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B. Shaibani MD, PhD Consultant nephrologist Azzawiyah kidney Center 2017 2 Nutrition in Dialysis
B. Shaibani MD, PhD
Consultant nephrologist
Azzawiyah kidney Center
2017
2
Nutrition in Dialysis
▶ The most neglected part of care
▶ Lack of dietitians
▶ND are not knowledgeable nor interested
▶No many literature
▶ Language barriers
▶Difficult to afford advice
▶Patient non- complains
3
Nutrition in Dialysis
Objectives
Participant will be able to:
▶ Recognize the importance of nutrition intervention in patients with CKD and on dialysis patients specially.
▶ Identify the components of a nutritional assessment
▶ Identify the components of the renal diet and the role of the dietitian
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5
Protein
Vegetables
Fruits
fluids
The NO food list for dialysis patients
Individualize patients 'need
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Does Nutrition Status Matter?
YES!
▶ Nutritional indicators can be directly linked to patient status and outcome
▶ Protein-Energy Malnutrition (PEM)
▶ BMI
▶ Albumin
▶ Potassium
▶ Phosphorus
▶ Calcium
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Renal Osteodystrophy
▶ Hyperphosphatemia
▶ Vascular and non-vascular calcification5
▶ Hypocalcemia
▶ Secondary Hyperparathyroidism
▶ Bone Disease
▶ Low bone mass and density
▶ Osteitis fibrosa cystica
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Protein Energy MalnutritionPEM
▶ Malnutrition
▶ PEM: marasmus-kwashiorkor
▶ muscle/fat wasting
▶ weight loss
▶ Marasmus: Inadequate nutrient intake
▶ Kwashiorkor: Inadequate protein intake
▶ Cachexia
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Causes of Malnutrition
▶ Uremic Syndrome
▶ Malaise
▶ Weakness
▶ Nausea and vomiting
▶ Muscle cramps
▶ Itching
▶ Metallic taste
▶ Neurologic impairment
▶ Hospitalizations
▶ Co-morbidities
▶ Diabetes
▶ Infections
▶ Amputations
▶ Cancer
▶ Inflammation
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Protein–energy wasting syndrome in kidney disease
Nutrition Assessment:Anthropometric Data
▶ Height
▶ Weight status
▶ Frame size
▶ Arm anthropometrics
▶ Appearance
▶ Amputations
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Nutrition Assessment:Weight Status Evaluation
▶ Standard Body Weight (SBW)
▶ Body Mass Index (BMI)
▶ Ideal Body Weight (IBW)
▶ Adjusted Body Weight (ABW)
▶ Usual Body Weight (UBW)
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Nutrition Assessment:Weight Status Evaluation
▶ 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
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Nutrition Assessment:Weight Status Evaluation
▶ 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
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Nutrition Assessment: Weight Status Evaluation
▶ Weight changes
▶ Intentional vs. unintentional weight loss
▶ Dry weight changes vs. fluid shifts
▶ Clinically significant weight loss
▶5% or > within 1 month
▶7.5% or > within 3 months
▶10% or > within 6 months
▶ Attitude toward changes
▶ Goals for weight changes
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Nutrition Assessment:Interdialytic Weight Gain (IDWG)
▶ General recommendation +2 kg
▶ >5% fluid gains
▶ Excessive fluid intake
▶ Weight gain
▶ <2% fluid gain
▶ Inadequate fluid and/or food intake
▶ Weight Loss/Decreased body mass
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Nutrition Assessment:Diet History
▶ Appetite/Intake
▶ Food preferences
▶ Allergies/Intolerance
▶ Taste changes
▶ Acute or chronic GI concerns
▶ Swallowing/Chewing concerns
▶ Urine output
▶ Pica
▶ Religious/Cultural Restriction
▶ Supplement intake
▶ Homeopathic Treatments
▶ Nutrition Knowledge
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Nutrition Assessment:Diet History
▶ Shopping and Cooking
▶ Abilities
▶ Facilities
▶ Medication
▶ Side Effects
▶ Compliance
▶ Physical limitations
Psychosocial problems
▶ Emotional support
▶ Economic limitations
▶ Depression
▶ Adjustment to disease Treatment Compliance
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Nutrition Assessment:Diet History
▶ Food Records
▶ 24 Hour Recall
▶ 3 Day Food Record
▶ 3 Day Calorie Count
