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Nutrition Care in Chronic Kidney Disease

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Nutrition Care in Chronic Kidney Disease An Overview Terry Banerjea, MS, RD, LDN Barbara Edgar, RD, LDN Case Study #1 Intervention: Check dietary intake ... – PowerPoint PPT presentation

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Title: Nutrition Care in Chronic Kidney Disease


1
Nutrition Care in Chronic Kidney Disease An
Overview
  • Terry Banerjea, MS, RD, LDN
  • Barbara Edgar, RD, LDN

2
Objectives
  • Understand goals of MNT for patients with CKD
  • Recognize renal related labs and their goal
    values
  • Become familiar with dialysis medications and
    their functions

3
Medical Nutrition Therapy
  • Protein
  • Calories
  • Potassium
  • Phosphorus
  • Calcium
  • Sodium
  • Fluid
  • Vitamins
  • Minerals

4
Protein
  • The backbone of the diet
  • Essential for growth, muscle building, boosting
    the immune system, preventing infection, anemia
  • Important for wound healing
  • Measured as ALBUMIN in the blood
  • Albumin goal is gt4.0 to live longer and healthier

5
Protein/Calorie Malnutrition
  • 40 of hemodialysis patients are thought to have
    protein/calorie malnutrition.
  • Dialysis population has a two-fold increase in
    mortality risk for those with albumin lt3.8 g/dl
    vs. those with albumin gt 3.8 g/dl

6
Some Potential Reasons for Low Albumin
  • Loss of metabolic function in the failing kidney
    leads to build up of waste products leading to
  • Anorexia
  • Decrease in nutrient intake
  • Changes in hormones and metabolism
  • Insulin resistance
  • Increased hepatic glucagon sensitivity
  • Excessive parathyroid hormone secretion
  • Change in the rate of protein/amino acid turnover
  • Acidosis loss of protein and muscle mass
  • Increased cytokine activation (pro-inflammatory
    response)

7
Some Potential Reasons for Low Albumin
  • Use of multiple medications
  • Multiple co-morbidities
  • Loss of amino acids in dialysate
  • Reduced ability to synthesize albumin in the
    elderly leads to slight albumin decrease
  • Liver failure decreases albumin synthesis
  • Fluid overload leads to dilution of the serum
    (would falsely lower albumin and BUN)

8
Calories/ Protein in CKD
  • Appetite and intake may be poor due to
  • Aging
  • Frequent illness, hospitalizations
  • Institutional food
  • GI problems
  • Gastroparesis and diabetes
  • Constipation due to CaCO3, iron, narcotics, other
    medications, low fluid, low fiber, limited
    exercise
  • Diarrhea due to C. difficile with antibiotic
    therapy

9
Calories/Protein in CKD
  • Appetite is made worse by CKD and dialysis due
    to
  • Anorexia caused by uremia
  • Nausea, vomiting, diarrhea
  • Dysgeusia due to uremia, zinc deficiency
  • Peritoneal Dialysis patients feeling of fullness
    from dialysate or sugar content of dialysate
  • Hemodialysis Interferes with regular meal pattern

10
Evaluating Protein Intake
  • Check Urea Reduction Rate (URR) or KT/V - URR
    should be gt70 and KT/V should be gt1.2
  • These measure dialysis adequacy and low values
    may adversely affect intake
  • Check nPCR
  • Normalized protein catabolic rate is determined
    from urea generation. It is an indicator of
    available protein. If patient is stable the nPCR
    indicates dietary protein as g/kg/EDW. nPCR will
    be low if protein intake is low or patient is
    anabolic

11
Evaluating Protein Intake
  • Check BUN 40-100 mg/dl
  • Urea derived from protein will decline if intake
    is poor or patient is anabolic
  • Check albumin (BCG) gt4.0
  • Albumin will decline if patient has trauma,
    infection, intake is poor, or if dialysis is
    inadequate

12
High Quality vs. Low Quality Protein
  • Dialysis patients should get 50 of their diet
    from HIGH BIOLOGICAL VALUE PROTEIN (animal
    products)
  • LOW BIOLOGICAL VALUE protein generally come from
    plants
  • Vegetarians can still maintain acceptable albumin
    levels by combining plants sources with the use
    of supplements

13
How Much Protein Does a Person on Dialysis Need?
  • Hemodialysis patients need 1.2 or more grams/kg
  • Peritoneal patients need 1.3 or more grams/kg
  • Greater protein losses in dialysate
  • Appetite loss due to fullness experienced while
    the dialysate fluid in peritoneum
  • Effect of glucose when using higher concentration
    dialysate
  • These recommendations are based on K/DOQI
    guidelines.

