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Nutrition Therapy and Dialysis

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Nutrition Therapy and Dialysis Melinda S. Leone, MS, RD St. Joseph's Regional Medical Center Division of Nephrology Paterson, NJ 07503 leonem_at_sjhmc.org – PowerPoint PPT presentation

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Title: Nutrition Therapy and Dialysis


1
Nutrition Therapy and Dialysis
  • Melinda S. Leone, MS, RD
  • St. Joseph's Regional Medical Center
  • Division of Nephrology
  • Paterson, NJ 07503
  • leonem_at_sjhmc.org

2
Objectives
  • Participant will be able to describe the
    importance of nutrition intervention in patients
    with ESRD
  • Participant will be able to identify the
    components of a nutritional assessment
  • Participant will be able to identify the
    components of the renal diet and the role of the
    dietitian

3
Does Nutrition Status Matter?YES!
  • Nutritional indicators can be directly linked to
    patient status and outcome
  • Protein-Energy Malnutrition (PEM)1
  • BMI2
  • Albumin3, 4
  • Potassium
  • Phosphorus5
  • Calcium

4
Renal Osteodystrophy
  • Hyperphosphatemia
  • Vascular and non-vascular calcification5
  • Hypocalcemia
  • Secondary Hyperparathyroidism
  • Bone Disease
  • Low bone mass and density
  • Osteitis fibrosa cystica

5
Protein Energy Malnutrition6
PEM
  • Malnutrition
  • PEM marasmus-kwashiorkor
  • muscle/fat wasting
  • weight loss
  • Marasmus Inadequate nutrient intake
  • Kwashiorkor Inadequate protein intake
  • Cachexia

6
Causes of Malnutrition
  • Uremic Syndrome
  • Malaise
  • Weakness
  • Nausea and vomiting
  • Muscle cramps
  • Itching
  • Metallic taste
  • Neurologic impairment
  • Hospitalizations
  • Co-morbidities
  • Diabetes
  • Infections
  • Amputations
  • Cancer
  • Inflammation

7
Proteinenergy wasting syndrome in kidney
disease7
8
Nutrition Assessment Anthropometric
Data
  • Height
  • Weight status
  • Frame size
  • Arm anthropometrics
  • Appearance
  • Amputations

9
Nutrition Assessment Weight Status
Evaluation
  • Standard Body Weight (SBW)
  • Body Mass Index (BMI)
  • Ideal Body Weight (IBW)
  • Adjusted Body Weight
  • Usual Body Weight (UBW)

10
Nutrition Assessment
Weight Status Evaluation
  • Weight changes
  • Intentional vs. unintentional weight loss
  • Dry weight changes vs. fluid shifts
  • Clinically significant weight loss
  • 5 or gt within 1 month
  • 7.5 or gt within 3 months
  • 10 or gt within 6 months
  • Attitude toward changes
  • Goals for weight changes

11
Nutrition Assessment6Interdialytic Weight Gain
(IDWG)
  • General recommendation 2 kg
  • gt5 fluid gains
  • Excessive fluid intake
  • Weight gain
  • lt2 fluid gain
  • Inadequate fluid and/or food intake
  • Weight Loss/Decreased body mass

12
Nutrition Assessment
Diet History
  • Appetite/Intake
  • Food preferences
  • Allergies/Intolerance
  • Taste changes
  • Acute or chronic GI concerns
  • Swallowing/Chewing concerns
  • Urine output
  • Pica
  • Religious/Cultural Restriction
  • Supplement intake
  • Homeopathic Treatments
  • Nutrition Knowledge

13
Nutrition Assessment
Diet History
  • Shopping and Cooking
  • Abilities
  • Facilities
  • Medication
  • Side Effects
  • Compliance
  • Physical limitations
  • Psychosocial problems
  • Emotional support
  • Economic limitations
  • Depression
  • Adjustment to disease Treatment Compliance

14
Nutrition Assessment
Diet History
  • Food Records
  • 24 Hour Recall
  • 3 Day Food Record
  • 3 Day Calorie Count
  • Food Frequency Questionnaire
  • Diet Assessment
  • Calories
  • Protein
  • Carbohydrates
  • Fat/Cholesterol
  • Sodium
  • Potassium
  • Phosphorus
  • Fluid
  • Vitamins
  • Minerals

