Nutrition Care in Chronic Kidney Disease – An Overview

Nutrition Care in Chronic Kidney Disease – An Overview
Terry Banerjea, MS, RD, LDN Barbara Edgar, RD, LDN

Objectives: Understand goals of MNT for patients with CKD
Recognize renal related labs and their goal values Become familiar with dialysis medications and their functions

Medical Nutrition Therapy
Protein Calories Potassium Phosphorus Calcium Sodium Fluid Vitamins Minerals

Protein The backbone of the diet
Essential for growth, muscle building, boosting the immune system, preventing infection, anemia Important for wound healing Measured as ALBUMIN in the blood Albumin goal is >=4.0 to live longer and healthier

Protein/Calorie Malnutrition
40% of hemodialysis patients are thought to have protein/calorie malnutrition. Dialysis population has a two-fold increase in mortality risk for those with albumin <3.8 g/dl vs. those with albumin > 3.8 g/dl

Some Potential Reasons for Low Albumin
Loss of metabolic function in the failing kidney leads to build up of waste products leading to: Anorexia Decrease in nutrient intake Changes in hormones and metabolism Insulin resistance Increased hepatic glucagon sensitivity Excessive parathyroid hormone secretion Change in the rate of protein/amino acid turnover Acidosis: loss of protein and muscle mass Increased cytokine activation (pro-inflammatory response)

Some Potential Reasons for Low Albumin
Use of multiple medications Multiple co-morbidities Loss of amino acids in dialysate Reduced ability to synthesize albumin in the elderly leads to slight albumin decrease Liver failure decreases albumin synthesis Fluid overload leads to dilution of the serum (would falsely lower albumin and BUN)

Calories/ Protein in CKD
Appetite and intake may be poor due to: Aging Frequent illness, hospitalizations Institutional food GI problems Gastroparesis and diabetes Constipation due to CaCO3, iron, narcotics, other medications, low fluid, low fiber, limited exercise Diarrhea due to C. difficile with antibiotic therapy

Calories/Protein in CKD
Appetite is made worse by CKD and dialysis due to: Anorexia caused by uremia Nausea, vomiting, diarrhea Dysgeusia due to uremia, zinc deficiency Peritoneal Dialysis patients: feeling of fullness from dialysate or sugar content of dialysate Hemodialysis: Interferes with regular meal pattern

Evaluating Protein Intake
Check Urea Reduction Rate (URR) or KT/V - URR should be >70% and KT/V should be >1.2 These measure dialysis adequacy and low values may adversely affect intake Check nPCR Normalized protein catabolic rate is determined from urea generation. It is an indicator of available protein. If patient is stable the nPCR indicates dietary protein as g/kg/EDW. nPCR will be low if protein intake is low or patient is anabolic

Evaluating Protein Intake
Check BUN mg/dl Urea derived from protein will decline if intake is poor or patient is anabolic Check albumin (BCG) >=4.0 Albumin will decline if patient has trauma, infection, intake is poor, or if dialysis is inadequate

High Quality vs. Low Quality Protein
Dialysis patients should get 50% of their diet from HIGH BIOLOGICAL VALUE PROTEIN (animal products) LOW BIOLOGICAL VALUE protein generally come from plants Vegetarians can still maintain acceptable albumin levels by combining plants sources with the use of supplements

How Much Protein Does a Person on Dialysis Need?
Hemodialysis patients need 1.2 or more grams/kg Peritoneal patients need 1.3 or more grams/kg Greater protein losses in dialysate Appetite loss due to fullness experienced while the dialysate fluid in peritoneum Effect of glucose when using higher concentration dialysate These recommendations are based on K/DOQI guidelines.

