NUTRITION ACROSS THE CONTINUUM OF CARE IN KIDNEY DISEASE

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NUTRITION ACROSS THE CONTINUUM OF CARE IN KIDNEY
DISEASE

• Judith Beto PhD RD FADA
• Chicago IL USA

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Objectives

• To define the five stages of chronic kidney
  disease (CKD)
• To discuss nutritional interventions appropriate
  to each stage with emphasis on delay of
  progression to end-stage disease (stage 5)
• To provide practice education and dietary
  strategies by life stage pediatric, adult,
  geriatric, end-of-life

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Five CKD Stages

• Created and published as part of the 2002
  National Kidney Foundation Kidney Disease
  Outcomes Quality Initiative (KDOQI) Clinical
  Practice Guidelines for CKD
• www.kidney.org for guidelines
• www.nephron.com for glomerular filtration rate
  (GFR) calculator

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Other KDOQI Guidelines

• Bone Metabolism
• Clinical Nutrition
• Cardiovascular Risk
• Anemia
• Vascular Access
• Dialysis Adequacy

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KDOQI Process

• Diverse interdisciplinary workgroups
• Evidence-based, systemic review
• Goal to gather data upon which to base the best
  care process
• Expert consensus and peer review

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Nutritional Management

• variable in every facet of patient care
• requires interactive problem-solving skills
• changes with health care environment
• particularly expansive in CKD
• covers multiple age groups and treatment
  modalities

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In any one day, you may be

• A renal specialist dietitian
• A diabetes educator
• A cardiac/lipid expert
• An exercise physiologist
• A psychotherapist/motivational speaker
• A combination of pharmacist, nurse, social
  worker, nephrologist, patients best friend

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Betos PAGE System

• Pediatrics
• Adults
• Geriatric
• End of Life

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CKD Key Focus

• PGrowth/development
• APromote health (prevention)
• GMaintain health (holding pattern)
• EMinimize aging effects (slow speed)
• Quality of life

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CKD Long-Term Goal

• Prevent or retard progression
• Institute renal replacement therapy, when
  necessary
• Actively seek transplant as appropriate
• Support end-of-life initiatives

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Risk Factors for Progression of Renal Disease
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Primary Diagnoses for Patients Who Start Dialysis
Other 10
Diabetes 50
Glomerulonephritis 13
Hypertension 27
United States Renal Data System (USRDS) 2000
Annual Data Report WWW.USRDS.ORG
www.hypertensiononline.org
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Dietary Parameters

• Each nutrient component has a specific purpose
• All components function in an organized
  supportive manner
• Every diet needs to be individualized to the
  patient

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Protein

• Ad lib intake in pediatrics to encourage growth
  matched to necessary treatment
• 0.6-0.8 gm/kg/day to retard or delay in adults
  (non-growth)
• 1.0-1.2 gm/kg/day to support therapy (dialysis)

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Protein Challenges

• High biological value (50-70) maximizes use
  egg, animal protein
• Keep serum albumin in normal ranges
• Dont overload kidney by replacing urinary
  protein losses
• Match diet to kidney

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Calories

• Minimum 25 kcal/kg/d and titrate upward to
  achieve body weight goal
• Adequate calories needed to spare protein
• Body weight can mask protein malnutrition

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Calorie Challenges

• Diabetics present special challenge
• Calculate peritoneal dialysis solution calories
  into daily intake
• Controversy what weight to use?

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Sodium

• Sodium
• 2-4 g/d (43 mEq 1 g)
• Variable with urine output and disease etiology
• Evaluate effect on hypertension control
• and cardiac function

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Sodium Challenges

• Tight blood pressure control helps retard or slow
  down progression of CKD
• Sodium found widely in processed food supply

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Fluid

• Unrestricted until urine output declines
• Urine output plus 1000 cc/d
• Evaluate effect on blood pressure and
• cardiac function

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Calcium/Phosphorus

• Preserve bone metabolism
• Control dietary calcium (1.0-1.5 g/d from diet
  and meds
• Role of calcification still under study
• Growth in children is challenge

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Calcium/Phosphorus

• Phosphorus dietary control 10-15 mg/g dietary
  protein
• Phosphate binders by mouth bind dietary
  phosphorus in the gut
• Restricts most dairy products

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Bone protection

• Vitamin D oral or IV
• Calcium x phosphorus product
• Parathyroid hormone (PTH)
• Calcium-sensing receptors
• Role of weight-bearing
• exercise??

