Nutrition Therapy: Nutrition Therapy: Chronic Kidney DiseaseChronic Kidney Disease

Sheryl Rosenberg Thouin, MPH, RD, CDESheryl Rosenberg Thouin, MPH, RD, CDE

Chronic Kidney DiseaseChronic Kidney DiseaseCKD is defined as either kidney damage or CKD is defined as either kidney damage or GFR < 60mL/min for <GFR < 60mL/min for < 3 months3 months

Kidney damage is defined as pathologic Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities or markers of damage, including abnormalities in blood or urine tests, or abnormalities in blood or urine tests, or imaging studies.imaging studies.

20 million Americans have CKD and 20 million 20 million Americans have CKD and 20 million more (1 out of every 9) are at risk.more (1 out of every 9) are at risk.

Approx 50% of dialysis patients have diabetesApprox 50% of dialysis patients have diabetes– Note: Insulin requirements decrease with progressive CKD Note: Insulin requirements decrease with progressive CKD

due to inefficient excretion of insulindue to inefficient excretion of insulin

Functions of the KidneyFunctions of the Kidney

Excretion of metabolic waste through urineExcretion of metabolic waste through urineWater and Electrolyte Homeostasis Water and Electrolyte Homeostasis Acid/base balanceAcid/base balanceMaintenance of bone healthMaintenance of bone health– Activation of vitamin DActivation of vitamin D– Calcium/phosphorus homeostasisCalcium/phosphorus homeostasis

Blood Pressure RegulationBlood Pressure Regulation– Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone

Stimulate red blood cell productionStimulate red blood cell production– ErythropoietinErythropoietin

Consequences of Kidney DiseaseConsequences of Kidney Disease

Decreased excretion of nutrients/wasteDecreased excretion of nutrients/wasteAbnormal calcium/phosphorus metabolism Abnormal calcium/phosphorus metabolism leading to bone diseaseleading to bone diseaseWeight loss and malnutritionWeight loss and malnutritionFluid and electrolyte imbalances Fluid and electrolyte imbalances Cardiovascular disease and mortalityCardiovascular disease and mortality

Uremic SyndromeUremic Syndrome

NauseaNausea

VomitingVomiting

Metallic tasteMetallic taste

ItchingItching

Lack of energyLack of energy

Protein-energy wasting syndromeProtein-energy wasting syndrome

Kidney Int. 2008;73(4):391-398

Goals of CKD ManagementGoals of CKD Management Achieve/maintain optimal nutritional status Prevent protein energy malnutrition Slow the rate of disease progression Prevention/treatment of complications and

other medical conditionsDM

HTN

Dyslipidemias and CVD

Anemia

Metabolic acidosis

Secondary hyperparathyroidism

Evidenced based clinical practice guidelines Evidenced based clinical practice guidelines – For all stages of kidney diseaseFor all stages of kidney disease– For related complicationsFor related complications

Glomerular Filtration RateGlomerular Filtration Rate

GFR = (140-age) X body weight (kg) X 0.85 if female [72 X serum creatinine (mg/dL)]

GFR of 100 approximates 100% kidney fxn

Normal GFR = 120 to 130 mL/min

Stages of Chronic Kidney DiseaseStages of Chronic Kidney DiseaseStage 1Stage 1 CVD risk reduction

Treat co-morbiditiesGFR > 90 ml/min

Stage 2Stage 2 Monitor progression GFR = 60-89 ml/min

Stage 3Stage 3 Evaluate

Test complicationsGFR = 30-59 ml/min

Stage 4Stage 4 Preparation for renal replacement therapy

GFR = 15-29 ml/min

Stage 5Stage 5 Renal replacement therapy (RRT)

GFR < 15ml/min

or on dialysis

Deterioration of Nutritional Status Begins Early

GFR 28 – 35 mL/min or greater Protein Energy Malnutrition (PEM) is often present at

the time patients begin dialysis. Malnutrition in pts beginning dialysis is a strong

predictor of poor clinical outcome

Medical Nutrition Therapy Medical Nutrition Therapy Recommendations (Stages 3 to 5)Recommendations (Stages 3 to 5)

Calories 30-35 kcals/kg IBW

Protein 0.6-0.8 gm/kg IBW

Sodium 1000-4000mg

Fluids Evaluate need to restrict

Potassium Evaluate need to restrict

Calcium <2000mg

Phosphorus 800-1000 mg

Vitamins Individualized

Optimal Nutritional StatusOptimal Nutritional Status

Albumin > 4.0 Stable, desirable dry weight Adequate fat stores and muscle mass Appropriate appetite and intake

