Presentation on theme: "ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11"— Presentation transcript:
1ABC’s of Nephrology Sobha Malla RD,CSR 9/17/11 Renal DietABC’s of Nephrology Sobha Malla RD,CSR 9/17/11
2ObjectivesNursing staff will understand the basic premise of a renal dietUnderstand the nutritional needs Hemo and Peritoneal Dialysis patients
3CHRONIC 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.
4CHRONIC RENAL FAILUREProgressive and irreversible loss of function that occurs over many months or yearsCauses include diabetes, hypertension and glomerular diseasesSome form of renal replacement therapy is needed for life
5STAGES OF CHRONIC KIDNEY DISEASE GFR (mL/min/1.73m2)EFFECT ON HOMEOSTASIS1≥ 90Minimal; excretory and secretory functions intact.2Usually no symptoms, but may have high BP, anemia & disturbance in Ca+ & Phos+ metabolism.3May have fatigue, anemia, swelling, high BP &/or Ca+ & Phos+ disturbance.4Usually symptomatic. Prepare for renal replacement therapy.5< 15Unable to maintain homeostasis without dialysis or transplant.
6Goals of the Patient Specific Renal Diet Improve/preserve nutritional statusOptimize functional statusMaintain patient safetyPrepare for transplantCompensate/adjust diet for illness, catabolic eventsIt 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.
7Subjective Global Assessment Recognized by KDOQI as a useful measure of PEMProvides a nutritional score based on 2 componentsMedical history: history of wt. loss (6 months), eating habits, GI symptoms, physiological functions and metabolic stressPhysical assessment: visual assessment of loss of subcutaneous fat and muscle massPatient is scored on a 7–point scale (1)6-7 well nourished3,4,5 mild to moderately nourished1 or 2 severely malnourished
8Renal diet for Dialysis patients consists of individualized modifications CaloriesProteinSodiumPotassiumPhosphorusCalciumFluidCarbohydratesFat/Cholesterol
9KDOQI recommends NHANES II Data CALORIESAdults on Hemo Dialysis and Peritoneal Dialysis< 60 years old Kcals / Kg SBW> 60 years old or obese Kcals / Kg SBWKDOQI recommends NHANES II Datafor assessing SBW
10Protein 1.2 grams of protein per Kg SBW for Hemo Dialysis grams of protein per Kg SBW with for PD
11Protein Important for growth and maintenance of body tissue Provides energy and fights infectionKeep fluid balance in the blood2 types of ProteinHigh Biological Value (HBV) or animal protein-meat, fish, poultry, eggs, tofu, soy milk, and dairyLow Biological Value (LBV) or plant protein – breads, gains, vegetables, dried beans and peas and fruits
12Protein 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
13Phosphorus 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/dayNormal range <5.5Hemo 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.
14Phosphorus Foods high in phosphorus include: Dairy products Dried beans and peasNutsPeanut butterBran cerealsWhole wheat breadMeatsFood Additives
15Potassium 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 levelsMonitor residual renal function, changes in appetite for dietary adjustmentsA 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.
16Low Potassium foods Apples Grapes Berries Pineapple Tangerine Cabbage Green BeansCauliflowerEggplant
17Potassium Common high K+ foods include many fruits and vegetables: Prunes and Prune juiceOrange and Orange juiceBananasDried fruitsPotatoesTomatoesBrussels sproutsSpinachBeetsMilk
18Sodium 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 meatsCanned soupsSalty snack foodsDeli meats
19Sodium 1 Tsp salt = 2000mg sodium Most of us eat 3,000-6,000mg of sodium /dayLow sodium = ≤140mg/servingDo not buy a food that has mg sodium/serving
20FluidsHemo 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 temperature1500ml-2000ml~6 c-8 c /day4 cups=32 oz=1 qt=1000ml=1 literFluid 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.
21FluidsChoices include all drinks and foods that are liquid at room temperature.WaterCoffeeTeaSodasSoupsJuicesJell-O
22Fluids Cont.. Thirst Quenching Ideas : Suck on sour candies or chew gumEat chilled fruit, frozen grapes and berriesAdd lemon or Lime juice to waterTake pills with apple sauce instead of liquidsUse smaller cups or glassesKeep track of all liquidsLimit salty foodsIf diabetic, control blood sugars
23CALCIUM Hemo Dialysis Patients Balance is determined by: Dietary Calcium IntakeCalcium Supplements and Calcium Based BindersDialysate Calcium LevelsVitamin D TherapyPhysician Monitoring of PTHDietary 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.
24PD - HYPERGLYCEMIA / WEIGHT GAIN CARBOHYDRATECarbohydrate intake may need to be modified for Patients with Diabetes to achieve the goal of HgAIC < 7 %CAUTION !HYPOGLYCEMIAPD - HYPERGLYCEMIA / WEIGHT GAIN
25FAT / CHOLESTEROLCardiovascular 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 goalsConsider nutritional status / protein, energy deficitsMortality 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 1998HD patients generally have normal LDL, Low HDL and High TGPD patients have higher Total Cholesterol and LDL, and elvated TG due to continuous absorption of glucose from the dialysate.Encourage fiber intake.
26Supplements Multi Vitamins Vitamin C Water solubleVitamin CSupplementation may improve Iron availability from storesLimit to mg/d to avoid oxalate formationIron and Zinc supplementation must be determined individually based on labs
27MonitoringMonthly QAPI report to review the labs and discuss plan of action to correct the problemMonthly interdisciplinary Care plan meeting to review the patient performanceAlbumin 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)
28SummaryWhen 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
29Question and Answers Which food is highest in Potassium? Apple PineappleBroccoliBananaPotato
30Q & A Correct answer… Apple -1 medium(62 mg) Pineapple -1/2c(150mg) Broccoli -1/2c(127mg)Banana -medium(451mg)Potato- medium (926 mg)
31Q & AWhat are the foods high in Phosphorus? Pizza (Cheese and meat) Chicken American Cheese Yogurt Cream Cheese Cottage Cheese Oatmeal
33Q &AWhy do dialysis patients need to limit dairy and high phosphorus foods?
34Q &AHealthy 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.
35Q &AHow does the diet for someone on peritoneal dialysis differ from the one for hemodialysis?A. It requires more caloriesB. It requires more calciumC. It requires less proteinD. None of the above
36Q &A A. It requires more calories B. It requires more calcium C. It requires less proteinD. None of the above
37Q &AIf 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, potassiumd. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.
38Q &A a. Apples, oranges, grapes. b. Carrot cake, ice cream, Coke. c. Sodium, phosphorus, potassiumd. Seafood, surf-and-turf Red Lobster entrees, macaroni and cheese.
39References 1) A Clinical Guide to Nutrition Care in Kidney Disease American Dietetic Association, 20042) Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease, 4 th Edition, National Kidney Foundation, 20093) Core Curriculum for Nephrology Nursing, Fifth Edition. American Nephrology Nurses Association, 2008.