Renal Nutrition

Kidney Disease 2 kidneys 2 kidneys Each the size of your fist Each the size of your fist One on each side of your spine One on each side of your spine Weight 4-6 ounces each Weight 4-6 ounces each Nephron - the basic functioning unit of the kidney Nephron - the basic functioning unit of the kidney 1 million per kidney 1 million per kidney 2

What do they do? 1. Remove waste products and extra fluid from the blood by forming urine 2. Keep blood chemicals in balance 3. Produce some of the body’s hormones to control anemia, blood pressure, and bone health 3

Causes Diabetes and high blood pressure are the leading causes of chronic kidney disease Diabetes and high blood pressure are the leading causes of chronic kidney disease Glomerulonephritis Glomerulonephritis Genetic diseases (e.g. polycystic kidney disease) Genetic diseases (e.g. polycystic kidney disease) Inflammatory conditions (e.g. lupus) Inflammatory conditions (e.g. lupus) Obstruction to the urinary tract Obstruction to the urinary tract Repeat urinary tract infections Repeat urinary tract infections 4

Starting to feel it ….. Waste products and fluid build up in the blood causing a condition called uremia. Waste products and fluid build up in the blood causing a condition called uremia. Symptoms of uremia include: Symptoms of uremia include: Edema or swelling (face, hands, feet) Edema or swelling (face, hands, feet) Shortness of breath Shortness of breath Itching Itching Poor appetite Poor appetite Nausea and vomiting Nausea and vomiting Trouble concentrating Trouble concentrating 5

Diet with CKD – Early Stages Protein: To restrict or not to restrict? Protein: To restrict or not to restrict? Stages, 1, 2, and 3: protein intake is often limited to 12-15% of each day’s calorie intake or to 0.8 grams/kg body weight. Stages, 1, 2, and 3: protein intake is often limited to 12-15% of each day’s calorie intake or to 0.8 grams/kg body weight. Stage 4 CKD may be advised to reduce protein to 10% of calorie intake each day or to grams protein/kg body weight. Stage 4 CKD may be advised to reduce protein to 10% of calorie intake each day or to grams protein/kg body weight. 6

Phosphorus Phosphorus restriction is recommended as soon as an elevated blood level is seen Phosphorus restriction is recommended as soon as an elevated blood level is seen Some experts think mg of phosphorus daily is adequate Some experts think mg of phosphorus daily is adequate 7

Potassium If the level is high, a low potassium diet is prescribed. If the level is high, a low potassium diet is prescribed. Restricting foods such as avocados, dried fruits (raisins, apricots, prunes), potatoes, tomatoes, oranges/OJ, and bananas are often needed. Restricting foods such as avocados, dried fruits (raisins, apricots, prunes), potatoes, tomatoes, oranges/OJ, and bananas are often needed. 8

That was the early stages of CKD Any questions? 9

Additional Items to Know… Diaphoresis Diaphoresis Glomerulus Glomerulus Antigen & antibody Antigen & antibody Alkaline-Ash guidelines Alkaline-Ash guidelines Protein for Peritoneal Dialysis Protein for Peritoneal Dialysis Acute glomerulonephritis Urinary Calculi (Kidney Stones) Nephrotic Syndrome nutrition guidelines General uremia or kidney disease nutrition guidelines 10

Treatment for Stage 5 Blood is cleaned through dialysis or filtration Blood is cleaned through dialysis or filtration 2 filtration or treatment options: 2 filtration or treatment options: Peritoneal Dialysis: a natural filter inside the body Peritoneal Dialysis: a natural filter inside the body Hemodialysis: an artificial filter outside of the body Hemodialysis: an artificial filter outside of the body Dialysis must be done on a regular basis to replace kidney function Dialysis must be done on a regular basis to replace kidney function 11

Types of treatment Home therapy : Peritoneal Dialysis, Hemodialysis Home therapy : Peritoneal Dialysis, Hemodialysis In center Hemodialysis In center Hemodialysis Nocturnal hemodialysis Nocturnal hemodialysis Self-care hemodialysis Self-care hemodialysis Transplant Transplant Conservative treatment Conservative treatment 12

Peritoneal Dialysis Removes wastes & fluid Removes wastes & fluid Catheter in abdomen Catheter in abdomen Several exchanges daily Several exchanges daily 13

Hemodialysis Blood circulates through a filter (dialyzer) to remove wastes and fluid Blood circulates through a filter (dialyzer) to remove wastes and fluid A machine controls speed and safety factors A machine controls speed and safety factors Hemodialysis can be done in-center or at home, night or day Hemodialysis can be done in-center or at home, night or day Traditional: At a dialysis facility Traditional: At a dialysis facility 3 treatments/week 3 to 4 hours each treatment 3 treatments/week 3 to 4 hours each treatment Option for self-care and nocturnal hemodialysis Option for self-care and nocturnal hemodialysis 14

Hemodialysis 15

16 Role of the Dietitian   Assess nutritional status; evaluate & identify current nutritional problems.   Determine appropriate interventions and recommendations (individualized)   Provide nutrition education and counseling

17 Role of the Dietitian Interpret blood test results & review with patients Monitor outcomes Mineral and Bone Disorder Specialist Member of Health Care Team

18 Objectives of Nutritional Management Objectives of Nutritional Management Achieve optimal nutritional status Prevent tissue breakdown Manage co-existing conditions Prevent complications Enhance quality of life and outcome

