Nutrition in renal patient
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Transcript of Nutrition in renal patient
Dr. Doaa Hamed
Lecturer of Clinical Nutrition
National Nutrition Institute –Cairo (Egypt)
Diet Planning
In
CKD & HD
Nutrition Care Process
in renal diseases
Nutrition Care Process
in renal diseases
Objective
1.Integrated renal care .
2.Importance of renal diet .
3.Nutritional counseling
4.Nutrition Care Process
Steps:-Assessment
Diagnosis
Intervention
Monitoring and Evaluation
Stages of Chronic Kidney Disease
Stage CKD I CKD II CKD III CKD IV CKD V
Description Kidney Damage
with Normal or
↑GFR
Mild ↓GFR Moderate ↓ GFR Severe ↓ GFR Kidney Failure
GFR(ml/min/1.73 m2 )
> 90 60 -89 30 -59 15 -29 < 15 or Dialysis
Stage
dependent
Actions
Prevent complications
Mineral metabolism
Nutritional monitoring
Anemia prevention
Care process Requires
A psychotherapist / motivation speaker
A diabetes educator
A renal specialist dietitian
A combination of:- Nephrologist
Nurse
pharmacist
Social Worker
patient's best friend
أكــــل أيـــه؟
What is the role of ?
Trained & experienced in Renal nutrition
Implementation of many guidelines concerning
nutritional assessment
Anthropometry, SGA, dietary interviews
Plan for nutritional management & therapy
Counseling the patient & the family
Educational activities
Why there are for ?
All patients should receive nutritional counselling based
on an individualized plane of care.(Evidence Level C) Nutrition in peritoneal dialysis Guidelines 2005
Nephrol Dial Transplant (2005) 20 ( Suppl 9) : ix28-ix33
Clinicians use several strategies, but there are barriers to
nutritional counseling which include:-
skepticism about the effectiveness of nutritional interventions
lack of specific knowledge and training about therapeutic nutrition
lack of specialty clinics, absence of guidelines, and an inadequate number of dietitians
screening
CKD
We recommend that screening should be performed (1D)
o for inpatients
o for outpatients with eGFR <20 but not on dialysis
o of commencement of dialysis then 6-8 weeks
later
Screening may need to occur more frequently if risk of
undernutrition is increased (for example by intercurrent illness)
screening
HD
Stable and well-nourished haemodialysis patients should be
interviewed by a qualified dietitian every 6–12 months or
every 3 months if they are over 50 years of age or on
haemodialysis for more than 5 years (Evidence level III).
Malnourished haemodialysis patients should undergo at
least a 24-h dietary recall more frequently until improved
(Opinion).UK Renal Association, March 2010
CKD HD
Clinical studies have shown that renal patients may
have inadequate dietary intakes during early stages
40 - 70 % of patients with end-stage renal disease are
malnourished
Protein–energy malnutrition should be avoided in
maintenance hemodialysis because of poor patient
outcome (Evidence III).
Tow types of malnutrition I & II has been described
in CKD patients
(ESPEN 2008)
PEW
Kidney International (2013) 84, 1096–1107
Beto’s PAGE System
Pediatrics • Growth / development
Adults • Promote health ( Prevention)
Geriatric • Maintain health ( Holding pattern)
End of Life • Minimaze aging effects
CKD Key Focus on…
Quality of life
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
Renal diet minimizes the amount of wastes
A good meal plan choices can:
Minimize build-up of waste products &
fluid between treatments
Improve nutritional and functional status
Conserve muscle mass
Nutrition Care Process Steps
ADIME
Nutrition
Care
Process
assessment
History and physical examination looking for loss
of weight and muscle wasting
Dietary history
SGA (Subjective Global Assessment)
Anthropometry
Biochemical / laboratory tests
Is albumin can predicts mortality at
onset of dialysis?
Strong predictor of morbidity and mortality
(CANUSA study)
However,
Albumin is affected by non-nutritional factors Infection
Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Blood loss
Metabolic acidosis
Albumin may not increase in response to nutritional intervention
There is No Single Magic Nutritional Index
How can we monitor and Follow-up
nutritional status?
