nutrition in renal patient
TRANSCRIPT
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Dr. Doaa Hamed
Lecturer of Clinical Nutrition
National Nutrition Institute –Cairo (Egypt)
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Diet Planning
In
CKD & HD
Nutrition Care Process
in renal diseases
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Nutrition Care Process
in renal diseases
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Objective
1.Integrated renal care .
2.Importance of renal diet .
3.Nutritional counseling
4.Nutrition Care Process
Steps:-Assessment
Diagnosis
Intervention
Monitoring and Evaluation
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Stages of Chronic Kidney Disease
Stage CKD I CKD II CKD III CKD IV CKD V
Description Kidney Damage
with Normal or
↑GFR
Mild ↓GFR Moderate ↓ GFR Severe ↓ GFR Kidney Failure
GFR(ml/min/1.73 m2 )
> 90 60 -89 30 -59 15 -29 < 15 or Dialysis
Stage
dependent
Actions
Prevent complications
Mineral metabolism
Nutritional monitoring
Anemia prevention
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Care process Requires
A psychotherapist / motivation speaker
A diabetes educator
A renal specialist dietitian
A combination of:- Nephrologist
Nurse
pharmacist
Social Worker
patient's best friend
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أكــــل أيـــه؟
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What is the role of ?
Trained & experienced in Renal nutrition
Implementation of many guidelines concerning
nutritional assessment
Anthropometry, SGA, dietary interviews
Plan for nutritional management & therapy
Counseling the patient & the family
Educational activities
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Why there are for ?
All patients should receive nutritional counselling based
on an individualized plane of care.(Evidence Level C) Nutrition in peritoneal dialysis Guidelines 2005
Nephrol Dial Transplant (2005) 20 ( Suppl 9) : ix28-ix33
Clinicians use several strategies, but there are barriers to
nutritional counseling which include:-
skepticism about the effectiveness of nutritional interventions
lack of specific knowledge and training about therapeutic nutrition
lack of specialty clinics, absence of guidelines, and an inadequate number of dietitians
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screening
CKD
We recommend that screening should be performed (1D)
o for inpatients
o for outpatients with eGFR <20 but not on dialysis
o of commencement of dialysis then 6-8 weeks
later
Screening may need to occur more frequently if risk of
undernutrition is increased (for example by intercurrent illness)
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screening
HD
Stable and well-nourished haemodialysis patients should be
interviewed by a qualified dietitian every 6–12 months or
every 3 months if they are over 50 years of age or on
haemodialysis for more than 5 years (Evidence level III).
Malnourished haemodialysis patients should undergo at
least a 24-h dietary recall more frequently until improved
(Opinion).UK Renal Association, March 2010
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CKD HD
Clinical studies have shown that renal patients may
have inadequate dietary intakes during early stages
40 - 70 % of patients with end-stage renal disease are
malnourished
Protein–energy malnutrition should be avoided in
maintenance hemodialysis because of poor patient
outcome (Evidence III).
Tow types of malnutrition I & II has been described
in CKD patients
(ESPEN 2008)
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PEW
Kidney International (2013) 84, 1096–1107
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Beto’s PAGE System
Pediatrics • Growth / development
Adults • Promote health ( Prevention)
Geriatric • Maintain health ( Holding pattern)
End of Life • Minimaze aging effects
CKD Key Focus on…
Quality of life
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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
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Renal diet minimizes the amount of wastes
A good meal plan choices can:
Minimize build-up of waste products &
fluid between treatments
Improve nutritional and functional status
Conserve muscle mass
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Nutrition Care Process Steps
ADIME
Nutrition
Care
Process
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assessment
History and physical examination looking for loss
of weight and muscle wasting
Dietary history
SGA (Subjective Global Assessment)
Anthropometry
Biochemical / laboratory tests
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Is albumin can predicts mortality at
onset of dialysis?
Strong predictor of morbidity and mortality
(CANUSA study)
However,
Albumin is affected by non-nutritional factors Infection
Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Blood loss
Metabolic acidosis
Albumin may not increase in response to nutritional intervention
There is No Single Magic Nutritional Index
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How can we monitor and Follow-up
nutritional status?