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

20 Medical Nutrition Therapy Calories Protein Fluids Sodium Potassium Phosphorus Calcium Vitamins

22 Calories Calorie requirements: 30 to 40 kcal/kg of actual or Adjusted BW/day Adjusted to maintain, decrease, or increase actual body weight as desired Individualized for carbohydrate, fat and cholesterol recommendations

Protein Essential for growth, maintenance, preventing infection, and anemia Important for wound healing and repair

24 Inadequate Protein Intake Muscle wasting Lack of energy Edema Weight loss Poor wound healing Low or declining albumin

Foods High in Protein

26 Protein Requirements Higher protein requirement= 1.2 to 1.5 gm/kg weight per day for hemodialysis and peritoneal dialysis 50% to 60% high biological value Increased needs in catabolic states Adequate calories for protein sparing

Supplements Protein Powder Procel, Egg/Pro, Beneprotein Liquid Protein Pro-Stat, ProSource Liquid Nutritional Ensure, Boost, Enlive Calorie Dense Ensure Plus, Boost Plus Renal Specific Nepro, Novasource Renal, Nutren Renal. ReGen

28 Sodium Helps regulate body fluid volume and balance Limiting sodium helps to prevent: Excessive thirst Fluid retention Elevated blood pressure

29 Sodium Allowance 1.5 to 3.0 gm (1500 to 3000 mg)/day May be higher for patients with residual renal function and those on peritoneal dialysis

Foods High in Sodium

31 FluidsFluids Fluid accumulates in the body between dialysis treatments Interdialytic weight gain 3 to 5% of dry weight Excess fluid can cause: Edema Shortness of breath Hypertension Congestive heart failure Fluid accumulates in the body between dialysis treatments Interdialytic weight gain 3 to 5% of dry weight Excess fluid can cause: Edema Shortness of breath Hypertension Congestive heart failure

32 Fluid Allowance ~1.0 to 1.5 liters per day or use calculation of urine output + 500mL Includes all foods (jello, ice cream, popsicles, soup) & liquids at room temperature ~1.0 to 1.5 liters per day or use calculation of urine output + 500mL Includes all foods (jello, ice cream, popsicles, soup) & liquids at room temperature

34 Potassium Mineral required for muscle contraction and nerve function Maintain levels between 3.5 and 5.5 mEq/L

35 Potassium Symptoms of elevated potassium or hyperkalemia are: Muscle weakness Numbness and tingling of extremities Decreasing pulse rate Cardiac arrest

36 Potassium Allowance 2.0 to 3.0 gm (2000 to 3000 mg) per day Based on lab values Allowed more if residual renal function or on peritoneal dialysis

Foods High in Potassium

39 Phosphorus Mineral widely available in many foods 85-90% found in bones & teeth Vital to energy production and storage Goal: Maintain levels between 3.5 and 5.5 mg/dl

40 Hyperphosphatemia (high phosphorus) Symptoms : Itching Bone damage Increased risk for soft tissue calcification (including heart and blood vessels) Lowers serum calcium levels

Foods High in Phosphorus

42 Phosphorus Allowance 800 – 1000 mg ½ cup milk ~100 mg 1 ounce cheese 100 – 290 mg ½ beans (pinto, lima) = 125 mg 3 ounces meat = 195 mg 1 ounce nuts = 120 mg 2 tablespoons peanut butter = 120 mg

43Calcium Mineral needed for: healthy bones muscle contraction & relaxation proper nerve functioning Goal: Maintain level between 8.5 – 9.5 mg/dl

44Calcium   Hypercalcemia   Increased risk for heart disease   Increased risk for calcification of soft tissue   confusion (when very high)   Hypocalcemia (rare)   muscle spasms   numbness   confusion   seizures (when very low)

45 Calcium Allowance   2000 mg   Sources to limit:   Dairy products (milk, cheese, yogurt, ice cream)   Fortified foods   Medications

46 Mineral and Bone Disorder (MBD) Management Involves: Maintaining Calcium and Phosphorus balance  controlled by Vitamin D Controlling Parathyroid Hormone (PTH) levels

47 MBD Management Requires: Dialysis Diet Additional Therapies

MBD Management   Additional Therapies:   Phosphate Binders   PhosLo, Tums   Renagel, Renvela, Fosrenol   Vitamin D therapy   IV: Zemplar, Hectoral, Calcitriol   Oral: Rocaltrol, Hectorol   Calcimimetics   Sensipar

49Vitamins   Water soluble   Supplemented due to diet restrictions and dialysis losses; special prescription   Fat soluble   Not removed by dialysis, discuss with doctor/dietitian

Nutrition and Renal-Related Laboratory Measures HealthyStage 5 CKD BUN mg/dl<2550 – 100 Creatinine mg/dl<1.610 – 18 Albumin g/dl>4.0≥4.0 Hg g/dl14 – 1811 – 12 Iron Saturation %>2525 – 50 Ferritin ng/ml12 – – 500 Potassium mEq/l3.5 – – 5.5 Corrected Calcium mg/dl8.5 – – 9.5 Phosphorus mg/dl2.5 – – 5.5 Intact PTH pg/ml<

Resources National Kidney Foundation National Institute of Diabetes and Digestive and Kidney Diseases 52