Severely underweight Less than 16.0
Underweight From 16.0 to 18.5
Normal From 18.5 to 24.9
Overweight From 25 to 29.9
Obese Class I From 30 to 34.9
Obese Class II From 35 to 39.9
Obese Class III Over 40
Haemodialysis patients should maintain a BMI >23.0
BMI = Weight (kg) / (height [m]2)
Ideal Body Weight (IBW)
For men = [ (height(cm) – 152.4) x 0.91) ] + 50
For women= [ (height(cm) – 152.4) x 0.91) ] + 45.5
Adjusted Body Weight (ABW)
For men: Adjusted weight = [( actual weight- IB weight) x 0.38] + IB weight
For women: Adjusted wt = [(actual weight- IB weight) x 0.32 ] + IB weight
If Actual BW > 30% IBW
use
Interdialytic Weight Gain (IDWG)
General recommendation +2 kg
>5% fluid gains
Excessive fluid intake
Weight gain
<2% fluid gain
Inadequate fluid and/or food intake
Weight Loss/Decreased body mass
Subjective Global Assessment Rating Form
Dr. Doaa Hamed
Lecture of Clinical Nutrition
National Nutrition Institute –Cairo (Egypt)
HD CAPD
Loss of amino acids
6-10 g/dialysis 2-4 g/bag
Loss of glucose~25 g/dialysis
(glucose free dialysate)
uptake
Loss of protein0 5-15 g/day
(higher with peritonitis)
Inflammatory stimuli
Blood membrane contact
Cytokine release
Low grade inflammation
(particles chemicals)
Cytokine release
Is Dialysis has effect on Nutrition?
Is Dialysis has effect on Nutrition?
Daily HD or 6 HD sessions/ week
(Schulman G. Am J Kidney Dis 41:S112-S115,2003)
Improve appetite & food intake
General feeling of well being,↑ed physical activity
Fewer dietetic restrictions
↓ ed dose of medications → Phosphate & K binders,
antihypertensive drugs
↑es clearance of potential anorexic factors
Improves serum albumin levels
Dietary Recommendations
Diet Focus on…
Important Nutrients
Individual Differences
CKD
Diet Goals
HD
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Phosphorus (stage 3)
• Size
• Stage of CKD
• Nutrition
• Lab results
• Size
• Nutrition
• Lab results
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Na & Fluids
• Potassium
• Phosphorus
• Calcium
• Management of
• Blood pressure
• Glucose
• Minerals
• Fluid
• Weight
• Good nutrition
• Management of
• Blood pressure
• Glucose
Adequate energy intake essential to optimize nutritional
status
Present in (Carbohydrates – Fats - Protein)
Calculated based on your
current weight,
weight loss goals
age and gender
physical activity and metabolic stress
35 kcal/kg/d < 60 yrs
30–35 kcal/kg/d ≥ 60 yrs
Regular physical activity should be encouraged, and energy intake should be
increased according to the level of physical activity (Opinion).
Calories
To increase the energy content of meals:
Add extra oil to rice, noodles, breads, crackers, and
cooked vegetables.
Add extra salad dressing.
Non-protein calorie (NPC) supplement can be added
(J Ren Nutr. Nov. 2012 )
Protein
Essential for ❖ building muscles ❖ repairing tissue
❖ fighting infection ❖Keeping fluid balance in the blood
There are two kinds of proteins
◦ (HBV) or animal protein-meat, fish, poultry, eggs and dairy
◦ (LBV) or plant protein – breads, grains, vegetables, dried beans and peas
and fruits
50 -70% should be of HBV.
A well balanced diet for kidney patients should include
both kinds of proteins every day.
Protein Alternativesprotein bars, protein powders, supplement drinks
Stage 5 -
On dialysis
All stages – if
malnourished
Protein Intake
Example:
A 150 lb
(68kg)
• 82 grams• ½ cup milk
• 2 eggs or 4
egg whites
• 6 oz meat
• 3 veg.& 3 fruits
• 11 servings of
grains
• 41 – 48 grams• ½ cup milk
• 1 egg or 2 egg
whites
• 2 oz meat
• 5 – 6 veg.&
fruits
• 5 – 6 servings
of grains
Stage 4 or 5 -
Not on dialysisStages 1 - 3
• 55 grams• ½ cup milk
• 1 egg or 2 egg
whites
• 3 oz meat
• 3 veg. & 3 fruits
• 8 servings of
grains
0.75 gm/kg/d 1.2-1.3 gm/kg/d0.6 gm/kg/d
• Eat additional protein
Potential beneficial effect of
low-protein diet in CKD
Uremic symptoms diminish or disappear
(especially nausea, vomiting)
Reduce the burden of uremic toxins
(urea, H+, K+, phosphate, other)
Slow progression of renal failure ?
