ESRD - Dialysis Nutrition YOU

1. ESRD - Dialysis Nutrition & YOU!

2. Goals for Today� Describe the functions of a kidney & review Treatment options for ESRD Learn the nutritional requirements of patients on dialysis Describe the relationship between fluid management and dialysis treatment outcomes Discuss the renal dietitian can help you with your nutritional education and support

3. What do healthy kidneys do for us? Balance fluid/minerals in body Produce Urine Filter Blood Regulate Blood Pressure Produce Erythropoietin Helps make Red Blood Cells  Activate Vitamin D Keep bones healthy

4. Treatment Options:  Stage V: eGFR <15mL/min/1.73 m2 Dialysis Hemodialysis Traditional S.L.E.D Nocturnal Short-Daily Peritoneal Dialysis CAPD CCPD Transplant

5. Hemodialysis Usually 4o, 3 x wk In-center In-center, home or nocturnal Requires a vascular access Removal of �toxins� � Waste Products Amino acid losses 10-12 g/tx, with desired clearance Loss of water-soluble vitamins PD Higher protein needs 1.3g/kg Peritonitis (? risk): ?er pro needs 1.5 gm/kg Amino acid (IDPN), if qualifications met ? phos: a challenge PD Higher protein needs 1.3g/kg Peritonitis (? risk): ?er pro needs 1.5 gm/kg Amino acid (IDPN), if qualifications met ? phos: a challenge

6. Peritoneal Dialysis Uses the peritoneum: abdominal cavity CAPD : continuous Ambulatory PD 4 - 5 exchanges daily CCPD: Continuous Cyclic PD overnight cycler + last fill + 1 manual in day if more clearance needed Fluid removal Dextrose (1.5%, 2.5%, 4.25%) � high calorie absorption

7. Considerations� Healthy kidneys work 24 hrs/day to remove waste products and fluid Waste comes from what we eat and drink Dialysis only replaces ~10% - 15% of healthy kidney function Calorie, protein requirements: higher for dialysis

8. Why is diet important? There is no �one diet� for all since the reasons for kidney failure are varied (high blood pressure, diabetes, lupus, etc.).� Other health conditions, medications, and the stage of kidney disease also need to be considered.� This makes individual diet counseling provided by a dietitian an important part of treatment. There is no �one diet� for all since the reasons for kidney failure are varied (high blood pressure, diabetes, lupus, etc.).� Other health conditions, medications, and the stage of kidney disease also need to be considered.� This makes individual diet counseling provided by a dietitian an important part of treatment.

9. Why NO Two are alike�? Treatments/Medications CKD, Hemodialysis, Peritoneal dialysis, Transplant Nephrologists/Patient Priorities Nutritional Status Residual Renal Function Laboratory Analysis Physical Status/ Co-morbidities Social Mental Economic Cultural

10. A dietitian would review YOUR� Medical history, other medical problems Physical parameters Lab results Personal food preferences and lifestyle

11. How can a Renal Dietitian help YOU? Assess your nutritional status Address nutritional concerns with you and team members Instruct you/caregiver on diet and rationale for recommendations Assist with planning meals YOU can enjoy Renal dietitian is a �Registered Dietitian� who has special training and experience with kidney disease and can help you on your journey The dietitian will do a full assessment which includes: Who is cooking shopping ht/wt diet interview dietary intake: diet record other medical conditions: DM or wt management review your blood tests a lot of calculations and come up with a plan that best fits you The dietitian will teach you how to implement this plan in a practical way that fits into your lifestyle. Renal dietitian is a �Registered Dietitian� who has special training and experience with kidney disease and can help you on your journey The dietitian will do a full assessment which includes: Who is cooking shopping ht/wt diet interview dietary intake: diet record other medical conditions: DM or wt management review your blood tests a lot of calculations and come up with a plan that best fits you The dietitian will teach you how to implement this plan in a practical way that fits into your lifestyle.

