Nutritional Markers in hemodialysis

1. Nutritional Markers in hemodialysis Julie Atteritano, RD, CDE, CDN

2. Albumin • Biochemical marker reflecting visceral protein stores • Most common protein found in the blood • Produced by the liver (9-12g /day) • Life span 12-20 days

3. Role of Albumin in the Body • Maintains intravascular oncotic pressure • Transports small molecules in the blood such as billirubin, Ca+, Mg, Progesterone, and medications • Provides the body with necessary protein needed to maintain growth and repair tissue

4. Target Levels for Albumin Stabilized serum albumin equal to or greater than the lower limit of the normal range. Approximately 4.0mg/dl K/DOQI

5. Consequences of hypoalbuminemia • Increased morbidity and mortality • Serum albumin concentrations are identified as the most powerful indicator of mortality • Risk of death in patients with serum albumin concentration < 2.5gm/dl was 20 fold than that of patients with serum albumin 4.0- 4.5gm/dl • Serum albumin 3.5- 4.0gm/dl resulted in a 2 fold increase in relative risk of death • (Lowrie et al.)

6. Consequences continued… • Edema and ascites • Decreased healing • Increased risk of infection

7. Reasons for hypoalbuminemia • Protein Energy Malnutrition (PEM) Caloric and protein intake are inadequate to meet nutrition needs ** Patients on hemodialysis have a higher Resting Energy Expenditure than patients in Stage 2 CKD ** Goal for intake- 30-35Kcal/Kg 1.2- 1.4 gm/Kg protein

8. Hypoalbuminemia continued… • Inflammation • Characterized by acute phase proteins C- reactive protein (CRP), Alpha -1 acid glycoprotein (a1-AG), Ferritin, Ceruloplasm • Inflammation secondary to infection, trauma, obesity, poorly controlled DM • Hydration status • Proteinuria • Metabolic acidosis

9. Dietary strategies to improve albumin levels • Ensure adequate caloric and protein intake • Increase intake of high biological value (HBV) proteins (Chicken, turkey, fish, red meat, eggs) • Nutritional supplementation: Nepro, Liquid protein supplements (Liquacel, Prostat), whey protein powder

10. Strategies to improve albumin continued…. • Intradialytic Parenteral Nutrition (IDPN) Amino acids (AA), Dextrose, and lipids delivered directly into the blood stream during hemodialysis

11. Potassium (K+) • Potassium is a mineral and an electrolyte

12. Role of potassium in the body • Potassium is an electrolyte which means it conducts electricity in the body along with Na+, Ca+, Mg, and chloride • Responsible for skeletal and smooth muscle contraction (crucial for heart function) • Plays a role in biochemical reactions and energy metabolism • Catalyst in the synthesis of amino acids from protein sources

13. Target levels for potassium Low : less than 3.5mg/dl Goal :3.5mg/dl – 5.5mg/dl High : 5.6mg/dl – 6.0mg/dl Unsafe: > 6.0mg/dl

14. Hyperkalemia • K+ levels > 5.5mg/dl Causes of Hyperkalemia include: • Dietary indiscretion • K+ shifts from intracellular to extracellular space (Caused by metabolic acidosis, NSAID’s, non-selective Beta-blockers) • K+ bath (3K+,4K+) • Non-compliance with treatment Rx

15. Consequences of hyperkalemia • Nausea • Weakness • Numbness and tingling • Irregular heart beat • Heart failure • Sudden death

16. Dietary strategies to improve hyperkalemia • Goal for intake 2,000mg K+ per day • Avoid/limit high K+ foods • Avocado (1oz) 144mg • Banana (small) 422mg • Cantaloupe/honeydew (1 cup) 388mg • Orange (small) 240mg • Mango/papaya 323mg • Dried fruit (ex-Apricots 10 halves:470mg) • Potato/sweet potato 512-694mg • Tomato (1 cup canned) 1098mg

17. Dietary strategies continued… • Spinach (1 cup cooked) 839mg • Winter squash (1 cup) 494mg • Dried beans and peas (ex: kidney beans 1 cup 713mg) • Milk (1 cup) 382mg • Yogurt (8oz) 579mg • Salt substitutes

18. Low potassium choices • Apples • Berries (strawberries and blueberries) • Cabbage • Canned peaches and pears • Carrots • Cauliflower • Cucumber • Eggplant • Green beans • Grapes • Lettuce • Non-dairy creamer • Onion • Rice milk • Sorbet • Watermelon

