they may benefit.

192 Many of the other nutritional problems that the dialysis patient with AIDS faces may be corrected by a number of interventions that have been used for other chronic disease states. It is important to move quickly with this group of patients when making nutritional recommendations because their nutritional status can deteriorate rapidly without appropriate intervention.

CONCLUSION The multifactorial nature of the nutritional complications in this unique population of dialysis patients is quite overt. The nutritional treatment is complex and challenging. Although AIDS patients can be expected to tolerate long-term dialysis, at this time the survival rate and rehabilitation is dismal.12 The majority of AIDS patients with ESRD survive less than 1 year. Most patients die as a result of infection and malnutrition. Some HIVAN patients with ESRD who have not yet developed symptoms of AIDS do tolerate maintenance dialysis well and survive for prolonged periods of time.” As our understanding and knowledge in treating AIDS improves, and as additional therapies to slow the progression of the disease and prophylactic treatments to lessen chances of life-threatening illness are developed, we will see longer survival times for these patients on dialysis.8,12 Practitioners in the field of renal nutrition must have the ability to assess and intervene so that these patients are able to attain or maintain the best nutritional status possable.

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