12. More ways a dietitian can help� Help you with diabetes management Work with you to get a healthy weight Review vitamins, minerals, herbal supplements Clarify any diet information you may have heard about�  Provide an ongoing, individualized care

13. Common causes of kidney failure

14.  First, the kidney disease� Take control of the original problems� If you have diabetes� Control blood glucose to avoid damage to other organs Blood pressure control A low sodium diet BP meds prescribed to protect your kidneys Weight Management

15.  Diabetes Ask your doctor what your target blood levels are for glucose and A1C  Take all medications as prescribed Check your blood sugars as prescribed Learn about foods and drinks that turn into sugar Tell the doctor if you have low sugars �hypoglycemia� Remember we talked about one of the ways to slow kidney progression was controlling blood glucose! Medications may need to be adjusted so be sure that all doctors know that you have kidney disease Watch for hypoglycemia for CKD 3-5 (longer half-life insulin) Carbohydrates are what affect blood sugar the most (these are grains, milk products, fruits, and starchy vegetables like potatoes) (per KDOQI A1C <7% for anyone, with or without CKD, shown to decrease risk of microalbuminuria) Remember we talked about one of the ways to slow kidney progression was controlling blood glucose! Medications may need to be adjusted so be sure that all doctors know that you have kidney disease Watch for hypoglycemia for CKD 3-5 (longer half-life insulin) Carbohydrates are what affect blood sugar the most (these are grains, milk products, fruits, and starchy vegetables like potatoes) (per KDOQI A1C <7% for anyone, with or without CKD, shown to decrease risk of microalbuminuria)

16. Obesity and Kidney Disease Reducing body weight may: Improve blood pressure Improve diabetes control Obesity may be linked to decreased kidney function Your doctor & dietitian can help you manage your weight goal and help you make a plan

17. Questions so far? Let�s move on to potassiumLet�s move on to potassium

18. Key Parts of Renal Diet Include: Calories Protein Carbohydrates Lipids Fluids Potassium Phosphorus Sodium Vitamins Other Minerals Trace Elements

19. Energy/Calories Provides energy for body functions Present in Carbohydrates Fats Protein Calculated based on your Weight Age Frame Size Activity Level Heath Condition Goal Weight

20. Energy/Calories Inadequate Caloric Intake Body draws on own muscle tissue for energy Loss of Lean Body Mass (muscle wasting) Patient becomes Malnourished

21. High risk of malnutrition Loss of nutrients during dialysis Hospitalizations, surgeries Confusion about diet Depression/Social/Financial limitations Inadequate dialysis time/missed treatments

22. Protein Necessary to make & repair cells, builds muscle and keeps the immune system working Important for growth & maintenance of body tissue Provides energy (if needed)

23. Protein Intake Indicator: Albumin Albumin  Helps you have a good dialysis treatment Keep the fluid where it belongs Keep you out of the hospital Keep your heart and blood vessels healthy

24. Protein Intake Indicator: Albumin Low Albumin due to low protein intake can result in: Muscle loss Undesired weight loss Make you feel weaker Less desire to eat Higher chances of infection & longer time to healA vicious cycle Low Albumin makes it harder for dialysis to remove fluid

25. Protein Sources Animal sources meat, fish, poultry, eggs & dairy products* High Biological Value Protein Recommend 50-75% intake Complete protein all essential amino acids

26. Protein Sources Vegetable Protein Plant sources Nuts, beans, fruits, vegetables, grains & breads Low Biological Value Protein Incomplete protein Does not contain all essential amino acids

27. Protein Sources Oral Supplements Nepro (dialysis) Suplena (non-dialyis) Protein powders, Protein bars Clinimix, Proteinex Intradialytic Parenteral Nutrition (IDPN) Loss of appetite, failure to thrive Failure of oral nutrition supplements No improved albumin trend noted with other interventions