Inadequate Protein Intake
Muscle Wasting Lack of Energy Weight Loss Poor Wound Healing Albumin </=3.5 considered protein malnutrition (Goal >/=4.0) Low albumin can make it hard to dialyze fluid off of a patient

Evaluating Calorie Intake
Check EDW (Estimated Dry Weight) Check IDWG (Interdialytic Weight Gain) Check labs Poor intake indicated by: Low BUN Low Albumin Low K Low PO4

How Many Calories Does a Person on Dialysis Need?
Hemodialysis patients need kcal/kg >60 years old, 35 kcal < 60 years old Obese dialysis patients 25 kcal/kg regardless of age Peritoneal dialysis patients have the same calorie requirements however the calories from the dialysate need to be included

Suggestions for Improving Intake
Encourage patient to not miss meals even when they are not hungry Small, frequent meals If a patient is eating poorly and K and PO4 are low- liberalize diet If dysgeusia is present- eggs or cottage cheese may be better tolerated than meat, meat at room temperature Consider zinc supplement Send lunch with patient to hemodialysis treatment if clinic allows or send supplement

Protein recommendations are not a restriction Do not sacrifice protein intake in order to lower PO4 intake Help patient with fluid/sodium restriction Avoid large fluid weight gains Encourage physical activity to maintain muscle mass

Protein: may need to increase portion size if standards are used Serve HBVP at 2 meals/day minimum Serve at least 2+ ounces HBVP Serve 4-6 ounces HBVP at large meal Include a HBVP with snack Consider supplements

Snacks for Dialysis Many dialysis patients miss 3 meals per week due to dialysis schedule so it is important to replace this meal with a protein rich snack If patients do not wish to eat a sandwich or if it is not allowed, send a supplement as a meal replacement Snack Ideas: Egg salad, tuna salad, chicken salad, turkey or roast beef sandwich Cheese stick and a piece of fruit Greek yogurt A peeled hard boiled egg Binders should be sent with the bag meal

Potassium Absorbed in small intestine 90% in cells 8% in bones
<1% in circulation Excretion 80-95% in urine 5-20% in stools

Potassium Primary Roles of Potassium:
Maintains fluid balance within cells Conduction of nerve impulses Muscle contraction

Potassium (K) Normal serum potassium values:3.5-5.1mEq/L
Goal range for dialysis patients: mEq/L Serum level is dependent on urine output K is usually WNL if producing >1000cc/day May be altered by diuretics and antihypertensive medications

Causes of High Potassium (Hyperkalemia)
Excessive potassium intake Inadequate dialysis Inadequate treatment time or missed treatments Low blood flow rate, recirculation Metabolic acidosis-causes K to shift from cell to serum

Dehydration-hyperosmolar state impairs cellular uptake of K+ Insulin deficiency-cellular uptake of K+ requires insulin Blood transfusions-old packed cells will break down and release K+ Hemolysis (incorrect handling of specimen)-release of K+ from RBC into serum

Catabolism due to tissue breakdown: Infection and ischemia (bowel) Starvation Trauma surgery GI Bleed Chewing tobacco Use of illicit drugs Some forms of pica Constipation Medications-ACE Inhibitors and ARBS (Angiotensin receptor blockers) which are commonly used for blood pressure control

Symptoms of Hyperkalemia
Muscle weakness Numbness and tingling of extremities Slow pulse rate Heart attack

Diet Recommendations for Potassium
Hemodialysis – 2-3 grams/day Peritoneal Dialysis – 3-4 grams/day however often times a restriction is not needed A high K+ usually indicates treatments are not being done

High Potassium Fruits Avocados Papaya Bananas Pomegranate Kiwi
Prunes/juice Mango Raisins Melons Rhubarb Nectarines Orange/juice

High Potassium Vegetables
Artichokes Pumpkin Asparagus- fresh Tomatoes and tomato products Brussels sprouts Winter squash Dried beans and peas Lima beans Mushrooms Potato-white/sweet

Diet Recommendations High potassium foods may be allowed in small amounts depending on frequency in meal plan EXAMPLE: ¼ cup of tomato sauce on noodles Consult with renal dietitian DIALYSIS PATIENTS SHOULD NEVER EAT STAR FRUIT

If K+ is high: Check URR (urea reduction rate) or KT/V (clearance of volume over time) Check BS and HgbA1C for lack of insulin Check Hgb and transferrin saturation for the possibility of a GI bleed Check potassium if specimen was hemolyzed Check medication list – Captopril, Enalapril, Accupril, Lisinopril Diet review

