Nutrition Therapy and Dialysis

1
Nutrition Therapy and Dialysis

• Melinda S. Leone, MS, RD
• St. Joseph's Regional Medical Center
• Division of Nephrology
• Paterson, NJ 07503
• leonem_at_sjhmc.org

2
Objectives

• Participant will be able to describe the
  importance of nutrition intervention in patients
  with ESRD
• Participant will be able to identify the
  components of a nutritional assessment
• Participant will be able to identify the
  components of the renal diet and the role of the
  dietitian

3
Does Nutrition Status Matter?YES!

• Nutritional indicators can be directly linked to
  patient status and outcome
• Protein-Energy Malnutrition (PEM)1
• BMI2
• Albumin3, 4
• Potassium
• Phosphorus5
• Calcium

4
Renal Osteodystrophy

• Hyperphosphatemia
• Vascular and non-vascular calcification5
• Hypocalcemia
• Secondary Hyperparathyroidism
• Bone Disease
• Low bone mass and density
• Osteitis fibrosa cystica

5
Protein Energy Malnutrition6
PEM

• Malnutrition
• PEM marasmus-kwashiorkor
• muscle/fat wasting
• weight loss
• Marasmus Inadequate nutrient intake
• Kwashiorkor Inadequate protein intake
• Cachexia

6
Causes of Malnutrition

• Uremic Syndrome
• Malaise
• Weakness
• Nausea and vomiting
• Muscle cramps
• Itching
• Metallic taste
• Neurologic impairment

• Hospitalizations
• Co-morbidities
• Diabetes
• Infections
• Amputations
• Cancer
• Inflammation

7
Proteinenergy wasting syndrome in kidney
disease7
8
Nutrition Assessment Anthropometric
Data

• Height
• Weight status
• Frame size
• Arm anthropometrics
• Appearance
• Amputations

9
Nutrition Assessment Weight Status
Evaluation

• Standard Body Weight (SBW)
• Body Mass Index (BMI)
• Ideal Body Weight (IBW)
• Adjusted Body Weight
• Usual Body Weight (UBW)

10
Nutrition Assessment
Weight Status Evaluation

• Weight changes
• Intentional vs. unintentional weight loss
• Dry weight changes vs. fluid shifts
• Clinically significant weight loss
• 5 or gt within 1 month
• 7.5 or gt within 3 months
• 10 or gt within 6 months
• Attitude toward changes
• Goals for weight changes

11
Nutrition Assessment6Interdialytic Weight Gain
(IDWG)

• General recommendation 2 kg
• gt5 fluid gains
• Excessive fluid intake
• Weight gain
• lt2 fluid gain
• Inadequate fluid and/or food intake
• Weight Loss/Decreased body mass

12
Nutrition Assessment
Diet History

• Appetite/Intake
• Food preferences
• Allergies/Intolerance
• Taste changes
• Acute or chronic GI concerns
• Swallowing/Chewing concerns

• Urine output
• Pica
• Religious/Cultural Restriction
• Supplement intake
• Homeopathic Treatments
• Nutrition Knowledge

13
Nutrition Assessment
Diet History

• Shopping and Cooking
• Abilities
• Facilities
• Medication
• Side Effects
• Compliance
• Physical limitations

• Psychosocial problems
• Emotional support
• Economic limitations
• Depression
• Adjustment to disease Treatment Compliance

14
Nutrition Assessment
Diet History

• Food Records
• 24 Hour Recall
• 3 Day Food Record
• 3 Day Calorie Count
• Food Frequency Questionnaire

• Diet Assessment
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Sodium
• Potassium
• Phosphorus
• Fluid
• Vitamins
• Minerals

15
Nutrition Assessment
Laboratory Analysis6

• Monthly
• Albumin 4.0g /dL or gt
• Potassium 3.5-5.3 mEq/L
• Phosphorus 3.5-5.5 mg/dL
• Calcium 8.4-10.2 mg/dl
• Glucose lt200 mg/dL
• Non-fasting
• Product lt 55
• URR gt65
• Hgb 10-12 g/dL

• Quarterly
• Hemoglobin A1C lt 7
• PTH 150-600 pg/mL
• Lipid Panel
• Chol lt 200 mg/dL
• HDL gt 40mg/dL
• LDL lt100mg/dL
• Triglycerides lt200 mg/dL

16
Nutrition Assessment Subjective Global
Assessment6

• Protein-energy nutritional status measurement
• Valid and reliable8
• KDOQI recommended9
• Medical history and physical exam
• Body composition focus on nutrient intake
• Subjective rating 7 point scale6
• Well-nourished
• Mild to moderately malnourished
• Severely malnourished

17
Nutrient Needs KDOQI
Guidelines9
18
Nutrient Needs KDOQI
Guidelines9
Vitamins and Minerals
19
Nutrition Therapy Goals

• Provide an attractive and palatable diet
• Control edema and serum electrolytes
• Prevent nutritional deficiencies
• Prevent renal osteodystrophy
• Prevent cardiovascular complications