Reverse epidemiology of obesity in dialysis Reverse epidemiology of obesity in dialysis patients compared with the general populationpatients compared with the general population

Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

Assessing Anemia in CDKAssessing Anemia in CDK

TESTTEST K/DOQI Goal

HgbHgb 11 to 12 mg/dL Hct can be falsely low due to fluid overload

Iron SATIron SAT > 20% Monthly test

FerritinFerritin 200-500 ng/mL Reflects tissue iron stores

Low AlbuminLow Albumin

Non-nutritional factors Infection Inflammation Co-morbidities Fluid overload Inadequate dialysis Blood loss Metabolic acidosis

CaloriesCalories

Recommended energy intake = 30 to 35 day kcals/kg

Spares body protein Maintains neutral nitrogen balancePromotes higher serum albumin levels

ChallengesDecreased appetite from uremiaVarious CKD dietary restrictionsFinding food sources for added calories

PROTEINPROTEIN

Dietary Protein Restriction…Dietary Protein Restriction…

Reduces nitrogenous waste

Reduces inorganic ions

Reduces metabolic/ clinical disturbance (uremia)

Slows rate of decline in GFR

K/DOQI protein guidelinesK/DOQI protein guidelines

(Average American Intake = 1.2 g per kg/day)

0.75 grams per kg/day for CKD stages 1 thru 3

0.6 grams per kg/day for CKD stages 4, 5

50% of the dietary protein should be HBV– HBV protein produces less nitrogenous waste

45 to 60 grams protein per day

No Protein Restriction for Dialysis Patients1.2 g per kg/day hemodialysis

– 10-12 grams lost per HD treatment

1.3 g per kg/day peritoneal dialysis

– 5-15 grams lost per PD treatment

Food

Carbohydrate4 kcals/g

Protein4 kcals/g

Fat9 kcals/g

1 cup milk 12 8 0 –10

1 oz meat 0 7 1 – 12

1 oz bread 15 3 0

1 cup veg 5 2 0

1 fruit 15 0 0

1 teaspoon fat/ oil

0 0 5

FFood Portion Estimationsood Portion Estimations

3 oz

¼ cup

1 cup&

½ cup

1 tsp

1 oz

Protein in FoodsProtein in Foods1 oz meat, poultry, fish = 7 g– ¼ cup tuna– ½ cup beans, peas, or lentils– 2 Tablespoons peanut butter– 2 egg whites = 7 g

1 cup milk = 8 g– 1 oz cheese– 1/3 cup cottage cheese

1 cup veg = 2 g1 slice bread = 3 g– ½ cup rice or pasta– ½ cup cereal

Fruit, fats, sugars = 0

Challenges with High Protein FoodsChallenges with High Protein FoodsAlso high in phosphorus and potassiumAlso high in phosphorus and potassium

MilkMilk

CheeseCheese

BeansBeans

Peanut butterPeanut butter

How much protein?How much protein?

Lunch A– 2 slices bread– Chicken breast (3 oz)– Lettuce, tomato– Mayonnaise– 16 oz milk– banana

Lunch B– 2 slices bread– 1 oz chicken – Lettuce– Mayonnaise– Iced tea– apple

Nutritional InterventionsNutritional Interventions

Encourage patients to eatEncourage patients to eat– Adjust or liberalize diet as appropriateAdjust or liberalize diet as appropriate– Frequent small meals/snacksFrequent small meals/snacks

High protein foods first if they get full High protein foods first if they get full quicklyquickly

Calorie dense foodsCalorie dense foods

Consider use of nutritional supplementsConsider use of nutritional supplements

SupplementsSupplementsProtein PowderProtein Powder– Procel, Egg/ProProcel, Egg/Pro

Liquid ProteinLiquid Protein– Pro-Stat, ProSource, LiquicelPro-Stat, ProSource, Liquicel

Liquid NutritionalLiquid Nutritional– Ensure, Boost, EnliveEnsure, Boost, Enlive

Calorie DenseCalorie Dense– Ensure Plus, Boost PlusEnsure Plus, Boost Plus

Renal SpecificRenal Specific– Nepro with Carb Steady, Re/GenNepro with Carb Steady, Re/Gen– Novasource Renal, NutriRenalNovasource Renal, NutriRenal

SODIUMSODIUM

SodiumSodiumDietary sodium restriction prevents:Dietary sodium restriction prevents:– Excessive thirstExcessive thirst

– EdemaEdema– HypertensionHypertension– CHFCHF

Sodium restriction = 2000 mg/daySodium restriction = 2000 mg/day– Range from 1000mg to 4000mgRange from 1000mg to 4000mg– Varies depending on co-morbiditiesVaries depending on co-morbidities– More liberal sodium with frequent dialysisMore liberal sodium with frequent dialysis

Sodium excretion falls at GFR < 20mL/minSodium excretion falls at GFR < 20mL/min

Sources of dietary sodiumSources of dietary sodium

Pre-prepared foods

Processed foods

Canned, bottled, packaged foods.

