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Nutrition for Diseases of the Kidney

Nutrition for Diseases of the Kidney. Functions of the Kidney. Excretion of metabolic waste through urine Water and Electrolyte Homeostasis Acid/base balance Maintenance of bone health Activation of vitamin D Calcium/phosphorus homeostasis Blood Pressure Regulation

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Nutrition for Diseases of the Kidney

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  1. Nutrition for Diseases of the Kidney

  2. Functions of the Kidney • Excretion of metabolic waste through urine • Water and Electrolyte Homeostasis • Acid/base balance • Maintenance of bone health • Activation of vitamin D • Calcium/phosphorus homeostasis • Blood Pressure Regulation • Renin-Angiotensin-Aldosterone • Stimulate red blood cell production • Erythropoietin

  3. Consequences of Kidney Disease • Decreased excretion of nutrients/waste • Abnormal calcium/phosphorus metabolism leading to bone disease • Weight loss and malnutrition • Fluid and electrolyte imbalances • Cardiovascular disease and mortality

  4. Uremic Syndrome • Nausea • Vomiting • Metallic taste • Itching • Lack of energy

  5. Protein-energy wasting syndrome Kidney Int. 2008;73(4):391-398

  6. Goals of CKD Management • Achieve/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

  7. Evidenced based clinical practice guidelines • For all stages of kidney disease • For related complications

  8. Glomerular Filtration Rate • GFR = (140-age) X body weight (kg) X 0.85 if female [72 X serum creatinine (mg/dL)] • GFR of 100 approximates 100% kidney fxn • Normal GFR = 120 to 130 mL/min

  9. Stages of Chronic Kidney Disease

  10. Deterioration of Nutritional Status Begins Early • GFR 28 – 35 mL/min or greater • Protein Energy Malnutrition (PEM) is often present at the time patients begin dialysis. • Malnutrition in pts beginning dialysis is a strong predictor of poor clinical outcome

  11. Medical Nutrition Therapy Recommendations (Stages 3 to 5)

  12. Optimal Nutritional Status • Albumin > 4.0 • Stable, desirable dry weight • Adequate fat stores and muscle mass • Appropriate appetite and intake

  13. Reverse epidemiology of obesity in dialysis patients compared with the general population Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

  14. Assessing Anemia in CDK

  15. Low Albumin • Non-nutritional factors • Infection • Inflammation • Co-morbidities • Fluid overload • Inadequate dialysis • Blood loss • Metabolic acidosis

  16. Calories • Recommended energy intake = 30 to 35 day kcals/kg • Spares body protein • Maintains neutral nitrogen balance • Promotes higher serum albumin levels • Challenges • Decreased appetite from uremia • Various CKD dietary restrictions • Finding food sources for added calories

  17. Dietary Protein Restriction… • Reduces nitrogenous waste • Reduces inorganic ions • Reduces metabolic/ clinical disturbance (uremia) • Slows rate of decline in GFR

  18. K/DOQI protein guidelines • (Average American Intake = 1.2 g per kg/day) • 0.75 grams per kg/day for CKD stages 1 thru 3 • 0.6 grams per kg/day for CKD stages 4, 5 • 50% of the dietary protein should be HBV • HBV protein produces less nitrogenous waste • 45 to 60 grams protein per day • No Protein Restriction for Dialysis Patients • 1.2 g per kg/day hemodialysis • 10-12 grams lost per HD treatment • 1.3 g per kg/day peritoneal dialysis • 5-15 grams lost per PD treatment

  19. Food Portion Estimations 1 tsp 3 oz 1 cup & ½ cup ¼ cup 1 oz

  20. Protein in Foods • 1 oz meat, poultry, fish = 7 g • ¼ cup tuna • ½ cup beans, peas, or lentils • 2 Tablespoons peanut butter • 2 egg whites = 7 g • 1 cup milk = 8 g • 1 oz cheese • 1/3 cup cottage cheese • 1 cup veg = 2 g • 1 slice bread = 3 g • ½ cup rice or pasta • ½ cup cereal • Fruit, fats, sugars = 0

  21. Challenges with High Protein FoodsAlso high in phosphorus and potassium • Milk • Cheese • Beans • Peanut butter

  22. Lunch A 2 slices bread Chicken breast (3 oz) Lettuce, tomato Mayonnaise 16 oz milk banana Lunch B 2 slices bread 1 oz chicken Lettuce Mayonnaise Iced tea apple How much protein?