15
Nutrition Assessment
Laboratory Analysis6
  • Monthly
  • Albumin 4.0g /dL or gt
  • Potassium 3.5-5.3 mEq/L
  • Phosphorus 3.5-5.5 mg/dL
  • Calcium 8.4-10.2 mg/dl
  • Glucose lt200 mg/dL
  • Non-fasting
  • Product lt 55
  • URR gt65
  • Hgb 10-12 g/dL
  • Quarterly
  • Hemoglobin A1C lt 7
  • PTH 150-600 pg/mL
  • Lipid Panel
  • Chol lt 200 mg/dL
  • HDL gt 40mg/dL
  • LDL lt100mg/dL
  • Triglycerides lt200 mg/dL

16
Nutrition Assessment Subjective Global
Assessment6
  • Protein-energy nutritional status measurement
  • Valid and reliable8
  • KDOQI recommended9
  • Medical history and physical exam
  • Body composition focus on nutrient intake
  • Subjective rating 7 point scale6
  • Well-nourished
  • Mild to moderately malnourished
  • Severely malnourished

17
Nutrient Needs KDOQI
Guidelines9
18
Nutrient Needs KDOQI
Guidelines9
Vitamins and Minerals
19
Nutrition Therapy Goals
  • Provide an attractive and palatable diet
  • Control edema and serum electrolytes
  • Prevent nutritional deficiencies
  • Prevent renal osteodystrophy
  • Prevent cardiovascular complications

20
Dialysis Diet
  • Diet Order
  • 2000 calorie, 80 g protein, 2 g Na, 2 g K, 1 g
    PO4,
  • 1500 ml fluid restriction
  • Meal Planning
  • Individualize diet for patients lifestyle
  • Assistance programs
  • Nursing Homes
  • National Renal Diet American Dietetic
    Association10

21
Dialysis Diet
  • Adequacy and Balance
  • Calories
  • Protein
  • Variety
  • Actual intakes of HD patients11
  • 23 kcals/kg/day
  • Less than 1 g/kg/day

22
Albumin
  • Controversial key nutrition status measure12
  • Depressed values
  • PEM, fluid overload, chronic liver/pancreatic
    disease, steatorrhea, inflammatory GI disease,
    infection, catabolism r/t surgery, abnormalities
    in protein metabolism, acidosis6
  • Elevated Values
  • Dehydration, high dietary protein intake6

23
Albumin
  • Dialysis Treatment
  • HD 10-12 g free amino acids lost13
  • Losses increase with glucose free dialysate
  • PD 5 to 15 g protein lost 9, 14
  • Lost as albumin

24
Protein
  • 1.2-1.3 g protein/kg SBW9
  • Average patient 80 g Protein
  • 50 HBV protein foods
  • HBV Proteins
  • Beef, poultry, fish, shell fish, fresh pork,
    turkey, eggs, cottage cheese, soy
  • 6 to 10 ounces daily
  • Protein Alternatives
  • protein bars, protein powders, supplement drinks

25
Potassium
  • 2-3 g daily9 - adjust per serum levels
  • Dialysis bath concentrations
  • Stricter diet restrictions
  • Insulin deficiency, metabolic acidosis, beta
    blocker or aldosterone antagonists treatments,
    hypercatabolic state
  • Non-diet causes Hyperkalemia
  • Hemolysis, high glucose, insulin deficiency,
    inadequate dialysis, incorrect dialysate
    potassium concentration, starvation, catabolism,
    sickle cell anemia, Addison's disease, long-term
    constipation15

26
Potassium10
  • Avoid Highest Foods
  • Oranges/Juice
  • Banana
  • Potato
  • Plantains
  • Mango
  • Melon
  • Avocado
  • Tomato
  • Nuts
  • Fruits Vegetables
  • Low 20-150 mg
  • Medium 150-250 mg
  • High 250-550 mg
  • Portion size is essential
  • Avoid Salt Substitutes
  • Dairy
  • 1 cup 380-400 mg
  • High phosphorus foods

27
Phosphorus
  • Dietary intake 800 to 1000 mg/day
  • lt17 mg/kg SBW
  • HD removes 500-1000 mg/treatment
  • PD removes 400 mg/treatment
  • 50 dietary phosphorus removed by binders16
  • Control Binders Diet Adequate dialysis

