1. ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11
Renal Diet
ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11

2. Objectives
Nursing staff will understand the basic premise of a renal diet
Understand the nutritional needs Hemo and Peritoneal Dialysis patients

3. CHRONIC KIDNEY DISEASE
One in nine Americans has Chronic Kidney Disease.
Early detection can help prevent the progression of kidney disease to kidney failure.
High risk groups for CKD include those with diabetes, hypertension and family history of kidney disease.
Groups with increased risk include African Americans, Hispanics, Pacific Islanders, Native Americans and the elderly.

4. CHRONIC RENAL FAILURE
Progressive and irreversible loss of function that occurs over many months or years
Causes include diabetes, hypertension and glomerular diseases
Some form of renal replacement therapy is needed for life

5. STAGES OF CHRONIC KIDNEY DISEASE
GFR (mL/min/1.73m2)
EFFECT ON HOMEOSTASIS 1
≥ 90
Minimal; excretory and secretory functions intact. 2
Usually no symptoms, but may have high BP, anemia & disturbance in Ca+ & Phos+ metabolism. 3
May have fatigue, anemia, swelling, high BP &/or Ca+ & Phos+ disturbance. 4
Usually symptomatic. Prepare for renal replacement therapy. 5
< 15
Unable to maintain homeostasis without dialysis or transplant.

6. Goals of the Patient Specific Renal Diet
Improve/preserve nutritional status
Optimize functional status
Maintain patient safety
Prepare for transplant
Compensate/adjust diet for illness, catabolic events
It is important to adequately assess patients that are risk for PEM. Liberalized diet may be necessary for malnourished patients.
Preparing for transplant: If BMI>40, suggest wt.loss, better phos control.

7. Subjective Global Assessment
Recognized by KDOQI as a useful measure of PEM
Provides a nutritional score based on 2 components
Medical history: history of wt. loss (6 months), eating habits, GI symptoms, physiological functions and metabolic stress
Physical assessment: visual assessment of loss of subcutaneous fat and muscle mass
Patient is scored on a 7–point scale (1)
6-7 well nourished
3,4,5 mild to moderately nourished
1 or 2 severely malnourished

8. Renal diet for Dialysis patients consists of individualized modifications
Calories
Protein
Sodium
Potassium
Phosphorus
Calcium
Fluid
Carbohydrates
Fat/Cholesterol

9. KDOQI recommends NHANES II Data
CALORIES
Adults on Hemo Dialysis and Peritoneal Dialysis
< 60 years old Kcals / Kg SBW
> 60 years old or obese Kcals / Kg SBW
KDOQI recommends NHANES II Data
for assessing SBW

10. Protein 1.2 grams of protein per Kg SBW for Hemo Dialysis
grams of protein per Kg SBW with for PD

11. Protein Important for growth and maintenance of body tissue
Provides energy and fights infection
Keep fluid balance in the blood
2 types of Protein
High Biological Value (HBV) or animal protein-meat, fish, poultry, eggs, tofu, soy milk, and dairy
Low Biological Value (LBV) or plant protein – breads, gains, vegetables, dried beans and peas and fruits

12. Protein The following list contains foods and their protein content:
▪ 1 egg=7 g protein ▪ 1-2 ounce (oz) chicken thigh=14 g protein ▪ 8 oz skim milk=8 g protein ▪ 1 slice of bread=2 g protein ▪ 1 cup (C) cooked rice=4 g protein ▪ ½ C corn=2 g protein

13. Phosphorus A mineral found in almost all foods.
Normal kidneys will balance the amount of phosphorus in our bodies. When the kidneys fail the phosphorus increases in the blood.
It is necessary to limit and/or avoid high-phosphorus foods.
Control of phosphorus is often difficult for kidney failure patients.
Dietary goal is 1-1.5gms/day
Normal range <5.5
Hemo clears mg per treatment, mainly during the first 60-90minutes of HD.Because hyperphosphatemia alone was linked to increased morbidity and mortality, dietary phos control and binder compliance is very important.

14. Phosphorus Foods high in phosphorus include: Dairy products
Dried beans and peas
Nuts
Peanut butter
Bran cereals
Whole wheat bread
Meats
Food Additives

15. Potassium Dietary Goal is usually 2 - 3 gms/day
Potassium is a mineral , plays a role in regulating your heartbeat; so, too much can result in heart problems.
Explore with patient high or low serum potassium levels
Monitor residual renal function, changes in appetite for dietary adjustments
A stricter K+ allowance may be indicated if the pt has insulin deficiency, metabolic acidosis, is treated with beta blockers or is in a hypercatabolic state.

16. Low Potassium foods Apples Grapes Berries Pineapple Tangerine Cabbage
Green Beans
Cauliflower
Eggplant

17. Potassium Common high K+ foods include many fruits and vegetables:
Prunes and Prune juice
Orange and Orange juice
Bananas
Dried fruits
Potatoes
Tomatoes
Brussels sprouts
Spinach
Beets
Milk

18. Sodium HD 2-4 gm/d PD usually more liberal
Too much sodium in the blood is related to high blood pressure and congestive heart failure.
Foods high in sodium include:
Processed meats
Canned soups
Salty snack foods
Deli meats

19. Sodium 1 Tsp salt = 2000mg sodium
Most of us eat 3,000-6,000mg of sodium /day
Low sodium = ≤140mg/serving
Do not buy a food that has mg sodium/serving

20. Fluids
Hemo Dialysis: Fluid individualized to accommodate fluid gains, blood pressure control, residual renal function.
Peritoneal Dialysis: Fluid individualized to patient tolerance. Strive for minimal use of hypertonic solution to maintain fluid balance.
Everything that is liquid at room temperature
1500ml-2000ml
~6 c-8 c /day
4 cups=32 oz=1 qt=1000ml=1 liter
Fluid balance in PD is maintained by varying the dextrose concentrations of the dialysate. If pt is unable to maintain fluid balance, fluid and sodium may be restricted.

