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@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. Uremic Syndrome Malaise Weakness Nausea and vomiting Muscle cramps Itching Metallic taste Neurologic impairment Hospitalizations Co-morbidities Diabetes Infections Amputations Cancer Inflammation Causes of Malnutrition

7. Protein–energy 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 > within 1 month • 7.5% or > within 3 months • 10% or > within 6 months • Attitude toward changes • Goals for weight changes

11. Nutrition Assessment6Interdialytic 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

12. 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 Nutrition Assessment Diet History

13. Shopping and Cooking Abilities Facilities Medication Side Effects Compliance Physical limitations Psychosocial problems Emotional support Economic limitations Depression Adjustment to disease Treatment Compliance Nutrition Assessment Diet History

14. 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 Nutrition Assessment Diet History

15. Monthly Albumin: 4.0g /dL or > Potassium: 3.5-5.3 mEq/L Phosphorus: 3.5-5.5 mg/dL Calcium: 8.4-10.2 mg/dl Glucose <200 mg/dL Non-fasting Product: < 55 URR: >65% Hgb: 10-12 g/dL Quarterly Hemoglobin A1C: < 7% PTH: 150-600 pg/mL Lipid Panel Chol < 200 mg/dL HDL > 40mg/dL LDL <100mg/dL Triglycerides <200 mg/dL Nutrition Assessment Laboratory Analysis6

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 patient’s 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. Dialysis Treatment HD: 10-12 g free amino acids lost13 Losses increase with glucose free dialysate PD: 5 to 15 g protein lost9, 14 Lost as albumin 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. 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 Potassium10

27. Phosphorus • Dietary intake ~800 to 1000 mg/day <17 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. High Phosphorus Foods Dairy products Beans & Nuts Processed meats Chocolate Pancakes, waffles, biscuits, cakes Sardines Whole wheat, bran cereals Lower Phosphorus Foods Fresh meat products Homemade baked goods Nondairy creamer Unenriched rice milk Cream cheese White flour products Rice cakes Phosphorus10

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 <46 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 => 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 <30% of calories • Saturated fat <10% • Cholesterol <300 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. Anemia Management APN Anemia Manager Protocols Bone Management APN Bone Manager Protocols MD input as needed RD recommendations RD RolesAnemia and Bone Management

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. 2002;62:2238-2245. • 3. Acchiardo SR, et al. Morbidity and mortality in hemodialysis patients. ASAIOTrans. 1990;46:830-837. • 4. Lowrie EG et al. Death risk predictors among peritoneal dialysis and hemodialysis patients: a preliminary comparison. Am J Kidney Dis. 1995;26:220-228. • 5. Kestenbaum, B et al. Serum phosphate levels and mortality risk among people with chronic kidney disease. JASN. 2005;16(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. 2008;73:391-398. • 8. Steibe A et al. Multicenter study of validity and reliability of subjective global assessment in the hemodialysis population. Journal of Renal Nutrition. 2007;17(5):336-342.

45. References • 9. NKF K/DOQI practice guidelines. Clinical practice guidelines for nutrition in chronic renal failure. Am J Kid Dis. 2000;35:S40-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. 2002;39:245-256. • 12. Friedman AN, Fadem SZ. Reassessment of albumin as a nutritional marker in kidney disease. J Am Soc Nephrol. 2010;21:223-230. • 13. Ikizler, TA et al. Amino acid losses during hemodialysis. Kidney Int. 1994;46:830-837. • 14. Blumenkrantz MJ et al. Metabolic balance studies and dietary protein requirements in patients undergoing continuous ambulatory peritoneal dialysis. Kidney Int. 1982;21: 849-861. • 15. Beto J. Hyperkalemia: Evaluation of dietary and non-dietary etiology. J Ren Nutr. 1992;2:28-29. • 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. 2004;44(S2):S61-S67.

46. Thank You ?? Questions ??