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Dietary issues ON Chronic Kidney Disease (CKD)

Dietary issues ON Chronic Kidney Disease (CKD). 賴建賓 中港澄清腎臟內科. Agenda. General dietary advice in relation to nutrition and the kidney Discuss the importance of salt restriction in more detail. Discuss the importance of potassium & phosphate restriction

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Dietary issues ON Chronic Kidney Disease (CKD)

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  1. Dietary issues ON Chronic Kidney Disease (CKD) 賴建賓 中港澄清腎臟內科

  2. Agenda • General dietary advice in relation to nutrition and the kidney • Discuss the importance of salt restriction in more detail. • Discuss the importance of potassium & phosphate restriction • Discuss the importance of low protein diet • Discuss the high incidence of malnutrition in CKD • Practical application- quiz

  3. Early stages 1-3A (GFR >90- 45ml/min) • Statement from NICE study 2008 • A CKD management programme encompasses; blood pressure control, reduction of proteinuria, treatment of hyperlipidemia, smoking cessation & dietary advice, treatment of anemia, treatment of acidosis and mineral bone disease and just as importantly the provision of timely and understandable information & education.

  4. Dietary considerations- Stages 4-5 (GFR < 30 ml/min) • Salt • Phosphate • Potassium • Fluid • Protein • Calories • Diabetic control

  5. Outcomes • JAMA (2007) attributes increase in CKD to increasing incidence of DM and HTN • ABC Hypertension (2005) Hypertension is associated with increased risk of CHD & CKD • WHO (2003) advise that hypertension is one of the most preventable causes of premature morbidity and mortality through out the world.

  6. Dietary intakes of salt • CASH (Consenus Action on Salt for Health) (2008) estimate the average British diet contains 8.6 salt/d (based on 24hour urinary sodium) • National food survey (2007) suggests that average British adult intake is 7.1gsalt/d (dietary analysis, does not include table/added salt!) • 1g sodium= 2.5g salt • 1g salt (NaCl) = 17.1mmol Na • 1mmol Na = 23mg Na • 100mmol Na = 6g salt (NaCl)

  7. RECOMMENDED INTAKES OF SALT (ADULTS)

  8. Evidence salt-Population studies • Intersalt (Am J Clin Nutr,1996) • Large worldwide study (n=10079) • 24hrs Na excretion & BP measured • Linear relationship found between Na excretion & BP (systolic). From cross-population analysis controlled for age, sex, BMI and OH intake where the median sodium intake decreased by 100mmol/d, median SBP/DBP lowered by 5/2mg Hg • Salt institute requested re-analysis which strengthened findings!

  9. Intervention studies • DASH (NEMJ 2001) • N=412 • Participants >22yrs >120/80mmHg • 3 levels Na (150, 100 & 50 mmol/d) • Normal US diet, low Na US diet & DASH diet. High sodium run in period.

  10. Intervention studies • Reduction of Na significantly reduces BP • DASH diet significantly reduced systolic BP at every Na Level and diastolic in the high to intermediate group. • DASH low Na group produced the greatest BP reduction- 11.5 mg Hg in systolic BP.

  11. Intervention studies • FINLAND (Eur J Clin Nut 2006) • Population education, collaboration with food industry over 20years • Legislated use of Pan Salt (K & Mg rich, reduced Na) to manufacturers • Trends in Na excretion reduced by 1/3 • BP reduced by 10mmHg • 75-80% reduction in stroke & CHD mortality • BMI & EtOH consumption have increased

  12. Intervention studies • JAPAN (cited by He & MacGregor J Hum Hypertension 2008) • 1950’s regions of high stroke mortality related to high salt intake • Government campaign to reduce salt intake • North Japan intakes fell from 18 to 14g/d • BMI, fat intake, smoking and Etoh increased • BP fell in adults and children • Stroke mortality reduced by 80%