If K+ is high due to a non-dietary cause:
Consult MD for changes: Blood pressure medications Possible use of Kayexalate Change dialysis bath (3K to a 2K) Discontinue potassium supplement (KCl) if prescribed

Phosphorus Primary Roles of Phosphorus: Bone and Teeth Formation
Energy Metabolism Acid-Base Balance

Phosphorus Normal serum phosphorus level:2.6-4.5mg/dL
Goal range for dialysis patients: mg/dL Three ways to control phosphorus: Diet restriction is nearly always necessary Phosphate binders Dialysis – 800mg/treatment is removed at each hemodialysis treatment and mg/day for peritoneal dialysis

Symptoms of High Phosphorus (Hyperphosphatemia)
Itching Blood shot eyes Bone pain

Effects of High Phosphorus
Combines with calcium to form deposits in and joints CVD, PVD Calcification of soft tissue Calciphylaxis Causes parathyroid hormone to increase Decalcification of bones Bone pain, high risk of fractures

Relative Mortality Risk by Serum Phosphorus Levels

Dietary Recommendations for Phosphorus
mg/day, adjust to meet protein needs (10-12mg/gram of protein) for hemodialysis and peritoneal dialysis

High Phosphorus Foods Dairy products – milk, cheese, ice cream, yogurt
Beans – dry beans and legumes Peanut butter and nuts Chocolate products Cola beverages Bran – bran muffins and cereals Whole grains – whole wheat bread, cheerios

Treatment of High Phosphorus
Dietary recommendations Limit milk/dairy to ½ cup per day Limit use of non-dairy high phosphorus foods: Nuts Legumes Limit foods that contain phosphorus additives: Processed and spreadable cheeses Instant products-puddings and sauces Cola, some flavored waters and fruit drinks (Hawaiian punch) 90% of the phosphorus in additives are absorbed vs. 50% in natural foods

Phosphate Binders Must be taken with meals and snacks to be effective
The active component of the phosphate binder combines with the digested phosphorus, forming a compound that is eliminated in the stool Patients should also take a binder with the protein supplements

Calcium Carbonate – Tums, Oscal, Caltrate
Binders Calcium Carbonate – Tums, Oscal, Caltrate OTC so not costly Many different pleasant flavors to choose from Chewable May cause hypercalcemia May cause constipation, gas, nausea Strength vary from regular Tums (500mg tab which provides 200mg of elemental calcium) to Tums EX (750mg tab which provides 300 mg of elemental calcium) to Ultra Tums (1000mg tab which provides 400mg of elemental calcium) Typical dose is 1-3 tablets per meal Should be limited to 7-8 regular Tums per day Absorb 20-30% of calcium

Phoslo – calcium acetate
Binders Phoslo – calcium acetate Capsule is 667mg which is 169mg of elemental calcium Typical dose is 1-3 capsules per meal, should be limited to 9 per day Easy to swallow May cause hypercalcemia Generic is calcium acetate which is either a capsule or tablet Less calcium absorbed than calcium carbonate 21% calcium absorbed with meals, 40% absorbed in between meals

Phoslyra- calcium acetate oral solution
Binders Phoslyra- calcium acetate oral solution Can be used in tube feedings Can be used for patients with swallowing issues Black cherry/menthol flavor Single dose is 5ml Typical dose is 5ml-15ml per meal

Binders Renagel (sevelamer hydrochloride)
Renvela (sevelamer carbonate) Tablet 400mg and 800mg dose for Renagel, 800mg dose for Renvela Renagel lowers cholesterol due to binding with bile acids Renagel lowers serum bicarbonate Typical dose is 3 tablets per meal though some patients require more Non-calcium based binder so is used for patients that have issues with hypercalcemia Renvela comes in a powder form of 800mg or 2.4g that is mixed with 2 ounces of water for patients with swallowing issues Renagel and Renvela may cause some n/v, diarrhea or gas