▶ Food Frequency Questionnaire
▶ Diet Assessment▶ Calories
▶ Protein
▶ Carbohydrates
▶ Fat/Cholesterol
▶ Sodium
▶ Potassium
▶ Phosphorus
▶ Fluid
▶ Vitamins
▶ Minerals
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Nutrition Assessment:Laboratory Analysis
Monthly ▶ Albumin: 4.0g /dL or >
▶ Potassium: 3.5-5.3 mEq/L
▶ Phosphorus: 3.5-5.5 mg/dL
▶ Calcium: 8.4-10.2 mg/dl
▶ Glucose <200 mg/dL
▶ Non-fasting
▶ Product: < 55
▶ URR: >65%
▶ Hgb: 10-12 g/dL
Quarterly
▶ Hemoglobin A1C: < 7%
▶ PTH: 150-600 pg/mL
▶ Lipid Panel ▶ Chol < 200 mg/dL
▶ HDL > 40mg/dL
▶ LDL <100mg/dL
▶ Triglycerides <200 mg/dL
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Nutrition Assessment:Subjective Global Assessment
▶ Protein-energy nutritional status measurement
▶ Valid and reliable
▶ KDOQI recommended
▶ Medical history and physical exam
▶ Body composition focus on nutrient intake
▶ Subjective rating: 7 point scale
▶ Well-nourished
▶ Mild to moderately malnourished
▶ Severely malnourished
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Nutrient Needs KDOQI Guidelines
HD
Protein
(>/= 50% HBV protein)
HD: 1.2 g/kg
PD: 1.2-1.3 g/kg
Energy 35 kcal/kg <60 years 30-35 kcal/kg > 60 years
Phosphorus 10 – 12 mg/g protein
800-1000 mg/day
Adjust to meet protein needs
Potassium 2-3 g Monitor serum levels
Fluid Output + 1000 ml
Limit IDWG
Sodium 2 g
Calcium <2g including binder load
Maintain Serum WNL
Vitamins/Minerals Next Slide
Fiber 20-25 g
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Nutrient NeedsKDOQI Guidelines
HD
Vitamin C 60-100 mg
B6 2 mg
Folate 1-5 mcg
B12 3 mcg
Vitamin E 15 IU
Zinc 11-15 mg
Iron Individualize
Vitamin D Individualize
B1 1.1-1.2 mg
Vitamins and Minerals
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Nutrition Therapy Goals
▶ Provide an attractive and palatable diet
▶ Control edema and serum electrolytes
▶ Prevent nutritional deficiencies
▶ Prevent renal osteodystrophy
▶ Prevent cardiovascular complications
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Dialysis Diet
▶ Diet Order
▶ 2000 calorie, 80 g protein, 2 g Na+, 2 g K+, 1 g PO4,
1500 ml fluid restriction
▶ Meal Planning
▶ Individualize diet for patient’s lifestyle
▶ Assistance programs
▶ Nursing Homes
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Dialysis Diet
▶ Adequacy and Balance
▶ Calories
▶ Protein
▶ Protein : 1.2- 1.3 g/kg of body weight, >50% HBVp
▶ Variety
▶ Actual intakes of HD patients
▶ 23 kcals/kg/day
▶ Less than 1 g/kg/day
Energy 35 kcal/kg of body weight for <60 years;
30 to 35 kcal/kg of body weight for >60 years
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Dialysis Diet
▶ Protein is found in 2 types of foods:
Animal sources Plant sources
poultry , meat , eggs,
seafood , milk and cheese
nuts, seeds , legumes, soy
and tofu . بقوليات
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▶ Controversial key nutrition status measure
▶ Depressed values
▶ PEM, fluid overload, chronic liver/pancreatic disease, steatorrhea, inflammatory GI disease, infection, catabolism r/t surgery, abnormalities in protein metabolism, acidosis
▶ Elevated Values
▶ Dehydration, high dietary protein intake
Albumin 29
Albumin
▶ Dialysis Treatment ▶HD: 10-12 g free amino acids lost
▶ Losses increase with glucose free dialysate
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Protein
▶ 1.2-1.3 g protein/kg SBW
▶ Average patient: 80 g Protein
▶ 50% HBV protein foods
▶ HBV Proteins
▶ Beef, poultryدجاج, fish, shell fish, fresh pork, turkey, eggs, cottage cheese, soy
▶ 6 to 10 ounces daily
▶ Protein Alternatives
▶ protein bars, protein powders, supplement drinks
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▶ 2-3 g daily - adjust per serum levels
▶ Dialysis bath concentrations
▶ Stricter diet restrictions
▶ Insulin deficiency, metabolic acidosis, beta blocker or aldosterone antagonists treatments, hypercatabolic state
▶ Non-diet causes Hyperkalemia
▶ Hemolysis, high glucose, insulin deficiency, inadequate dialysis, incorrect dialysate potassium concentration, starvation, catabolism, sickle cell anemia, Addison's disease, long-term constipation
Potassium 32
Potassium Hi k foods
▶ Fruits & Vegetables
▶ Low: 20-150 mg
▶ Medium: 150-250 mg
