Nutrition Therapy: Chronic Kidney Disease

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 lt
  60mL/min for lt 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

• Nausea
• Vomiting
• Metallic taste
• Itching
• Lack of energy

6
Protein-energy wasting syndrome
Kidney Int. 200873(4)391-398
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
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)
13
Optimal Nutritional Status

• Albumin gt 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
200581543-554
15
Assessing Anemia in CDK
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

18
protein
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 3
• 0.6 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
(No Transcript)
22
Food Portion Estimations
1 tsp
3 oz
1 cup ½ cup
¼ cup
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 FoodsAlso high in
phosphorus and potassium

• Milk
• Cheese
• Beans
• 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

28
Sodium
29
(No Transcript)
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 lt 20mL/min

31
(No Transcript)
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

35
Potassium
36
Potassium

• Potassium Restriction Indications
• Urine output lt 1 liter per day
• GFR lt 10 mL/min
• ACE inhibitors, beta blockers, lasix
• Hyperglycemia
• Serum potassium gt 5.0 mEq/L
• Dietary Potassium Restriction 2 grams/day
• Serum Potassium Goal 3.5- 5.0 mEq/L

37
Potassium in the Diet

• High (gt 400 mg/serving)
• Banana
• Potato
• Avocado
• Orange juice
• Moderate (gt200 mg/serving)
• Berries
• Broccoli
• Tomato

38
Low Potassium Fruit Vegetables

• gt100 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

40
Managing Bone Health
41
Altered Bone Turnover in CKD

• Kidney Failure leads to
• Decreased production of active Vit D
• Low serum calcium
• Phosphorus retention
• Elevated PTH
• Secondary Hyperparathyroidism
• Mineral and Bone Disorder

42
(No Transcript)
43
Phosphorus
44
(No Transcript)
45
Phosphorus

• High serum phosphorus
• Bone decalcification
• Soft tissue calcifications
• Hyperparathyroidism
• Phosphorus restriction for GFR lt 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
48
calcium
49
Calcium in CKD

• Maintain serum calcium 8.4 10.2 mg/dL
• Optimal lt 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

51
Fluid Restriction
52
Fluid Restriction CKD Stage 4 or 5

• Fluid any food that is liquid at room temp
• 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 SupplementsDietary
restrictions result in a diet deficient in
nutrients

• Vitamin C 90 mg/day
• Over 75 of kidney disease patients have
  increased homocysteine levels. 
• Folic acid 1 mg/day
• B6 5 mg/day
• No Vitamin A due to its accumulation in CKD
• Vitamin D in its active form
• 1,25 dihydroxycholecalciferol
• 1,25 (0H2)D3
• 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
• Lead
• mercury
• Herbs can interact with medications
• Renal patients take gt 10 meds/day
• Renal toxicity
• Wormwood
• Horse chestnut
• Sassafras

56
Herbs with diuretic properties that may cause
renal inflammation

• Bucha leaves
• Juniper berries
• Uva ursi
• Parsley capsules

57
Making Meals Appetizing
LunchTwo slices white breadTwo Tbsp mayonnaise
with lettuce and onion 1 ounce chicken or one
hard boiled eggTwo canned peach halves 7 Up or
Lemonade
58
CKD Nutrition Resources

• www.dietconsultpro.com
• Relevant and easy-to-understand nutrition
  education guides by Medi-Diets
• Renal Nutrition Principles (non-dialysis)
• You Potassium Intake
• Lowering Your Sodium Intake
• www.davita.org
• Complete CKD education site