Mary Ann Vespignani RD LDN

WHAT DOES THE KIDNEY DO?Remove Waste Products from the bodyRemove Drugs from bodyBalance the body’s fluidsRelease hormones that regulate blood

pressureProduce an active form Vit D that promotes

strong healthy bonesControl production of red blood cells

What is the Dietitian’s/CDM role?To educate and advise people on dietTo provide support through treatmentTo work with Renal RD to review monthly

labs and adjust diet as neededTo provide support for non-renal staff

National Kidney Foundation Outcomes Quality Initiative

KDOQI’s evidence-based clinical practice guidelines are updated on an ongoing basis, as new evidence becomes available. KDOQI also provides timely commentary on the applicability of the global KDOQI guidelines in the US clinical and regulatory environment.

KDOQI Goals

Albumin 4.0 or greaterPotassium 3.5-5.5Phosphorus 3.5-5.5Calcium 8.5-9.5

OVERVIEWWhat the tests measure

URRAlbuminCalcium, Phosphorus, Potassium

Why they are importantWhat to do when the results are outside the

acceptable rangeSummary

Why do you need to understand the Patient Report Card?

Urea Reduction RatioTells us if the treatments are

are doing a good enough job of cleaning the blood.

Formula Pre dialysis BUN – Post dialysis BUN x 100

Pre dialysis BUNGoal:Greater than or equal to 65 (> 65)

Urea Reduction Ratio

URR < 65 means that the person’s blood is not being cleansed well enough.

The person may have:Poor appetiteNausea / vomitingBad taste in mouthWeight loss

ALBUMIN

An important protein in the bloodIndicator of person’s nutritional statusInfection/Inflammatory response affects

AlbuminThe single most important indicator of a

person’s mortalityGoal: 4.0 – 5.4 g/Dl

Albumin Albumin may mean

MalnutritionIncreased risk for illness and death

(long term)Over hydration/fluid overload

Albumin makes it difficult for dialysis to remove fluid

What factors affect AlbuminPoor appetiteNot eating enough protein-rich foods

Meat, fish, poultry or eggs

Fluid overloadIllness / infectionLiver problemsOther health problems

CALCIUM

Needed for healthy bonesmuscle contraction & relaxationproper nerve functioning

Normal range on “Report Card” is 8.5 – 9.5

CALCIUMHypercalcemia (Ca > 10.2):

nausea confusioncoma risk for heart disease

Hypocalcemia:numbnessseizuresconfusionpainful muscle spasmsosteoporosis

What to do if calcium levels are too high or too low?Hypercalcemia ( calcium)Patient should decrease calcium intake STOPSTOP PhosLo, Tums, etc

Doctor will D/C active form of Vit D3 (Calcijex or Zemplar

What to do if calcium levels are too high or too low?Hypocalcemia ( calcium)

Patient may need Calcijex, or Zemplaradditional dietary/supplemental calcium

May be due to low albumin levels

Phosphorus (“P”) or Phosphate (PO4) Needed for

healthy bones & teethenergy metabolism (ATP)

When the kidneys fail, phosphorus levels usually

Hemodialysis does not remove phosphorus from the blood very well Protein-rich foods are high in P

Very challenging for patients to maintain optimal P levels

PhosphorusNormal ranges currently on “report card” are 2.5 –

5.5Hyperphosphatemia ( phosphorus)

itchingbone damage

risk for soft tissue calcification (including heart and blood vessels)

Hypophosphatemia ( phosphorus)raremuscle weaknesscomapatient needs to stop PO4 binders (PhosLo, Renagel

Phosphorus to HIGHPatient needs to decrease intake of P-rich food and/or

take PO4 binders as prescribed(Binders must be taken with meals)

Phosphorus rich foodsBeans, peas, lentils (“legumes”)Nuts (peanut butter), seedsChocolate, cocoaCheese (pizza), milk, yogurtWhole grains (whole wheat bread)Bran cerealsCoke, Pepsi & other sodas with “phosphoric acid”

Guidelines for Phosphorus Most patients need to limit their

phosphorus intake to 800 – 1000 mg per day

½ cup milk = ~100 mg What about skim milk? 124 mg What about heavy cream? 74 mg

Potassium-Function Allows nerves and muscles

(including the heart) to work properly

Too much or too little can cause sudden death

Normal range on “report card” is 3.5 to 6.0 some doctors prefer 3.5 to 5.5

Elevated Potassium

Hyperkalemia (high potassium level) can cause muscle weakness the heart to stop

Hyperkalemia

What to do? Alert doctor immediately if > 7.0 Review symptoms with patient Kayexalate may be needed Review diet with patient

High Potassium Foods Orange / juice Tomato / sauce / juice Bananas/apricots Potato / chips / french fried / sweet Prune juice Large quantities of “low potassium”

foods Fresh Fruit

Summary We reviewed the following lab values:

URR Albumin Calcium Phosphorus Potassium

What they mean Why they are important What to do when they are above or below

the acceptable range

Dietary advice EnergyProteinSaltPotassiumPhosphateFluid

Goals of Diet TherapyMaintain normal biochemistry levelsMinimise symptomsPrevent malnutrition and unintentional

weight lossImprove quality of Life

Factors that influence dietary advice

Stage of CKDBiochemistry levels (trends)MedicationsTreatments e.g. Conservative, DialysisOther medical conditions e.g. DiabetesLifestyle (social, psychological aspects)

Dietary advice 1. Weight Management - activity/lifestyle,

current intake, food preferences, cooking methods, food labelling, alcohol.

2. DM Control - meds, regular meals & starchy CHOs, low sugar, fruit & veg.

3. Lipid Control – ↓saturated fats, ↑mono fats, oily fish, fruit & veg.

4. Salt Intake - at table, in cooking, convenience foods.

Dietary advice:1. Low Appetite, Depressed & Symptomatic – small &

frequent meals, energy dense and high protein foods.2. High Potassium Level – cooking methods, food

choices & frequencies of high K foods.3. Hypertension – salt intake4. Phosphate Level –Need to evaluate binders and when

they are taken. Binders need to be taken with meals

Factors Considered by Dietitian:Family situation / recent loss of love one/other medical conditionsCulture – Asian diet & cooking methodsFuture ‘life changing’ treatments – Hemodialysis

Dietary Guidelines

Protein Intakes of 1.2 gm/kg body weight30-35 Kcals/kg body weightFluid weight gains between treatments of 2-3

kgSodium intakes = 2.5 grams/dayPhosphorus =800 -1200mg/dayCalcium intakes <1200 mg/dayPotassium intakes <3200 mg/day

MedicationsPhosphate Binders PhosLo,Renzela and Fosrenol-these must be taken with meals

and snacks to be effective!!!!!

Iron- Epogen/Procrit often provided at Dialysis center.

Calcium-

Renal Vitamins- Common names Nephrovite, Nephrocaps, Renaltab, Diatex

Medication Alerts!!

Dialysis patients are not to be given

1. Milk of Mag,Citracal or calcium citrate, PeptoBismol; KCL supplements or PRN calcium or aluminum based antacids

1. Renal patients are normally taken off Lasix, Bumex or other diuretics when starting HD

Interactions: HERBAL SUPPLEMENTS

NEED CAREFUL CHECK AS THEY MAY INTERACT WITH OTHER MEDICATIONS

1. Can affect K levels-alfalfa, Dandelion, Licorice root, Noni fruit/juice and St John’s wort

2. Has diuretic properties/electrolyte imbalance –Goldenrod,Juniper berries and parsley

3. Can effect blood thinning agents: garlic and Ginger4. Do not use in CKD-Ginseng

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