Kidney Disease-What You Need to Know

1. Kidney Disease-What You Need to Know Mary Ann Vespignani RD LDN

2. WHAT DOES THE KIDNEY DO? • Remove Waste Products from the body • Remove Drugs from body • Balance the body’s fluids • Release hormones that regulate blood pressure • Produce an active form Vit D that promotes strong healthy bones • Control production of red blood cells

3. What is the Dietitian’s/CDM role? • To educate and advise people on diet • To provide support through treatment • To work with Renal RD to review monthly labs and adjust diet as needed • To provide support for non-renal staff

4. 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.

5. KDOQI Goals • Albumin 4.0 or greater • Potassium 3.5-5.5 • Phosphorus 3.5-5.5 • Calcium 8.5-9.5

6. OVERVIEW • What the tests measure • URR • Albumin • Calcium, Phosphorus, Potassium • Why they are important • What to do when the results are outside the acceptable range • Summary

7. Why do you need to understand the Patient Report Card? • So you can answer patients’ questions • So you can reinforce the dietary changes the patient needs to make • So we can work as a team …so we can provide better patient care… • \

8. Urea Reduction Ratio • Tells 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 BUN • Goal: Greater than or equal to 65 (> 65)

9. Urea Reduction Ratio • URR < 65 means that the person’s blood is not being cleansed well enough. • The person may have: • Poor appetite • Nausea / vomiting • Bad taste in mouth • Weight loss

10. ALBUMIN • An important protein in the blood • Indicator of person’s nutritional status • Infection/Inflammatory response affects Albumin • The single most important indicator of a person’s mortality • Goal: 4.0 – 5.4 g/Dl

11. Albumin •  Albumin may mean • Malnutrition • Increased risk for illness and death (long term) • Over hydration/fluid overload •  Albumin makes it difficult for dialysis to remove fluid

12. What factors affect Albumin • Poor appetite • Not eating enough protein-rich foods • Meat, fish, poultry or eggs • Fluid overload • Illness / infection • Liver problems • Other health problems

13. CALCIUM • Needed for • healthy bones • muscle contraction & relaxation • proper nerve functioning • Normal range on “Report Card” is 8.5 – 9.5

14. CALCIUM • Hypercalcemia (Ca > 10.2): • nausea • confusion • coma •  risk for heart disease • Hypocalcemia: • numbness • seizures • confusion • painful muscle spasms • osteoporosis

15. What to do if calcium levels are too high or too low? • Hypercalcemia ( calcium) • Patient should decrease calcium intake • STOPPhosLo, Tums, etc • Doctor will D/C active form of Vit D3 (Calcijex or Zemplar

16. What to do if calcium levels are too high or too low? • Hypocalcemia ( calcium) • Patient may need • Calcijex, or Zemplar • additional dietary/supplemental calcium • May be due to low albumin levels

17. Phosphorus (“P”) or Phosphate (PO4) • Needed for • healthy bones & teeth • energy 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

18. Phosphorus • Normal ranges currently on “report card” are 2.5 –5.5 • Hyperphosphatemia ( phosphorus) • itching • bone damage •  risk for soft tissue calcification (including heart and blood vessels) • Hypophosphatemia ( phosphorus) • rare • muscle weakness • coma • patient needs to stop PO4 binders (PhosLo, Renagel

19. Phosphorus to HIGH Patient needs to • decrease intake of P-rich food and/or • take PO4 binders as prescribed(Binders must be taken with meals)

20. Phosphorus rich foods • Beans, peas, lentils (“legumes”) • Nuts (peanut butter), seeds • Chocolate, cocoa • Cheese (pizza), milk, yogurt • Whole grains (whole wheat bread) • Bran cereals • Coke, Pepsi & other sodas with “phosphoric acid”

21. 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

22. 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

23. Elevated Potassium • Hyperkalemia (high potassium level) can cause • muscle weakness • the heart to stop

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

25. 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

26. 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

27. Dietary advice • Energy • Protein • Salt • Potassium • Phosphate • Fluid

28. Goals of Diet Therapy • Maintain normal biochemistry levels • Minimise symptoms • Prevent malnutrition and unintentional weight loss • Improve quality of Life

29. Factors that influence dietary advice • Stage of CKD • Biochemistry levels (trends) • Medications • Treatments e.g. Conservative, Dialysis • Other medical conditions e.g. Diabetes • Lifestyle (social, psychological aspects)

30. Dietary advice • Weight Management - activity/lifestyle, current intake, food preferences, cooking methods, food labelling, alcohol. • DM Control - meds, regular meals & starchy CHOs, low sugar, fruit & veg. • Lipid Control – ↓saturated fats, ↑mono fats, oily fish, fruit & veg. • Salt Intake - at table, in cooking, convenience foods.

31. Dietary advice: • Low Appetite, Depressed & Symptomatic – small & frequent meals, energy dense and high protein foods. • High Potassium Level – cooking methods, food choices & frequencies of high K foods. • Hypertension – salt intake • 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 conditions Culture – Asian diet & cooking methods Future ‘life changing’ treatments – Hemodialysis

32. Dietary Guidelines • Protein Intakes of 1.2 gm/kg body weight • 30-35 Kcals/kg body weight • Fluid weight gains between treatments of 2-3 kg • Sodium intakes = 2.5 grams/day • Phosphorus =800 -1200mg/day • Calcium intakes <1200 mg/day • Potassium intakes <3200 mg/day

33. Medications Phosphate 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

34. Medication Alerts!! • Dialysis patients are not to be given • Milk of Mag,Citracal or calcium citrate, PeptoBismol; KCL supplements or PRN calcium or aluminum based antacids • Renal patients are normally taken off Lasix, Bumex or other diuretics when starting HD

35. Interactions: HERBAL SUPPLEMENTS NEED CAREFUL CHECK AS THEY MAY INTERACT WITH OTHER MEDICATIONS • Can affect K levels-alfalfa, Dandelion, Licorice root, Noni fruit/juice and St John’s wort • Has diuretic properties/electrolyte imbalance –Goldenrod,Juniper berries and parsley • Can effect blood thinning agents: garlic and Ginger • Do not use in CKD-Ginseng

36. Questions

37. Contact Details