14
Inadequate Protein Intake
  • Muscle Wasting
  • Lack of Energy
  • Weight Loss
  • Poor Wound Healing
  • Albumin lt/3.5 considered protein malnutrition
    (Goal gt/4.0)
  • Low albumin can make it hard to dialyze fluid off
    of a patient

15
Evaluating Calorie Intake
  • Check EDW (Estimated Dry Weight)
  • Check IDWG (Interdialytic Weight Gain)
  • Check labs
  • Poor intake indicated by
  • Low BUN
  • Low Albumin
  • Low K
  • Low PO4

16
How Many Calories Does a Person on Dialysis Need?
  • Hemodialysis patients need 30-35 kcal/kg gt60
    years old, 35 kcal lt 60 years old
  • Obese dialysis patients 25 kcal/kg regardless of
    age
  • Peritoneal dialysis patients have the same
    calorie requirements however the calories from
    the dialysate need to be included

17
Suggestions for Improving Intake
  • Encourage patient to not miss meals even when
    they are not hungry
  • Small, frequent meals
  • If a patient is eating poorly and K and PO4 are
    low- liberalize diet
  • If dysgeusia is present- eggs or cottage cheese
    may be better tolerated than meat, meat at room
    temperature
  • Consider zinc supplement
  • Send lunch with patient to hemodialysis treatment
    if clinic allows or send supplement

18
Suggestions for Improving Intake
  • Protein recommendations are not a restriction
  • Do not sacrifice protein intake in order to lower
    PO4 intake
  • Help patient with fluid/sodium restriction
  • Avoid large fluid weight gains
  • Encourage physical activity to maintain muscle
    mass

19
Suggestions for Improving Intake
  • Protein may need to increase portion size if
    standards are used
  • Serve HBVP at 2 meals/day minimum
  • Serve at least 2 ounces HBVP
  • Serve 4-6 ounces HBVP at large meal
  • Include a HBVP with snack
  • Consider supplements

20
Snacks for Dialysis
  • Many dialysis patients miss 3 meals per week due
    to dialysis schedule so it is important to
    replace this meal with a protein rich snack
  • If patients do not wish to eat a sandwich or if
    it is not allowed, send a supplement as a meal
    replacement
  • Snack Ideas
  • Egg salad, tuna salad, chicken salad, turkey or
    roast beef sandwich
  • Cheese stick and a piece of fruit
  • Greek yogurt
  • A peeled hard boiled egg
  • Binders should be sent with the bag meal

21
Potassium
  • Absorbed in small intestine
  • 90 in cells
  • 8 in bones
  • lt1 in circulation
  • Excretion
  • 80-95 in urine
  • 5-20 in stools

22
Potassium
  • Primary Roles of Potassium
  • Maintains fluid balance within cells
  • Conduction of nerve impulses
  • Muscle contraction

23
Potassium (K)
  • Normal serum potassium values3.5-5.1mEq/L
  • Goal range for dialysis patients3.5-6.0mEq/L
  • Serum level is dependent on urine output
  • K is usually WNL if producing gt1000cc/day
  • May be altered by diuretics and antihypertensive
    medications

24
Causes of High Potassium (Hyperkalemia)
  • Excessive potassium intake
  • Inadequate dialysis
  • Inadequate treatment time or missed treatments
  • Low blood flow rate, recirculation
  • Metabolic acidosis-causes K to shift from cell to
    serum

25
Causes of High Potassium (Hyperkalemia)
  • Dehydration-hyperosmolar state impairs cellular
    uptake of K
  • Insulin deficiency-cellular uptake of K requires
    insulin
  • Blood transfusions-old packed cells will break
    down and release K
  • Hemolysis (incorrect handling of
    specimen)-release of K from RBC into serum

26
Causes of High Potassium (Hyperkalemia)
  • Catabolism due to tissue breakdown
  • Infection and ischemia (bowel)
  • Starvation
  • Trauma surgery
  • GI Bleed
  • Chewing tobacco
  • Use of illicit drugs
  • Some forms of pica
  • Constipation
  • Medications-ACE Inhibitors and ARBS (Angiotensin
    receptor blockers) which are commonly used for
    blood pressure control