▶ High: 250-550 mg
▶ Portion size is essential
▶ Avoid Salt Substitutes
▶ Dairy
▶ 1 cup 380-400 mg
▶ High phosphorus foods
Artichokeخرشوف
Baked Beans
Squashقرع
Beets, fresh then boiledبنجر
Black Beans
Broccoli, cooked
Brussels Sproutsبراعم
Chinese Cabbageكرنب
Carrots, raw
Lentilsعدس
Dried Beans and Peasبازيلاء فاصوليا
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PotassiumHi k foods
Bran/Bran products نخالة
Chocolate (1.5-2 ounces)
Granola
Milk, all types (1 cup)
Molasses دبس السكر 1tablespoon)
Yogurt
▶ (>200 mg / portion) The portion size is ½ cup
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PotassiumLow k fruits
Apple (1 medium)
Apple Juice
Apple sauce
Blackberries
Blueberries
Cherriesكرز
Cranberriesتوت
Fruit Cocktail
Grapefruit (½ whole)
Grapes, Grape Juice
Raspberries العليقتوت
Plums (1 whole)برقوق
Tangerine (1 whole)يوسفي
Strawberriesفراولة
Pears(1 small) canned (½ cup)انجاص
Pineapple, Pineapple Juiceاناناس
Peaches,(1small)canned(½cup) خوخ
Watermelon(limit to 1 cup)
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PotassiumLow k other foods
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 )
Rice
Noodlesمكرونة
Pasta
Bread and
bread products: (Not
Whole Grains)
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PotassiumLow k vegs
Asparagus (6 spears)
Beans, green or wax
Cabbage, green and red
Carrots, cooked
Cauliflowerقرنبيط
Celery (1 stalk)
Corn, fresh (½ ear) frozen (½ cup)
Cucumberخيار
Eggplantبادنجان
Mixed Vegetables
Mushrooms, fresh
Watercressنبات البقلة
Yellow Squashقرعة
Zucchini Squash
Onions
Parsleyبقدونس
Peas, green
Peppers
Radishفجل
Kaleكرنب
Lettuceخس
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Phosphorus
▶ Dietary intake ~800 to 1000 mg/day
<17 mg/kg SBW
▶ HD removes ~500-1000 mg/treatment
▶ 50% dietary phosphorus removed by binders
▶ Control = Binders + Diet + Adequate dialysis
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Phosphate Binders
Generic Name Brand Name Estimated Binding
Capacity
Calcium acetate
667 mg
PhosLo 30 mg
Sevelamer HCL
800 mg
Renagel, Renvela 64 mg
Calcium carbonate
500-600 mg
TUMS, Os-Cal,
Calci-Chew, Caltrate
20-24 mg
Lanthanum
carbonate
1000 mg
Fosrenol 320 mg
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Phosphorus Balance
Phos Intake
+1000 mg/day
+7000 mg/wk
Absorption
~60%
+600 mg/day
+4200 mg/wk
Binding
~50%
-300 mg/day
(10 Phoslo)
-2100 mg/wk
Dialysis removal
HD
-700 x 3 =
-2100 mg/wk
PD
-400 x 7 =
-2800 mg/wk
Weekly Phosphorus Balance + 4200 (diet) – 2100 (Binders) – 2100( HD) = Balance
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Phosphorus
High Phosphorus Foods
▶ Dairy productsمنتجات الالبان
▶ Beans & Nuts
▶ Processed meats
▶ Chocolate
▶ Pancakes, waffles, biscuits, cakes
▶ Whole wheat, bran cereals
▶ Carp, sardines, beef liver, chicken liver ,organ meats, oystersمحار
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Phosphorus
baked beans
black beans
chick peas
kidney beans
lentils
northern beans
split peas
soy beans
bran cereals
brewer’s yeast
nutscaramels
seedsBeverages
Ale, Beer
drinks made with milkchocolate drinks
Cocoa, dark colas
High Phosphorus Foods
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Phosphorus
Lower Phosphorus Foods
▶ Fresh meat products
▶ Homemade baked goods
▶ Nondairy creamer
▶ Unenriched rice milk
▶ Cream cheese
▶ White flour products
▶ Rice cakes
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Phosphorus Additives
▶ Inorganic Phosphorus absorbed easily
▶ Phosphorus binders ineffective with many additives
▶ READ THE INGREDENTS LABEL!!▶ Phosphoric acid
▶ Sodium hexametaphosphate
▶ Calcium phosphate
▶ Disodium phosphate
▶ Trisodium triphosphate
▶ Monosodium phosphate
▶ Sodium tripolyphosphate
▶ Tetrasodium pyrophosphate
▶ Potassium tripolyphosphate
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Calcium
▶ Use corrected calcium (adjusted calcium) for albumin <4 Calculation: [ (4-albumin) x 0.8] + Ca++]
▶ Diet: Less than 2 g daily
▶ Hypercalcemia▶ Ca++ based binders, supplements
▶ Vitamin D analogs/treatment
▶ Diet, fortified foods
▶ Dialysate calcium levels
▶ Hypocalcemia▶ Vitamin D, Calcijex
▶ Supplement between meals
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Parathyroid Hormone (PTH)
