Doqi guidelines for nutrition in long-term peritoneal dialysis patients: a dissenting view

The DOQI guidelines recommend a dietary protein intake of 1.2 to 1.3 g/kg/d in long-term peritoneal dialysis patients. A quantitative analysis of the relationship between this high protein intake and phosphorus intake shows that this daily load of protein is likely to lead to hyperphosphatemia in anuric patients with borderline dialysate clearance. Currently available phosphorus binders are not efficient enough to offset completely the adverse effects of a phosphorus-rich diet. An inverse correlation has been shown between serum phosphorus and outcome among dialysis patients, probably mediated by an increase in the Ca x P product. Evidence, theoretic or experimental, that such a high protein intake is by itself beneficial to dialysis patients is lacking. Because high protein intake may increase the daily load of phosphorus and predispose to hyperphosphatemia, it may lead to harmful consequences, and it should be modified. Using the general recommendation for normal subjects plus the usual excessive nitrogen loss during peritoneal dialysis, between 0.9 and 1 g/kg/d most likely would be an appropriate protein intake without exposing the patient to excessive phosphorus load.