Severely underweight Less than 16.0
Underweight From 16.0 to 18.5
Normal From 18.5 to 24.9
Overweight From 25 to 29.9
Obese Class I From 30 to 34.9
Obese Class II From 35 to 39.9
Obese Class III Over 40
Haemodialysis patients should maintain a BMI >23.0
BMI = Weight (kg) / (height [m]2)
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Ideal Body Weight (IBW)
For men = [ (height(cm) – 152.4) x 0.91) ] + 50
For women= [ (height(cm) – 152.4) x 0.91) ] + 45.5
Adjusted Body Weight (ABW)
For men: Adjusted weight = [( actual weight- IB weight) x 0.38] + IB weight
For women: Adjusted wt = [(actual weight- IB weight) x 0.32 ] + IB weight
If Actual BW > 30% IBW
use
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Interdialytic Weight Gain (IDWG)
General recommendation +2 kg
>5% fluid gains
Excessive fluid intake
Weight gain
<2% fluid gain
Inadequate fluid and/or food intake
Weight Loss/Decreased body mass
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Subjective Global Assessment Rating Form
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Dr. Doaa Hamed
Lecture of Clinical Nutrition
National Nutrition Institute –Cairo (Egypt)
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HD CAPD
Loss of amino acids
6-10 g/dialysis 2-4 g/bag
Loss of glucose~25 g/dialysis
(glucose free dialysate)
uptake
Loss of protein0 5-15 g/day
(higher with peritonitis)
Inflammatory stimuli
Blood membrane contact
Cytokine release
Low grade inflammation
(particles chemicals)
Cytokine release
Is Dialysis has effect on Nutrition?
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Is Dialysis has effect on Nutrition?
Daily HD or 6 HD sessions/ week
(Schulman G. Am J Kidney Dis 41:S112-S115,2003)
Improve appetite & food intake
General feeling of well being,↑ed physical activity
Fewer dietetic restrictions
↓ ed dose of medications → Phosphate & K binders,
antihypertensive drugs
↑es clearance of potential anorexic factors
Improves serum albumin levels
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Dietary Recommendations
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Diet Focus on…
Important Nutrients
Individual Differences
CKD
Diet Goals
HD
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Phosphorus (stage 3)
• Size
• Stage of CKD
• Nutrition
• Lab results
• Size
• Nutrition
• Lab results
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Na & Fluids
• Potassium
• Phosphorus
• Calcium
• Management of
• Blood pressure
• Glucose
• Minerals
• Fluid
• Weight
• Good nutrition
• Management of
• Blood pressure
• Glucose
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Adequate energy intake essential to optimize nutritional
status
Present in (Carbohydrates – Fats - Protein)
Calculated based on your
current weight,
weight loss goals
age and gender
physical activity and metabolic stress
35 kcal/kg/d < 60 yrs
30–35 kcal/kg/d ≥ 60 yrs
Regular physical activity should be encouraged, and energy intake should be
increased according to the level of physical activity (Opinion).
Calories
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To increase the energy content of meals:
Add extra oil to rice, noodles, breads, crackers, and
cooked vegetables.
Add extra salad dressing.
Non-protein calorie (NPC) supplement can be added
(J Ren Nutr. Nov. 2012 )
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Protein
Essential for ❖ building muscles ❖ repairing tissue
❖ fighting infection ❖Keeping fluid balance in the blood
There are two kinds of proteins
◦ (HBV) or animal protein-meat, fish, poultry, eggs and dairy
◦ (LBV) or plant protein – breads, grains, vegetables, dried beans and peas
and fruits
50 -70% should be of HBV.
A well balanced diet for kidney patients should include
both kinds of proteins every day.
