Nutritional Assessment in Hemodialysis Patient

1. Nutritional Assessment in HemodialysisPatient Haneen NabeelMolla M.Sc. Clinical Dietitian King Khalid University Hospital

2. Stages of Kidney Disease There are five stages of kidney disease. It based on the presence of kidney damage and the glomerular filtration rate (GFR) The treatment is based on the stage of kidney disease.

3. Stages of Kidney Disease

4. End Stage Renal Disease ( ESRD ) : Inability to excrete waste products , maintain fluid and electrolyte balance and produce hormones.

5. When is Dialysis Needed? Kidneys no longer remove enough wastes and fluid from the blood When only 10 to 15 percent of the kidney function left.

6. When is Dialysis Needed? Symptoms such as nausea, vomiting, swelling and fatigue. Ahigh level of wastes in their blood that may be toxic to their body.

7. Nutrition and Hemodialysis • Diet is an important part in hemodialysis patient overall care. • We will go over some of the important points in the patient diet which include : • Getting the right amount of calories and protein • Staying at a healthy body weight • Important nutrients in the diet • Potassium • phosphorus • sodium and fluids • calcium • Diabetic – Renal Diet

8. The Goals of the Nutritional Management in Dialysis Prevent nutrients deficiencies Control edema and serum electrolytes Provide an attractive healthy diet

9. Anthropometric Measurement • Weight kg • High cm • Body mass index (BMI ): Weight (Height)2 • Underweight 16.0 to 18.5 • Normal (healthy weight) 18.5 to 25 • Overweight 25 to 30 • Obese Class I (Moderately obese) 30 to 35 • Obese Class II (Severely obese) 35 to 40 • Obese Class III (Very severely obese) over 40

10. Anthropometric Measurement adjusted body weight (AIBW)= (Actual weight – IBW) x 0.32 + IBW women x 0.38 + IBW men Ideal body weight (IBW) : (Height)2 x 22.4 men x 22.1 women % of IBW: Actual Weight x 100 IBW

11. Getting the Right Amount of Calories • To the patients overall health and helps to give them energy to do their normal activities . • Calories come from all the foods they eat , and are important because : • Give the body energy • Help to stay at a healthy body weight • Help the body use protein for building muscles and tissues.

12. Getting the Right Amount of Calories • Energy35 kcal/kg of body weight for <60 years; 30 to 35 kcal/kg of body weight for >60 years Will keep the patients from losing weight. The amount of calories recommended will depend on the individual needs.

13. Getting the Right Amount of Protein • In pre-dialysis patients have to be on a low-protein diet. • During dialysis patients will need diet with more protein. • It is important for overall health and how well they feel. • Body needs the right amount of protein for: • Building muscles • Repairing tissue • Fighting infections.

14. Protein • Protein is found in 2 types of foods:

15. Protein • Some of these protein-rich foods may also contain lots of phosphorus, which need to be controlled in their diet. • Protein : 1.2- 1.3 g/kg of body weight, >50% HBV protein

16. Potassium Potassium is an important mineral found in food. Potassium helps the muscles and heart work properly. Healthy kidneys helps to keep the right amount of potassium in the body.

17. Potassium Too much or too little potassium level in the blood can be dangerous. With hemodialysis, patients need to limit their intake of high-potassium foods.

18. Potassium • Soaking the vegetables after cutting it and cooking it helps to remove high amount of potassium • Potassium: 2 to 3 g/day; or 40mg/kg IBW

19. High-Potassium Fruit (>200 mg / portion) The portion size is ½ cup Mango(1 medium) Nectarine(1 medium) Orange(1 medium) Orange Juice Papaya (½ whole) Pomegranate (1 whole) Pomegranate Juice Prunes Prune Juice Raisins Apricot, raw (2 medium)dried (5 halves) Avocado (¼ whole) Banana (½ whole) Cantaloupe Dates (5 whole) Dried fruits Figs, dried Grapefruit Juice Honeydew Kiwi (1 medium)

20. High-Potassium Vegetables (>200 mg / portion) The portion size is ½ cup Legumes Mushrooms, canned Okra Parsnips Potatoes, white and sweet Pumpkin Rutabagas Spinach, cooked Tomatoes/Tomato products Vegetable Juices Artichoke Baked Beans Squash Beets, fresh then boiled Black Beans Broccoli, cooked Brussels Sprouts Chinese Cabbage Carrots, raw Lentils Dried Beans and Peas

21. Other High Potassium Foods (>200 mg / portion) The portion size is ½ cup Bran/Bran products Chocolate (1.5-2 ounces) Granola Milk, all types (1 cup) Molasses (1 Tablespoon) Yogurt