27
Symptoms of Hyperkalemia
  • Muscle weakness
  • Numbness and tingling of extremities
  • Slow pulse rate
  • Heart attack

28
Diet Recommendations for Potassium
  • Hemodialysis 2-3 grams/day
  • Peritoneal Dialysis 3-4 grams/day however often
    times a restriction is not needed
  • A high K usually indicates treatments are not
    being done

29
High Potassium Fruits
  • Avocados
  • Bananas
  • Kiwi
  • Mango
  • Melons
  • Nectarines
  • Orange/juice
  • Papaya
  • Pomegranate
  • Prunes/juice
  • Raisins
  • Rhubarb

30
High Potassium Vegetables
  • Artichokes
  • Asparagus- fresh
  • Brussels sprouts
  • Dried beans and peas
  • Lima beans
  • Mushrooms
  • Potato-white/sweet
  • Pumpkin
  • Tomatoes and tomato products
  • Winter squash

31
Diet Recommendations
  • High potassium foods may be allowed in small
    amounts depending on frequency in meal plan
  • EXAMPLE ¼ cup of tomato sauce on noodles
  • Consult with renal dietitian
  • DIALYSIS PATIENTS SHOULD NEVER EAT STAR FRUIT

32
If K is high
  • Check URR (urea reduction rate) or KT/V
    (clearance of volume over time)
  • Check BS and HgbA1C for lack of insulin
  • Check Hgb and transferrin saturation for the
    possibility of a GI bleed
  • Check potassium if specimen was hemolyzed
  • Check medication list Captopril, Enalapril,
    Accupril, Lisinopril
  • Diet review

33
If K is high due to a non-dietary cause
  • Consult MD for changes
  • Blood pressure medications
  • Possible use of Kayexalate
  • Change dialysis bath (3K to a 2K)
  • Discontinue potassium supplement (KCl) if
    prescribed

34
Phosphorus
  • Primary Roles of Phosphorus
  • Bone and Teeth Formation
  • Energy Metabolism
  • Acid-Base Balance

35
Phosphorus
  • Normal serum phosphorus level2.6-4.5mg/dL
  • Goal range for dialysis patients3.0-5.5mg/dL
  • Three ways to control phosphorus
  • Diet restriction is nearly always necessary
  • Phosphate binders
  • Dialysis 800mg/treatment is removed at each
    hemodialysis treatment and 300-315mg/day for
    peritoneal dialysis

36
Symptoms of High Phosphorus (Hyperphosphatemia)
  • Itching
  • Blood shot eyes
  • Bone pain

37
Effects of High Phosphorus
  • Combines with calcium to form deposits in and
    joints
  • CVD, PVD
  • Calcification of soft tissue
  • Calciphylaxis
  • Causes parathyroid hormone to increase
  • Decalcification of bones
  • Bone pain, high risk of fractures

38
Relative Mortality Risk by Serum Phosphorus Levels
39
Dietary Recommendations for Phosphorus
  • 800-1000mg/day, adjust to meet protein needs
    (10-12mg/gram of protein) for hemodialysis and
    peritoneal dialysis

40
High Phosphorus Foods
  • Dairy products milk, cheese, ice cream, yogurt
  • Beans dry beans and legumes
  • Peanut butter and nuts
  • Chocolate products
  • Cola beverages
  • Bran bran muffins and cereals
  • Whole grains whole wheat bread, cheerios

41
Treatment of High Phosphorus
  • Dietary recommendations
  • Limit milk/dairy to ½ cup per day
  • Limit use of non-dairy high phosphorus foods
  • Nuts
  • Legumes
  • Limit foods that contain phosphorus additives
  • Processed and spreadable cheeses
  • Instant products-puddings and sauces
  • Cola, some flavored waters and fruit drinks
    (Hawaiian punch)
  • 90 of the phosphorus in additives are absorbed
    vs. 50 in natural foods

42
Phosphate Binders
  • Must be taken with meals and snacks to be
    effective
  • The active component of the phosphate binder
    combines with the digested phosphorus, forming a
    compound that is eliminated in the stool
  • Patients should also take a binder with the
    protein supplements

