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Nutrition Therapy: Chronic Kidney Disease Sheryl Rosenberg Thouin, MPH, RD, CDE.

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Presentation on theme: "Nutrition Therapy: Chronic Kidney Disease Sheryl Rosenberg Thouin, MPH, RD, CDE."— Presentation transcript:

1 Nutrition Therapy: Chronic Kidney Disease Sheryl Rosenberg Thouin, MPH, RD, CDE

2 Chronic Kidney Disease CKD is defined as either kidney damage or GFR < 60mL/min for < 3 months Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests, or imaging studies. 20 million Americans have CKD and 20 million more (1 out of every 9) are at risk. Approx 50% of dialysis patients have diabetes –Note: Insulin requirements decrease with progressive CKD due to inefficient excretion of insulin

3 Functions of the Kidney Excretion of metabolic waste through urine Water and Electrolyte Homeostasis Acid/base balance Maintenance of bone health –Activation of vitamin D –Calcium/phosphorus homeostasis Blood Pressure Regulation –Renin-Angiotensin-Aldosterone Stimulate red blood cell production –Erythropoietin

4 Consequences of Kidney Disease Decreased excretion of nutrients/waste Abnormal calcium/phosphorus metabolism leading to bone disease Weight loss and malnutrition Fluid and electrolyte imbalances Cardiovascular disease and mortality

5 Uremic Syndrome NauseaVomiting Metallic taste Itching Lack of energy

6 Protein-energy wasting syndrome Kidney Int. 2008;73(4):

7 Goals of CKD Management Achieve/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

8 Evidenced based clinical practice guidelines –For all stages of kidney disease –For related complications

9 Glomerular Filtration Rate GFR = (140-age) X body weight (kg) X 0.85 if female [72 X serum creatinine (mg/dL)] GFR of 100 approximates 100% kidney fxn Normal GFR = 120 to 130 mL/min

10 Stages of Chronic Kidney Disease Stage 1 CVD risk reduction Treat co-morbidities GFR > 90 ml/min Stage 2 Monitor progression GFR = ml/min Stage 3 Evaluate Test complications GFR = ml/min Stage 4 Preparation for renal replacement therapy GFR = ml/min Stage 5 Renal replacement therapy (RRT) GFR < 15ml/min or on dialysis

11 Deterioration of Nutritional Status Begins Early GFR 28 – 35 mL/min or greater Protein Energy Malnutrition (PEM) is often present at the time patients begin dialysis. Malnutrition in pts beginning dialysis is a strong predictor of poor clinical outcome

12 Medical Nutrition Therapy Recommendations (Stages 3 to 5) Calories30-35 kcals/kg IBW Protein gm/kg IBW Sodium mg FluidsEvaluate need to restrict PotassiumEvaluate need to restrict Calcium<2000mg Phosphorus mg VitaminsIndividualized

13 Optimal Nutritional Status Albumin > 4.0 Stable, desirable dry weight Adequate fat stores and muscle mass Appropriate appetite and intake

14 Reverse epidemiology of obesity in dialysis patients compared with the general population Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:

15 Assessing Anemia in CDK TESTK/DOQI Goal Hgb11 to 12 mg/dL Hct can be falsely low due to fluid overload Iron SAT > 20% Monthly test Ferritin ng/mL Reflects tissue iron stores

16 Low Albumin Non-nutritional factors Infection Inflammation Co-morbidities Fluid overload Inadequate dialysis Blood loss Metabolic acidosis

17 Calories Recommended energy intake = 30 to 35 day kcals/kg Spares body protein Maintains neutral nitrogen balance Promotes higher serum albumin levels Challenges Decreased appetite from uremia Various CKD dietary restrictions Finding food sources for added calories


19 Dietary Protein Restriction… Reduces nitrogenous waste Reduces inorganic ions Reduces metabolic/ clinical disturbance (uremia) Slows rate of decline in GFR