Fosrenol (Lanthanum Carbonate)
Binders Fosrenol (Lanthanum Carbonate) Chewable tablet of 500mg, 750mg, 1000mg Typical dose is 1000mg tablet per meal Maximum dose is 4500mg per day Non-calcium based binder so is used for patients that have issues with hypercalcemia Tablet must be completely chewed, can not swallow whole pieces Tablet must be taken after meal is completed, not before or during Chalky flavor % lanthanum is absorbed

Binders Velphoro (Sucroferric Oxyhydroxide) Chewable tablet of 500mg
Typical dose is 1 tablet per meal May require 2 tablets with a large meal or a meal that contains a high PO4 food Tablet must be completely chewed, can not swallow whole pieces Non-calcium based binder so is used for patients that have issues with hypercalcemia May cause dark stools

Calcium Primary roles of calcium: Bone strength Teeth formation
Catalyst in the conversion of prothrombin to thrombin Involved in transmission of nerve impulses and relates to muscle contractions Activates several enzymes such as lipase

Calcium Normal serum calcium level: 8.4-10.2
Normal serum calcium level for dialysis patients: Calcium is corrected for an albumin <4.0 (4.0-albumin level X .8)

Calcium Causes of Hypercalcemia Addison’s disease Cancer Medications
Calcium enriched foods

Calcium Symptoms of Hypercalcemia Weakness Headache Drowsiness
Nausea/Vomiting Dry Mouth Constipation Muscle pain/Bone pain Metallic Taste

Calcium Symptoms of hypocalcemia: Paresthesia Chvostek’s sign
Trousseau’s sign Tetany Seizures Bronchospasm and laryngospasm

If Calcium is High: High Calcium levels can lead to calcification
Evaluate binder – Change to a non-calcium based binder if on a calcium based binder Evaluate Vitamin D analog– hold or decrease dose May need to start Sensipar which decreases PTH and calcium Make sure calcium bath is 2.25 Counsel on avoiding calcium fortified foods

Calcium Receive calcium from diet, supplements, phosphate binders and dialysate K/DOQI guidelines limit p.o. calcium to 2000mg from all sources Limit calcium from phosphate binders and calcium supplements to 1500mg/day Do not give calcium with iron or zinc supplements Renal RD works with MD to change dialysis bath, phosphate binders as appropriate

Calcium Possible Problems for the Elderly:
Decreased absorption due to achlorhydria Calcium citrate may increase aluminum absorption Calcium with a meal will decrease phosphorus (hence the calcium based phosphate binders) Decrease response to Vitamin D Immobility increases calcium loss

Calcium Drawbacks of Excess Calcium: Parathyroid over-suppression
Adynamic bone disease occurs with low parathyroid hormone (PTH) Extraskeletal calcification may occur

Sodium and Fluids Roles of Sodium Principle electrolyte in extracellular fluid involved in the maintenance of normal osmotic pressure and water balance Acid base balance Osmotic equilibrium

Sodium and Fluids Normal serum value is mEq/L for the general population and dialysis patients A high serum level indicates dehydration Severe diarrhea Vomiting Diuretics A low serum level indicates fluid overload Low fluid intake Edema

Sodium and Fluids A high sodium intake results in:
Thirst and increased fluid intake Fluid drawn into interstitial space causing edema High blood pressure Shortness of breath when fluid is in lungs

Sodium and Fluids Difficult Treatments:
Sudden drop in blood pressure when large volumes are removed Cramping when sodium in interstitial spaces is holding fluid which then cannot be removed Nausea A generally miserable treatment

Diet Recommendations for Sodium
Hemodialysis: 2-3 grams per day Peritoneal Dialysis: 2-4 grams per day Should be most strict when patient has CHF or is a cardio-renal patient and on weekends due to 3 day interval Avoid law sodium products with KCl added Give salty foods as a special treat

Sodium and Fluids Fluid Losses (non-urinary): Perspiration from skin
Water vapor expired from lungs Fecal losses or ostomy output Fever

Sodium and Fluids Diet Recommendations for Fluids:
Hemodialysis – cc/day or 1000 cc + urine output/day 1000 cc if anuric Peritoneal dialysis – to maintain balance Patients should not push fluids but drink only to quench thirst If a patient has residual renal function they can have more fluids.