43
Binders
  • Calcium Carbonate Tums, Oscal, Caltrate
  • OTC so not costly
  • Many different pleasant flavors to choose from
  • Chewable
  • May cause hypercalcemia
  • May cause constipation, gas, nausea
  • Strength vary from regular Tums (500mg tab which
    provides 200mg of elemental calcium) to Tums EX
    (750mg tab which provides 300 mg of elemental
    calcium) to Ultra Tums (1000mg tab which provides
    400mg of elemental calcium)
  • Typical dose is 1-3 tablets per meal
  • Should be limited to 7-8 regular Tums per day
  • Absorb 20-30 of calcium

44
Binders
  • Phoslo calcium acetate
  • Capsule is 667mg which is 169mg of elemental
    calcium
  • Typical dose is 1-3 capsules per meal, should be
    limited to 9 per day
  • Easy to swallow
  • May cause hypercalcemia
  • Generic is calcium acetate which is either a
    capsule or tablet
  • Less calcium absorbed than calcium carbonate
  • 21 calcium absorbed with meals, 40 absorbed in
    between meals

45
Binders
  • Phoslyra- calcium acetate oral solution
  • Can be used in tube feedings
  • Can be used for patients with swallowing issues
  • Black cherry/menthol flavor
  • Single dose is 5ml
  • Typical dose is 5ml-15ml per meal

46
Binders
  • Renagel (sevelamer hydrochloride)
  • Renvela (sevelamer carbonate)
  • Tablet 400mg and 800mg dose for Renagel, 800mg
    dose for Renvela
  • Renagel lowers cholesterol due to binding with
    bile acids
  • Renagel lowers serum bicarbonate
  • Typical dose is 3 tablets per meal though some
    patients require more
  • Non-calcium based binder so is used for patients
    that have issues with hypercalcemia
  • Renvela comes in a powder form of 800mg or 2.4g
    that is mixed with 2 ounces of water for patients
    with swallowing issues
  • Renagel and Renvela may cause some n/v, diarrhea
    or gas

47
Binders
  • Fosrenol (Lanthanum Carbonate)
  • Chewable tablet of 500mg, 750mg, 1000mg
  • Typical dose is 1000mg tablet per meal
  • Maximum dose is 4500mg per day
  • Non-calcium based binder so is used for patients
    that have issues with hypercalcemia
  • Tablet must be completely chewed, can not swallow
    whole pieces
  • Tablet must be taken after meal is completed, not
    before or during
  • Chalky flavor
  • 0.00003 lanthanum is absorbed

48
Binders
  • Velphoro (Sucroferric Oxyhydroxide)
  • Chewable tablet of 500mg
  • Typical dose is 1 tablet per meal
  • May require 2 tablets with a large meal or a meal
    that contains a high PO4 food
  • Tablet must be completely chewed, can not swallow
    whole pieces
  • Non-calcium based binder so is used for patients
    that have issues with hypercalcemia
  • May cause dark stools

49
Calcium
  • Primary roles of calcium
  • Bone strength
  • Teeth formation
  • Catalyst in the conversion of prothrombin to
    thrombin
  • Involved in transmission of nerve impulses and
    relates to muscle contractions
  • Activates several enzymes such as lipase

50
Calcium
  • Normal serum calcium level 8.4-10.2
  • Normal serum calcium level for dialysis patients
    8.4-10.2
  • Calcium is corrected for an albumin lt4.0
  • (4.0-albumin level X .8)

51
Calcium
  • Causes of Hypercalcemia
  • Addisons disease
  • Cancer
  • Medications
  • Calcium enriched foods

52
Calcium
  • Symptoms of Hypercalcemia
  • Weakness
  • Headache
  • Drowsiness
  • Nausea/Vomiting
  • Dry Mouth
  • Constipation
  • Muscle pain/Bone pain
  • Metallic Taste

53
Calcium
  • Symptoms of hypocalcemia
  • Paresthesia
  • Chvosteks sign
  • Trousseaus sign
  • Tetany
  • Seizures
  • Bronchospasm and laryngospasm

54
If Calcium is High
  • High Calcium levels can lead to calcification
  • Evaluate binder Change to a non-calcium based
    binder if on a calcium based binder
  • Evaluate Vitamin D analog hold or decrease dose
  • May need to start Sensipar which decreases PTH
    and calcium
  • Make sure calcium bath is 2.25
  • Counsel on avoiding calcium fortified foods

