1. Kidney Disease-What You Need to Know
Mary Ann Vespignani RD LDN

2. WHAT DOES THE KIDNEY DO? Remove Waste Products from the body
Remove Drugs from body
Balance the body’s fluids
Release hormones that regulate blood pressure
Produce an active form Vit D that promotes strong healthy bones
Control production of red blood cells

3. What is the Dietitian’s/CDM role?
To educate and advise people on diet
To provide support through treatment
To work with Renal RD to review monthly labs and adjust diet as needed
To provide support for non-renal staff

4. National Kidney Foundation Outcomes Quality Initiative
KDOQI’s evidence-based clinical practice guidelines are updated on an ongoing basis, as new evidence becomes available. KDOQI also provides timely commentary on the applicability of the global KDOQI guidelines in the US clinical and regulatory environment.

5. KDOQI Goals Albumin 4.0 or greater Potassium 3.5-5.5
Phosphorus
Calcium

6. OVERVIEW What the tests measure Why they are important
URR
Albumin
Calcium, Phosphorus, Potassium
Why they are important
What to do when the results are outside the acceptable range
Summary

7. Why do you need to understand the Patient Report Card?
So you can answer patients’ questions
So you can reinforce the dietary changes the patient needs to make
So we can work as a team
…so we can provide better patient care… \

8. Urea Reduction Ratio
Tells us if the treatments are are doing a good enough job of cleaning the blood.
Formula
Pre dialysis BUN – Post dialysis BUN x Pre dialysis BUN
Goal:
Greater than or equal to 65 (> 65)

9. Urea Reduction Ratio
URR < 65 means that the person’s blood is not being cleansed well enough.
The person may have:
Poor appetite
Nausea / vomiting
Bad taste in mouth
Weight loss

10. ALBUMIN An important protein in the blood
Indicator of person’s nutritional status
Infection/Inflammatory response affects Albumin
The single most important indicator of a person’s mortality
Goal: 4.0 – 5.4 g/Dl

11. Albumin  Albumin may mean
Malnutrition
Increased risk for illness and death (long term)
Over hydration/fluid overload
 Albumin makes it difficult for dialysis to remove fluid

12. What factors affect Albumin
Poor appetite
Not eating enough protein-rich foods
Meat, fish, poultry or eggs
Fluid overload
Illness / infection
Liver problems
Other health problems

13. CALCIUM Needed for healthy bones muscle contraction & relaxation
proper nerve functioning
Normal range on “Report Card” is 8.5 – 9.5

14. CALCIUM Hypercalcemia (Ca > 10.2): Hypocalcemia: nausea confusion
coma
 risk for heart disease
Hypocalcemia:
numbness
seizures
painful muscle spasms
osteoporosis

15. What to do if calcium levels are too high or too low?
Hypercalcemia ( calcium)
Patient should decrease calcium intake
STOP PhosLo, Tums, etc
Doctor will D/C active form of Vit D3 (Calcijex or Zemplar

16. What to do if calcium levels are too high or too low?
Hypocalcemia ( calcium)
Patient may need
Calcijex, or Zemplar
additional dietary/supplemental calcium
May be due to low albumin levels

17. Phosphorus (“P”) or Phosphate (PO4)
Needed for
healthy bones & teeth
energy metabolism (ATP)
When the kidneys fail, phosphorus levels usually 
Hemodialysis does not remove phosphorus from the blood very well Protein-rich foods are high in P
Very challenging for patients to maintain optimal P levels

18. Phosphorus Normal ranges currently on “report card” are 2.5 –5.5
Hyperphosphatemia ( phosphorus)
itching
bone damage
 risk for soft tissue calcification (including heart and blood vessels)
Hypophosphatemia ( phosphorus)
rare
muscle weakness
coma
patient needs to stop PO4 binders (PhosLo, Renagel

19. Phosphorus to HIGH Patient needs to
decrease intake of P-rich food and/or
take PO4 binders as prescribed(Binders must be taken with meals)

20. Phosphorus rich foods Beans, peas, lentils (“legumes”)
Nuts (peanut butter), seeds
Chocolate, cocoa
Cheese (pizza), milk, yogurt
Whole grains (whole wheat bread)
Bran cereals
Coke, Pepsi & other sodas with “phosphoric acid”

21. Guidelines for Phosphorus
Most patients need to limit their phosphorus intake to – 1000 mg per day
½ cup milk = ~100 mg
What about skim milk?
124 mg
What about heavy cream?
74 mg

22. Potassium-Function
Allows nerves and muscles (including the heart) to work properly
Too much or too little can cause sudden death
Normal range on “report card” is 3.5 to 6.0
some doctors prefer 3.5 to 5.5