28. Protein Tips Choose lean cuts of meats, remove visible fat Try to eat some protein soon after dialysis Limit yolks to 3 times per week At meal times, eat the protein first � don�t skip the meat! If trying a protein bar: Look for more than 10 grams with less than 200 mg of phosphorus or less than 20% Discuss what level of protein is best for you with your dietitian May have increased need of protein Malnutrition, Metabolic Stress, Peritonitis. EXERCISE! Keep your muscles active

29. Potassium (K+) Potassium helps control muscle function, including the heart! If the potassium level is too high or too low it can cause the heart not to work well, it can even stop the heart Kidneys filter potassium

30. Potassium Medications can affect blood levels Some water pills cause low potassium Some blood pressure pills can cause high potassium levels No changes in diet are needed unless YOUR lab results show high or low levels (CKD or dialysis) Peritoneal dialysis patients may have a liberal allowance of potassium High potassium: When kidney function decreases potassium can build up in the blood. Low potassium: Some medications can cause serum potassium to become low. (FYI for presenter) (A diuretic may cause low levels of K. Some ACE inhibitors like Lisinopril and angiotensin receptor blockers (ARBs) can cause higher levels K) Some ARBS are: irbesartan (Avapro),  valsartan (Diovan),  losartan (Cozaar), and  olmesartan (Benicar). High potassium: When kidney function decreases potassium can build up in the blood. Low potassium: Some medications can cause serum potassium to become low. (FYI for presenter) (A diuretic may cause low levels of K. Some ACE inhibitors like Lisinopril and angiotensin receptor blockers (ARBs) can cause higher levels K) Some ARBS are: irbesartan (Avapro), valsartan (Diovan), losartan (Cozaar), and olmesartan (Benicar).

31. Potassium Sources Potassium is a mineral found mostly in fruits and vegetables It is also added to many foods as a preservative Do not use salt substitutes (imitation salt) if you have a potassium limit Ask your dietitian if you need more or less potassium in your meal plan

32. What About Salt Substitutes? Many brands are made with potassium: No-Salt? Co-Salt? Nu-Salt ? Lite Salt Morton�s Salt Substitute ?

33. Potassium (K+) Sources Some salt substitutes Oranges and some juices Bananas Melons Tomatoes Avocados Chocolate Raisins Fresh or cooked spinach and other green vegetables Potatoes* Sweet potatoes Nuts Beans Seed, all kinds

34. Potassium: �Quantity & Qaulity� Low Medium High � c applesauce � apple juice 1 large apple 1 tangerine � cup mandarin 1 fresh orange 2 tomato slices � fresh tomato 1/3 c tomato sauce 1 cup slaw � c turnip greens � cup cooked spinach � cup rice � c canned � sm baked potato sweet potato __________________________________________________________

35. A Note about Star Fruit� Star fruit, also called Carambola, looks pretty sliced in a fruit salad But for low kidney function, research shows that star fruit can cause agitation, confusion, and even death Avoid Star Fruit!

36. Phosphorus

37. Phosphorus Kidneys get rid of extra phosphorus. Low kidney function phosphorus is high, calcium will come out of the bones. resulting in bone disease, tissue calcification& problems with the heart Symptoms � Itching, red eyes, joint pain Sometimes obvious calcium deposits Calcification of vessels evident on X-rays Phosphorus is a mineral found in almost all foods

38. High Phosphorus Foods Sodas - Colas(Coke/Pepsi/Dr. Pepper) Peanut butter Nuts Seeds Beans, Peas, Lentils (legumes) Processed meats & cheese with phosphate additives Dairy products: Milk, cheese, cheese, ice-cream Puddings, custard Yogurt

39. High Phosphorus Foods Beer Bran and bran products Caramel & chocolate Organ meats (Liver) Whole grain products

40. Phosphate Binders The doctor may prescribe a medication that you take the same time as eating. It helps bind to phosphorus, and removes it before it goes to the blood Binders are like a sponge. They �soak up� phosphorus from food!