▶ Vitamin D is activated in the kidney to calcitriol, or vitamin D3
▶ Vitamin D3 levels fall with kidney failure
Calcium absorption ↓ and phosphorus excretion ↓ PTH increases => bone disease
▶ Vitamin D3 therapy helps prevent renal bone disease
▶ Ca and Phosphorus precipitate and calcify soft tissue
▶ Ca x Phos product goal range with treatment
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Fluid
▶HD
▶Urine Output + 1000 ml ?750
▶Limit IDWG
▶2-5% Estimated Dry weight
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Fluid
▶ 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 Popsicles Gelatin
▶Gravyصلصة الحم and Soups
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Sodium
▶ ≥ 1 L fluid output: 2-3 g Na and 2 L fluid
▶ ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid
▶ Anuria: 2 g Na and 1 L fluid
▶ Individualize
▶ IDWG, blood pressure, residual renal functions
▶ Increased Restrictions if ↑ IDWG, CHF, edema, HTN
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Sodium SEASONINGS High
Sodium Sauces
Salted Snacks
MEATS PROCESSED FOODS
Table saltSeasoning salt
Garlic saltOnion saltCelery salt
Barbecue Steak Soy
Teriyaki Oyster
CrackersPotato chips
Corn chipsPretzelsكعك مالح
TortillachipsNuts
PopcornSunflower
seeds
Hot DogsCold cuts, PastramiSausageCorned
beefSpam
Frozen prepared foodsCommercial mixesButtermilkCheeseSoupsTomato productsVegetable juicesCanned vegetables Canned raviolisChiliMacaroni & CheeseSpaghettiFast foodsPicklesمخلل
Olives
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Lipids
▶ Increased risk of lipid disorders
▶ Recommended fat intake
▶ Total Fat <30% of calories
▶ Saturated fat <10%
▶ Cholesterol <300 mg/day
▶ Difficult restrictions to achieve
▶ Omega 3 supplements for elevated triglycerides
▶ Optimum fiber intake 20-25 g/day
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Micronutrients
▶ Renal Multivitamin containing water soluble vitamins
▶ Dialyzable – take after dialysis
▶ Vitamin C in renal vitamin
▶ Limit total vitamin C 60-100 mg
↑ Vitamin C → ↑ oxalate → calcification of soft tissues and kidney stones
▶ Individualize: Fe++, Vitamin D, Ca++, Zinc
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Nutritional Supplements
▶ Oral supplements: Nepro, Ensure, Boost
▶ Powders: Beneprotein, ProSource, Eggpro
▶ Modular Protein: Pro-Stat, Promod
▶ Cookies: NutraBalance
▶ Protein Bars
▶ Meal replacements vs. snacks
▶ Over the counter
▶ Evaluate potassium, phosphorus
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Nutrition SupportEnteral
▶ Oral Supplements
▶ Barriers: compliance, fluid , palatability, cost
▶ Tube feeding
▶ Renal Formulas
▶ Nepro and Novasource Renal
▶ Barriers: acceptance, intolerance, tube placement, fluid intake, reimbursements, assistance
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Nutrition SupportParenteral
▶ IDPN
▶ Barriers
▶ Oral intake is maximized without improvement in status
▶ Usually requires documented malabsorption diagnosis
▶ Benefits
▶ Supplemented during treatment
▶ No additional tube/access needed
▶ Dialysis clinics have individual rules and criteria
▶ Specific qualifying criteria from insurance companies
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RD RolesAnemia and Bone management
▶ Anemia Management
▶ Anemia Manager
▶ Protocols
▶ Bone Management
▶ Bone Manager
▶ Protocols
▶ MD input as needed
▶ RD recommendations
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▶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.
Diabetic-Renal Diet in Hemodialysis
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▶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.
Diabetic-Renal Diet in Hemodialysis
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▶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.
Diabetic-Renal Diet in Hemodialysis
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▶Our goal for hemodialysis patients should be ahealthy lifestyle that can be maintained in the longrun, rather than a short-term "diet”. It's all aboutmaking changes that will last a lifetime--changes thatare focused on smart, sensible eating.
Conclusion 60
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