Protein Alternativesprotein bars, protein powders, supplement drinks
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Stage 5 -
On dialysis
All stages – if
malnourished
Protein Intake
Example:
A 150 lb
(68kg)
• 82 grams• ½ cup milk
• 2 eggs or 4
egg whites
• 6 oz meat
• 3 veg.& 3 fruits
• 11 servings of
grains
• 41 – 48 grams• ½ cup milk
• 1 egg or 2 egg
whites
• 2 oz meat
• 5 – 6 veg.&
fruits
• 5 – 6 servings
of grains
Stage 4 or 5 -
Not on dialysisStages 1 - 3
• 55 grams• ½ cup milk
• 1 egg or 2 egg
whites
• 3 oz meat
• 3 veg. & 3 fruits
• 8 servings of
grains
0.75 gm/kg/d 1.2-1.3 gm/kg/d0.6 gm/kg/d
• Eat additional protein
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Potential beneficial effect of
low-protein diet in CKD
Uremic symptoms diminish or disappear
(especially nausea, vomiting)
Reduce the burden of uremic toxins
(urea, H+, K+, phosphate, other)
Slow progression of renal failure ?
Reduce proteinuria
Improve nutritional status
Increases insulin sensitivity and glucose tolerance
Antioxidant effect
No Protein Restriction for Dialysis Patients10-12 grams lost per HD treatment
Aparicio M et al J Renal Nutr, 19, No 5S (September), 2009: pp S33–S35
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Lipids
Patients considered at highest risk for cardiovascular disease
Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and
individualized treatment goals
requirement of fat
( 30 % total cal ) Minimize the ↑ in TG & Cholesterol
< 10% of calories → SFAc Ratio of USFAc to SFAc l fats = 2 : 1
8% SFAc l :10 % PUSFAc : 12% , MUFAc
250–300 mg cholesterol/day
Omega 3 fatty acid↓ TG & Chol. as well as phospholipids may be tried
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Lipid disorders
Hypertriglyceridemia,
often normal cholesterol
but low HDL cholesterol
Chmielewski M et al. J Nephrol 21: 635-44, 2008
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Carbohydrates
65-70% total kcal
70% complex sugar
(reduceTG synthesis and improve glucose tolerance)
30% simple sugar
Carbohydrate intake may need to be modified for Patients
with Diabetes to achieve the goal of HgAIC < 7 %
Carbohydrate Counting
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Fiber Intake
Optimum fiber intake 20-25 g/day
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Fiber Intake
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Sodium
Plays vital role in regulation of fluid balance and blood
pressure
In CKD& HD:-
May result in :-high blood pressure,
fluid retention/swelling (edema)
lead to shortness of breath
Excessive thirst
CHF
Serum Sodium (nl 133-145 mEq/L)
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Sources of Dietary Sodium
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Eat out less (especially Fast Food)
Cook at home with low-sodium ingredients
Read labels
1,000- 4,000mg/d
for
CKD&HD
patient
diets
Cut out: • Salt
• High-sodium condiments
• Processed, cured foods
Add: • Herbs
• Spices
• Lemon
• Vinegar
No Added Salt (NAS)
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Fluids
“any food that is liquid at room temp”
Soup, gelatin, ice cream, ect.
HDUrine Output + 1000 ml
Limit IDWG (2-5% Estimated Dry weight )
Excess fluid buildup
Edema, HTN, CHF and
Breathlessness
Delays wound healing
Fluid restriction estimations
are based upon:-
Urinary output
Disease state
Treatment modality (dialysis, etc.)
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Tips for thirst and fluid control!
Track your fluids
Avoid chewing lots of ice
Avoid refills at restaurant
Avoid super-sized beverages
Limit salty foods
Small glasses at meals & meds
Add lemon or Lime juice to water
Hot weather, temperature
Keep your skin cool: cold wash cloth, mist-bottle
Keep your lips moist with a chap stick
Keep your mouth wet
◦ Keep your mouth clean
toothpaste for dry mouth (biotene)
◦ Rinse your mouth with cold water, but don’t swallow it
◦ Rinse your mouth with chilled mouthwash
◦ Chew on gum: Quench gum
◦ Try lemon wedges or freeze grapes & strawberries
If diabetic, control blood sugars
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Sodium & Fluids
The requirement for sodium and water varies markedly, and each patient must be managed individually.