55
Calcium
  • Receive calcium from diet, supplements, phosphate
    binders and dialysate
  • K/DOQI guidelines limit p.o. calcium to 2000mg
    from all sources
  • Limit calcium from phosphate binders and calcium
    supplements to 1500mg/day
  • Do not give calcium with iron or zinc supplements
  • Renal RD works with MD to change dialysis bath,
    phosphate binders as appropriate

56
Calcium
  • Possible Problems for the Elderly
  • Decreased absorption due to achlorhydria
  • Calcium citrate may increase aluminum absorption
  • Calcium with a meal will decrease phosphorus
    (hence the calcium based phosphate binders)
  • Decrease response to Vitamin D
  • Immobility increases calcium loss

57
Calcium
  • Drawbacks of Excess Calcium
  • Parathyroid over-suppression
  • Adynamic bone disease occurs with low parathyroid
    hormone (PTH)
  • Extraskeletal calcification may occur

58
Sodium and Fluids
  • Roles of Sodium
  • Principle electrolyte in extracellular fluid
    involved in the maintenance of normal osmotic
    pressure and water balance
  • Acid base balance
  • Osmotic equilibrium

59
Sodium and Fluids
  • Normal serum value is 136-145 mEq/L for the
    general population and dialysis patients
  • A high serum level indicates dehydration
  • Severe diarrhea
  • Vomiting
  • Diuretics
  • A low serum level indicates fluid overload
  • Low fluid intake
  • Edema

60
Sodium and Fluids
  • A high sodium intake results in
  • Thirst and increased fluid intake
  • Fluid drawn into interstitial space causing edema
  • High blood pressure
  • Shortness of breath when fluid is in lungs

61
Sodium and Fluids
  • Difficult Treatments
  • Sudden drop in blood pressure when large volumes
    are removed
  • Cramping when sodium in interstitial spaces is
    holding fluid which then cannot be removed
  • Nausea
  • A generally miserable treatment

62
Diet Recommendations for Sodium
  • Hemodialysis 2-3 grams per day
  • Peritoneal Dialysis 2-4 grams per day
  • Should be most strict when patient has CHF or is
    a cardio-renal patient and on weekends due to 3
    day interval
  • Avoid law sodium products with KCl added
  • Give salty foods as a special treat

63
Sodium and Fluids
  • Fluid Losses (non-urinary)
  • Perspiration from skin
  • Water vapor expired from lungs
  • Fecal losses or ostomy output
  • Fever

64
Sodium and Fluids
  • Diet Recommendations for Fluids
  • Hemodialysis 1000-1500 cc/day or
  • 1000 cc urine output/day
  • 1000 cc if anuric
  • Peritoneal dialysis to maintain balance
  • Patients should not push fluids but drink only to
    quench thirst
  • If a patient has residual renal function they can
    have more fluids.

65
Sodium and Fluids
  • Causes of High Interdialytic Weight Gains
  • Increase in intake of fluid due to excessive
    thirst
  • High sodium intake
  • High serum glucose
  • High urea
  • Medications-antihypertensives, anti-inflammatories
    , decongestants, diuretics, sedatives,
    antianxiety, anti-depressant, anti-diarrhea,
    anti-histamines
  • Lack of saliva

66
Fluid Management in Dialysis
  • Assessing Fluid Retention
  • Hemodialysis check interdialytic weight gain
  • Goal during the week no more than 3 of EDW
  • Goal over the weekend no more than 5 of EDW
  • Peritoneal dialysis - check whether patient
  • Reaches target weight
  • May need a higher strength dialysate
  • Typically no fluid restriction required

67
Fluid Management in Dialysis
  • Any beverage or food that is fluid at room
    temperature is considered fluid (fruits and
    vegetables are not counted as fluid)
  • Fluid guidelines
  • Measure, monitor, mindful
  • Watch sodium intake
  • Take medications with meal beverages when
    possible or applesauce
  • Use only 4-8 ounce beverage containers
  • Avoid bedside water containers

68
Fluid Management in Dialysis
  • Suggestions for thirst control
  • Suck on lemon wedge or add lemon to water-citric
    acid increases saliva
  • Eat sour candy or mints
  • Chew gum
  • Rinse mouth with cold water or mouth wash
  • Eat frozen grapes, pineapple chunks, etc.
  • Brush teeth more often to feel refreshed
  • Use breath spray
  • Use Biotene mouthwash and other products