Sodium and Fluids Causes of High Interdialytic Weight Gains:
Increase in intake of fluid due to excessive thirst High sodium intake High serum glucose High urea Medications-antihypertensives, anti-inflammatories, decongestants, diuretics, sedatives, antianxiety, anti-depressant, anti-diarrhea, anti-histamines Lack of saliva

Fluid Management in Dialysis
Assessing Fluid Retention Hemodialysis – check interdialytic weight gain Goal during the week –no more than 3% of EDW Goal over the weekend – no more than 5% of EDW Peritoneal dialysis - check whether patient Reaches target weight May need a higher strength dialysate Typically no fluid restriction required

Any beverage or food that is fluid at room temperature is considered fluid (fruits and vegetables are not counted as fluid) Fluid guidelines: Measure, monitor, mindful Watch sodium intake Take medications with meal beverages when possible or applesauce Use only 4-8 ounce beverage containers Avoid bedside water containers

Suggestions for thirst control: Suck on lemon wedge or add lemon to water-citric acid increases saliva Eat sour candy or mints Chew gum Rinse mouth with cold water or mouth wash Eat frozen grapes, pineapple chunks, etc. Brush teeth more often to feel refreshed Use breath spray Use Biotene mouthwash and other products

Vitamins and Minerals Some nutrients are lost during dialysis
B Vitamins Biotin- low levels are thought to result in restless leg syndrome Folic Acid, B12, B6 – low levels thought to be associated with homecysteinemia Vitamin C Zinc Iron

Vitamins and Minerals Fat soluble vitamins are stored in the body and not removed during dialysis so supplementation is not needed (Vitamin A,D,E,K) Schedule renal multivitamin at bedtime to prevent removal at dialysis treatment

Vitamins and Minerals Supplements are prescribed:
Renavite, Renaplex, Nephrovite, Nephrocaps, Renal Caps, Prorenal, Triphocaps, Diatx, Dialyvite Oral iron is used mainly for peritoneal patients IV iron may be provided in-center (Venofer, Ferrlecit)

Vitamins and Minerals Other vitamins and minerals accumulate and may be toxic: Vitamin A Vitamin D Potassium Calcium Phosphorus Iron Therefore OTC vitamins are not recommended

Vitamins and Minerals Vitamin D: 1,25 dihydroxy Vitamin D- calcitriol
25, hydroxy Vitamin D - calcidol Vitamin D2 – ergocalciferol Vitamin D3 – cholecalciferol Normal value is ng/ml Vitamin D analogs: Hectorol Zemplar Calcitriol Available IV for hemodialysis patients and oral for peritoneal patients –used to manage parathyroid hormone (PTH) levels

Parathyroid Hormone (PTH)
Maintains calcium and phosphorus balance in the blood Kidneys turn the active form of Vitamin D (from the sun and food/supplements) to the active form When the kidneys do not work, PTH increases and active Vitamin D in the form of the Vitamin D analog is given to suppress PTH Normal serum PTH – 14-72pg/ml Goal range for dialysis patients pg/ml

Parathyroid gland becomes less sensitive to calcium and Vitamin D A high PTH can lead to: Increase risk for extraskeletal calcification High turnover bone disease (osteitis fibrosa cystica) Good bone is replaced with poorly formed bone and fibrous tissue Also increases phosphorus

Treatment of Hyperparathyroidism: Vitamin D analogs: Zemplar (paricalcitol) Hectorol (doxercalciferol) Calcijex and Rocaltrol (calcitriol) Parathyroidectomy: If PTH > 1000 Calciminetics - Sensipar

Sensipar PTH, calcium and phosphorus decrease
Doses are 30mg, 60mg, 90mg, 120mg and 180mg PTH is monitored monthly until goal range is met Dose of sensipar is increased until goal range is met Patients continue to receive Vitamin D analogs Hypocalcemia can be a problem so calcium level is monitored closely