1 tsp salt = 2,300 mg sodium1 tsp salt = 2,300 mg sodium

2 gram Sodium Diet…2 gram Sodium Diet…Fresh foods

Limit– Cured/pickled foods– Processed– Can/bottled/packaged– Instant cereals, mixes

Avoid salt substitutes (potassium chloride)

Flavor foods with spices, vinegar, lemon juice, pepper

POTASSIUMPOTASSIUM

PotassiumPotassiumPotassium Restriction IndicationsPotassium Restriction Indications– Urine output < 1 liter per dayUrine output < 1 liter per day– GFR < 10 mL/minGFR < 10 mL/min– ACE inhibitors, beta blockers, lasixACE inhibitors, beta blockers, lasix– Hyperglycemia Hyperglycemia – Serum potassium > 5.0 mEq/LSerum potassium > 5.0 mEq/L

Dietary Potassium Restriction = 2 grams/dayDietary Potassium Restriction = 2 grams/day

Serum Potassium Goal: 3.5- 5.0 mEq/LSerum Potassium Goal: 3.5- 5.0 mEq/L

Potassium in the DietPotassium in the Diet

High (> 400 mg/serving)High (> 400 mg/serving)– BananaBanana– PotatoPotato– AvocadoAvocado– Orange juiceOrange juice

Moderate (>200 mg/serving)Moderate (>200 mg/serving)– BerriesBerries– BroccoliBroccoli– TomatoTomato

Low Potassium Fruit & VegetablesLow Potassium Fruit & Vegetables

>100 mg/serving>100 mg/serving

– CranberriesCranberries– AppleApple– CornCorn– LettuceLettuce– PineapplePineapple– String beansString beans

How much potassium?How much potassium?

Lunch A– 2 slices bread– Chicken breast (3 oz)– Lettuce, tomato– Mayonnaise– 16 oz milk– banana

Lunch B– 2 slices bread– 1 oz chicken – Lettuce– Mayonnaise– Iced tea– apple

MANAGING BONE HEALTHMANAGING BONE HEALTH

Altered Bone Turnover in CKDAltered Bone Turnover in CKD

Kidney Failure leads to…Kidney Failure leads to…

Decreased production of active Vit DDecreased production of active Vit D

Low serum calciumLow serum calcium

Phosphorus retentionPhosphorus retention

Elevated PTHElevated PTH

Secondary HyperparathyroidismSecondary Hyperparathyroidism

Mineral and Bone DisorderMineral and Bone Disorder

KI (2007) 71, 31-38. Levin et. al.

Prevalence of Abnormal Mineral Metabolism in CKD

>4.6

PHOSPHORUSPHOSPHORUS

PhosphorusPhosphorus

High serum phosphorus Bone decalcification Soft tissue calcifications Hyperparathyroidism

Phosphorus restriction for GFR < 25mL/min Normal dietary phosphorus = 1000 to 1800 mg/day

Dietary restriction = 560 to 850 mg/day Phosphate binders:

Bind phosphorus in the GI tract Must take with meals

Phoslo (calcium containing) Renvela (Sevelamer) (calcium free) Fosrenol (chewable)

Phosphorus is Phosphorus is notnot found on the found on the

Nutrition Facts LabelNutrition Facts Label

High Phosphorous FoodsHigh Phosphorous FoodsDAIRY

Cheese

Milk

1 oz

½ cup

150 mg

120 mg

PROTEIN

Egg

Liver

Peanut butter

Salmon or tuna

Nuts

1 large

1 oz

2 Tbsp

1 oz

1 oz

100 mg

150 mg

120 mg

75 mg

100 mg

VEGETABLES

Baked beans

Soybeans

½ cup

½ cup

130 mg

160 mg

BREADS

Bran

Cornbread

Whole-grain bread

½ cup

2 inch square

1 slice

350 mg

200 mg

60 mg

BEVERAGES

Beer

Cola

12 oz can

12 oz can

50 mg

50 mg

CALCIUMCALCIUM

Calcium in CKDCalcium in CKD

Maintain serum calcium 8.4 – 10.2 mg/dLMaintain serum calcium 8.4 – 10.2 mg/dL

Optimal < 9.6 mg/dLOptimal < 9.6 mg/dL

Dietary CalciumDietary Calcium1200 – 1500 mg/day (stages 3 and 4)1200 – 1500 mg/day (stages 3 and 4)

