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NUTRITION ACROSS THE CONTINUUM OF CARE IN KIDNEY DISEASE

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Title: NUTRITION ACROSS THE CONTINUUM OF CARE IN KIDNEY DISEASE


1
NUTRITION ACROSS THE CONTINUUM OF CARE IN KIDNEY
DISEASE
  • Judith Beto PhD RD FADA
  • Chicago IL USA

2
Objectives
  • To define the five stages of chronic kidney
    disease (CKD)
  • To discuss nutritional interventions appropriate
    to each stage with emphasis on delay of
    progression to end-stage disease (stage 5)
  • To provide practice education and dietary
    strategies by life stage pediatric, adult,
    geriatric, end-of-life

3
Five CKD Stages
  • Created and published as part of the 2002
    National Kidney Foundation Kidney Disease
    Outcomes Quality Initiative (KDOQI) Clinical
    Practice Guidelines for CKD
  • www.kidney.org for guidelines
  • www.nephron.com for glomerular filtration rate
    (GFR) calculator

4
(No Transcript)
5
Other KDOQI Guidelines
  • Bone Metabolism
  • Clinical Nutrition
  • Cardiovascular Risk
  • Anemia
  • Vascular Access
  • Dialysis Adequacy

6
KDOQI Process
  • Diverse interdisciplinary workgroups
  • Evidence-based, systemic review
  • Goal to gather data upon which to base the best
    care process
  • Expert consensus and peer review

7
Nutritional Management
  • variable in every facet of patient care
  • requires interactive problem-solving skills
  • changes with health care environment
  • particularly expansive in CKD
  • covers multiple age groups and treatment
    modalities

8
In any one day, you may be
  • A renal specialist dietitian
  • A diabetes educator
  • A cardiac/lipid expert
  • An exercise physiologist
  • A psychotherapist/motivational speaker
  • A combination of pharmacist, nurse, social
    worker, nephrologist, patients best friend

9
Betos PAGE System
  • Pediatrics
  • Adults
  • Geriatric
  • End of Life

10
CKD Key Focus
  • PGrowth/development
  • APromote health (prevention)
  • GMaintain health (holding pattern)
  • EMinimize aging effects (slow speed)
  • Quality of life

11
CKD Long-Term Goal
  • Prevent or retard progression
  • Institute renal replacement therapy, when
    necessary
  • Actively seek transplant as appropriate
  • Support end-of-life initiatives

12
Risk Factors for Progression of Renal Disease
13
Primary Diagnoses for Patients Who Start Dialysis
Other 10
Diabetes 50
Glomerulonephritis 13
Hypertension 27
United States Renal Data System (USRDS) 2000
Annual Data Report WWW.USRDS.ORG
www.hypertensiononline.org
14
Dietary Parameters
  • Each nutrient component has a specific purpose
  • All components function in an organized
    supportive manner
  • Every diet needs to be individualized to the
    patient

15
Protein
  • Ad lib intake in pediatrics to encourage growth
    matched to necessary treatment
  • 0.6-0.8 gm/kg/day to retard or delay in adults
    (non-growth)
  • 1.0-1.2 gm/kg/day to support therapy (dialysis)

16
Protein Challenges
  • High biological value (50-70) maximizes use
    egg, animal protein
  • Keep serum albumin in normal ranges
  • Dont overload kidney by replacing urinary
    protein losses
  • Match diet to kidney

17
Calories
  • Minimum 25 kcal/kg/d and titrate upward to
    achieve body weight goal
  • Adequate calories needed to spare protein
  • Body weight can mask protein malnutrition

18
Calorie Challenges
  • Diabetics present special challenge
  • Calculate peritoneal dialysis solution calories
    into daily intake
  • Controversy what weight to use?

19
Sodium
  • Sodium
  • 2-4 g/d (43 mEq 1 g)
  • Variable with urine output and disease etiology
  • Evaluate effect on hypertension control
  • and cardiac function

20
Sodium Challenges
  • Tight blood pressure control helps retard or slow
    down progression of CKD
  • Sodium found widely in processed food supply

21
Fluid
  • Unrestricted until urine output declines
  • Urine output plus 1000 cc/d
  • Evaluate effect on blood pressure and
  • cardiac function

22
Calcium/Phosphorus
  • Preserve bone metabolism
  • Control dietary calcium (1.0-1.5 g/d from diet
    and meds
  • Role of calcification still under study
  • Growth in children is challenge

23
Calcium/Phosphorus
  • Phosphorus dietary control 10-15 mg/g dietary
    protein
  • Phosphate binders by mouth bind dietary
    phosphorus in the gut
  • Restricts most dairy products

24
Bone protection
  • Vitamin D oral or IV
  • Calcium x phosphorus product
  • Parathyroid hormone (PTH)
  • Calcium-sensing receptors
  • Role of weight-bearing
  • exercise??