20
Dialysis Diet

• Diet Order
• 2000 calorie, 80 g protein, 2 g Na, 2 g K, 1 g
  PO4,
• 1500 ml fluid restriction
• Meal Planning
• Individualize diet for patients lifestyle
• Assistance programs
• Nursing Homes
• National Renal Diet American Dietetic
  Association10

21
Dialysis Diet

• Adequacy and Balance
• Calories
• Protein
• Variety
• Actual intakes of HD patients11
• 23 kcals/kg/day
• Less than 1 g/kg/day

22
Albumin

• Controversial key nutrition status measure12
• Depressed values
• PEM, fluid overload, chronic liver/pancreatic
  disease, steatorrhea, inflammatory GI disease,
  infection, catabolism r/t surgery, abnormalities
  in protein metabolism, acidosis6
• Elevated Values
• Dehydration, high dietary protein intake6

23
Albumin

• Dialysis Treatment
• HD 10-12 g free amino acids lost13
• Losses increase with glucose free dialysate
• PD 5 to 15 g protein lost 9, 14
• Lost as albumin

24
Protein

• 1.2-1.3 g protein/kg SBW9
• Average patient 80 g Protein
• 50 HBV protein foods
• HBV Proteins
• Beef, poultry, fish, shell fish, fresh pork,
  turkey, eggs, cottage cheese, soy
• 6 to 10 ounces daily
• Protein Alternatives
• protein bars, protein powders, supplement drinks

25
Potassium

• 2-3 g daily9 - adjust per serum levels
• Dialysis bath concentrations
• Stricter diet restrictions
• Insulin deficiency, metabolic acidosis, beta
  blocker or aldosterone antagonists treatments,
  hypercatabolic state
• Non-diet causes Hyperkalemia
• Hemolysis, high glucose, insulin deficiency,
  inadequate dialysis, incorrect dialysate
  potassium concentration, starvation, catabolism,
  sickle cell anemia, Addison's disease, long-term
  constipation15

26
Potassium10

• Avoid Highest Foods
• Oranges/Juice
• Banana
• Potato
• Plantains
• 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

27
Phosphorus

• Dietary intake 800 to 1000 mg/day
• lt17 mg/kg SBW
• HD removes 500-1000 mg/treatment
• PD removes 400 mg/treatment
• 50 dietary phosphorus removed by binders16
• Control Binders Diet Adequate dialysis

28
Phosphate Binders
29
Phosphorus Balance
Weekly Phosphorus Balance 4200 (diet) 2100
(Binders) 2100( HD) Balance
30
Phosphorus10

• Lower Phosphorus Foods
• Fresh meat products
• Homemade baked goods
• Nondairy creamer
• Unenriched rice milk
• Cream cheese
• White flour products
• Rice cakes

• High Phosphorus Foods
• Dairy products
• Beans Nuts
• Processed meats
• Chocolate
• Pancakes, waffles, biscuits, cakes
• Sardines
• Whole wheat, bran cereals

31
Phosphorus Additives

• Inorganic Phosphorus absorbed easily
• Phosphorus binders ineffective with many
  additives
• READ THE INGREDENTS LABEL!!
• Phosphoric acid
• Sodium hexametaphosphate
• Calcium phosphate
• Disodium phosphate
• Trisodium triphosphate
• Monosodium phosphate
• Sodium tripolyphosphate
• Tetrasodium pyrophosphate
• Potassium tripolyphosphate

32
Calcium

• Use corrected calcium (adjusted calcium) for
  albumin lt46 Calculation
  (4-albumin) x 0.8 Ca
• Diet Less than 2 g daily
• Hypercalcemia
• Ca based binders, supplements
• Vitamin D analogs/treatment
• Diet, fortified foods
• Dialysate calcium levels
• Hypocalcemia
• Vitamin D, Calcijex
• Supplement between meals

33
Parathyroid Hormone (PTH)

• Vitamin D is activated in the kidney to
  calcitriol, or vitamin D31
• Vitamin D3 levels fall with kidney failure
• Calcium absorption ? and phosphorus excretion
  ? PTH increases gt bone disease
• Vitamin D3 therapy helps prevent renal bone
  disease
• Ca and Phosphorus precipitate and calcify soft
  tissue
• Ca x Phos product goal range with treatment

34
Fluid

• HD
• Urine Output 1000 ml
• Limit IDWG
• 2-5 Estimated Dry weight
• PD
• Maintain fluid balance
• Vary dextrose concentrations in dialysate
• Restrict if fluid balance not obtained without
  frequent hypertonic exchanges

35
Sodium1,6

• 1 L fluid output 2-3 g Na and 2 L fluid
• 1 L fluid output 2 g Na and 1-1.5 L fluid
• Anuria 2 g Na and 1 L fluid
• Individualize
• IDWG, blood pressure, residual renal functions
• Increased Restrictions if ? IDWG, CHF, edema, HTN
• PD liberalize restriction to 2-4 grams sodium
• High sodium intake may increase thirst