Calcimimetics: A new family of drugs (Sensipar)

Binds to calcium receptor

Decreases PTH

Active orally

Advantageous: Suppression of PTH without risk of hypercalcemia or hyperphosphatemia

FDA approved

FLUID FLUID RESTRICTIONRESTRICTION

Fluid RestrictionFluid Restriction CKD Stage 4 or 5 CKD Stage 4 or 5

Fluid: “any food that is liquid at room temp”Fluid: “any food that is liquid at room temp” Soup, gelatin, ice cream, popsiclesSoup, gelatin, ice cream, popsicles

Excess fluid buildupExcess fluid buildup– Edema, SOB, HTN, CHFEdema, SOB, HTN, CHF– Delays wound healingDelays wound healing

Fluid restriction estimations are based uponFluid restriction estimations are based upon– Urinary outputUrinary output– Disease stateDisease state– Treatment modality (dialysis, etc.)Treatment modality (dialysis, etc.)

Fluid Allowance TipsFluid Allowance Tips

Approx 48oz/dayApprox 48oz/day

Pre-measure mealtime liquidsPre-measure mealtime liquids

Drink very hot or very cold Drink very hot or very cold beveragesbeverages

Drinking from smaller cupsDrinking from smaller cups

Use spray bottle to mist mouthUse spray bottle to mist mouth

Freeze juice in ice cube tray Freeze juice in ice cube tray and eat like popsiclesand eat like popsicles

Vitamin & Mineral SupplementsVitamin & Mineral SupplementsDietary restrictions result in a diet deficient in nutrientsDietary restrictions result in a diet deficient in nutrients

Vitamin C 90 mg/dayVitamin C 90 mg/dayOver 75% of kidney disease patients have Over 75% of kidney disease patients have increased homocysteine levels. increased homocysteine levels. – Folic acid 1 mg/dayFolic acid 1 mg/day– BB66 5 mg/day 5 mg/day

No Vitamin A due to its accumulation in CKDNo Vitamin A due to its accumulation in CKDVitamin D in its active formVitamin D in its active form

1,25 dihydroxycholecalciferol1,25 dihydroxycholecalciferol

[1,25 (0H[1,25 (0H22)D)D33]]

Procrit and iron supplementationProcrit and iron supplementationSuggestion: Suggestion: NephrocapsNephrocaps

Herbal SupplementsHerbal Supplements

Use may be unsafe for CKD patientsUse may be unsafe for CKD patients– Poor clearancePoor clearance– Purity, safety, effectiveness unknownPurity, safety, effectiveness unknown– No regulation, no testing requirementsNo regulation, no testing requirements– Subject to contaminationSubject to contamination

LeadLeadmercurymercury

Herbs can interact with medicationsHerbs can interact with medications– Renal patients take > 10 meds/dayRenal patients take > 10 meds/day

Renal toxicityRenal toxicity– WormwoodWormwood– Horse chestnutHorse chestnut– SassafrasSassafras

Herbs with diuretic properties that Herbs with diuretic properties that may cause renal inflammationmay cause renal inflammation

Bucha leavesBucha leaves Juniper berriesJuniper berries Uva ursiUva ursi Parsley capsulesParsley capsules

Making Meals AppetizingMaking Meals AppetizingLunch:Two slices white breadTwo Tbsp mayonnaise with lettuce and onion1 ounce chicken or one hard boiled eggTwo canned peach halves 7 Up or Lemonade

CKD Nutrition ResourcesCKD Nutrition Resources

www.dietconsultpro.com– Relevant and easy-to-understand Relevant and easy-to-understand

nutrition education guides by Medi-Diets™nutrition education guides by Medi-Diets™Renal Nutrition Principles (non-dialysis)Renal Nutrition Principles (non-dialysis)

You Potassium IntakeYou Potassium Intake

Lowering Your Sodium IntakeLowering Your Sodium Intake

www.davita.org– Complete CKD education siteComplete CKD education site