25
Potassium
  • Accumulates in CKD stage 5
  • Hyperkalemia ?cardiac danger
  • Restrict to 2-4g/d (26 mEq1g)

26
Relation of Fractional Excretion of Potassium
(FEK) to GFR Under Baseline Conditions
150
120
105
90
75
FEK ()
GFR (ml/min)
60
45
30
15
0
30
60
90
120
150
27
GI tract compensation in chronic kidney failure
  • May increase 30
  • Usual load handled 2 g oral/d of K
  • Constipation issues
  • Pica/clay consumption decrease absorption

28
Which food serving contains the highest amount of
potassium?
  • 1 medium avocado
  • 1 large banana
  • 10 dried prunes
  • 1 medium tomato

29
Amount of potassium per serving
  • 1 medium avocado (1096-1483 mg)
  • 1 large banana (467 mg)
  • 10 dried prunes (626 mg)
  • 1 medium tomato (250 mg or 60 mg/oz)

30
Licorice as the culprit (glycyrrhenitic acid)
  • 100 mg potassium in 4 twists of real licorice
  • May also increase blood pressure
  • Licorice-like compounds (carbonoxolone)
  • Mimics syndrome similar to primary aldosterone
    secretion

31
Potassium Challenges
  • No taste
  • Found widely in fruits and vegetables
  • Not found on food labels
  • Confusion with prior diuretic supplementation

32
Vitamin/Minerals
  • Water soluble vitamins (folic acid)
  • Standard vitamin C (60-100 mg/d)
  • No additional A, E, K
  • Minerals zinc for taste acuity
  • No magnesium

33
Anemia
  • Pediatric challenges with growth
  • CKD adults due to low hormone
  • Iron supplementation oral, IV
  • Need adequate iron stores
  • Epotein
  • Correlated with higher energy

34
Nutrition Extras
  • Vitamin E/omega fatty acids/grafts
  • Prognostic nutrition index
  • Growth hormone in children
  • Daily dialysis modality
  • Cyclic/nocturnal treatments

35
GI Health is Key!
  • Binding of phosphorus
  • Excretion of potassium
  • Re-absorption of fluid
  • Fiber and lipid lowering relationship
  • Better patient conversation

36
Nutrition Extras
  • Focus on cardiovascular
  • Plant sterols/stanol esters
  • Saturated fat awareness with adequate calories
  • Fiber and fluid restriction
  • Physical activity

37
Target Lipid Levels
  • Best Borderline
  • Chol
  • LDL
  • HDL 40
  • TG

38
Modality changes lipid pattern
  • CKD-Proteinuria/nephrotic syndrome
  • Hemodialysis LDL/HDL vs total cholesterol
  • Peritoneal triglyceride challenge
  • Transplant obesity, drug-lipid interactions

39
Soluble Fiber
  • Eggplant (123 mg K/0.5 cup)
  • Okra (365 mg K/4 ounces)
  • Over the counter psyillum capsules or other soft
    fiber equivalents
  • Oatmeal (1.5 cups 267 mg P, 196 mg K)

40
Nuts/Omega Fatty Acids
  • 4 Tbsp (1/4 cup) almonds
  • 280 Kcal 348 mg K
  • 9.5 gm protein 5 gm fiber
  • 247 mg P 24 gm fat (good)

41
Autonomy
  • Expand scope of practice with written standing
    orders and protocols
  • Utilize mathematical equations to identify risk
    (HD-PNI, Kt/V, and more)
  • Provide decision making opportunities for direct
    patient care benefits

42
Creativity
  • Develop non-traditional approaches to perceived
    obstacles
  • Overcome barriers to intended practice
  • Think outside the box

43
Overview by CKD Stage
44
Overview by Group
45
Future Pathways
  • Nutrigenomics study of genes
  • Metabolomics study of metabolites
  • Proteomics study of proteins
  • …….and bioactive food components
  • JADA 106403, 2006

46
CKD Prevention
  • www.kidneyfund.org
  • Wallet card Take Charge Protect Your Kidneys
  • The earlier you identify, the greater the ability
    to protect or retard progression

47
Conclusion
  • Better health is a family affair
  • Focus on healthy eating habits earlier in life to
    reap the benefits later in life
  • Everyone eats so we can influence diets that
    protect kidney function
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