69
Vitamins and Minerals
  • Some nutrients are lost during dialysis
  • B Vitamins
  • Biotin- low levels are thought to result in
    restless leg syndrome
  • Folic Acid, B12, B6 low levels thought to be
    associated with homecysteinemia
  • Vitamin C
  • Zinc
  • Iron

70
Vitamins and Minerals
  • Fat soluble vitamins are stored in the body and
    not removed during dialysis so supplementation is
    not needed (Vitamin A,D,E,K)
  • Schedule renal multivitamin at bedtime to prevent
    removal at dialysis treatment

71
Vitamins and Minerals
  • Supplements are prescribed
  • Renavite, Renaplex, Nephrovite, Nephrocaps, Renal
    Caps, Prorenal, Triphocaps, Diatx, Dialyvite
  • Oral iron is used mainly for peritoneal patients
  • IV iron may be provided in-center (Venofer,
    Ferrlecit)

72
Vitamins and Minerals
  • Other vitamins and minerals accumulate and may be
    toxic
  • Vitamin A
  • Vitamin D
  • Potassium
  • Calcium
  • Phosphorus
  • Iron
  • Therefore OTC vitamins are not recommended

73
Vitamins and Minerals
  • Vitamin D
  • 1,25 dihydroxy Vitamin D- calcitriol
  • 25, hydroxy Vitamin D - calcidol
  • Vitamin D2 ergocalciferol
  • Vitamin D3 cholecalciferol
  • Normal value is 30-100ng/ml
  • Vitamin D analogs
  • Hectorol
  • Zemplar
  • Calcitriol
  • Available IV for hemodialysis patients and oral
    for peritoneal patients used to manage
    parathyroid hormone (PTH) levels

74
Parathyroid Hormone (PTH)
  • Maintains calcium and phosphorus balance in the
    blood
  • Kidneys turn the active form of Vitamin D (from
    the sun and food/supplements) to the active form
  • When the kidneys do not work, PTH increases and
    active Vitamin D in the form of the Vitamin D
    analog is given to suppress PTH
  • Normal serum PTH 14-72pg/ml
  • Goal range for dialysis patients 150-600pg/ml

75
Parathyroid Hormone (PTH)
  • Parathyroid gland becomes less sensitive to
    calcium and Vitamin D
  • A high PTH can lead to
  • Increase risk for extraskeletal calcification
  • High turnover bone disease (osteitis fibrosa
    cystica)
  • Good bone is replaced with poorly formed bone and
    fibrous tissue
  • Also increases phosphorus

76
Parathyroid Hormone (PTH)
  • Treatment of Hyperparathyroidism
  • Vitamin D analogs
  • Zemplar (paricalcitol)
  • Hectorol (doxercalciferol)
  • Calcijex and Rocaltrol (calcitriol)
  • Parathyroidectomy If PTH gt 1000
  • Calciminetics - Sensipar

77
Sensipar
  • PTH, calcium and phosphorus decrease
  • Doses are 30mg, 60mg, 90mg, 120mg and 180mg
  • PTH is monitored monthly until goal range is met
  • Dose of sensipar is increased until goal range is
    met
  • Patients continue to receive Vitamin D analogs
  • Hypocalcemia can be a problem so calcium level is
    monitored closely

78
Parathyoidectomy
  • Calcium level drops
  • Patients will need calcium supplements, usually
    1-2 gm tid between meals
  • May need to change from a non-calcium based
    binder (Renvela, Renagel, Fosrenol, Velphoro) to
    a calcium-based binder (calcium carbonate or
    calcium acetate)
  • Phosphorus usually drops as well but patients
    still need phosphate binder
  • May supplement with calcitriol as a calcium
    supplement
  • May change calcium bath from a 2.25 to a 3.0

79
Low PTH
  • PTH lt100
  • Leads to adynamic bone disease
  • Low rates of bone formation
  • Decreased numbers of osteoblasts and osteoclasts
  • Osteomalacia (related to aluminum or Vitamin D
    deficiency

80
Fiber
  • Constipation is a common problem in the dialysis
    population due to
  • Fluid restriction
  • Lack of exercise
  • Medications
  • Calcium carbonate, oral iron supplements,
    narcotics