22. Low-Potassium Fruit (<200 mg/ portion) The portion size is ½ cup Grapes, Grape Juice Raspberries Plums (1 whole) Tangerine (1 whole) Strawberries Pears(1 small) canned (½ cup) Pineapple, Pineapple Juice Peaches, (1 small) canned (½ cup) Watermelon(limit to 1 cup) Apple (1 medium) Apple Juice Applesauce Blackberries Blueberries Cherries Cranberries Fruit Cocktail Grapefruit (½ whole)

23. Low-Potassium Vegetables (<200 mg/ portion) The portion size is ½ cup Watercress Yellow Squash Zucchini Squash Onions Parsley Peas, green Peppers Radish Kale Lettuce Asparagus (6 spears) Beans, green or wax Cabbage, green and red Carrots, cooked Cauliflower Celery (1 stalk) Corn, fresh (½ ear) frozen (½ cup) Cucumber Eggplant Mixed Vegetables Mushrooms, fresh

24. Other Foods Low Potassium ( <200 mg/ portion) The portion size is ½ cup Rice Noodles Pasta Bread and bread products: (Not Whole Grains) Cake: angel, yellow Coffee: limit to 8 ounces ( 1 cup ) Pies without chocolate or high potassium fruit Cookies without nuts or chocolate Tea: limit to 16 ounces (2 cups )

25. Phosphorus Phosphorus is a mineral found in different kind of foods. Eating foods high in phosphorus will raise the amount of phosphorus in the blood. When phosphorus builds up in the blood, calcium is pulled from the bones. Over time, the bones will become weak and break easily. Dialysis cannot remove all of this phosphorus.

26. Phosphorus • A high level of phosphorus in the blood may also cause calcium phosphorus crystals to build up in the joints, muscles, skin, blood vessels and heart. • These crystals may cause serious problems such as • Bone pain • Damage to the heart and other organs • Poor blood circulation • Skin ulcers.

27. Phosphorus • To keep blood phosphorus at safe levels, patients will need to limit phosphorus-rich foods, and may need to take some medications. • Phosphorus 800 to 1,000 mg/day; or 17mg/kg IBW

28. High Phosphorus Food ( >150 mg/portion) The portion size is ½ cup Dairy Products: Milk, Yogurt ,Pudding, Custard, Ice cream and Cream soups Protein • Carp, sardines, beef liver, chicken liver ,organ meats, oysters

29. High Phosphorus Food Other foods bran cereals brewer’s yeast nuts caramels seeds Beverages Ale, Beer drinks made with milk chocolate drinks Cocoa, dark colas Vegetables dried beans and peas: baked beans black beans chick peas kidney beans lentils northern beans split peas soy beans

30. Sodium Sodium is a mineral found naturally in foods. It is found in large amounts in table salt and in foods that have added table salt. Eating too much sodium can make the patient thirsty and cause the body to hold onto more fluid.

31. Sodium • The extra sodium can cause: • Swelling or puffiness around eyes, hands or feet • Fluid weight gain • Shortness of breath • Rise in blood pressure • More work for their heart • Sodium1 - 3 g/day

32. Sodium

33. Fluids • Fluid is any food or beverage that is liquid at room temperature. • Some examples are: • Ice • Beverages like coffee, tea, sodas, juices and water • Frozen desserts such as ice cream, sherbet or PopsiclesGelatin • Gravy and Soups

34. Fluids • Signs may noticed with drinking too many fluids • A sudden increase in weight along with swelling • Shortness of breath • A rise in the blood pressure Fluid : output + 1000 ml

35. Calcium Calcium is the mineral that is important for building strong bones. However, foods that are good sources of calcium are also high in phosphorus.

36. Calcium • To prevent loss of calcium from bones • Follow a diet that limits high-phosphorus foods • Take phosphate binders. • In some cases the physician may prescribe a special form of vitamin D to help keep calcium and phosphorus levels in balance and prevent bone disease.

37. Diabetic-Renal Diet in Hemodialysis Patient on hemodialysis diet will have restrictions in foods containing high amounts of phosphorus, sodium and potassium. Diabetic patients who are on hemodialysis will be tightly controlled the Carbohydrate intake in order to manage the blood glucose levels.

38. Diabetic-Renal Diet in Hemodialysis High sugar foods and all carbohydrate containing foods, increase blood glucose levels. The total amount of carbohydrates the patients eat will be balanced with their medication and activity level. They could use system called carbohydrate counting to keep their carbohydrate intake balanced.

39. Diabetic-Renal Diet in Hemodialysis Take low phosphorus and low potassium foods . Limit milk and dairy intake. Control blood sugar to help control thirst and fluid gains. Avoid cooking with salt, salt substitutes, or add salt at the table.

40. Conclusion Our goal for hemodialysis patients should be a healthy lifestyle that can be maintained in the long run, rather than a short-term "diet”. It's all about making changes that will last a lifetime--changes that are focused on smart, sensible eating.

41. Thank you