41. Kidneys and Bones Kidneys Activate Vitamin D! Phosphorus, calcium and Vitamin D work together to keep your bones strong Your doctor may prescribe you an �activated� form of Vitamin D Hectorol Zemplar Ergocalciferol (CKD)

43. Sodium (Salt) Sodium helps your body balance fluid and chemicals Kidneys remove extra sodium in urine Dialysis can be harder with extra sodium in your body!  May result in high blood pressure, fluid retention/swelling (edema) & lead to shortness of breath

44. High Sodium Foods Processed Meats Ham Bacon Sausage Canned meat Cold cuts Hot dogs Corned beef Salt pork Smoked dried fish Seasonings, etc Garlic salt / Onion salt Lemon Pepper Accent Meat tenderizers Packaged seasoning mix Soy sauce chili sauce bouillon cubes

45. High Sodium Foods Canned Foods Soup Stews Vegetable juices Vegetables Other Fast foods Frozen foods Pot pies

46. High Sodium Foods Pretzels-salted Chips Salted Crackers Salted Nuts Salted/Buttered Popcorn

47. Salt-free ways to make food taste better! Spices and Herbs Fresh garlic and onion, basil, Italian seasoning, curry, dill, ginger, rosemary, thyme, parsley, oregano Lemon & lime juice Vinegar Ground pepper Mrs. Dash � Check to be sure salt is not an ingredient of a seasoning If not salt, then what else? These are some examples Use fresh herbs and seasonings instead of salt: Remember lower sodium intake can improve blood pressure, so it�s worth it!If not salt, then what else? These are some examples Use fresh herbs and seasonings instead of salt: Remember lower sodium intake can improve blood pressure, so it�s worth it!

48. Sodium Tips Try to not use salt shaker for cooking or on table Limit convenience foods Cook more � a little planning is all it takes! Choose fresher foods Try to limit to 1500-2000 mg of sodium each day

49. How do you know if you are getting 2,000 mg sodium per day? Look at the food label! Ask audience, does anyone know what is the first thing you want to check on the food label? Hint: it�s toward the top: Check serving size Check number of servings per container For this food, if you eat 1 cup, you�ll have to double the sodium to 940 mg Sodium: DV is 2400 mg daily Daily Values are reference values developed by the FDA specifically for food labeling.� They are a sort of one-size-fits-all recommendation, designed to help you plan a healthy diet. The DV assume that you eat about 2,000 calories per day. (If more questions arise) *Look for these nutrients listed in milligrams (mg). Cholesterol: DV for healthy adults is 300 mg daily Calcium: DV is 1000 mg daily (multiply by 10) (20 x 10 = 200) Potassium: DV is 3500 mg daily (multiply by 35) � (20 x 35 = 700) Phosphorus: DV is 1000 mg daily (multiply by 10) (10 x 10 = 100) Total Fat: 2000 kcal = 65 g; 2500 kcal = 80 g Saturated Fat: 2000 kcal = 20 g; 2500 kcal = 25 g How do you know if you are getting 2,000 mg sodium per day? Look at the food label! Ask audience, does anyone know what is the first thing you want to check on the food label? Hint: it�s toward the top: Check serving size Check number of servings per container For this food, if you eat 1 cup, you�ll have to double the sodium to 940 mg Sodium: DV is 2400 mg daily Daily Values are reference values developed by the FDA specifically for food labeling.� They are a sort of one-size-fits-all recommendation, designed to help you plan a healthy diet. The DV assume that you eat about 2,000 calories per day. (If more questions arise) *Look for these nutrients listed in milligrams (mg). Cholesterol: DV for healthy adults is 300 mg daily Calcium: DV is 1000 mg daily (multiply by 10) (20 x 10 = 200) Potassium: DV is 3500 mg daily (multiply by 35) � (20 x 35 = 700) Phosphorus: DV is 1000 mg daily (multiply by 10) (10 x 10 = 100) Total Fat: 2000 kcal = 65 g; 2500 kcal = 80 g Saturated Fat: 2000 kcal = 20 g; 2500 kcal = 25 g

50. Let�s see who is paying attention! Ask the audience: Is this a lot of sodium or not? Yes, it�s 700mg out of 2,000 for the day, 35% of the day�s worth. Let�s see who is paying attention! Ask the audience: Is this a lot of sodium or not? Yes, it�s 700mg out of 2,000 for the day, 35% of the day�s worth.