  13. Meta-analysis, Reviews and Mathematical Modelling • Bibbins-Domingo AHA 49th Annual Conference 2009, • Mathematical modelling (computer generated) based on predictions between 2010-2019 • 3g reduction in salt: • would give same benefit as eliminating smoking! • CHD reduce new cases by 6% • MI reduce new cases by 8% • Other reductions 3% • Reducing salt intake to 6g/d could save 800,000 life years in the USA for each g lowered (USA intakes are 9-12g/d)

  14. Observational follow-up of the trials of hypertension preventation (TOHP) • Cook et al (2007)- 3000 partipiants without hypertension were randomised to one of the following grps: TOHPI- reduced salt intake by 2.6g/d for 18 mnths TOHPII- reduced salt intake by 2g/d for 36-48 mnths Control group

  15. Results • People originally allocated to either of the two sodium reduced groups had a 30% lower incidence of cardiovascular events in the next 10-15yrs, irrespective of sex, ethnic origin, age, body mass and blood pressure.

  16. Summary • A recent meta-analysis of randomised salt reduction trials (He & MacGregor 2008) supported this with an estimation that a reduction to 6g/d salt would reduce strokes by 24% and CHD by 18%. This would prevent approx 35000 stroke and CHD deaths in the UK. • The reduction in salt may help reduce LVH independent of BP. • Also a modest reduction in salt from 10 to 5g/d may reduce proteinuria.

  17. Salt • All patients in ESRD should limit salt intake to less than 6g a day(Renal Ass 2010) • Non renal patients - Salt intake linked to hypertension in many studies, and anti-hypertensives shown to work better with a low salt diet(DASH diet Sacks 2001, Singer 1995)

  18. Salt in HD Patients • Direct relationship observed between Na intake and IDWG (Panzetta 2001) • Thompson 2001 - Salt reducing advice should always come before fluid reducing advice as very difficult to control thirst on a high salt diet.

  19. Low salt diet • 70-80% salt eaten as processed and convenience foods - cheap and easy to prepare • Malnutrition is common and restrictions can cause more problems • May be best to advise this change early in pre-dialysis when no other dietary restriction needed.

  20. Low salt diet • Avoid 湯, 醬, 肉汁, 馬鈴薯片and nuts • Avoid adding salt in cooking or at the table, and avoid using salt subsitutes. Use pepper, herbs or spices as alternative seasonings. • Cut down 火腿, 燻肉, 派and 麵糊, 煙燻魚and cheese. • If choosing processed foods aim for those with less than 0.3g salt or 0.1g sodium . A main meal should have less than 2g salt or 0.8g sodium.

  21. Phosphate • Effects of a high phosphate level • Itching • Mineral bone disease • Calcification of blood vessels

  22. Target phosphate levels • HD and PD - below 1.7mmol/l (5.1 mg/dL) ( Renal Association 2010) • Pre dialysis - below 1.5mmol/l (4.5 mg/dL)( Renal Association 2010) • Phosphate protocol used at UHCW to help the team control HD phosphate levels.

  23. Low phosphate diet • Associated with protein foods • Dairy products especially high • 罐頭魚類(帶骨) • Shellfish • Chocolate & nuts • Phosphate binders – 鈣片(碳酸, 醋酸), 鋁片, Renegel, fosrenol • Usual advice to have 10 minutes before meals containing protein (Fosrenol after meals) • Monitor PTH and give Vitamin D if necessary

  24. Potassium Target potassium levels • HD Patients • Renal association – Pre dialysis 3.5-6.5mmol/l (meq/L) • UHCW 3.5-5.8mmol/l • PD and Pre Dialysis Patients • Renal association and UHCW – 3.5-5.5mmol/l

  25. Low potassium diet • Limit fruit and vegetables, and avoid those with high levelsAllow 4-5 portions suitable fruit or vegetables a day • Potatoes - should always be boiled • Milk limited to half a pint a day • Avoid nuts, peanut butter and care with chocolate and toffee(太妃糖) • Consider other cause of high potassium before restricting diet!

