Dr. Doaa Hamed

Lecturer of Clinical Nutrition

National Nutrition Institute –Cairo (Egypt)

Diet Planning

In

CKD & HD

Nutrition Care Process

in renal diseases

Nutrition Care Process

in renal diseases

Objective

1.Integrated renal care .

2.Importance of renal diet .

3.Nutritional counseling

4.Nutrition Care Process

Steps:-Assessment

Diagnosis

Intervention

Monitoring and Evaluation

Stages of Chronic Kidney Disease

Stage CKD I CKD II CKD III CKD IV CKD V

Description Kidney Damage

with Normal or

↑GFR

Mild ↓GFR Moderate ↓ GFR Severe ↓ GFR Kidney Failure

GFR(ml/min/1.73 m2 )

> 90 60 -89 30 -59 15 -29 < 15 or Dialysis

Stage

dependent

Actions

Prevent complications

Mineral metabolism

Nutritional monitoring

Anemia prevention

Care process Requires

A psychotherapist / motivation speaker

A diabetes educator

A renal specialist dietitian

A combination of:- Nephrologist

Nurse

pharmacist

Social Worker

patient's best friend

أكــــل أيـــه؟

What is the role of ?

Trained & experienced in Renal nutrition

Implementation of many guidelines concerning

nutritional assessment

Anthropometry, SGA, dietary interviews

Plan for nutritional management & therapy

Counseling the patient & the family

Educational activities

Why there are for ?

All patients should receive nutritional counselling based

on an individualized plane of care.(Evidence Level C) Nutrition in peritoneal dialysis Guidelines 2005

Nephrol Dial Transplant (2005) 20 ( Suppl 9) : ix28-ix33

Clinicians use several strategies, but there are barriers to

nutritional counseling which include:-

skepticism about the effectiveness of nutritional interventions

lack of specific knowledge and training about therapeutic nutrition

lack of specialty clinics, absence of guidelines, and an inadequate number of dietitians

screening

CKD

We recommend that screening should be performed (1D)

o for inpatients

o for outpatients with eGFR <20 but not on dialysis

o of commencement of dialysis then 6-8 weeks

later

Screening may need to occur more frequently if risk of

undernutrition is increased (for example by intercurrent illness)

screening

HD

Stable and well-nourished haemodialysis patients should be

interviewed by a qualified dietitian every 6–12 months or

every 3 months if they are over 50 years of age or on

haemodialysis for more than 5 years (Evidence level III).

Malnourished haemodialysis patients should undergo at

least a 24-h dietary recall more frequently until improved

(Opinion).UK Renal Association, March 2010

CKD HD

Clinical studies have shown that renal patients may

have inadequate dietary intakes during early stages

40 - 70 % of patients with end-stage renal disease are

malnourished

Protein–energy malnutrition should be avoided in

maintenance hemodialysis because of poor patient

outcome (Evidence III).

Tow types of malnutrition I & II has been described

in CKD patients

(ESPEN 2008)

PEW

Kidney International (2013) 84, 1096–1107

Beto’s PAGE System

Pediatrics • Growth / development

Adults • Promote health ( Prevention)

Geriatric • Maintain health ( Holding pattern)

End of Life • Minimaze aging effects

CKD Key Focus on…

Quality of life

Maintain optimal nutritional status

Prevent protein energy malnutrition

Slow the rate of disease progression

Prevention/treatment of complications and

other medical conditions DM

HTN

Dyslipidemias and CVD

Anemia

Metabolic acidosis

Secondary hyperparathyroidism

Renal diet minimizes the amount of wastes

A good meal plan choices can:

Minimize build-up of waste products &

fluid between treatments

Improve nutritional and functional status

Conserve muscle mass

Nutrition Care Process Steps

ADIME

Nutrition

Care

Process

assessment

History and physical examination looking for loss

of weight and muscle wasting

Dietary history

SGA (Subjective Global Assessment)

Anthropometry

Biochemical / laboratory tests

Is albumin can predicts mortality at

onset of dialysis?