28
Phosphate Binders
29
Phosphorus Balance
Weekly Phosphorus Balance 4200 (diet) 2100
(Binders) 2100( HD) Balance
30
Phosphorus10
  • Lower Phosphorus Foods
  • Fresh meat products
  • Homemade baked goods
  • Nondairy creamer
  • Unenriched rice milk
  • Cream cheese
  • White flour products
  • Rice cakes
  • High Phosphorus Foods
  • Dairy products
  • Beans Nuts
  • Processed meats
  • Chocolate
  • Pancakes, waffles, biscuits, cakes
  • Sardines
  • Whole wheat, bran cereals

31
Phosphorus Additives
  • Inorganic Phosphorus absorbed easily
  • Phosphorus binders ineffective with many
    additives
  • READ THE INGREDENTS LABEL!!
  • Phosphoric acid
  • Sodium hexametaphosphate
  • Calcium phosphate
  • Disodium phosphate
  • Trisodium triphosphate
  • Monosodium phosphate
  • Sodium tripolyphosphate
  • Tetrasodium pyrophosphate
  • Potassium tripolyphosphate

32
Calcium
  • Use corrected calcium (adjusted calcium) for
    albumin lt46 Calculation
    (4-albumin) x 0.8 Ca
  • Diet Less than 2 g daily
  • Hypercalcemia
  • Ca based binders, supplements
  • Vitamin D analogs/treatment
  • Diet, fortified foods
  • Dialysate calcium levels
  • Hypocalcemia
  • Vitamin D, Calcijex
  • Supplement between meals

33
Parathyroid Hormone (PTH)
  • Vitamin D is activated in the kidney to
    calcitriol, or vitamin D31
  • Vitamin D3 levels fall with kidney failure
  • Calcium absorption ? and phosphorus excretion
    ? PTH increases gt bone disease
  • Vitamin D3 therapy helps prevent renal bone
    disease
  • Ca and Phosphorus precipitate and calcify soft
    tissue
  • Ca x Phos product goal range with treatment

34
Fluid
  • HD
  • Urine Output 1000 ml
  • Limit IDWG
  • 2-5 Estimated Dry weight
  • PD
  • Maintain fluid balance
  • Vary dextrose concentrations in dialysate
  • Restrict if fluid balance not obtained without
    frequent hypertonic exchanges

35
Sodium1,6
  • 1 L fluid output 2-3 g Na and 2 L fluid
  • 1 L fluid output 2 g Na and 1-1.5 L fluid
  • Anuria 2 g Na and 1 L fluid
  • Individualize
  • IDWG, blood pressure, residual renal functions
  • Increased Restrictions if ? IDWG, CHF, edema, HTN
  • PD liberalize restriction to 2-4 grams sodium
  • High sodium intake may increase thirst

36
Lipids10
  • Increased risk of lipid disorders
  • Recommended fat intake
  • Total Fat lt30 of calories
  • Saturated fat lt10
  • Cholesterol lt300 mg/day
  • Difficult restrictions to achieve
  • Omega 3 supplements for elevated triglycerides
  • Optimum fiber intake 20-25 g/day

37
Micronutrients1,6
  • Renal Multivitamin containing water soluble
    vitamins17
  • Dialyzable take after dialysis
  • Vitamin C in renal vitamin
  • Limit total vitamin C 60-100 mg
  • ? Vitamin C ? ? oxalate ? calcification of soft
    tissues and kidney stones
  • Individualize Fe, Vitamin D, Ca, Zinc

38
Specific PD Concerns
  • Higher protein needs
  • Lose 5-15 grams of protein a day 9, 14
  • Weight Gain1
  • Include dialysate calories in total intake
  • May absorb as much as 1/3 (500-800 kcals) of
    daily energy needs
  • Limit sodium and fluid to minimize hypertonic
    exchanges
  • Hypertonic agents such as Icodextrin (Extraneal)
  • High Triglycerides6
  • Modify intake of sugars/carbohydrates
  • Limit intake of fats, saturated fats

