Renal nutrition (for non-renal dietitians)

Dr Lina Johansson

Lead Renal Dietitian / NIHR Clinical Lecturer

30th September 2015

overview • Basics

– Measurement and stages – Prevalence – Functions of the kidney – Symptoms

• Nutrition – Role of renal dietitian – Protein – Potassium – Fluid – Malnutrition

• Case study

DOH LTCs Compendium of Information, 2012

Measuring Kidney Function Glomerular Filtration Rate (GFR)

Glomerulus

Normal GFR: ~120mls/min =~ 180L/day

eGFR- progression

• Abnormally declining eGFR

– >5ml/min/yr

– or >10ml/min in 5 years

Stages of Renal Disease

Dialysis/

transplantation

needed for survival

(there is no cure)

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Normal function

Mild decrease Moderate decrease

Severe decrease

End stage renal disease

130mls/min 90mls/min 60mls/min 30mls/min 15mls/min 0

Screen for CKD risk factors •Hypertension •Diabetes •Obesity

CKD risk factor reduction •Lower bp •Control diabetes •Weight loss

Treat complications of CKD •Uraemia •Manage anaemia •Prevent malnutrition

Prepare or undergo replacement •Uraemia •Manage bp and fluid volume •Control diabetes •Control mineral imbalances •Prevent and treat malnutrition

UK prevalence CKD 3-5

Prevalence of dialysis

2005

2013

20635

27348

UK trend of people on dialysis

87% on haemodialysis (HD)

13% on peritoneal dialysis (PD)

Renal Registry Reports 2006-2014

https://www.renalreg.org/publications-reports/

What causes end stage renal disease?

Primary renal diagnosis % distribution in incident Renal Replacement Therapy 2013

Diabetes 25.4

Glomerulonephritis 14.4

Pyelonephritis 6.9

Hypertension 7.6

Polycystic kidneys 7.6

Renal vascular disease 5.4

Other 18.3

Uncertain aetiology 14.5

https://www.renalreg.org/reports/2014-seventeenth-annual-report/

(Chapter 1)

Question

What are the consequences of reduced kidney function within the body?

Impaired kidney function

Uraemia and accumulation of waste products

Raised blood pressure/ fluid retention

Anaemia

Raised potassium levels

Low serum calcium

Metabolic acidosis

• What are the symptoms of advanced chronic kidney disease/ renal failure?

Uraemic symptoms • Loss of appetite • Nausea/vomiting • Diarrhoea • Weakness • Oedema • Taste changes • Insomnia • Fatigue • Decreased concentration • Muscle cramps • Itching

What is the role of the renal dietitian?

• Improve nutritional status

• Improve electrolyte balance

• Improve fluid balance

• Communication

• Symptom control

• Educators: support self-mgt

• Support non-renal dietetic colleagues

Minimise uraemic symptoms

” in patients with chronic renal failure it is possible to

postpone the increase of serum urea concentration for a

long time, reducing the nitrogen intake to 3-5 g.

Sometimes we have succeeded in reducing considerably high

serum urea concentrations. Consequently the first uremic

symptoms disappeared.”

Volhard, 1918

(Handbuch der Inneren Medizin) Volhard, 1918

(Handbuch der Inneren

Medizin)

What do you think about restricted protein diets?

What are the guidelines for protein in chronic kidney disease in the UK?

Protein intake: recommendations for stages 4-5 (not on dialysis)

Recommended Protein intake 0.75 g/kg IBW/day for patients with stage 4-5 not on dialysis

Rationale • Prevent malnutrition (risk highlighted in MDRD study) • Improve symptoms of uraemia • Aid compliance (challenging to follow very low protein diets)

Renal Association 2010 Nutrition guidelines

Average protein intake for men and women g/kg/d

0

0.2

0.4

0.6

0.8

1

1.2

Men average daily protein intake

g/kg/d

Women average daily protein intake

g/kg/d

Pro

tein

in

take g

/kg

/d

Recommended protein intake for CKD 0.75g/kg IBW/d

Protein intake: recommendations for dialysis

Recommended Protein intake

1.2g/kg IBW/day for patients on dialysis

Rationale • Protein loss through dialysis : peritoneal and haemodialysis

Haemodialysis v Peritoneal Dialysis

• What are key differences between these two modes of dialysis that will affect:

– Interpretation of clinical signs and biochemistry

– Nutritional management

• http://www.youtube.com/watch?v=IQKQ4eoKfTg

Potassium

• Hyperkalaemia can be present in CKD, HD and PD patients, can lead to sudden death

• Targets for potassium • Normal range – CKD (no dialysis) • 3.5-6.0mmol/L haemodialysis • 3.5-5.5mmol/L peritoneal dialysis

• Recommended intake • RNG (1998) 1mmol/kg/IBW • EDTNA/ERCA (european renal guidelines 2002) 50-65

mmols/d

Potassium

Diet

Medications

Causes of

Hyperkalaemia

Hyperglycaemia

Potassium

Causes of hyperkalaemia

Acidosis Fall in plasma bicarbonate as GFR decreases. Can lead to hyperkalaemia

Diet Excess K intake

Medications Ace Inhibitors e.g. enalapril Angiotension II receptor antagonists e.g. candesartan Potassium sparing diuretics e.g. Spironolactone

Constipation K reabsorbed from stools

Blood transfusion Blood is K rich

Poor diabetic control Can lead to hyperkalaemia

Medications and potassium

• ACEI/ARBs: – Hyperkalaemia known complication. Serum K levels

increase by 0.4-0.6mmol/L during ACEI/ARB treatment.