20 K/DOQI protein guidelines (Average American Intake = 1.2 g per kg/day) 0.75 grams per kg/day for CKD stages 1 thru grams per kg/day for CKD stages 4, 5 50% of the dietary protein should be HBV – –HBV protein produces less nitrogenous waste 45 to 60 grams protein per day No Protein Restriction for Dialysis Patients 1.2 g per kg/day hemodialysis – –10-12 grams lost per HD treatment 1.3 g per kg/day peritoneal dialysis – –5-15 grams lost per PD treatment

21 Food Carbohydrate 4 kcals/g Protein 4 kcals/g Fat 9 kcals/g 1 cup milk1280 –10 1 oz meat071 – 12 1 oz bread cup veg520 1 fruit teaspoon fat/ oil 005

22 F ood Portion Estimations 3 oz ¼ cup 1 cup & ½ cup 1 tsp 1 oz

23 Protein in Foods 1 oz meat, poultry, fish = 7 g – –¼ cup tuna – –½ cup beans, peas, or lentils – –2 Tablespoons peanut butter – –2 egg whites = 7 g 1 cup milk = 8 g – –1 oz cheese – –1/3 cup cottage cheese 1 cup veg = 2 g 1 slice bread = 3 g – –½ cup rice or pasta – –½ cup cereal Fruit, fats, sugars = 0

24 Challenges with High Protein Foods Also high in phosphorus and potassium MilkCheeseBeans Peanut butter

25 How much protein? Lunch A – –2 slices bread – –Chicken breast (3 oz) – –Lettuce, tomato – –Mayonnaise – –16 oz milk – –banana Lunch B –2 slices bread –1 oz chicken –Lettuce –Mayonnaise –Iced tea –apple

26 Nutritional Interventions Encourage patients to eat –Adjust or liberalize diet as appropriate –Frequent small meals/snacks High protein foods first if they get full quickly Calorie dense foods Consider use of nutritional supplements

27 Supplements Protein Powder –Procel, Egg/Pro Liquid Protein –Pro-Stat, ProSource, Liquicel Liquid Nutritional –Ensure, Boost, Enlive Calorie Dense –Ensure Plus, Boost Plus Renal Specific –Nepro with Carb Steady, Re/Gen –Novasource Renal, NutriRenal



30 Sodium Dietary sodium restriction prevents: –Excessive thirst –Edema –Hypertension –CHF Sodium restriction = 2000 mg/day –Range from 1000mg to 4000mg –Varies depending on co-morbidities –More liberal sodium with frequent dialysis Sodium excretion falls at GFR < 20mL/min


32 Sources of dietary sodium Pre-prepared foods Processed foods Canned, bottled, packaged foods.

33 1 tsp salt = 2,300 mg sodium

34 2 gram Sodium Diet… Fresh foods Limit – –Cured/pickled foods – –Processed – –Can/bottled/packaged – –Instant cereals, mixes Avoid salt substitutes (potassium chloride) Flavor foods with spices, vinegar, lemon juice, pepper


36 Potassium Potassium Restriction Indications –Urine output < 1 liter per day –GFR < 10 mL/min –ACE inhibitors, beta blockers, lasix –Hyperglycemia –Serum potassium > 5.0 mEq/L Dietary Potassium Restriction = 2 grams/day Serum Potassium Goal: mEq/L

37 Potassium in the Diet High (> 400 mg/serving) –Banana –Potato –Avocado –Orange juice Moderate (>200 mg/serving) –Berries –Broccoli –Tomato

38 Low Potassium Fruit & Vegetables >100 mg/serving >100 mg/serving –Cranberries –Apple –Corn –Lettuce –Pineapple –String beans

39 How much potassium? Lunch A – –2 slices bread – –Chicken breast (3 oz) – –Lettuce, tomato – –Mayonnaise – –16 oz milk – –banana Lunch B –2 slices bread –1 oz chicken –Lettuce –Mayonnaise –Iced tea –apple


