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What is potassium (K+)? • A mineral found in most foods. • K+ is the principle ca6on of the intracellular fluid and func6ons as an electrolyte.
• Along with sodium, it regulates the fluid and electrolyte balance and the acid-‐base balance in the blood and 6ssues.
• K+ is crucial to heart func6on and plays a key role in skeletal and smooth muscle contrac6on.
• BP control
Serum Potassium and Renal Disease
• Normally: The kidneys are the chief regulators of our body K+, keeping the blood levels steady even with wide varia6on in intake.
• Most excess K+ is eliminated in the urine; some is eliminated in the sweat.
• With renal failure: kidneys are not able to remove excess K+ à hyperkalemia
Role of HD in improving K+ • Dialysis is very effec6ve at removing excess K+ from the blood.
• However, between HD sessions, serum K+ levels é.
• High dietary K+ +êkidney func6on èéserum K+
• Must limit high K+ foods so serum K+ does not become dangerously elevated between treatments.
Consider… • Our properly working kidneys func6on 168 hours/week to keep serum K+ WNL.
• HD pa6ents (3 sessions/week, 3-‐4 hours/session)-‐ only filtering K+ 9-‐12 hours/week.
• Leaving just 2 minutes early for each HD session adds up to >5 hours of missed Tx/year.
Healthy Kidneys, 93%
Hemodialysis, 7%
168 Hours Per Week
Further ConsideraQon
• Studies have shown é rate of sudden & cardiac death on Mondays in HD pa6ents.
• Why is this important? – Need to educate pa6ents on immediate effects of éfluid and éelectrolyte intake, especially over weekends.
– The short, intermittent nature of HD can have adverse effects.
Death in HD paQents by day of the week
From h`p://www.nature.com/ki/journal/v55/n4/fig_tab/4490725f3.html#figure-‐6tle
K+ Lab Values for HD
Low <3.5 mEq/L
*Goal 3.5-‐5.0 mEq/L
Unsafe 5.1-‐6.0 mEq/L
*Very dangerous >6.0 mEq/L
Causes of Hyperkalemia
• *Excessive intake of dietary K+ • Fever • Infec6on • Surgery • GI bleeding • Catabolism • Acidosis
Dangers of Hyperkalemia
• Symptoms: – Diarrhea – Nausea/vomi6ng – Weakness – Numbness/6ngling – Breathing difficulty – asymptoma6c
• *Cardiac arrythmia • *Sudden death
Management of Hyperkalemia
• Encourage pa6ents to: – Be consistent with a`ending HD sessions – Stay the recommended amount of 6me/session – Adhere to K+ dietary restric6on – *Take kayexalate, if prescribed
Dangers of Hypokalemia
• Muscle weakness • Cramping • Fa6gue • Confusion • Poor muscle coordina6on • Irregular heartbeat • Heart failure
Dietary ModificaQons
• Almost all foods contain some K+. • Typically, HD diet limits dietary K+ consumpQon to 2,000-‐3,000 mg/d.
• RD educates paQents on importance of dietary modificaQons and how to achieve them.
• Making and maintaining dietary changes is difficult for many paQents.
• PaQents need reinforcement/encouragement.
What does 2-‐3 g K+/d look like?
▪ 1 por6on of milk or milk products/day ▪ 1 por6on of milk subs6tutes/day ▪ 7 por6ons of meat or equivalent/day ▪ 3 por6ons of fruit or juices/day ▪ 7 por6ons of bread or starches/day ▪ 2 por6ons of vegetables/day
Low Dietary Sources (<150 mg)
Vegetables ü Green beans ü Corn ü Cucumber ü Le`uce ü Cauliflower ü Carrots ü Eggplant ü Cabbage (American)
Fruits ü Apple ü Berries ü Grapes ü Canned peaches ü Pineapple ü Cranberry juice ü Canned pears ü Plums
Moderate Dietary Sources (150-‐250 mg)
Fruits • Blackberries • Cherries • Grapefruit • Mandarin
oranges • Mango • Peaches, fresh • Pears, fresh
Vegetables • Asparagus • Broccoli • Eggplant • Kale • Radishes • Snow peas • Summer squash
High Dietary Sources (250-‐300 mg)
Fruits ý Banana ý Cantaloupe ý Honeydew ý Kiwi ý Orange/OJ ý Papaya ý Pomegranate ý Prunes/Prune Juice ý Avocado
Vegetables ý Persimmon ý Bok Choy ý Rhubarb ý Kiwi ý Beans ý Okra ý Potato/yams ý Tomato ý Spinach
Other foods high in K+ ▪ Bran ▪ Chocolate ▪Coconut milk/H20 ▪ Granola ▪Juice of High K+fruits ▪ Milk, all types ▪ Molasses
§ Nutri6onal supplements (those not intended for HD pa6ents) ▪ Nuts
▪ Peanut bu`er ▪ Salt subs6tutes ▪ Seeds ▪ Vegetable juices ▪ Yogurt
The Leaching Method • Can be used to leach K+ from: Potatoes, carrots, rutabagas, beets, frozen vegetables
• Peel and slice vegetables, and rinse in warm water. • Soak for at least 2 hours in warm water, using about 10x as much water as vegetables.
• If soaking for >2 hours, change the water q 4 hours. Rinse under warm water before cooking.
• Cook in a generous amount of water, about 5x the amount of water:vegetables.
Discussion: Why don’t paQents comply with diet restricQons?
References • h`p://www.dialysispa6ents.org/images/pdf/potassiumar6cle060717_000.pdf • h`p://www.aakp.org/aakp-‐library/Potassium-‐Safety-‐Zone/ • h`p://www.kidneydialysis.org.uk/potassium-‐and-‐dialysis.htm • h`p://www.kidney.ca/document.doc?id=945 • h`p://www.davita.com/kidney-‐disease/diet-‐and-‐nutri6on/diet-‐basics/potassium,-‐
phosphorus-‐and-‐the-‐dialysis-‐diet/e/5309 • h`p://www.ultracare-‐dialysis.com/HealthyLifestyles/EatHealthy/ManagingYourDiet.aspx • h`p://www.kidney.org.uk/Medical-‐Info/factsheets/potassium.html • h`p://www.nature.com/ki/journal/v55/n4/full/4490725a.html • h`p://www.nature.com/ki/journal/v55/n4/fig_tab/4490725f3.html#figure-‐6tle