23. Elevated Potassium Hyperkalemia (high potassium level) can cause
muscle weakness
the heart to stop

24. Hyperkalemia What to do? Alert doctor immediately if > 7.0
Review symptoms with patient
Kayexalate may be needed
Review diet with patient

25. High Potassium Foods Orange / juice Tomato / sauce / juice
Bananas/apricots
Potato / chips / french fried / sweet
Prune juice
Large quantities of “low potassium” foods
Fresh Fruit

26. Summary We reviewed the following lab values: What they mean
URR
Albumin
Calcium
Phosphorus
Potassium
What they mean
Why they are important
What to do when they are above or below the acceptable range

27. Dietary advice
Energy
Protein
Salt
Potassium
Phosphate
Fluid

28. Goals of Diet Therapy Maintain normal biochemistry levels
Minimise symptoms
Prevent malnutrition and unintentional weight loss
Improve quality of Life

29. Factors that influence dietary advice
Stage of CKD
Biochemistry levels (trends)
Medications
Treatments e.g. Conservative, Dialysis
Other medical conditions e.g. Diabetes
Lifestyle (social, psychological aspects)

30. Dietary advice
Weight Management - activity/lifestyle, current intake, food preferences, cooking methods, food labelling, alcohol.
DM Control - meds, regular meals & starchy CHOs, low sugar, fruit & veg.
Lipid Control – ↓saturated fats, ↑mono fats, oily fish, fruit & veg.
Salt Intake - at table, in cooking, convenience foods.

31. Dietary advice:
Low Appetite, Depressed & Symptomatic – small & frequent meals, energy dense and high protein foods.
High Potassium Level – cooking methods, food choices & frequencies of high K foods.
Hypertension – salt intake
Phosphate Level –Need to evaluate binders and when they are taken. Binders need to be taken with meals
Factors Considered by Dietitian:
Family situation / recent loss of love one/other medical conditions
Culture – Asian diet & cooking methods
Future ‘life changing’ treatments – Hemodialysis

32. Dietary Guidelines Protein Intakes of 1.2 gm/kg body weight
30-35 Kcals/kg body weight
Fluid weight gains between treatments of 2-3 kg
Sodium intakes = 2.5 grams/day
Phosphorus = mg/day
Calcium intakes <1200 mg/day
Potassium intakes <3200 mg/day

33. Medications Phosphate Binders Iron- Calcium- Renal Vitamins-
PhosLo,Renzela and Fosrenol-these must be taken with meals and snacks to be effective!!!!!
Iron-
Epogen/Procrit often provided at Dialysis center.
Calcium-
Renal Vitamins-
Common names Nephrovite, Nephrocaps, Renaltab, Diatex

34. Medication Alerts!! Dialysis patients are not to be given
Milk of Mag,Citracal or calcium citrate, PeptoBismol; KCL supplements or PRN calcium or aluminum based antacids
Renal patients are normally taken off Lasix, Bumex or other diuretics when starting HD

35. Interactions: HERBAL SUPPLEMENTS
NEED CAREFUL CHECK AS THEY MAY INTERACT WITH OTHER MEDICATIONS
Can affect K levels-alfalfa, Dandelion, Licorice root, Noni fruit/juice and St John’s wort
Has diuretic properties/electrolyte imbalance –Goldenrod,Juniper berries and parsley
Can effect blood thinning agents: garlic and Ginger
Do not use in CKD-Ginseng

36. Questions

37. Contact Details
Binik, Y., Devins, G., Barre, P., Guttman, R., Hollomby, D and Mandin, H. et al (1993) Live and learn: Patient education delays the need to initiate renal replacement therapy in end-stage renal disease Journal of Nervous and Mental Disease 181(pp
Christensen, A. and Ehlers, S (2002) Psychological factors in end-stage renal disease: and emerging context for behavioural medicine research Journal of Consulting and Clinical Psychology 70 (3) pp
Hener, T., Weisenberg, M. and Har-Evan, D. (1996) Supportive versus cognitive-behavioural intervention programs in achieving adjustment to home peritoneal kidney dialysis Journal of Consulting and Clinical Psychology 64 pp
Kimmel, P. (2002) Depression in patients with chronic renal disease: What we know and what we need to know. Journal of Psychosomatic Research 53 (pp 951 – 956)
Leake, R., Friend, R. and Wadhwa, N (1999) Improving adjustment to chronic illness through strategic self presentation: an experimental study on a renal dialysis unit Health Psychology 18 (pp 54 – 62)
Petrie K (1997) Renal failure, dialysis and transplantation. In Baum, A., Newman, S., Weinman, J., West, R. and McManus, C (Eds) Cambridge Handbook of Psychology, Health and Medicine. Pp 573 – 574 Cambridge University Press