Parathyoidectomy Calcium level drops
Patients will need calcium supplements, usually 1-2 gm tid between meals May need to change from a non-calcium based binder (Renvela, Renagel, Fosrenol, Velphoro) to a calcium-based binder (calcium carbonate or calcium acetate) Phosphorus usually drops as well but patients still need phosphate binder May supplement with calcitriol as a calcium supplement May change calcium bath from a 2.25 to a 3.0

Low PTH PTH <100 Leads to adynamic bone disease
Low rates of bone formation Decreased numbers of osteoblasts and osteoclasts Osteomalacia (related to aluminum or Vitamin D deficiency

Fiber Constipation is a common problem in the dialysis population due to: Fluid restriction Lack of exercise Medications Calcium carbonate, oral iron supplements, narcotics

Fiber Low Fiber Intake:
Restriction of fruits and vegetables due to the high potassium content of them Self restriction of fruit and vegetables due to GI problems or food preferences Poor general intake

Prevention/Treatment of Constipation
Fiber Prevention/Treatment of Constipation Encourage fruit and vegetable intake within limits of potassium restriction Encourage exercise Fiber supplements and stool softners can be used: Unifiber, Metamucil, Miralax, Colace, Senokot Laxatives: Dolcolax, Lactulose, Sorbitol, Docusate Sodium Enemas: Mineral Oils, Soap suds Fleets should not be used

Factors to Consider in Choosing a Nutritional Supplement
Current Oral Intake Recent Lab Values Co-morbidities Body weight Fluid status Recent changes in health status Cognitive state Patient preferences

Important Content of the Nutritional Supplement
Serving size Calories Carbohydrates Fat Protein Sodium Potassium Calcium Phosphorus

Renal Supplements Per 8 ounces: 400-500 calories
>15 grams of protein <200 mg sodium <300 mg potassium <350 mg calcium <200 mg phosphorus

Renal Supplements Nepro Novasource Renal Re/Gen
Suplena – used for pre-dialysis patients only that need to be on a low protein diet

Non-Renal Supplements
Can be useful when a patient’s potassium and phosphorus are well controlled Some patients may also find these choices more palatable

Non-Renal Supplements
Boost Ensure Liquacel Pro-Stat Procel Powder Protein Bars Body Quest Ice Cream Enlive Resource

Supplements Providing supplements in small amounts throughout the day i.e. a med pass program, can be useful for patients with limited appetite and to decrease fluid intake

Vegetarian Diet for Dialysis Patients
Protein Vegetable proteins include foods such as legumes, beans, nuts, seeds, soy products such as soy milk, tofu and meat analogs Tofu is a good protein choice because it is low in sodium, potassium and phosphorus and is very versatile Select “regular” or “silken” tofu as they contain less potassium than “extra firm” or “firm” tofu Legumes are a good source of protein and soluable fiber but can be a major contributor to a high potassium level in the blood The following beans are lower in potassium: Lupin, chickpeas, black beans, black eye peas, red kidney, pinto as well as hummus which is made from chickpeas Meat analogs can be used in moderation if balanced with other lower sodiun foods Consider using protein powder or other supplements depending on the type of vegetarian

Meat analogs: Many provide grams of protein per serving They are made from soy protein with flavor and color added so they taste and feel like real meat Contain a lot of sodium so check labels Brands – Morningstar Farms, Loma Linda, Green Giant

Phosphorus Some of the foods that contain high levels of phosphorus include beans, nuts and whole grains Phosphate found in vegetable protein is not absorbed as well as the phosphorus found in the animal protein Phosphate binders are necessary to manage phsophorus levels

Potassium Always select the lower potassium fruits and vegetables Grains also contain potassium -the lower potassium grains would be rice and barley Avoid quinoa, miso and naho Avoid high potassium legumes such as lentils, soybeans, adzuki, navy and white beans

Calories When following a renal diet it is often a challenge to consume enough calories May need include fats as well as some sugars to meet calorie needs