Strong predictor of morbidity and mortality

(CANUSA study)

However,

Albumin is affected by non-nutritional factors Infection

Inflammation

Co-morbidities

Fluid overload

Inadequate dialysis

Blood loss

Metabolic acidosis

Albumin may not increase in response to nutritional intervention

There is No Single Magic Nutritional Index

How can we monitor and Follow-up

nutritional status?

Severely underweight Less than 16.0

Underweight From 16.0 to 18.5

Normal From 18.5 to 24.9

Overweight From 25 to 29.9

Obese Class I From 30 to 34.9

Obese Class II From 35 to 39.9

Obese Class III Over 40

Haemodialysis patients should maintain a BMI >23.0

BMI = Weight (kg) / (height [m]2)

Ideal Body Weight (IBW)

For men = [ (height(cm) – 152.4) x 0.91) ] + 50

For women= [ (height(cm) – 152.4) x 0.91) ] + 45.5

Adjusted Body Weight (ABW)

For men: Adjusted weight = [( actual weight- IB weight) x 0.38] + IB weight

For women: Adjusted wt = [(actual weight- IB weight) x 0.32 ] + IB weight

If Actual BW > 30% IBW

use

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

Subjective Global Assessment Rating Form

Dr. Doaa Hamed

Lecture of Clinical Nutrition

National Nutrition Institute –Cairo (Egypt)

HD CAPD

Loss of amino acids

6-10 g/dialysis 2-4 g/bag

Loss of glucose~25 g/dialysis

(glucose free dialysate)

uptake

Loss of protein0 5-15 g/day

(higher with peritonitis)

Inflammatory stimuli

Blood membrane contact

Cytokine release

Low grade inflammation

(particles chemicals)

Cytokine release

Is Dialysis has effect on Nutrition?

Is Dialysis has effect on Nutrition?

Daily HD or 6 HD sessions/ week

(Schulman G. Am J Kidney Dis 41:S112-S115,2003)

Improve appetite & food intake

General feeling of well being,↑ed physical activity

Fewer dietetic restrictions

↓ ed dose of medications → Phosphate & K binders,

antihypertensive drugs

↑es clearance of potential anorexic factors

Improves serum albumin levels

Dietary Recommendations

Diet Focus on…

Important Nutrients

Individual Differences

CKD

Diet Goals

HD

• Calories

• Protein

• Carbohydrates

• Fat/Cholesterol

• Phosphorus (stage 3)

• Size

• Stage of CKD

• Nutrition

• Lab results

• Size

• Nutrition

• Lab results

• Calories

• Protein

• Carbohydrates

• Fat/Cholesterol

• Na & Fluids

• Potassium

• Phosphorus

• Calcium

• Management of

• Blood pressure

• Glucose

• Minerals

• Fluid

• Weight

• Good nutrition

• Management of

• Blood pressure

• Glucose

Adequate energy intake essential to optimize nutritional

status

Present in (Carbohydrates – Fats - Protein)

Calculated based on your

current weight,

weight loss goals

age and gender

physical activity and metabolic stress

35 kcal/kg/d < 60 yrs

30–35 kcal/kg/d ≥ 60 yrs

Regular physical activity should be encouraged, and energy intake should be

increased according to the level of physical activity (Opinion).

Calories

To increase the energy content of meals:

Add extra oil to rice, noodles, breads, crackers, and

cooked vegetables.

Add extra salad dressing.

Non-protein calorie (NPC) supplement can be added

(J Ren Nutr. Nov. 2012 )

Protein

Essential for ❖ building muscles ❖ repairing tissue

❖ fighting infection ❖Keeping fluid balance in the blood

There are two kinds of proteins

◦ (HBV) or animal protein-meat, fish, poultry, eggs and dairy

◦ (LBV) or plant protein – breads, grains, vegetables, dried beans and peas

and fruits

50 -70% should be of HBV.

A well balanced diet for kidney patients should include

both kinds of proteins every day.