Reduce proteinuria
Improve nutritional status
Increases insulin sensitivity and glucose tolerance
Antioxidant effect
No Protein Restriction for Dialysis Patients10-12 grams lost per HD treatment
Aparicio M et al J Renal Nutr, 19, No 5S (September), 2009: pp S33–S35
Lipids
Patients considered at highest risk for cardiovascular disease
Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and
individualized treatment goals
requirement of fat
( 30 % total cal ) Minimize the ↑ in TG & Cholesterol
< 10% of calories → SFAc Ratio of USFAc to SFAc l fats = 2 : 1
8% SFAc l :10 % PUSFAc : 12% , MUFAc
250–300 mg cholesterol/day
Omega 3 fatty acid↓ TG & Chol. as well as phospholipids may be tried
Lipid disorders
Hypertriglyceridemia,
often normal cholesterol
but low HDL cholesterol
Chmielewski M et al. J Nephrol 21: 635-44, 2008
Carbohydrates
65-70% total kcal
70% complex sugar
(reduceTG synthesis and improve glucose tolerance)
30% simple sugar
Carbohydrate intake may need to be modified for Patients
with Diabetes to achieve the goal of HgAIC < 7 %
Carbohydrate Counting
Fiber Intake
Optimum fiber intake 20-25 g/day
Fiber Intake
Sodium
Plays vital role in regulation of fluid balance and blood
pressure
In CKD& HD:-
May result in :-high blood pressure,
fluid retention/swelling (edema)
lead to shortness of breath
Excessive thirst
CHF
Serum Sodium (nl 133-145 mEq/L)
Sources of Dietary Sodium
Eat out less (especially Fast Food)
Cook at home with low-sodium ingredients
Read labels
1,000- 4,000mg/d
for
CKD&HD
patient
diets
Cut out: • Salt
• High-sodium condiments
• Processed, cured foods
Add: • Herbs
• Spices
• Lemon
• Vinegar
No Added Salt (NAS)
Fluids
“any food that is liquid at room temp”
Soup, gelatin, ice cream, ect.
HDUrine Output + 1000 ml
Limit IDWG (2-5% Estimated Dry weight )
Excess fluid buildup
Edema, HTN, CHF and
Breathlessness
Delays wound healing
Fluid restriction estimations
are based upon:-
Urinary output
Disease state
Treatment modality (dialysis, etc.)
Tips for thirst and fluid control!
Track your fluids
Avoid chewing lots of ice
Avoid refills at restaurant
Avoid super-sized beverages
Limit salty foods
Small glasses at meals & meds
Add lemon or Lime juice to water
Hot weather, temperature
Keep your skin cool: cold wash cloth, mist-bottle
Keep your lips moist with a chap stick
Keep your mouth wet
◦ Keep your mouth clean
toothpaste for dry mouth (biotene)
◦ Rinse your mouth with cold water, but don’t swallow it
◦ Rinse your mouth with chilled mouthwash
◦ Chew on gum: Quench gum
◦ Try lemon wedges or freeze grapes & strawberries
If diabetic, control blood sugars
Sodium & Fluids
The requirement for sodium and water varies markedly, and each patient must be managed individually.
Individualize
◦ IDWG, blood pressure, residual renal functions
Increased Restrictions if
↑ IDWG, CHF, edema, HTN
fluid output Na fluid
≥ 1 L 2-3 g 2 L
≤ 1 L 2 g 1-1.5 L
Anuria 2 g 1 L
Phosphorus
High serum phosphorus Bone decalcification
Soft tissue calcifications
Hyperparathyroidism
Dietary intake ~800 to 1000 mg/day OR <17 mg/kg SBW
HD removes ~500-1000 mg/treatment
Binders removes 50% of dietary phosphorus
Control = Binders + Diet + Adequate dialysis
Organic phosphorus
40 – 60% absorbed Phytates ↓ absorption
Dairy products Meat, poultry, fishSoy (soy milk, tofu)Nuts and seedsDried beans and peas Whole grains
Inorganic phosphorus
> 90% absorbed
Food additivesDietary supplementsCalcium fortification
Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519-530
Phosphorus Types
Control Phosphorus
Diet
READ THE INGREDENTS LABEL!!
