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Nutrition Therapy: Chronic Kidney Disease

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Nutrition Therapy: Chronic Kidney Disease Sheryl Rosenberg Thouin, MPH, RD, CDE * * CKD patients have depressed production of the hormone erythropoietin (needed to ... – PowerPoint PPT presentation

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Title: Nutrition Therapy: Chronic Kidney Disease


1
Nutrition Therapy Chronic Kidney Disease
  • Sheryl Rosenberg Thouin, MPH, RD, CDE

2
Chronic Kidney Disease
  • CKD is defined as either kidney damage or GFR lt
    60mL/min for lt 3 months
  • Kidney damage is defined as pathologic
    abnormalities or markers of damage, including
    abnormalities in blood or urine tests, or imaging
    studies.
  • 20 million Americans have CKD and 20 million more
    (1 out of every 9) are at risk.
  • Approx 50 of dialysis patients have diabetes
  • Note Insulin requirements decrease with
    progressive CKD due to inefficient excretion of
    insulin

3
Functions of the Kidney
  • Excretion of metabolic waste through urine
  • Water and Electrolyte Homeostasis
  • Acid/base balance
  • Maintenance of bone health
  • Activation of vitamin D
  • Calcium/phosphorus homeostasis
  • Blood Pressure Regulation
  • Renin-Angiotensin-Aldosterone
  • Stimulate red blood cell production
  • Erythropoietin

4
Consequences of Kidney Disease
  • Decreased excretion of nutrients/waste
  • Abnormal calcium/phosphorus metabolism leading to
    bone disease
  • Weight loss and malnutrition
  • Fluid and electrolyte imbalances
  • Cardiovascular disease and mortality

5
Uremic Syndrome
  • Nausea
  • Vomiting
  • Metallic taste
  • Itching
  • Lack of energy

6
Protein-energy wasting syndrome
Kidney Int. 200873(4)391-398
7
Goals of CKD Management
  • Achieve/maintain optimal nutritional status
  • Prevent protein energy malnutrition
  • Slow the rate of disease progression
  • Prevention/treatment of complications and other
    medical conditions
  • DM
  • HTN
  • Dyslipidemias and CVD
  • Anemia
  • Metabolic acidosis
  • Secondary hyperparathyroidism

8
  • Evidenced based clinical practice guidelines
  • For all stages of kidney disease
  • For related complications

9
Glomerular Filtration Rate
  • GFR (140-age) X body weight (kg) X 0.85 if
    female
  • 72 X serum creatinine
    (mg/dL)
  • GFR of 100 approximates 100 kidney fxn
  • Normal GFR 120 to 130 mL/min

10
Stages of Chronic Kidney Disease
11
Deterioration of Nutritional Status Begins Early
  • GFR 28 35 mL/min or greater
  • Protein Energy Malnutrition (PEM) is often
    present at the time patients begin dialysis.
  • Malnutrition in pts beginning dialysis is a
    strong predictor of poor clinical outcome

12
Medical Nutrition Therapy Recommendations
(Stages 3 to 5)
13
Optimal Nutritional Status
  • Albumin gt 4.0
  • Stable, desirable dry weight
  • Adequate fat stores and muscle mass
  • Appropriate appetite and intake

14
Reverse epidemiology of obesity in dialysis
patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr
200581543-554
15
Assessing Anemia in CDK
16
Low Albumin
  • Non-nutritional factors
  • Infection
  • Inflammation
  • Co-morbidities
  • Fluid overload
  • Inadequate dialysis
  • Blood loss
  • Metabolic acidosis

17
Calories
  • Recommended energy intake 30 to 35 day kcals/kg
  • Spares body protein
  • Maintains neutral nitrogen balance
  • Promotes higher serum albumin levels
  • Challenges
  • Decreased appetite from uremia
  • Various CKD dietary restrictions
  • Finding food sources for added calories

18
protein
19
Dietary Protein Restriction
  • Reduces nitrogenous waste
  • Reduces inorganic ions
  • Reduces metabolic/ clinical disturbance (uremia)
  • Slows rate of decline in GFR