21. Fluids
Choices include all drinks and foods that are liquid at room temperature.
Water
Coffee
Tea
Sodas
Soups
Juices
Jell-O

22. Fluids Cont.. Thirst Quenching Ideas :
Suck on sour candies or chew gum
Eat chilled fruit, frozen grapes and berries
Add lemon or Lime juice to water
Take pills with apple sauce instead of liquids
Use smaller cups or glasses
Keep track of all liquids
Limit salty foods
If diabetic, control blood sugars

23. CALCIUM Hemo Dialysis Patients Balance is determined by:
Dietary Calcium Intake
Calcium Supplements and Calcium Based Binders
Dialysate Calcium Levels
Vitamin D Therapy
Physician Monitoring of PTH
Dietary intake of calcium is frequently decreased to ~500mg per day, due to the limitation of high phos dairy foods in the HD diet. Current recommendation for PD patients is 2000mg per day, with no more than 1500mg from calcium based phos binders.
Vit D supresses PTH production and enhances calcium absorption in the gut.

24. PD - HYPERGLYCEMIA / WEIGHT GAIN
CARBOHYDRATE
Carbohydrate intake may need to be modified for Patients with Diabetes to achieve the goal of HgAIC < 7 %
CAUTION !
HYPOGLYCEMIA
PD - HYPERGLYCEMIA / WEIGHT GAIN

25. FAT / CHOLESTEROL
Cardiovascular Disease is the most frequent cause of death among patients with Renal Disease regardless of treatment modality.
Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and individualized treatment goals
Consider nutritional status / protein, energy deficits
Mortality from CVD in HD and PD patients is ~9% per year, which is about 30 times the risk in the general population.
Am J Kidney Dis 1998
HD patients generally have normal LDL, Low HDL and High TG
PD patients have higher Total Cholesterol and LDL, and elvated TG due to continuous absorption of glucose from the dialysate.
Encourage fiber intake.

26. Supplements Multi Vitamins Vitamin C
Water soluble
Vitamin C
Supplementation may improve Iron availability from stores
Limit to mg/d to avoid oxalate formation
Iron and Zinc supplementation must be determined individually based on labs

27. Monitoring
Monthly QAPI report to review the labs and discuss plan of action to correct the problem
Monthly interdisciplinary Care plan meeting to review the patient performance
Albumin to monitor intake
(Goal >3.5mg/dl)
Potassium to determine dietary restriction
(Goal mg/dl)
Phosphorus to adjust binders & compliance
(Goal <5.5 mg/dl)

28. Summary
When a patient has a diagnosis of renal failure, their nutritional needs are complex—Levels of Protein, Calories, Fluid, Sodium, Potassium, Calcium Phosphors need to be regularly monitored and make changes based on pt’s needs.
It is important to continuously monitor their labs , PO intake , provide or offer nutritional supplements, encourage dietary and medication compliance

29. Question and Answers Which food is highest in Potassium? Apple
Pineapple
Broccoli
Banana
Potato

30. Q & A Correct answer… Apple -1 medium(62 mg) Pineapple -1/2c(150mg)
Broccoli -1/2c(127mg)
Banana -medium(451mg)
Potato- medium (926 mg)

31. Q & A
What are the foods high in Phosphorus? Pizza (Cheese and meat) Chicken American Cheese Yogurt Cream Cheese Cottage Cheese Oatmeal

32. Q &A
Pizza (1-1/8 slice -131mg Po4, 1780mg K+, 382mg Na) Chicken (1oz-60mg po4) American Cheese (1oz- 211 mg Po4, 46 mg K+, 405 mg Na) Yogurt (fruit 6 oz mg Po4, 310 mg K+, 100 mg Na) Cream Cheese (1tbsp- 15 mg PO4, 17mg K+, 43 mg Na) Cottage Cheese (4 oz- 152 mg Po4, 97 mg K+, 459 mg Na) Oatmeal (instant, 1 cup mg PO4, 131 mg K+, 377 mg Na)

33. Q &A
Why do dialysis patients need to limit dairy and high phosphorus foods?

34. Q &A
Healthy kidneys get rid of Phosphorus from the body, but when kidneys fail, phosphorus builds in the blood.
High levels cause calcium to come out of the bones and make them brittle, weak and painful. It also gets deposited in soft tissues like blood vessels and heart, causing damage to them.

35. Q &A
How does the diet for someone on peritoneal dialysis differ from the one for hemodialysis?
A. It requires more calories
B. It requires more calcium
C. It requires less protein
D. None of the above

36. Q &A A. It requires more calories B. It requires more calcium
C. It requires less protein
D. None of the above

37. Q &A
If you are on a renal diet, you most need to limit your intake of what three things? 
a. Apples, oranges, grapes.
b. Carrot cake, ice cream, Coke.
c. Sodium, phosphorus, potassium
d. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.

38. Q &A a. Apples, oranges, grapes. b. Carrot cake, ice cream, Coke.
c. Sodium, phosphorus, potassium
d. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.

39. References 1) A Clinical Guide to Nutrition Care in Kidney Disease
American Dietetic Association, 2004
2) Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease, 4 th Edition, National Kidney Foundation, 2009
3) Core Curriculum for Nephrology Nursing, Fifth Edition. American Nephrology Nurses Association, 2008.

40. Thank You