41 Altered Bone Turnover in CKD Kidney Failure leads to… Decreased production of active Vit D Decreased production of active Vit D Low serum calcium Low serum calcium Phosphorus retention Phosphorus retention Elevated PTH Elevated PTH Secondary Hyperparathyroidism Secondary Hyperparathyroidism Mineral and Bone Disorder Mineral and Bone Disorder

42 >4.6



45 Phosphorus High serum phosphorus Bone decalcification Soft tissue calcifications Hyperparathyroidism Phosphorus restriction for GFR < 25mL/min Normal dietary phosphorus = 1000 to 1800 mg/day Dietary restriction = 560 to 850 mg/day Phosphate binders: Bind phosphorus in the GI tract Must take with meals Phoslo (calcium containing) Renvela (Sevelamer) (calcium free) Fosrenol (chewable)

46 Phosphorus is not found on the Nutrition Facts Label

47 High Phosphorous Foods DAIRY Cheese Milk 1 oz ½ cup 150 mg 120 mg PROTEIN Egg Liver Peanut butter Salmon or tuna Nuts 1 large 1 oz 2 Tbsp 1 oz 100 mg 150 mg 120 mg 75 mg 100 mg VEGETABLES Baked beans Soybeans ½ cup 130 mg 160 mg BREADS Bran Cornbread Whole-grain bread ½ cup 2 inch square 1 slice 350 mg 200 mg 60 mg BEVERAGES Beer Cola 12 oz can 50 mg


49 Calcium in CKD Maintain serum calcium 8.4 – 10.2 mg/dL Optimal < 9.6 mg/dL Dietary Calcium 1200 – 1500 mg/day (stages 3 and 4)

50 Calcimimetics: A new family of drugs (Sensipar) Binds to calcium receptor Decreases PTH Active orally Advantageous: Suppression of PTH without risk of hypercalcemia or hyperphosphatemia FDA approved


52 Fluid Restriction CKD Stage 4 or 5 Fluid: any food that is liquid at room temp Soup, gelatin, ice cream, popsicles Soup, gelatin, ice cream, popsicles Excess fluid buildup –Edema, SOB, HTN, CHF –Delays wound healing Fluid restriction estimations are based upon –Urinary output –Disease state –Treatment modality (dialysis, etc.)

53 Fluid Allowance Tips Approx 48oz/day Pre-measure mealtime liquids Drink very hot or very cold beverages Drinking from smaller cups Use spray bottle to mist mouth Freeze juice in ice cube tray and eat like popsicles

54 Vitamin & Mineral Supplements Dietary restrictions result in a diet deficient in nutrients Vitamin C 90 mg/day Over 75% of kidney disease patients have increased homocysteine levels. Over 75% of kidney disease patients have increased homocysteine levels. –Folic acid 1 mg/day –B 6 5 mg/day No Vitamin A due to its accumulation in CKD Vitamin D in its active form 1,25 dihydroxycholecalciferol 1,25 dihydroxycholecalciferol [1,25 (0H 2 )D 3 ] [1,25 (0H 2 )D 3 ] Procrit and iron supplementation Suggestion: Nephrocaps

55 Herbal Supplements Use may be unsafe for CKD patients –Poor clearance –Purity, safety, effectiveness unknown –No regulation, no testing requirements –Subject to contamination Leadmercury Herbs can interact with medications –Renal patients take > 10 meds/day Renal toxicity –Wormwood –Horse chestnut –Sassafras

56 Herbs with diuretic properties that may cause renal inflammation Bucha leaves Bucha leaves Juniper berries Juniper berries Uva ursi Uva ursi Parsley capsules Parsley capsules

57 Making Meals Appetizing Lunch: Two slices white bread Two Tbsp mayonnaise with lettuce and onion 1 ounce chicken or one hard boiled egg Two canned peach halves 7 Up or Lemonade

58 CKD Nutrition Resources –Relevant and easy-to-understand nutrition education guides by Medi-Diets Renal Nutrition Principles (non-dialysis) You Potassium Intake Lowering Your Sodium Intake – Complete CKD education site

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