  23. Nutritional Interventions • Encourage patients to eat • Adjust or liberalize diet as appropriate • Frequent small meals/snacks • High protein foods first if they get full quickly • Calorie dense foods • Consider use of nutritional supplements

  24. Supplements • Protein Powder • Procel, Egg/Pro • Liquid Protein • Pro-Stat, ProSource, Liquicel • Liquid Nutritional • Ensure, Boost, Enlive • Calorie Dense • Ensure Plus, Boost Plus • Renal Specific • Nepro with Carb Steady, Re/Gen • Novasource Renal, NutriRenal

  25. Sodium • Dietary sodium restriction prevents: • Excessive thirst • Edema • Hypertension • CHF • Sodium restriction = 2000 mg/day • Range from 1000mg to 4000mg • Varies depending on co-morbidities • More liberal sodium with frequent dialysis • Sodium excretion falls at GFR < 20mL/min

  26. Sources of dietary sodium • Pre-prepared foods • Processed foods • Canned, bottled, packaged foods.

  27. 1 tsp salt = 2,300 mg sodium

  28. 2 gram Sodium Diet… • Fresh foods • Limit • Cured/pickled foods • Processed • Can/bottled/packaged • Instant cereals, mixes • Avoid salt substitutes (potassium chloride) • Flavor foods with spices, vinegar, lemon juice, pepper

  29. Potassium • Potassium Restriction Indications • Urine output < 1 liter per day • GFR < 10 mL/min • ACE inhibitors, beta blockers, lasix • Hyperglycemia • Serum potassium > 5.0 mEq/L • Dietary Potassium Restriction = 2 grams/day • Serum Potassium Goal: 3.5- 5.0 mEq/L

  30. Potassium in the Diet • High (> 400 mg/serving) • Banana • Potato • Avocado • Orange juice • Moderate (>200 mg/serving) • Berries • Broccoli • Tomato

  31. Low Potassium Fruit & Vegetables >100 mg/serving • Cranberries • Apple • Corn • Lettuce • Pineapple • String beans

  32. Lunch A 2 slices bread Chicken breast (3 oz) Lettuce, tomato Mayonnaise 16 oz milk banana Lunch B 2 slices bread 1 oz chicken Lettuce Mayonnaise Iced tea apple How much potassium?

  33. Altered Bone Turnover in CKD • Kidney Failure leads to… • Decreased production of active Vit D • Low serum calcium • Phosphorus retention • Elevated PTH • Secondary Hyperparathyroidism • Mineral and Bone Disorder

  34. >4.6

  35. Phosphorus • High serum phosphorus • Bone decalcification • Soft tissue calcifications • Hyperparathyroidism • Phosphorus restriction for GFR < 25mL/min • Normal dietary phosphorus = 1000 to 1800 mg/day • Dietary restriction = 560 to 850 mg/day • Phosphate binders: • Bind phosphorus in the GI tract • Must take with meals • Phoslo (calcium containing) • Renvela (Sevelamer) (calcium free) • Fosrenol (chewable)

  36. Phosphorus is not found on the Nutrition Facts Label

  37. High Phosphorous Foods

  38. Calcium in CKD • Maintain serum calcium 8.4 – 10.2 mg/dL • Optimal < 9.6 mg/dL • Dietary Calcium 1200 – 1500 mg/day (stages 3 and 4)

  39. Calcimimetics: A new family of drugs (Sensipar) • Binds to calcium receptor • Decreases PTH • Active orally • Advantageous: Suppression of PTH without risk of hypercalcemia or hyperphosphatemia • FDA approved

  40. Fluid Restriction CKD Stage 4 or 5 • Fluid: “any food that is liquid at room temp” Soup, gelatin, ice cream, popsicles • Excess fluid buildup • Edema, SOB, HTN, CHF • Delays wound healing • Fluid restriction estimations are based upon • Urinary output • Disease state • Treatment modality (dialysis, etc.)

  41. Fluid Allowance Tips • Approx 48oz/day • Pre-measure mealtime liquids • Drink very hot or very cold beverages • Drinking from smaller cups • Use spray bottle to mist mouth • Freeze juice in ice cube tray and eat like popsicles

  42. Vitamin & Mineral SupplementsDietary restrictions result in a diet deficient in nutrients • Vitamin C 90 mg/day • Over 75% of kidney disease patients have increased homocysteine levels.  • Folic acid 1 mg/day • B6 5 mg/day • No Vitamin A due to its accumulation in CKD • Vitamin D in its active form 1,25 dihydroxycholecalciferol [1,25 (0H2)D3] • Procrit and iron supplementation • Suggestion: Nephrocaps

  43. Herbal Supplements • Use may be unsafe for CKD patients • Poor clearance • Purity, safety, effectiveness unknown • No regulation, no testing requirements • Subject to contamination • Lead • mercury • Herbs can interact with medications • Renal patients take > 10 meds/day • Renal toxicity • Wormwood • Horse chestnut • Sassafras

  44. Herbs with diuretic properties that may cause renal inflammation • Bucha leaves • Juniper berries • Uvaursi • Parsley capsules

  45. Making Meals Appetizing Lunch:Two slices white breadTwo Tbsp mayonnaise with lettuce and onion 1 ounce chicken or one hard boiled eggTwo canned peach halves 7 Up or Lemonade

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