Protein Alternativesprotein bars, protein powders, supplement drinks

Stage 5 -

On dialysis

All stages – if

malnourished

Protein Intake

Example:

A 150 lb

(68kg)

• 82 grams• ½ cup milk

• 2 eggs or 4

egg whites

• 6 oz meat

• 3 veg.& 3 fruits

• 11 servings of

grains

• 41 – 48 grams• ½ cup milk

• 1 egg or 2 egg

whites

• 2 oz meat

• 5 – 6 veg.&

fruits

• 5 – 6 servings

of grains

Stage 4 or 5 -

Not on dialysisStages 1 - 3

• 55 grams• ½ cup milk

• 1 egg or 2 egg

whites

• 3 oz meat

• 3 veg. & 3 fruits

• 8 servings of

grains

0.75 gm/kg/d 1.2-1.3 gm/kg/d0.6 gm/kg/d

• Eat additional protein

Potential beneficial effect of

low-protein diet in CKD

Uremic symptoms diminish or disappear

(especially nausea, vomiting)

Reduce the burden of uremic toxins

(urea, H+, K+, phosphate, other)

Slow progression of renal failure ?

Reduce proteinuria

Improve nutritional status

Increases insulin sensitivity and glucose tolerance

Antioxidant effect

No Protein Restriction for Dialysis Patients10-12 grams lost per HD treatment

Aparicio M et al J Renal Nutr, 19, No 5S (September), 2009: pp S33–S35

Lipids

Patients considered at highest risk for cardiovascular disease

Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and

individualized treatment goals

requirement of fat

( 30 % total cal ) Minimize the ↑ in TG & Cholesterol

< 10% of calories → SFAc Ratio of USFAc to SFAc l fats = 2 : 1

8% SFAc l :10 % PUSFAc : 12% , MUFAc

250–300 mg cholesterol/day

Omega 3 fatty acid↓ TG & Chol. as well as phospholipids may be tried

Lipid disorders

Hypertriglyceridemia,

often normal cholesterol

but low HDL cholesterol

Chmielewski M et al. J Nephrol 21: 635-44, 2008

Carbohydrates

65-70% total kcal

70% complex sugar

(reduceTG synthesis and improve glucose tolerance)

30% simple sugar

Carbohydrate intake may need to be modified for Patients

with Diabetes to achieve the goal of HgAIC < 7 %

Carbohydrate Counting

Fiber Intake

Optimum fiber intake 20-25 g/day

Fiber Intake

Sodium

Plays vital role in regulation of fluid balance and blood

pressure

In CKD& HD:-

May result in :-high blood pressure,

fluid retention/swelling (edema)

lead to shortness of breath

Excessive thirst

CHF

Serum Sodium (nl 133-145 mEq/L)

Sources of Dietary Sodium

Eat out less (especially Fast Food)

Cook at home with low-sodium ingredients

Read labels

1,000- 4,000mg/d

for

CKD&HD

patient

diets

Cut out: • Salt

• High-sodium condiments

• Processed, cured foods

Add: • Herbs

• Spices

• Lemon

• Vinegar

No Added Salt (NAS)

Fluids

“any food that is liquid at room temp”

Soup, gelatin, ice cream, ect.

HDUrine Output + 1000 ml

Limit IDWG (2-5% Estimated Dry weight )

Excess fluid buildup

Edema, HTN, CHF and

Breathlessness

Delays wound healing

Fluid restriction estimations

are based upon:-

Urinary output

Disease state

Treatment modality (dialysis, etc.)

Tips for thirst and fluid control!

Track your fluids

Avoid chewing lots of ice

Avoid refills at restaurant

Avoid super-sized beverages

Limit salty foods

Small glasses at meals & meds

Add lemon or Lime juice to water

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

If diabetic, control blood sugars

Sodium & Fluids

The requirement for sodium and water varies markedly, and each patient must be managed individually.

