NUTRITIONAL MARKERS IN
HEMODIALYSISJulie Atteritano, RD, CDE, CDN
ALBUMIN Biochemical marker reflecting
visceral protein stores Most common protein found in
the blood Produced by the liver (9-12g
/day) Life span 12-20 days
ROLE OF ALBUMIN IN THE BODY Maintains intravascular oncotic
pressure Transports small molecules in the
blood such as billirubin, Ca+, Mg, Progesterone, and medications
Provides the body with necessary protein needed to maintain growth and repair tissue
TARGET LEVELS FOR ALBUMIN
Stabilized serum albumin equal to or greater than the lower limit of
the normal range. Approximately 4.0mg/dl
K/DOQI
CONSEQUENCES OF HYPOALBUMINEMIA
Increased morbidity and mortality
• Serum albumin concentrations are identified as the most powerful indicator of mortality
• Risk of death in patients with serum albumin concentration < 2.5gm/dl was 20 fold than that of patients with serum albumin 4.0- 4.5gm/dl
• Serum albumin 3.5- 4.0gm/dl resulted in a 2 fold increase in relative risk of death
• (Lowrie et al.)
CONSEQUENCES CONTINUED… Edema and ascites Decreased healing Increased risk of infection
REASONS FOR HYPOALBUMINEMIA Protein Energy Malnutrition (PEM) Caloric and protein intake are
inadequate to meet nutrition needs ** Patients on hemodialysis have a higher
Resting Energy Expenditure than patients in Stage 2 CKD
** Goal for intake- 30-35Kcal/Kg 1.2- 1.4 gm/Kg protein
HYPOALBUMINEMIA CONTINUED… Inflammation Characterized by acute phase proteins C- reactive protein (CRP), Alpha -1 acid
glycoprotein (a1-AG), Ferritin, Ceruloplasm Inflammation secondary to infection,
trauma, obesity, poorly controlled DM Hydration status Proteinuria Metabolic acidosis
DIETARY STRATEGIES TO IMPROVE ALBUMIN LEVELS Ensure adequate caloric and protein
intake Increase intake of high biological value
(HBV) proteins (Chicken, turkey, fish, red meat, eggs)
Nutritional supplementation: Nepro, Liquid protein supplements (Liquacel, Prostat), whey protein powder
STRATEGIES TO IMPROVE ALBUMIN CONTINUED…. Intradialytic Parenteral Nutrition (IDPN) Amino acids (AA), Dextrose, and lipids
delivered directly into the blood stream during hemodialysis
POTASSIUM (K+)
Potassium is a mineral and an electrolyte
ROLE OF POTASSIUM IN THE BODY Potassium is an electrolyte which means
it conducts electricity in the body along with Na+, Ca+, Mg, and chloride
Responsible for skeletal and smooth muscle contraction (crucial for heart function)
Plays a role in biochemical reactions and energy metabolism
Catalyst in the synthesis of amino acids from protein sources
TARGET LEVELS FOR POTASSIUM
Low : less than 3.5mg/dlGoal :3.5mg/dl – 5.5mg/dlHigh : 5.6mg/dl – 6.0mg/dl
Unsafe: > 6.0mg/dl
HYPERKALEMIA K+ levels > 5.5mg/dl
Causes of Hyperkalemia include: Dietary indiscretion K+ shifts from intracellular to
extracellular space (Caused by metabolic acidosis, NSAID’s, non-selective Beta-blockers)
K+ bath (3K+,4K+) Non-compliance with treatment Rx
CONSEQUENCES OF HYPERKALEMIA Nausea Weakness Numbness and tingling Irregular heart beat Heart failure Sudden death
DIETARY STRATEGIES TO IMPROVE HYPERKALEMIA
Goal for intake 2,000mg K+ per day Avoid/limit high K+ foods Avocado (1oz) 144mg Banana (small) 422mg Cantaloupe/honeydew (1 cup) 388mg Orange (small) 240mg Mango/papaya 323mg Dried fruit (ex-Apricots 10
halves:470mg) Potato/sweet potato 512-694mg Tomato (1 cup canned) 1098mg
DIETARY STRATEGIES CONTINUED… Spinach (1 cup cooked) 839mg Winter squash (1 cup) 494mg
Dried beans and peas (ex: kidney beans 1 cup 713mg) Milk (1 cup) 382mg Yogurt (8oz) 579mg Salt substitutes
LOW POTASSIUM CHOICES Apples Berries (strawberries and blueberries) Cabbage Canned peaches and pears Carrots Cauliflower Cucumber Eggplant Green beans Grapes Lettuce Non-dairy creamer Onion Rice milk Sorbet Watermelon
