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NUTRITION INTERVENTION FOR END STAGE RENAL DISEASE DIALYSIS PATIENTS Tara Greenley.

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Presentation on theme: "NUTRITION INTERVENTION FOR END STAGE RENAL DISEASE DIALYSIS PATIENTS Tara Greenley."— Presentation transcript:

1 NUTRITION INTERVENTION FOR END STAGE RENAL DISEASE DIALYSIS PATIENTS Tara Greenley

2 OBJECTIVES  Understand the different types of dialysis and effective nutrition intervention for each  Identify important nutrients that need to be monitored  Understand the importance of the role of the dietitian in ESRD patient care  Recognize abnormal lab values associated with ESRD

3 STAGES OF CHRONIC KIDNEY DISEASE

4 RENAL DIALYSIS TREATMENTS  Hemodialysis- Uses a dialysis machine  Nocturnal  Home  In-center Video

5 Dialysis Treatments  Peritoneal Dialysis

6 PREVALENCE: Statistics for 2007  23 million people 20 and above evidence of chronic kidney disease  16.6% of the US population  527,283 under treatment  368,544 received dialysis  deaths per 1,000 patients 87,812 total deaths  1,783,000 worldwide ESRD patients on treatment National Institute of Diabetes and Digestive and Kidney Diseases. (2010). Retrieved from

7 ASSOCIATED DISEASES  Diabetes: 197,037  Most common cause of CKD  Hypertension: 127,935  Glomuerulonephritis: 81,599  Cystic Kidney: 24,828  Urologic Diseases:13,139 National Institute of Diabetes and Digestive and Kidney Diseases. (2010). Retrieved from

8 COMPLICATIONS  Infection  Vaccines  Peritonitis  Malnutrition  Anemia Kidney.niddk.nih.gov

9 ROLE OF THE RD  Monitoring lab values  Monitoring dietary intake  Appetite assessments  Calculating dietary nutrient needs  Prevent protein-energy malnutrition  Consider modes of nutrition intervention Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

10 IMPORTANT LAB VALUES Lab Test for Kidney FunctionNormal Levels Serum CreatinineMen: mg/dL Women: mg/dL Creatinine ClearanceMen: mL/min Women: mL/min Glomerular Filtration Rate (GFR)Healthy Adults: 140 mL/min/1.73m2 Normal: Greater than 90 GFR less than 15: Kidney failure Urine AlbuminLess than 30 mg/day in 24 hrs MicroalbuminariaHealthy people: Less than 150 mg/L of albumin Blood Urea Nitrogen (BUN)Adults: 7-20 mg/dL Children: 5-18 mg/dL

11 IMPORTANT LAB VALUES Lab Tests for AnemiaNormal Levels Hematocrit (Hct)Men: 40-50% Women: 36-44% Hemoglobin (Hgb)Men: 14 to 18 g/dL Women: 12 to 16 g/dL Lab Tests for Diabetes Control Normal Levels Hemoglobin A1C (HgbQA1C) Less than 6.5% GlucoseFasting: mg/dL

12 MNT  Protein  Hemodialysis  1.2 g PRO/kg/d; at least 50% from high-biological value sources  For children, base RDA plus an increment of 0.4 g/kg/d  Peritoneal Dialysis  g PRO/kg/d; at least 50% from high-biological value sources  Children, base RDA plus anticipated loss Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

13 MNT  Energy  Hemodialysis  35 kcal/kg/d for patients who are 60 years of age  Children; follow RDA levels by age  Peritoneal Dialysis  Same as hemodialysis only include dialysate kcals  Children; follow RDA levels by age Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

14 MNT  Carbohydrate and Fat  Hemodialysis  After protein is calculated, assess patient needs and calculate percentages accordingly  Peritoneal Dialysis  Limit simple sugars and saturated fat  Extra kcal of glucose  Fluid  Hemodialysis  >1L fluid output = 2 L fluid needed  <1L fluid output= L fluid needed  Anuria = 1 L fluid needed  Peritoneal Dialysis  Restriction is less common  1-3 L/d  Determined on an individual basis Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

15 MNT  Phosphorus  Hemodialysis  Use mg or <17 mg/kg ideal body weight  Peritoneal Dialysis  Adjust according to serum levels  mg Phosphorus or mg phosphorus/g protein  Potassium  Hemodialysis  40 mg/kg BW  Peritoneal Dialysis  Adjust according to serum levels Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

16 MNT  Sodium  Hemodialysis  Limit unless large losses in dialysate or through vomiting or diarrhea  2-4 g  Peritoneal Dialysis  Liberal intake  2-4 g; some need no restriction Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

17 MNT  Vitamins  Hemodialysis  Use water-soluble vitamin supplements to replace dialysate losses  Children follow DRI levels  Common Recommendations  Folic acid: 1 microgram  Vitamin B6: mg  Vitamin C: mg  Vitamin B12: 2.4 micrograms  Vitamin D: Monitor and replace at recommended levels  Avoid excess Vitamin A Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

18 MNT  Vitamins  Peritoneal Dialysis  Water-soluble vitamins  Especially vitamin B6 and folic acid  Vitamin D should be monitored and replaced as recommended  Minerals  Hemodialysis  Calcium varies per individual  Magnesium: g  Zinc: 8-11 mg  Avoid excess vitamin A  Peritoneal Dialysis  Same as hemodialysis Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

19 MNT  Omega-3 Fatty Acids  Hemodialysis and Peritoneal Dialysis  Fish oil  Reduce prostaglandin synthesis  Improve hematocrit levels Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