39
Nutritional Supplements
  • Oral supplements Nepro, Ensure, Boost
  • Powders Beneprotein, ProSource, Eggpro
  • Modular Protein Pro-Stat, Promod
  • Cookies NutraBalance
  • Protein Bars
  • Meal replacements vs. snacks
  • Over the counter
  • Evaluate potassium, phosphorus

40
Nutrition Support
Enteral
  • Oral Supplements
  • Barriers compliance, fluid , palatability, cost
  • Tube feeding
  • Renal Formulas
  • Nepro and Novasource Renal
  • Barriers acceptance, intolerance, tube
    placement, fluid intake, reimbursements,
    assistance

41
Nutrition Support
Parenteral
  • IDPN
  • Barriers
  • Oral intake is maximized without improvement in
    status
  • Usually requires documented malabsorption
    diagnosis
  • Benefits
  • Supplemented during treatment
  • No additional tube/access needed
  • Dialysis clinics have individual rules and
    criteria
  • Specific qualifying criteria from insurance
    companies

42
RD Roles Anemia and Bone Management
  • Anemia Management
  • APN Anemia Manager
  • Protocols
  • Bone Management
  • APN Bone Manager
  • Protocols
  • MD input as needed
  • RD recommendations

43
Resources
  • www.davita.com/diethelper
  • www.case.edu/med/ccrhd/phosfoods
  • www.kidneyschool.org
  • www.aakp.org/brochures/phosphorus
  • www.aakp.org/aakp-library
  • www.rd411.com

44
References
  • 1. Byham-Gray L, Wiesen K. A Clinical Guide to
    Nutrition Care in Kidney Disease. Chicago
    American Dietetic Association 2004.
  • 2. Pifer TB et al. Mortality risk in hemodialysis
    patients and changes in nutritional indicators
    DOPPS. Kidney International. 2002622238-2245.
  • 3. Acchiardo SR, et al. Morbidity and mortality
    in hemodialysis patients. ASAIO Trans.
    199046830-837.
  • 4. Lowrie EG et al. Death risk predictors among
    peritoneal dialysis and hemodialysis patients a
    preliminary comparison. Am J Kidney Dis.
    199526220-228.
  • 5. Kestenbaum, B et al. Serum phosphate levels
    and mortality risk among people with chronic
    kidney disease. JASN. 200516(2)520-528.
  • 6. McCann L. Pocket Guide to Nutrition Assessment
    of the Patient with Chronic Kidney Disease. 4th
    ed. National Kidney Foundation 2009.
  • 7. Fouque D et al. A proposed nomencalture and
    diagnostic criteria for protein-energy wasting in
    acute and chronic kidney disease. Kidney
    International. 200873391-398.
  • 8. Steibe A et al. Multicenter study of validity
    and reliability of subjective global assessment
    in the hemodialysis population. Journal of Renal
    Nutrition. 200717(5)336-342.

45
References
  • 9. NKF K/DOQI practice guidelines. Clinical
    practice guidelines for nutrition in chronic
    renal failure. Am J Kid Dis. 200035S40-S41
  • 10. Schiro-Harvey K. National Renal Diet
    Professional Guide. 2nd ed. Chicago American
    Dietetic Association 2002.
  • 11. Rocco et al. Nutritional status in HEMO study
    cohort at baseline hemodialysis. Am J Kidney
    Dis. 200239245-256.
  • 12. Friedman AN, Fadem SZ. Reassessment of
    albumin as a nutritional marker in kidney
    disease. J Am Soc Nephrol. 201021223-230.
  • 13. Ikizler, TA et al. Amino acid losses during
    hemodialysis. Kidney Int. 199446830-837.
  • 14. Blumenkrantz MJ et al. Metabolic balance
    studies and dietary protein requirements in
    patients undergoing continuous ambulatory
    peritoneal dialysis. Kidney Int. 198221
    849-861.
  • 15. Beto J. Hyperkalemia Evaluation of dietary
    and non-dietary etiology. J Ren Nutr.
    1992228-29.
  • 16. Rocco MV et al. Handbook of Dialysis. 3rd ed.
    Philadelphia Lippincott, Williams Wilkins
    2001.
  • 17. Andreucci, VE et al. Dialysis outcomes and
    practice patterns study (DOPPS) data on
    medications in hemodialysis patients. Am J Kidney
    Dis. 200444(S2)S61-S67.

46
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