Case Study #1 67 year old female who receives hemodialysis on Mondays, Wednesdays and Fridays Access: A-V Fistula Fluid Status: Urine output of 75 ml/day, average interdialytic weight gain 2-4.8kg Medical History: ESRD due to hypertensive nephrosclerosis Secondary dx: CAD s/p CABG, CHF, PVD, Hyperparathyroidism, currently has an access infection

Case Study #1 Medications: Nephrocaps, 2 Phoslo with meals, Vitamin D, Accupril, Synthroid, Keflex Labs: BUN 55, Cr 6.8, K 6.3, Alb 3.1 (was 4.1 previous month) KT/V 0.9, Ca 9.5, PO4 4.7, Na 140 Nutrition/GI Issues: Anorexia, weight loss, constipation, hypocaloric intake, nausea, vomiting Psychosocial Factors: ride issues so misses 3 treatments per month, leg cramps due to excessive interdialytic weight gains

Case Study #1 Potential Rationale for elevated potassium: Diet
Medications Inadequate dialysis Inadequate intake Lab error Constipation

Case Study #1 Intervention:
Check dietary intake – adjust diet or review diet with patient as needed Repeat lab – if it was an error, repeat lab should be WNL Encourage patient to not miss treatments to improve adequacy Encourage patient to use fiber supplement or stool softner or refer to PCP Encourage adequate intake to prevent tissue breakdown

Case Study #1 Nephrologist’s interventions: Rx for access infection
Review BP medication – Accupril Adjust treatment to improve adequacy

Case Study #2 78 year old male who receives dialysis on Mondays, Wednesdays and Fridays Fluid Status: the patient is new to dialysis and still produces quite a bit of urine Medical History: Type 2 DM and HTN Labs: Alb 4.0, K 5.5, PO4 6.5, Ca 8.0

Case Study #2 24 Hour Diet Recall:
Breakfast – A bowl of bran cereal with 2% milk on it, 2 slices of toast with butter and low sugar jelly on them and a cup of coffee Lunch – A ham and cheese sandwich, an apple and 12 ounces of 2% milk Dinner – Meatloaf, mashed potatoes, green beans and 12 ounces of 2% milk HS Snack – Graham crackers and 12 ounces of milk

Case Study #2 Recommendations for this patient:
Decrease milk intake to 4 ounces a day or substitute rice milk in place of 2% milk Drink a beverage other than milk with meals (diet ginger-ale, diet sprite, sugarfree lemonade) Mix Unifiber, Benefiber with hot cereal or juice

Case Study #3 71 year old male who receives dialysis on Tuesday, Thursday and Saturday Medical History: Type 2 DM He was admitted to an ECF following a hospital admission for CHF and began dialysis at that time Labs: Alb 3.2, PO4 3.9 EDW is 15 pounds less than his usual weight His appetite has improved since starting dialysis and he consumes % of meals and snacks

Case Study #3 Second set of labs: Alb 3.5, PO4 6.0
Diet: PO4 restriction of 1000mg/day Medications: Phoslo is ordered 2 with meals and 1 with HS snack Third set of labs: PO4 5.0, Ca 10.5 Medications: Phoslo is discontinued and Renvela 2 with meals and 1 with HS snack is ordered

Nursing Home Considerations
Check clinic policies regarding bag lunches or allowed food Send appropriate finger foods Send appropriate supplements if solid foods are not allowed by clinic or not desired by patient Have nursing send phosphate binders with bag lunch

For Diabetics: Send food to clinic to treat hypoglycemia Avoid use of orange juice

Monthly communication between dietary and nursing staff at the nursing home and the dialysis dietitian is essential Each renal patient is different and may have different dietary needs, a standard diet may not be appropriate Avoid high phosphorus and potassium snacks – save them for special occasions when the nursing home is a special event

In Conclusion Our goals for our patients both in the dialysis clinic and in the ECF is to: Ensure their best possible health Maintain blood chemistries WNL Decrease their risk of morbidity

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