HYPOKALEMIA K+ < 3.5mg/dl Causes: - Decreased po intake - Excessive diarrhea or vomiting - Certain medications (ex-
diuretics) - Need for K+ bath change
(3K+,4K+)
CONSEQUENCES OF HYPOKALEMIA Muscle weakness and cramping Fatigue Confusion Problems with muscle coordination Irregular heart beat Heart failure
Dietary intervention: Liberalization
PHOSPHORUS (PO4)
Phosphorus is a mineral Most abundant after Calcium
(Ca+) 85% found in bones 14% spread throughout soft
tissue 1% in blood and extracellular
fluid
ROLE OF PO4 IN THE BODY Responsible for the growth,
maintenance, and repair of tissues and cells
Production of genetic building blocks (DNA/RNA)
Energy production: helps change protein, fat, and carbohydrates into energy
Combines with Calcium (Ca+) to form calcium phosphate (predominant mineral in bone)
TARGET LEVELS FOR PHOSPHORUS
Low: less than 3.5mg/dl Goal: 3.5mg/dl – 5.5mg/dl
High: greater than 5.5mg/dl
HYPERPHOSPHATEMIA
PO4 > 5.5mg/dl As kidney function diminishes
(decreased GFR), the kidney loses the ability to excrete PO4
Leading to elevated serum PO4 levels
CONSEQUENCES OF HYPERPHOSPHATEMIA
Calcium- phosphorus deposits - heart - skin - lungs - blood vessels Red eyes Bone disease - bone and joint pain - weak brittle bones Increased risk of mortality
DIETARY STRATEGIES TO IMPROVE HYPERPHOSPHATEMIA Lower PO4 diet Goal for intake 800- 1,000mg per day Avoid high PO4 foods - Dairy products (milk, cheese, ice cream, yogurt) - Chocolate - Dark cola (Coke and Pepsi) - Nuts and nut butters - Organ meats - Cream soups - Processed meats - Whole grain bread
DIETARY STRATEGIES CONTINUED… Phosphorus binders - Calcium Carbonate: TUMS - Calcium Acetate: Phoslo - Sevelamar Hydrochloride: Renvela - Lanthanum Carbonate: Fosrenol
Greatest limitation is Compliance!!
HYPOPHOSPHATEMIA PO4 level < 3.5mg/dl Possible causes: - Poor po intake - Need for binder dosage adjustment Consequences: - Decreased appetite - Confusion Dietary Strategies: - Dietary liberalization - Binder dosage decrease or D/C
PATHWAY OF CKDMINERAL AND BONE DISORDER
Decreased Renal Function
Decreased 1,25 (OH) Vitamin D Phosphate Retention
PTH Ca+ PO4
Secondary Hyperparathyroidism
CALCIUM (CA+) Calcium is a mineral Most abundant mineral in the body 99% of calcium in the body is in
bones and teeth 1% of calcium is found in the blood
and soft tissues
ROLE OF CALCIUM IN THE BODY Forms strong bones and teeth Aides in muscle contraction and
relaxation Transmits nerve impulses Aides in blood clotting Assists in enzymatic reactions Involved in the process of cell
division and multiplication
TARGET LEVEL FOR CALCIUM
Serum levels of corrected total Ca+ should be maintained within
the normal range for the laboratory used, preferably
toward the lower end: 8.4mg/dl – 9.5mg/dl
(K/DOQI)
HYPERCALCEMIA Corrected Ca+ > 10.2 mg/dl Causes: - Increased Ca+ intake (Ca+ based
binders, Ca+ supplements or high Ca+ foods) - Too much Hectorol/Zemplar (Active
form of Vitamin D) Treatment: - Avoid foods high in Ca+ - Change to non- calcium based binder - Decrease Hectorol/Zemplar dose
CONSEQUENCES OF HYPERCALCEMIA
CALCIFICATION
HYPOCALCEMIA Ca+ < 8.4mg/dl Causes: - Inadequate Ca+ intake - Vitamin D deficiency - High PO4 levels - Calcimimetics Treatment: - Increase Ca+ intake or begin supplementation - Initiate or increase Hectorol/Zemplar dose - Decrease PO4 levels to restore balance between Ca+, PO4 and PTH
CONSEQUENCES OF HYPOCALCEMIA
Paresthesia, bronchospasm, laryngospasm, tetany, and
seizures
PUTTING IT ALL TOGETHER…
How can we work together as a health care team to promote
patient compliance and improve patient outcome??
THANK YOU!!!!
Thank you so much for your time and attention!!
Hope you all learned a new thing or two!!