20
K/DOQI protein guidelines
  • (Average American Intake 1.2 g per kg/day)
  • 0.75 grams per kg/day for CKD stages 1 thru 3
  • 0.6 grams per kg/day for CKD stages 4, 5
  • 50 of the dietary protein should be HBV
  • HBV protein produces less nitrogenous waste
  • 45 to 60 grams protein per day
  • No Protein Restriction for Dialysis Patients
  • 1.2 g per kg/day hemodialysis
  • 10-12 grams lost per HD treatment
  • 1.3 g per kg/day peritoneal dialysis
  • 5-15 grams lost per PD treatment

21
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22
Food Portion Estimations
1 tsp
3 oz
1 cup ½ cup
¼ cup
1 oz
23
Protein in Foods
  • 1 oz meat, poultry, fish 7 g
  • ¼ cup tuna
  • ½ cup beans, peas, or lentils
  • 2 Tablespoons peanut butter
  • 2 egg whites 7 g
  • 1 cup milk 8 g
  • 1 oz cheese
  • 1/3 cup cottage cheese
  • 1 cup veg 2 g
  • 1 slice bread 3 g
  • ½ cup rice or pasta
  • ½ cup cereal
  • Fruit, fats, sugars 0

24
Challenges with High Protein FoodsAlso high in
phosphorus and potassium
  • Milk
  • Cheese
  • Beans
  • Peanut butter

25
How much protein?
  • Lunch A
  • 2 slices bread
  • Chicken breast (3 oz)
  • Lettuce, tomato
  • Mayonnaise
  • 16 oz milk
  • banana
  • Lunch B
  • 2 slices bread
  • 1 oz chicken
  • Lettuce
  • Mayonnaise
  • Iced tea
  • apple

26
Nutritional Interventions
  • Encourage patients to eat
  • Adjust or liberalize diet as appropriate
  • Frequent small meals/snacks
  • High protein foods first if they get full quickly
  • Calorie dense foods
  • Consider use of nutritional supplements

27
Supplements
  • Protein Powder
  • Procel, Egg/Pro
  • Liquid Protein
  • Pro-Stat, ProSource, Liquicel
  • Liquid Nutritional
  • Ensure, Boost, Enlive
  • Calorie Dense
  • Ensure Plus, Boost Plus
  • Renal Specific
  • Nepro with Carb Steady, Re/Gen
  • Novasource Renal, NutriRenal

28
Sodium
29
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30
Sodium
  • Dietary sodium restriction prevents
  • Excessive thirst
  • Edema
  • Hypertension
  • CHF
  • Sodium restriction 2000 mg/day
  • Range from 1000mg to 4000mg
  • Varies depending on co-morbidities
  • More liberal sodium with frequent dialysis
  • Sodium excretion falls at GFR lt 20mL/min

31
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32
Sources of dietary sodium
  • Pre-prepared foods
  • Processed foods
  • Canned, bottled, packaged foods.

33
  • 1 tsp salt 2,300 mg sodium

34
2 gram Sodium Diet
  • Fresh foods
  • Limit
  • Cured/pickled foods
  • Processed
  • Can/bottled/packaged
  • Instant cereals, mixes
  • Avoid salt substitutes (potassium chloride)
  • Flavor foods with spices, vinegar, lemon juice,
    pepper

35
Potassium
36
Potassium
  • Potassium Restriction Indications
  • Urine output lt 1 liter per day
  • GFR lt 10 mL/min
  • ACE inhibitors, beta blockers, lasix
  • Hyperglycemia
  • Serum potassium gt 5.0 mEq/L
  • Dietary Potassium Restriction 2 grams/day
  • Serum Potassium Goal 3.5- 5.0 mEq/L

37
Potassium in the Diet
  • High (gt 400 mg/serving)
  • Banana
  • Potato
  • Avocado
  • Orange juice
  • Moderate (gt200 mg/serving)
  • Berries
  • Broccoli
  • Tomato

38
Low Potassium Fruit Vegetables
  • gt100 mg/serving
  • Cranberries
  • Apple
  • Corn
  • Lettuce
  • Pineapple
  • String beans