Phosphorus binders ineffective
What are high and low phosphorus foods?
Control Phosphorus
Binders
Generic Name Brand Name Estimated Binding Capacity
Calcium acetate
667 mgPhosLo 30 mg
Sevelamer HCL
800 mgRenagel, Renvela 64 mg
Calcium carbonate
500-600 mg
TUMS, Os-Cal,
Calci-Chew, Caltrate20-24 mg
Lanthanum carbonate
1000 mgFosrenol 320 mg
Binders are like a sponge. They “soak up” phosphorus from food! in the GI tract
Must take with meals
Control Phosphorus
Dialysis
Among dialysis patients with persistent Hyperphosphatemia, we
suggest increasing phosphate removal via hemodialysis (Grade 2C)
Phosphate clearance is effective only during the first 2 hours of
dialysis. Serum phosphorus levels do not change during the second
half of dialysis. Haemodialysis removes approximately 900 mg of
phosphate three times weekly. (Mucsi et al., 1998; Block & Port,
2000)
Among patient with refractory Hyperphosphatemia, nocturnal HD is
an option among those who are welling to accept this form of
dialysis.
Ph IntakeAbsorption
~60%
Binding
~50%
Dialysis
Removal HD
+1000 mg/day
+7000 mg/wk
+600 mg/day
+4200 mg/wk
-300 mg/day
(10 Phoslo)
-2100 mg/wk
-700 x 3 =
-2100 mg/wk
Weekly Phosphorus Balance
+ 4200 (diet) – 2100 (Binders) – 2100 (HD) = Balance
Diet + Binders + Adequate dialysis
Calcium
Renal diet is approximately 500-800 mg / day
Diet (low ----- many foods high in ca high in ph )
1200 – 1500 mg/day based on DRI*
May need vitamin D3
Not to exceed 2g/day, including calcium-
based binders
Activated vitamin D
PTH control important
CKD Stages 1 – 4
CKD Stage 5 & HD
CKD Stages 1 – 3 Usually not restricted
CKD Stages 4 and 5 and HD Correct labs
Dietary Goal is usually 2 - 3 gms/day
adjust per serum levels
Dialysis bath concentrations
Low Potassium foods Avoid Highest Foods
Apples
Grapes
Berries
Pineapple
Tangerine
Cabbage
Green Beans
Cauliflower
Eggplant
◦ Oranges/Juice
◦ Banana
◦ Potato
◦ Mango
◦ Melon
◦ Avocado
◦ Tomato
◦ Nuts
Fruits & Vegetables
Low: 20-150 mg
Medium: 150-250 mg
High: 250-550 mg
Portion size is essential
Avoid Salt Substitutes
Dairy
1 cup 380-400 mg
High phosphorus foods
Potassium
Renal Multivitamin containing water soluble
vitamins
◦ Dialyzable – take after dialysis
◦ Supplementation may improve Iron availability from
stores
Vitamin C in renal vitamin
◦ Limit total vitamin C 60-100 mg
↑ Vitamin C → ↑ oxalate → calcification of soft tissues
and kidney stones
Individualize: Fe++, Vitamin D, Ca++, Zinc
Micronutrients
Assessment:
Diet history & any changes in dietary
intake
Weight history
SGA
Underlying medical condition
Biochemistry
GI symptoms
Social and psychological
factors
Nutrition in CKD& HD
ManagementOral Diet
Oral diet + extra snacks
Oral diet, extra snacks + supplements
Oral diet + supplementary NG/ PEG feeding
Exclusive NG/ PEG feeding
TPN
Must also optimize medical management (dialysis adequacy, acidosis, infection)
Conclusion
Poor nutrition is common in CKD & DH patients and has
adverse risk factor
Nutritional counseling –part of approach to CKD and
dialysis patients.
Routine nutritional screening & assessment should be done
for CKD and dialysis patients.
Qualified renal dietitian must be included in the staff of
every dialysis unit.
Personalized nutritional plan – worked out for every
patient.
Individualization