52. Dry Weight Dialysis patient�s weight neither too much nor too little fluid Feel well, have no excess fluid or difficulty breathing Dry weight can change & must be evaluation frequently Weight used to calculate how much fluid needs to be removed with dialysis and for other nutrient calculations

53. Fluid Fluids build up in the body and must be removed by dialysis Acceptable gains: 2 - 3 Kg btwn treatments Too much fluid removal leads to low BP & muscle cramping Not enough fluid removal can lead to fluid overload Edema Shortness of Breath High blood pressure Congestive Heart Failure

54. Fluids Goal for weight gain less than 1 � 1 � kg per day Most patient are to limit their fluid intake: 4 cups = 32 ounces 1 liter = 1000 cc  + output of fluid per 24 hours

55. Fluids Source� All foods that are liquid at room temperature

56. Thirst Control Low sodium intake Seasoning/ Alternatives Avoid high blood sugars Medication Changes - Causing dry mouth? Weight yourself at home

57. Tips for thirst and fluid control! Track your fluids  Avoid chewing lots of ice Avoid refills at restaurant Avoid super-sized beverages Small glasses at meals & meds Hot weather, temperature Keep your skin cool: cold wash cloth, mist-bottle Keep your lips moist with a chap stick Keep your mouth wet Keep your mouth clean toothpaste for dry mouth (biotene) Rinse your mouth with cold water, but don�t swallow it Rinse your mouth with chilled mouthwash Chew on gum: Quench gum Try lemon wedges or freeze grapes & strawberries

58. Vitamins Dialysis patients need supplements of water soluble vitamins Prescription vitamins specially formulated for a dialysis patient, such as Nephrocaps, RenaVite, etc B-Complex with Folic Acid: OTC OTC MVI and herbal supplements should not be taken by the dialysis patient because they include substances that may build to toxic levels in the blood

59. See your doctor for regular visits Take your medications as prescribed Be active with exercise Eat a kidney (and diabetes) friendly diet Control blood sugar and blood pressure Get to and keep a healthy weight Limit sodium and moderation of protein Summary Medications control blood pressure, diabetes, anemia, bone disease. Some medication can worsen your kidney damage. Take only what is prescribed to you and take it exactly the way it is prescribed. Make sure your kidney doctor is aware of all medication that you are on. Exercise can help control blood pressure, diabetes and heart disease. Try to work up to 30 minutes of aerobic exercise most days of the week. Talk to your doctor before starting any kind of exercise routine. Diet is very important: Making sure you are not consuming too much protein and salt Medications control blood pressure, diabetes, anemia, bone disease. Some medication can worsen your kidney damage. Take only what is prescribed to you and take it exactly the way it is prescribed. Make sure your kidney doctor is aware of all medication that you are on. Exercise can help control blood pressure, diabetes and heart disease. Try to work up to 30 minutes of aerobic exercise most days of the week. Talk to your doctor before starting any kind of exercise routine. Diet is very important: Making sure you are not consuming too much protein and salt

60. Medical Nutrition Therapy Ask your doctor for a referral to see a Registered Dietitian

61. Important Message!!! You don�t have to do it alone It takes a team effort to achieve success Do not start a diet for chronic kidney disease on your own � seek professional advice from a renal dietitian

62. A few good websites� www.aakp.org American Association of Kidney Patients www.kidney.org National Kidney Foundation www.nkdep.nih.gov National Institute of Diabetes & Digestive & Kidney Diseases www.kidneyschool.org www.ikidney.com

63. Questions? Thank You!