36
Lipids10

• Increased risk of lipid disorders
• Recommended fat intake
• Total Fat lt30 of calories
• Saturated fat lt10
• Cholesterol lt300 mg/day
• Difficult restrictions to achieve
• Omega 3 supplements for elevated triglycerides
• Optimum fiber intake 20-25 g/day

37
Micronutrients1,6

• Renal Multivitamin containing water soluble
  vitamins17
• Dialyzable take after dialysis
• 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

38
Specific PD Concerns

• Higher protein needs
• Lose 5-15 grams of protein a day 9, 14
• Weight Gain1
• Include dialysate calories in total intake
• May absorb as much as 1/3 (500-800 kcals) of
  daily energy needs
• Limit sodium and fluid to minimize hypertonic
  exchanges
• Hypertonic agents such as Icodextrin (Extraneal)
• High Triglycerides6
• Modify intake of sugars/carbohydrates
• Limit intake of fats, saturated fats

39
Nutritional Supplements

• Oral supplements Nepro, Ensure, Boost
• Powders Beneprotein, ProSource, Eggpro
• Modular Protein Pro-Stat, Promod
• Cookies NutraBalance
• Protein Bars
• Meal replacements vs. snacks
• Over the counter
• Evaluate potassium, phosphorus

40
Nutrition Support
Enteral

• Oral Supplements
• Barriers compliance, fluid , palatability, cost
• Tube feeding
• Renal Formulas
• Nepro and Novasource Renal
• Barriers acceptance, intolerance, tube
  placement, fluid intake, reimbursements,
  assistance

41
Nutrition Support
Parenteral

• IDPN
• Barriers
• Oral intake is maximized without improvement in
  status
• Usually requires documented malabsorption
  diagnosis
• Benefits
• Supplemented during treatment
• No additional tube/access needed
• Dialysis clinics have individual rules and
  criteria
• Specific qualifying criteria from insurance
  companies

42
RD Roles Anemia and Bone Management

• Anemia Management
• APN Anemia Manager
• Protocols
• Bone Management
• APN Bone Manager
• Protocols
• MD input as needed
• RD recommendations

43
Resources

• www.davita.com/diethelper
• www.case.edu/med/ccrhd/phosfoods
• www.kidneyschool.org
• www.aakp.org/brochures/phosphorus
• www.aakp.org/aakp-library
• www.rd411.com

44
References

• 1. Byham-Gray L, Wiesen K. A Clinical Guide to
  Nutrition Care in Kidney Disease. Chicago
  American Dietetic Association 2004.
• 2. Pifer TB et al. Mortality risk in hemodialysis
  patients and changes in nutritional indicators
  DOPPS. Kidney International. 2002622238-2245.
• 3. Acchiardo SR, et al. Morbidity and mortality
  in hemodialysis patients. ASAIO Trans.
  199046830-837.
• 4. Lowrie EG et al. Death risk predictors among
  peritoneal dialysis and hemodialysis patients a
  preliminary comparison. Am J Kidney Dis.
  199526220-228.
• 5. Kestenbaum, B et al. Serum phosphate levels
  and mortality risk among people with chronic
  kidney disease. JASN. 200516(2)520-528.
• 6. McCann L. Pocket Guide to Nutrition Assessment
  of the Patient with Chronic Kidney Disease. 4th
  ed. National Kidney Foundation 2009.
• 7. Fouque D et al. A proposed nomencalture and
  diagnostic criteria for protein-energy wasting in
  acute and chronic kidney disease. Kidney
  International. 200873391-398.
• 8. Steibe A et al. Multicenter study of validity
  and reliability of subjective global assessment
  in the hemodialysis population. Journal of Renal
  Nutrition. 200717(5)336-342.

45
References

• 9. NKF K/DOQI practice guidelines. Clinical
  practice guidelines for nutrition in chronic
  renal failure. Am J Kid Dis. 200035S40-S41
• 10. Schiro-Harvey K. National Renal Diet
  Professional Guide. 2nd ed. Chicago American
  Dietetic Association 2002.
• 11. Rocco et al. Nutritional status in HEMO study
  cohort at baseline hemodialysis. Am J Kidney
  Dis. 200239245-256.
• 12. Friedman AN, Fadem SZ. Reassessment of
  albumin as a nutritional marker in kidney
  disease. J Am Soc Nephrol. 201021223-230.
• 13. Ikizler, TA et al. Amino acid losses during
  hemodialysis. Kidney Int. 199446830-837.
• 14. Blumenkrantz MJ et al. Metabolic balance
  studies and dietary protein requirements in
  patients undergoing continuous ambulatory
  peritoneal dialysis. Kidney Int. 198221
  849-861.
• 15. Beto J. Hyperkalemia Evaluation of dietary
  and non-dietary etiology. J Ren Nutr.
  1992228-29.
• 16. Rocco MV et al. Handbook of Dialysis. 3rd ed.
  Philadelphia Lippincott, Williams Wilkins
  2001.
• 17. Andreucci, VE et al. Dialysis outcomes and
  practice patterns study (DOPPS) data on
  medications in hemodialysis patients. Am J Kidney
  Dis. 200444(S2)S61-S67.

46
Thank You
?? Questions ??