39
How much potassium?
  • Lunch A
  • 2 slices bread
  • Chicken breast (3 oz)
  • Lettuce, tomato
  • Mayonnaise
  • 16 oz milk
  • banana
  • Lunch B
  • 2 slices bread
  • 1 oz chicken
  • Lettuce
  • Mayonnaise
  • Iced tea
  • apple

40
Managing Bone Health
41
Altered Bone Turnover in CKD
  • Kidney Failure leads to
  • Decreased production of active Vit D
  • Low serum calcium
  • Phosphorus retention
  • Elevated PTH
  • Secondary Hyperparathyroidism
  • Mineral and Bone Disorder

42
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43
Phosphorus
44
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45
Phosphorus
  • High serum phosphorus
  • Bone decalcification
  • Soft tissue calcifications
  • Hyperparathyroidism
  • Phosphorus restriction for GFR lt 25mL/min
  • Normal dietary phosphorus 1000 to 1800 mg/day
  • Dietary restriction 560 to 850 mg/day
  • Phosphate binders
  • Bind phosphorus in the GI tract
  • Must take with meals
  • Phoslo (calcium containing)
  • Renvela (Sevelamer) (calcium free)
  • Fosrenol (chewable)

46
Phosphorus is not found on the Nutrition Facts
Label
47
High Phosphorous Foods
48
calcium
49
Calcium in CKD
  • Maintain serum calcium 8.4 10.2 mg/dL
  • Optimal lt 9.6 mg/dL
  • Dietary Calcium
  • 1200 1500 mg/day (stages 3 and 4)

50
Calcimimetics A new family of drugs (Sensipar)
  • Binds to calcium receptor
  • Decreases PTH
  • Active orally
  • Advantageous Suppression of PTH without risk of
    hypercalcemia or hyperphosphatemia
  • FDA approved

51
Fluid Restriction
52
Fluid Restriction CKD Stage 4 or 5
  • Fluid any food that is liquid at room temp
  • Soup, gelatin, ice cream, popsicles
  • Excess fluid buildup
  • Edema, SOB, HTN, CHF
  • Delays wound healing
  • Fluid restriction estimations are based upon
  • Urinary output
  • Disease state
  • Treatment modality (dialysis, etc.)

53
Fluid Allowance Tips
  • Approx 48oz/day
  • Pre-measure mealtime liquids
  • Drink very hot or very cold beverages
  • Drinking from smaller cups
  • Use spray bottle to mist mouth
  • Freeze juice in ice cube tray and eat like
    popsicles

54
Vitamin Mineral SupplementsDietary
restrictions result in a diet deficient in
nutrients
  • Vitamin C 90 mg/day
  • Over 75 of kidney disease patients have
    increased homocysteine levels. 
  • Folic acid 1 mg/day
  • B6 5 mg/day
  • No Vitamin A due to its accumulation in CKD
  • Vitamin D in its active form
  • 1,25 dihydroxycholecalciferol
  • 1,25 (0H2)D3
  • Procrit and iron supplementation
  • Suggestion Nephrocaps

55
Herbal Supplements
  • Use may be unsafe for CKD patients
  • Poor clearance
  • Purity, safety, effectiveness unknown
  • No regulation, no testing requirements
  • Subject to contamination
  • Lead
  • mercury
  • Herbs can interact with medications
  • Renal patients take gt 10 meds/day
  • Renal toxicity
  • Wormwood
  • Horse chestnut
  • Sassafras

56
Herbs with diuretic properties that may cause
renal inflammation
  • Bucha leaves
  • Juniper berries
  • Uva ursi
  • Parsley capsules

57
Making Meals Appetizing
LunchTwo slices white breadTwo Tbsp mayonnaise
with lettuce and onion 1 ounce chicken or one
hard boiled eggTwo canned peach halves 7 Up or
Lemonade
58
CKD Nutrition Resources
  • www.dietconsultpro.com
  • Relevant and easy-to-understand nutrition
    education guides by Medi-Diets
  • Renal Nutrition Principles (non-dialysis)
  • You Potassium Intake
  • Lowering Your Sodium Intake
  • www.davita.org
  • Complete CKD education site
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