81
Fiber
  • Low Fiber Intake
  • Restriction of fruits and vegetables due to the
    high potassium content of them
  • Self restriction of fruit and vegetables due to
    GI problems or food preferences
  • Poor general intake

82
Fiber
  • Prevention/Treatment of Constipation
  • Encourage fruit and vegetable intake within
    limits of potassium restriction
  • Encourage exercise
  • Fiber supplements and stool softners can be used
  • Unifiber, Metamucil, Miralax, Colace, Senokot
  • Laxatives
  • Dolcolax, Lactulose, Sorbitol, Docusate Sodium
  • Enemas
  • Mineral Oils, Soap suds
  • Fleets should not be used

83
Factors to Consider in Choosing a Nutritional
Supplement
  • Current Oral Intake
  • Recent Lab Values
  • Co-morbidities
  • Body weight
  • Fluid status
  • Recent changes in health status
  • Cognitive state
  • Patient preferences

84
Important Content of the Nutritional Supplement
  • Serving size
  • Calories
  • Carbohydrates
  • Fat
  • Protein
  • Sodium
  • Potassium
  • Calcium
  • Phosphorus

85
Renal Supplements
  • Per 8 ounces
  • 400-500 calories
  • gt15 grams of protein
  • lt200 mg sodium
  • lt300 mg potassium
  • lt350 mg calcium
  • lt200 mg phosphorus

86
Renal Supplements
  • Nepro
  • Novasource Renal
  • Re/Gen
  • Suplena used for pre-dialysis patients only
    that need to be on a low protein diet

87
Non-Renal Supplements
  • Can be useful when a patients potassium and
    phosphorus are well controlled
  • Some patients may also find these choices more
    palatable

88
Non-Renal Supplements
  • Boost
  • Ensure
  • Liquacel
  • Pro-Stat
  • Procel Powder
  • Protein Bars
  • Body Quest Ice Cream
  • Enlive
  • Resource

89
Supplements
  • Providing supplements in small amounts throughout
    the day i.e. a med pass program, can be useful
    for patients with limited appetite and to
    decrease fluid intake

90
Vegetarian Diet for Dialysis Patients
  • Protein
  • Vegetable proteins include foods such as legumes,
    beans, nuts, seeds, soy products such as soy
    milk, tofu and meat analogs
  • Tofu is a good protein choice because it is low
    in sodium, potassium and phosphorus and is very
    versatile
  • Select regular or silken tofu as they contain
    less potassium than extra firm or firm tofu
  • Legumes are a good source of protein and soluable
    fiber but can be a major contributor to a high
    potassium level in the blood
  • The following beans are lower in potassium
  • Lupin, chickpeas, black beans, black eye peas,
    red kidney, pinto as well as hummus which is
    made from chickpeas
  • Meat analogs can be used in moderation if
    balanced with other lower sodiun foods
  • Consider using protein powder or other
    supplements depending on the type of vegetarian

91
Vegetarian Diet for Dialysis Patients
  • Meat analogs
  • Many provide 10-24 grams of protein per serving
  • They are made from soy protein with flavor and
    color added so they taste and feel like real meat
  • Contain a lot of sodium so check labels
  • Brands Morningstar Farms, Loma Linda, Green
    Giant

92
Vegetarian Diet for Dialysis Patients
  • Phosphorus
  • Some of the foods that contain high levels of
    phosphorus include beans, nuts and whole grains
  • Phosphate found in vegetable protein is not
    absorbed as well as the phosphorus found in the
    animal protein
  • Phosphate binders are necessary to manage
    phsophorus levels

93
Vegetarian Diet for Dialysis Patients
  • Potassium
  • Always select the lower potassium fruits and
    vegetables
  • Grains also contain potassium -the lower
    potassium grains would be rice and barley
  • Avoid quinoa, miso and naho
  • Avoid high potassium legumes such as lentils,
    soybeans, adzuki, navy and white beans

94
Vegetarian Diet for Dialysis Patients
  • Calories
  • When following a renal diet it is often a
    challenge to consume enough calories
  • May need include fats as well as some sugars to
    meet calorie needs

95
Case Study 1
  • 67 year old female who receives hemodialysis on
    Mondays, Wednesdays and Fridays
  • Access A-V Fistula
  • Fluid Status Urine output of 75 ml/day, average
    interdialytic weight gain 2-4.8kg
  • Medical History ESRD due to hypertensive
    nephrosclerosis
  • Secondary dx CAD s/p CABG, CHF, PVD,
    Hyperparathyroidism, currently has an access
    infection