– 1 to 1.7% develop K >6.0mmol/L.

– Not normally start ACEI/ARB if K above normal range.

What to do if referred a CKD patient with a raised potassium?

• Check trend of potassium – Is it increasing and hovering around upper limit? – Have there been high potassium results in past?

• Check diet – What is the baseline diet like? – Identify high potassium foods and offer suitable

alternatives – Make diet achievable.

• Follow up – If high potassium, then need to re-check bloods – Allow patient to contact you for further questions – Get support from renal dietitians

potassium

• High potassium foods

Fruit juices

Coffee

Potato or veg based crisps

Bananas

Chocolate Dried fruit and nuts or foods containing these

Mushrooms

Spinach

potassium

• Cooking methods for vegetables

Breakfast: Glass of orange juice

All Bran with milk and sugar

1 slice of wholemeal toast with butter and marmalade

Mug of coffee with milk

Mid Morning: Mug of tea with milk and 2 chocolate digestives

Lunch: Wholemeal cheese and tomato sandwich

Packet of crisps and a banana

Mug of tea with milk

Mid Afternoon: Orange with glass of fruit squash

Evening Meal: Lamb chop with boiled potatoes and peas

Fruit yoghurt

Mug of tea with milk

Supper: Mug of ovaltine

1. Identify high potassium foods from 24 hour recall

2. Suggest suitable alternatives

Potassium exercise - answers Breakfast: Glass of orange juice

All Bran with milk and sugar

1 slice of wholemeal toast with butter and marmalade

Mug of coffee with milk

Mid Morning: Mug of tea with milk and 2 chocolate digestives

Lunch: Wholemeal cheese and tomato sandwich

Packet of crisps and a banana

Mug of tea with milk

Mid Afternoon: Orange with glass of fruit squash

Evening Meal: Lamb chop with boiled potatoes and peas

Fruit yoghurt

Mug of tea with milk

Supper: Mug of ovaltine

• peripheral oedema

• pulmonary oedema

Oedema

Fluid managment

• 500ml/24hr plus previous day’s urine output if on haemodialysis

• If not requiring dialysis then unlikely to be restricted (unless nephrotic)- guided by Drs

• Poor DM control and salt intake contribute to thirst

Fluid balance in HD

http://www.kidneypatientguide.org.uk/fluid.php

Just before HD session

Just after HD session= normally hydrated weight

Malnutrition: Nutritional intake as renal function declines: stage 4-5

Decreasing renal function Decreasing renal function

Male

Female

Male

Female

Protein Intake Calorie Intake

Kopple, Kid Int, 57:1688-1703, 2000

Decreasing renal function

Male

Female

BMI

Decreasing renal function associated with spontaneous reduction of protein and calorie intake and BMI reduction.

Kopple, Kid Int, 57:1688-1703, 2000

Malnutrition: Nutritional intake as renal function declines: stage 4-5

Treatment of malnutrition

Enteral

– Modified food first advice

– Oral nutritional supplements

– Tube feeding e.g. nasogastric/ gastrostomy

Parenteral

– Intra Dialytic Parenteral Nutrition (IDPN) – HD only (only

supplementary nutrition equivalent to ~420 kcals/ day, SMOFKABIVEN 8 EF)

– Total Parenteral Nutrition (TPN)- Home service

Modified Food First Advice

What do you have to consider in food first advice in patients with advanced CKD?

Enteral Nutritional Support

• Renal considerations

– Volume • are restrictions necessary?

– Electrolytes • are phosphate and potassium levels raised?

– Protein • how much protein does the patient need depending on their type of

dialysis treatment and stage of CKD?

ONS – Which one to choose

Product Volume Kcal Protein Potassium Phosphate

Build Up 85g/200ml 270 15 21.8 14

Fortified Milk 300ml 323 22.6 24.8 20

Calshake 87g/240ml 598 11.9 20.7 14.1

Nepro HP 220ml 400 17.8 5.4 4.4

Fresubin Energy 200ml 300 11.2 6.6 5.4

Fresubin protein energy

200ml 300 20 6.6 7.8

Fresubin 2kcal 200ml 400 20 8 7.6

Fresubin Jucy 200ml 300 8 0.4 0.8

Fresubin creme 125g 231 12.5 5.3 5.1

Fresubin 5kcal shot

30ml 150 0 0 0

Case study

Mr Remoh Nospmis

Type 2 diabetic

Overweight

CKD stage 4, eGFR 20mls/min

3 children

Works in a nuclear power plant

Weight 95kgs, height 1.7m, BMI 32.9kg/m2

Questions?