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Potassium

• Accumulates in CKD stage 5
• Hyperkalemia ?cardiac danger
• Restrict to 2-4g/d (26 mEq1g)

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Relation of Fractional Excretion of Potassium
(FEK) to GFR Under Baseline Conditions
150
120
105
90
75
FEK ()
GFR (ml/min)
60
45
30
15
0
30
60
90
120
150
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GI tract compensation in chronic kidney failure

• May increase 30
• Usual load handled 2 g oral/d of K
• Constipation issues
• Pica/clay consumption decrease absorption

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Which food serving contains the highest amount of
potassium?

• 1 medium avocado
• 1 large banana
• 10 dried prunes
• 1 medium tomato

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Amount of potassium per serving

• 1 medium avocado (1096-1483 mg)
• 1 large banana (467 mg)
• 10 dried prunes (626 mg)
• 1 medium tomato (250 mg or 60 mg/oz)

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Licorice as the culprit(glycyrrhenitic acid)

• 100 mg potassium in 4 twists of real licorice
• May also increase blood pressure
• Licorice-like compounds (carbonoxolone)
• Mimics syndrome similar to primary aldosterone
  secretion

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Potassium Challenges

• No taste
• Found widely in fruits and vegetables
• Not found on food labels
• Confusion with prior diuretic supplementation

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Vitamin/Minerals

• Water soluble vitamins (folic acid)
• Standard vitamin C (60-100 mg/d)
• No additional A, E, K
• Minerals zinc for taste acuity
• No magnesium

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Anemia

• Pediatric challenges with growth
• CKD adults due to low hormone
• Iron supplementation oral, IV
• Need adequate iron stores
• Epotein
• Correlated with higher energy

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Nutrition Extras

• Vitamin E/omega fatty acids/grafts
• Prognostic nutrition index
• Growth hormone in children
• Daily dialysis modality
• Cyclic/nocturnal treatments

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GI Health is Key!

• Binding of phosphorus
• Excretion of potassium
• Re-absorption of fluid
• Fiber and lipid lowering relationship
• Better patient conversation

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Nutrition Extras

• Focus on cardiovascular
• Plant sterols/stanol esters
• Saturated fat awareness with adequate calories
• Fiber and fluid restriction
• Physical activity

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Target Lipid Levels

• Best Borderline
• Chol
• LDL
• HDL 40
• TG

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Modality changes lipid pattern

• CKD-Proteinuria/nephrotic syndrome
• Hemodialysis LDL/HDL vs total cholesterol
• Peritoneal triglyceride challenge
• Transplant obesity, drug-lipid interactions

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Soluble Fiber

• Eggplant (123 mg K/0.5 cup)
• Okra (365 mg K/4 ounces)
• Over the counter psyillum capsules or other soft
  fiber equivalents
• Oatmeal (1.5 cups 267 mg P, 196 mg K)

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Nuts/Omega Fatty Acids

• 4 Tbsp (1/4 cup) almonds
• 280 Kcal 348 mg K
• 9.5 gm protein 5 gm fiber
• 247 mg P 24 gm fat (good)

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Autonomy

• Expand scope of practice with written standing
  orders and protocols
• Utilize mathematical equations to identify risk
  (HD-PNI, Kt/V, and more)
• Provide decision making opportunities for direct
  patient care benefits

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Creativity

• Develop non-traditional approaches to perceived
  obstacles
• Overcome barriers to intended practice
• Think outside the box

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Overview by CKD Stage
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Overview by Group
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Future Pathways

• Nutrigenomics study of genes
• Metabolomics study of metabolites
• Proteomics study of proteins
• .and bioactive food components
• JADA 106403, 2006

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CKD Prevention

• www.kidneyfund.org
• Wallet card Take Charge Protect Your Kidneys
• The earlier you identify, the greater the ability
  to protect or retard progression

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Conclusion

• Better health is a family affair
• Focus on healthy eating habits earlier in life to
  reap the benefits later in life
• Everyone eats so we can influence diets that
  protect kidney function