Individualize

◦ IDWG, blood pressure, residual renal functions

Increased Restrictions if

↑ IDWG, CHF, edema, HTN

fluid output Na fluid

≥ 1 L 2-3 g 2 L

≤ 1 L 2 g 1-1.5 L

Anuria 2 g 1 L

Phosphorus

High serum phosphorus Bone decalcification

Soft tissue calcifications

Hyperparathyroidism

Dietary intake ~800 to 1000 mg/day OR <17 mg/kg SBW

HD removes ~500-1000 mg/treatment

Binders removes 50% of dietary phosphorus

Control = Binders + Diet + Adequate dialysis

Organic phosphorus

40 – 60% absorbed Phytates ↓ absorption

Dairy products Meat, poultry, fishSoy (soy milk, tofu)Nuts and seedsDried beans and peas Whole grains

Inorganic phosphorus

> 90% absorbed

Food additivesDietary supplementsCalcium fortification

Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519-530

Phosphorus Types

Control Phosphorus

Diet

READ THE INGREDENTS LABEL!!

Phosphorus binders ineffective

What are high and low phosphorus foods?

Control Phosphorus

Binders

Generic Name Brand Name Estimated Binding Capacity

Calcium acetate

667 mgPhosLo 30 mg

Sevelamer HCL

800 mgRenagel, Renvela 64 mg

Calcium carbonate

500-600 mg

TUMS, Os-Cal,

Calci-Chew, Caltrate20-24 mg

Lanthanum carbonate

1000 mgFosrenol 320 mg

Binders are like a sponge. They “soak up” phosphorus from food! in the GI tract

Must take with meals

Control Phosphorus

Dialysis

Among dialysis patients with persistent Hyperphosphatemia, we

suggest increasing phosphate removal via hemodialysis (Grade 2C)

Phosphate clearance is effective only during the first 2 hours of

dialysis. Serum phosphorus levels do not change during the second

half of dialysis. Haemodialysis removes approximately 900 mg of

phosphate three times weekly. (Mucsi et al., 1998; Block & Port,

2000)

Among patient with refractory Hyperphosphatemia, nocturnal HD is

an option among those who are welling to accept this form of

dialysis.

Ph IntakeAbsorption

~60%

Binding

~50%

Dialysis

Removal HD

+1000 mg/day

+7000 mg/wk

+600 mg/day

+4200 mg/wk

-300 mg/day

(10 Phoslo)

-2100 mg/wk

-700 x 3 =

-2100 mg/wk

Weekly Phosphorus Balance

+ 4200 (diet) – 2100 (Binders) – 2100 (HD) = Balance

Diet + Binders + Adequate dialysis

Calcium

Renal diet is approximately 500-800 mg / day

Diet (low ----- many foods high in ca high in ph )

1200 – 1500 mg/day based on DRI*

May need vitamin D3

Not to exceed 2g/day, including calcium-

based binders

Activated vitamin D

PTH control important

CKD Stages 1 – 4

CKD Stage 5 & HD

CKD Stages 1 – 3 Usually not restricted

CKD Stages 4 and 5 and HD Correct labs

Dietary Goal is usually 2 - 3 gms/day

adjust per serum levels

Dialysis bath concentrations

Low Potassium foods Avoid Highest Foods

Apples

Grapes

Berries

Pineapple

Tangerine

Cabbage

Green Beans

Cauliflower

Eggplant

◦ Oranges/Juice

◦ Banana

◦ Potato

◦ Mango

◦ Melon

◦ Avocado

◦ Tomato

◦ Nuts

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

Potassium

Renal Multivitamin containing water soluble

vitamins

◦ Dialyzable – take after dialysis

◦ Supplementation may improve Iron availability from

stores

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

Micronutrients

Assessment:

Diet history & any changes in dietary

intake

Weight history

SGA

Underlying medical condition

Biochemistry

GI symptoms

Social and psychological

factors

Nutrition in CKD& HD

ManagementOral Diet

Oral diet + extra snacks

Oral diet, extra snacks + supplements

Oral diet + supplementary NG/ PEG feeding

Exclusive NG/ PEG feeding

TPN

Must also optimize medical management (dialysis adequacy, acidosis, infection)

Conclusion

Poor nutrition is common in CKD & DH patients and has

adverse risk factor

Nutritional counseling –part of approach to CKD and

dialysis patients.

Routine nutritional screening & assessment should be done

for CKD and dialysis patients.

Qualified renal dietitian must be included in the staff of

every dialysis unit.

Personalized nutritional plan – worked out for every

patient.

Individualization