19. Hypokalemia • K+ < 3.5mg/dl • Causes: - Decreased po intake - Excessive diarrhea or vomiting - Certain medications (ex- diuretics) - Need for K+ bath change (3K+,4K+)

20. Consequences of hypokalemia • Muscle weakness and cramping • Fatigue • Confusion • Problems with muscle coordination • Irregular heart beat • Heart failure • Dietary intervention: Liberalization

21. Phosphorus (PO4) • Phosphorus is a mineral • Most abundant after Calcium (Ca+) • 85% found in bones • 14% spread throughout soft tissue • 1% in blood and extracellular fluid

22. Role of pO4 in the body • Responsible for the growth, maintenance, and repair of tissues and cells • Production of genetic building blocks (DNA/RNA) • Energy production: helps change protein, fat, and carbohydrates into energy • Combines with Calcium (Ca+) to form calcium phosphate (predominant mineral in bone)

23. Target levels for phosphorus Low: less than 3.5mg/dl Goal: 3.5mg/dl – 5.5mg/dl High: greater than 5.5mg/dl

24. Hyperphosphatemia • PO4 > 5.5mg/dl • As kidney function diminishes (decreased GFR), the kidney loses the ability to excrete PO4 • Leading to elevated serum PO4 levels

25. Consequences of hyperphosphatemia • Calcium- phosphorus deposits - heart - skin - lungs - blood vessels • Red eyes • Bone disease - bone and joint pain - weak brittle bones • Increased risk of mortality

26. Dietary strategies to improve hyperphosphatemia • Lower PO4 diet • Goal for intake 800- 1,000mg per day • Avoid high PO4 foods - Dairy products (milk, cheese, ice cream, yogurt) - Chocolate - Dark cola (Coke and Pepsi) - Nuts and nut butters - Organ meats - Cream soups - Processed meats - Whole grain bread

27. Dietary strategies continued… • Phosphorus binders - Calcium Carbonate: TUMS - Calcium Acetate: Phoslo - Sevelamar Hydrochloride: Renvela - Lanthanum Carbonate: Fosrenol • Greatest limitation is Compliance!!

28. Hypophosphatemia • PO4 level < 3.5mg/dl • Possible causes: - Poor po intake - Need for binder dosage adjustment • Consequences: - Decreased appetite - Confusion • Dietary Strategies: - Dietary liberalization - Binder dosage decrease or D/C

29. Pathway of ckdmineral and bone disorder Decreased Renal Function Decreased 1,25 (OH) Vitamin D Phosphate Retention PTH Ca+ PO4 Secondary Hyperparathyroidism

30. Calcium (Ca+) • Calcium is a mineral • Most abundant mineral in the body • 99% of calcium in the body is in bones and teeth • 1% of calcium is found in the blood and soft tissues

31. Role of calcium in the body • Forms strong bones and teeth • Aides in muscle contraction and relaxation • Transmits nerve impulses • Aides in blood clotting • Assists in enzymatic reactions • Involved in the process of cell division and multiplication

32. Target level for calcium Serum levels of corrected total Ca+ should be maintained within the normal range for the laboratory used, preferably toward the lower end: 8.4mg/dl – 9.5mg/dl (K/DOQI)

33. hypercalcemia • Corrected Ca+ > 10.2 mg/dl • Causes: - Increased Ca+ intake (Ca+ based binders, Ca+ supplements or high Ca+ foods) - Too much Hectorol/Zemplar (Active form of Vitamin D) • Treatment: - Avoid foods high in Ca+ - Change to non- calcium based binder - Decrease Hectorol/Zemplar dose

34. Consequences of hypercalcemia • CALCIFICATION

35. Hypocalcemia • Ca+ < 8.4mg/dl • Causes: - Inadequate Ca+ intake - Vitamin D deficiency - High PO4 levels - Calcimimetics • Treatment: - Increase Ca+ intake or begin supplementation - Initiate or increase Hectorol/Zemplar dose - Decrease PO4 levels to restore balance between Ca+, PO4 and PTH

36. Consequences of hypocalcemia • Paresthesia, bronchospasm, laryngospasm, tetany, and seizures

37. Putting it all together… • How can we work together as a health care team to promote patient compliance and improve patient outcome??

38. Thank you!!!! • Thank you so much for your time and attention!! • Hope you all learned a new thing or two!!