20 SAMPLE DIET  BREAKFAST  1/2 cup (4 ounces) orange juice 1 English muffin or 2 slices bread At least one tablespoon margarine with jelly Coffee or tea with non-dairy creamer and sugar  LUNCH  2 slices white bread At least 2 tablespoons mayonnaise with lettuce and tomato 1 ounce chicken (such as a small thigh) or 1 hard boiled egg 2 canned peach halves in heavy syrup 7-UP, lemonade or Hawaiian Punch  DINNER  3-4 ounces steak (weigh after cooking, without bone), sauté in tablespoons olive oil 1 small baked potato with at least 2 tablespoons margarine 1/2 cup fresh green beans, carrots or broccoli with margarine Lettuce, onions, cucumbers, green pepper At least 2 tablespoons olive oil with vinegar or lemon /8 apple or cherry pie with 1/2 cup fruit sorbet (this is not sherbet) Iced tea with sugar and lemon or Sprite

21 NUTRITION SUPPORT  Drinks  Nutren Renal  Nepro  NovaSource  Enteral Nutrition  Parenteral Nutrition Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

22 POSITIVE EFFECT OF SOY IN ESRD PATIENTS?  Double blind, random 2:1 ratio  25 subjects  15 in soy group  10 in control group  Possible benefits from isolflavone-rich foods Fanti, P., Asmis, R., Stephenson, T.J., Sawaya, B.P., & Franke, A.A. (2006). Positive effect of dietary soy in esrd patients with systemic inflammation-correlation between blood levels of the soy isoflavones and the acute-phase reactants. Nephrology Dialysis Transplantation, 21,

23 EXERCISE CAPACITY AS A PREDICTOR OF SURVIVAL AMONG AMBULATORY ESRD PATIENTS  6 month trial  Assessment at beginning, 3 months, end  Measured VO2  Patients from two clinical trials  years old  On dialysis 26 months- 56 months  23 deaths  7 due to cardiovascular issues  7 due to infection  2 Cancer Sietsema, K.E., Amato, A., Adler, S.G., & Brass, E.P. (2004). Exercise capacity as a predicator of survival among ambulatory patients with end-stage renal disease. Kidney International, 65,

24 CONT.  2 due to transplant complications  7 unknown  Shows VO2 as a significant predictor of survival among a stable cohort of hemodialysis patients Sietsema, K.E., Amato, A., Adler, S.G., & Brass, E.P. (2004). Exercise capacity as a predicator of survival among ambulatory patients with end-stage renal disease. Kidney International, 65,

25 FOOD ADDITIVES AN UNRECOGNIZED RISK?  36 uncooked meat and poultry products  Tested the amount of potassium and phosphorus  Phosphorus 28.4% higher  Potassium 8.4% higher  Significant evidence proves need for monitoring Sherman, R.A., & Mehta, O. (2009). Phosphorus and potassium content of enhanced meat and poultry products: implications for patients who receive dialysis. Clin J Am Soc Nephrol, 1(4),

26 GOODBYE TO FAST FOOD?  194 randomly selected patients  44 hemodialysis facilities in NE Ohio  81 subjects  One meal in four days at fast food restaurants  Kcals increased from 18.9 to 26.1  Higher serum phosphorus levels Butt, S., Leon, J., David, C., Chang, H., Sehgal, A., & Sidhu, S. (2007). The prevalence and nutritional implications of fast food consumption among hemodialysis patients. National Institute of Health, 17(4),

27 DRUG THERAPY  ACE inhibitors  Antidepressants  Carnitine  Growth hormone  Insulin  Iron supplements  Lipid-lowering medications and statins  Phosphate binders  Potassium excretion  Ruboxistaurin  Water-soluble vitamins and vitamin D3 Escott-Stump S., (2008) Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

28 COST  In 2006 cost to Medicare $49 billion  If 5% percent more did at home Peritoneal Dialysis could potentially save $295 million  HD cost Medicare $69,758 pppy  PD cost Medicare $50,847 pppy Neil, N., Guest, S., Wong, L., Inglese, G., Gehr, T., Walker, D., Golper, T., & Bhattacharyya, S. (2009). The financial implications for Medicare of greater use of peritoneal dialysis. Clinical Therapeutics, 31(4), Just, P.M., Riella, M.C., Tschosik, E.A., Noe, L.L., Charro, F.D., & Bhattacharyya, S.K. (2001). Economic evaluations of dialysis treatment modalities. Science Direct, 86(2008),

29 REIMBURSEMENT  Medicare will pay for the following services:  Inpatient dialysis treatments  Outpatient dialysis treatments  Home dialysis equipment and supplies  Home support services  Certain drugs for home dialysis  Outpatient doctor and other related services as a part of the dialysis treatment  Medicare does not pay for:  Paid dialysis aides to help with home dialysis  Lost pay to you and your helper during self-dialysis training  A place to stay during treatment  Blood or packed red blood cells for home self-dialysis unless it is part of a doctor’s service or is needed to prime the dialysis equipment  Transportation to a dialysis facility  Medicare covers 80% of their approved amount, you are responsible for the remaining amount. Medicare.gov

30 ETHICAL ISSUES  Right to choose or suicide?  Religious views  Black market for obtaining organs  Donation  About 14,000 kidney transplants are performed each year  Just over one third of transplanted kidneys are from living donors.  About 55,000 people are on the waiting list for a kidney transplant.  Each year over 3,000 people die while waiting for a kidney transplant  One-year survival rate for kidney transplant recipients is about 95% sale-kidney-path-poverty-hope.html

31 CONCLUSION  Role of the Dietitian  Nutrients to closely monitor  Phosphorus  Potassium  Calcium  Protein  Sodium


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