96
Case Study 1
  • Medications Nephrocaps, 2 Phoslo with meals,
    Vitamin D, Accupril, Synthroid, Keflex
  • Labs BUN 55, Cr 6.8, K 6.3, Alb 3.1 (was 4.1
    previous month) KT/V 0.9, Ca 9.5, PO4 4.7, Na 140
  • Nutrition/GI Issues Anorexia, weight loss,
    constipation, hypocaloric intake, nausea,
    vomiting
  • Psychosocial Factors ride issues so misses 3
    treatments per month, leg cramps due to excessive
    interdialytic weight gains

97
Case Study 1
  • Potential Rationale for elevated potassium
  • Diet
  • Medications
  • Inadequate dialysis
  • Inadequate intake
  • Lab error
  • Constipation

98
Case Study 1
  • Intervention
  • Check dietary intake adjust diet or review diet
    with patient as needed
  • Repeat lab if it was an error, repeat lab
    should be WNL
  • Encourage patient to not miss treatments to
    improve adequacy
  • Encourage patient to use fiber supplement or
    stool softner or refer to PCP
  • Encourage adequate intake to prevent tissue
    breakdown

99
Case Study 1
  • Nephrologists interventions
  • Rx for access infection
  • Review BP medication Accupril
  • Adjust treatment to improve adequacy

100
Case Study 2
  • 78 year old male who receives dialysis on
    Mondays, Wednesdays and Fridays
  • Fluid Status the patient is new to dialysis and
    still produces quite a bit of urine
  • Medical History Type 2 DM and HTN
  • Labs Alb 4.0, K 5.5, PO4 6.5, Ca 8.0

101
Case Study 2
  • 24 Hour Diet Recall
  • Breakfast A bowl of bran cereal with 2 milk on
    it, 2 slices of toast with butter and low sugar
    jelly on them and a cup of coffee
  • Lunch A ham and cheese sandwich, an apple and
    12 ounces of 2 milk
  • Dinner Meatloaf, mashed potatoes, green beans
    and 12 ounces of 2 milk
  • HS Snack Graham crackers and 12 ounces of milk

102
Case Study 2
  • Recommendations for this patient
  • Decrease milk intake to 4 ounces a day or
    substitute rice milk in place of 2 milk
  • Drink a beverage other than milk with meals (diet
    ginger-ale, diet sprite, sugarfree lemonade)
  • Mix Unifiber, Benefiber with hot cereal or juice

103
Case Study 3
  • 71 year old male who receives dialysis on
    Tuesday, Thursday and Saturday
  • Medical History Type 2 DM
  • He was admitted to an ECF following a hospital
    admission for CHF and began dialysis at that time
  • Labs Alb 3.2, PO4 3.9
  • EDW is 15 pounds less than his usual weight
  • His appetite has improved since starting dialysis
    and he consumes 75-100 of meals and snacks

104
Case Study 3
  • Second set of labs Alb 3.5, PO4 6.0
  • Diet PO4 restriction of 1000mg/day
  • Medications Phoslo is ordered 2 with meals and 1
    with HS snack
  • Third set of labs PO4 5.0, Ca 10.5
  • Medications Phoslo is discontinued and Renvela 2
    with meals and 1 with HS snack is ordered

105
Nursing Home Considerations
  • Check clinic policies regarding bag lunches or
    allowed food
  • Send appropriate finger foods
  • Send appropriate supplements if solid foods are
    not allowed by clinic or not desired by patient
  • Have nursing send phosphate binders with bag lunch

106
Nursing Home Considerations
  • For Diabetics
  • Send food to clinic to treat hypoglycemia
  • Avoid use of orange juice

107
Nursing Home Considerations
  • Monthly communication between dietary and nursing
    staff at the nursing home and the dialysis
    dietitian is essential
  • Each renal patient is different and may have
    different dietary needs, a standard diet may not
    be appropriate
  • Avoid high phosphorus and potassium snacks save
    them for special occasions when the nursing home
    is a special event

108
In Conclusion
  • Our goals for our patients both in the dialysis
    clinic and in the ECF is to
  • Ensure their best possible health
  • Maintain blood chemistries WNL
  • Decrease their risk of morbidity

109
Questions
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