  26. Protein requirements • Excess protein – can be harmful leading to increased urea production and in some studies accelerating disease progression. • Pre dialysis - 0.8 -1g/kg IBW - reduced protein intake but not low enough to increase risk of malnutrition - must be monitored • HD and PD - high protein requirements of 1.2g/kg IBW • Lose protein during the dialysis process • During HD patients are more catabolic and have increased protein/calorie requirements.

  27. The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of Chronic Renal Disease Saulo Klahr, Andrew S. Levey, Gerald J. Beck, Arlene W. Caggiula, Lawrence Hunsicker, John W. Kusek, Gary Striker, for The Modification of Diet in Renal Disease Study Group*

  28. > .75 g/Kg/d < .62 .62 - .68 .68 - .75

  29. Cochrane systematic review and meta-analysis Fouque D, et al, Cochrane Database Syst Rev 2006; 19: CD001892.

  30. Low protein diet : effect on progression of CRF in diabetic CKD patients : meta-analysis  Dietary protein restriction significantly reduces the risk of decline in GFR or creatinine clearance in patients with diabetic nephropathy. PEDRINI et al. (1996): Effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: a meta-analysis. Ann Intern Med, 124, 627-632

  31. Low Protein Diet Incidence of ESRD/death in diabetic nephropathy • A protein restriction improves prognosis in type 1 diabetic patients with progressive diabetic nephropathy in addition to the beneficial effect of antihypertensive treatment. HANSEN et al. (2002): Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy Kidney Int, 62, 220-228

  32. Calorie requirements • In all cases, enough to achieve and maintain an appropriate weight • HD - High - 30-35cal/kg • PD - Gain calories from PD fluid,and gain more if use strong bags, so more likely to need to restrict dietary calories • Pre dialysis - 30-35cal/kg

  33. Malnutrition • Common in patients with renal failure (studies show incidence of between 20-50%) • Uremia • Anemia • Depression • Elderly, social isolation • Meals missed due to treatment regime • Dietary restrictions

  34. Malnutrition • Malnourished patients have an increased morbidity and mortality, and do less well on dialysis. • Benefit in starting dialysis early before weight loss severe. • Downward spiral - Malnutrition leads to increased risk of infection and sepsis - e.g. line infection, repeated admissions lead to increased malnutrition etc.

  35. Salt Quiz • What is the maximum amount of salt recommended for a renal patients? • 100mmol of sodium is equivalent to how many g’s of salt. • 70-80% of the salt in our diet comes from what type of foods?

  36. Which do you think contains more salt….. 2 slices of bread or a packet of crisps?

  37. Salt content • 2 slices bread- 0.7-1.2g salt • Bag of crisps- 0.5g salt

  38. Which do you think contains more salt..... a cooked breafast or a bowl of cornflakes?

  39. Salt content • Cooked breakfast- 4.75g salt • Cornflakes- 1.25g salt

  40. Which do you think contains more salt..... A ham roll or a jacket potato with cottage cheese?

  41. Salt content • Ham roll- 4.15g salt • Jacket potato with cottage cheese-1.05g salt

  42. REFERENCES • Bibbins-Domingo et al. Projected Effects of Dietary Salt Reductions on Future CVD. New Engl J of Med 2010 • Cook et al. Long term effects of dietary sodium reduction on CVD outcomes: observational follow-up of the trials of hypertension preventation (TOHP). BMJ 2007;334:885 • He FJ & MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reductions programmes. J of Human Hypertension 2008; 1-22 • He FJ & MacGregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database of Systematic Reviews. • Laatikainen et al. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. Eur J of Clin Nutr 2006; 60: 965-970 • Tomson C. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrol Dial Transplant 2001; 16: 1528-1542 • Sacks et al. Effects on blood pressure of reduced dietary sodium and the DASH diet. N Engl J Med 2001; 344: 3-10 • Stamler J. The INTERSALT study. Am C of Clin Nutr 1997; 65: 626-642Ikizler T. Protein and energy: Recommended intake and nutrient supplementation in chronic dialysis patients. Seminars in Dialysis 2004; 17 (6): 471-478

  43. Questions?

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