Individualize
◦ IDWG, blood pressure, residual renal functions
Increased Restrictions if
↑ IDWG, CHF, edema, HTN
fluid output Na fluid
≥ 1 L 2-3 g 2 L
≤ 1 L 2 g 1-1.5 L
Anuria 2 g 1 L
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Phosphorus
High serum phosphorus Bone decalcification
Soft tissue calcifications
Hyperparathyroidism
Dietary intake ~800 to 1000 mg/day OR <17 mg/kg SBW
HD removes ~500-1000 mg/treatment
Binders removes 50% of dietary phosphorus
Control = Binders + Diet + Adequate dialysis
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Organic phosphorus
40 – 60% absorbed Phytates ↓ absorption
Dairy products Meat, poultry, fishSoy (soy milk, tofu)Nuts and seedsDried beans and peas Whole grains
Inorganic phosphorus
> 90% absorbed
Food additivesDietary supplementsCalcium fortification
Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519-530
Phosphorus Types
Control Phosphorus
Diet
READ THE INGREDENTS LABEL!!
Phosphorus binders ineffective
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What are high and low phosphorus foods?
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Control Phosphorus
Binders
Generic Name Brand Name Estimated Binding Capacity
Calcium acetate
667 mgPhosLo 30 mg
Sevelamer HCL
800 mgRenagel, Renvela 64 mg
Calcium carbonate
500-600 mg
TUMS, Os-Cal,
Calci-Chew, Caltrate20-24 mg
Lanthanum carbonate
1000 mgFosrenol 320 mg
Binders are like a sponge. They “soak up” phosphorus from food! in the GI tract
Must take with meals
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Control Phosphorus
Dialysis
Among dialysis patients with persistent Hyperphosphatemia, we
suggest increasing phosphate removal via hemodialysis (Grade 2C)
Phosphate clearance is effective only during the first 2 hours of
dialysis. Serum phosphorus levels do not change during the second
half of dialysis. Haemodialysis removes approximately 900 mg of
phosphate three times weekly. (Mucsi et al., 1998; Block & Port,
2000)
Among patient with refractory Hyperphosphatemia, nocturnal HD is
an option among those who are welling to accept this form of
dialysis.
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Ph IntakeAbsorption
~60%
Binding
~50%
Dialysis
Removal HD
+1000 mg/day
+7000 mg/wk
+600 mg/day
+4200 mg/wk
-300 mg/day
(10 Phoslo)
-2100 mg/wk
-700 x 3 =
-2100 mg/wk
Weekly Phosphorus Balance
+ 4200 (diet) – 2100 (Binders) – 2100 (HD) = Balance
Diet + Binders + Adequate dialysis
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Calcium
Renal diet is approximately 500-800 mg / day
Diet (low ----- many foods high in ca high in ph )
1200 – 1500 mg/day based on DRI*
May need vitamin D3
Not to exceed 2g/day, including calcium-
based binders
Activated vitamin D
PTH control important
CKD Stages 1 – 4
CKD Stage 5 & HD
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CKD Stages 1 – 3 Usually not restricted
CKD Stages 4 and 5 and HD Correct labs
Dietary Goal is usually 2 - 3 gms/day
adjust per serum levels
Dialysis bath concentrations
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Low Potassium foods Avoid Highest Foods
Apples
Grapes
Berries
Pineapple
Tangerine
Cabbage
Green Beans
Cauliflower
Eggplant
◦ Oranges/Juice
◦ Banana
◦ Potato
◦ 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
Potassium
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Renal Multivitamin containing water soluble
vitamins
◦ Dialyzable – take after dialysis
◦ Supplementation may improve Iron availability from
stores
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
Micronutrients
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Assessment:
Diet history & any changes in dietary
intake
Weight history
SGA
Underlying medical condition
Biochemistry
GI symptoms
Social and psychological
factors
Nutrition in CKD& HD
ManagementOral Diet
Oral diet + extra snacks
Oral diet, extra snacks + supplements
Oral diet + supplementary NG/ PEG feeding
Exclusive NG/ PEG feeding
TPN
Must also optimize medical management (dialysis adequacy, acidosis, infection)
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Conclusion
Poor nutrition is common in CKD & DH patients and has
adverse risk factor
Nutritional counseling –part of approach to CKD and
dialysis patients.
Routine nutritional screening & assessment should be done
for CKD and dialysis patients.
Qualified renal dietitian must be included in the staff of
every dialysis unit.
Personalized nutritional plan – worked out for every
patient.
Individualization
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