CKD MNT Module 5: The Transition from Chronic Kidney Disease to Kidney Failure

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Module 5 begins with a case study that shows how diet and medications impact Maria's journey to kidney failure and reviews how to modify meal plans to lower sodium, phosphorus, and potassium. Simple …

Module 5 begins with a case study that shows how diet and medications impact Maria's journey to kidney failure and reviews how to modify meal plans to lower sodium, phosphorus, and potassium. Simple graphics are provided to help clients learn how they can prepare for renal replacement therapy – Hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation. Learn how HD and PD treatments differ and review why the diet requirements are not the same. The pros and cons of each option are included. Numerous patient resources are shown for use when discussing treatment options. The entire program content is briefly reviewed at the end.

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  • We will discuss the transition from chronic kidney disease to kidney failure. The diet changes as chronic kidney disease develops and progresses to kidney failure. The first half of the module includes a case study. We will follow Maria as she develops kidney disease that progresses to kidney failure. You will hear more about food composition and diet changes. The second half of the module includes a discussion of the options for treating kidney failure, including hemodialysis, peritoneal dialysis, kidney transplantation and conservative management, and diet recommendations for renal replacement therapy. Module_5_4-26
  • At the end of this module, you will be able to use biochemical data to assess and monitor CKD, recommend diet changes, identify the four treatment options for kidney failure, and differentiate between the diet requirements for hemodialysis, peritoneal dialysis, and kidney transplantation. The discussion on dialysis is meant to provide background on these treatment modalities and how the diet differs so you can educate patients about them as they progress to kidney failure. Your patients may have family members on dialysis and may have questions about why they are being given different nutrition and diet instructions from their relatives. Module_5_4-26
  • Maria is a 41-year-old woman who was diagnosed with type 2 diabetes at age 30. She has a history of gestational diabetes at age 27. She lives with her husband and 13-year-old son, and works full time as a teacher's aide. Module_5_4-26
  • This table shows measurements and lab results including weight, blood pressure, glucose, and A1C. The middle column shows reference ranges without specific units. The right-hand column has Maria’s data. In December 2006, Maria weighed 80 kilograms. Her blood pressure was 120/67, random glucose was 305 milligrams per deciliter, A1C was 10.1 percent, and LDL was 146 milligrams per deciliter. She was referred for medical nutrition therapy due to uncontrolled type 2 diabetes and dyslipidemia. Module_5_4-26
  • This shows Maria’s ABCs. Maria’s A, or A1C, is high. Her B, or blood pressure, is okay. Her C, or low density lipoprotein cholesterol, is high. Module_5_4-26
  • Look beyond the ABCs and assess kidney function and kidney damage. Maria’s eGFR is 56. Serum creatinine level appears to be within the normal range, at 1.1. However, her eGFR is lower than 60. She has CKD based on this data alone. Her urine dipstick result is greater than 300. Her UACR was requested but is not available. Module_5_4-26
  • Here are Maria’s other lab results. Her BUN is slightly elevated. Both albumin and calcium are low. Her corrected calcium is in parentheses within the calcium cell. Module_5_4-26
  • Her UACR is 7,443. As you recall, a UACR of 30 milligrams per gram or less is currently considered normal. Module_5_4-26
  • If we just look at the ABCs, we miss the CKD. Module_5_4-26
  • The assessment data from 2006 is in the same format used in the other modules. For breakfast she eats a cup of oatmeal with a 1/ 2 cup whole milk, two eggs fried in butter, and two slices of buttered wheat toast. She drinks 16 ounces of coffee. Or she has just has yogurt. She tends to skip lunch. Her supper is fast foods. The night before, she ate two pieces of fried chicken, a biscuit, and coleslaw. Sometimes supper is a large burger and fries. She does not add salt to her food. Her diet experience includes following the diet for gestational diabetes during pregnancy, and she had nutrition counseling when first diagnosed with type 2 diabetes. Due to budget constraints, her son eats most of the purchased fruits and vegetables. Her medications include 70/30 insulin, 40 units twice a day, metformin 850 milligrams twice a day, lisinopril 10 milligrams daily, and simvastatin 20 milligrams daily. She takes the evening medications when she remembers, maybe twice a week. She may take 70/30 insulin at bed time instead of before supper. Maria has no exercise plan. During summer, she may walk at weekend flea markets. Height is 63 inches, weight is 176 pounds, BMI is 31.2. You have seen the lab results already. Elevated A1C, LDL, and UACR. She has poor dentition, although this is not a problem for her. Module_5_4-26
  • She has a very strong family history of diabetes. Her mother, father, and paternal grandfather had diabetes. Her mother is now on hemodialysis. Her grandfather had a left foot amputated due to uncontrolled diabetes. She is not planning on pregnancy and uses birth control. This is an important point for any of us who work with women of child-bearing age with diabetes. She is taking metformin, which may increase fertility. She denies polyuria, thirst, fatigue, and blurry vision. She checks fasting glucose, results range between 150 to 180; and experiences night-time lows when she takes 70/30 insulin at bed time. She denies mid-day lows, even though she skips lunch. She refuses to change the type of insulin and declines the use of multiple daily injections. She has difficulty coming to appointments during the school year. The food budget is tight, as her husband is between jobs. Her son is doing great in school. However, his evening activities make her meal time and medication use erratic. Module_5_4-26
  • Module_5_4-26
  • Here are the nutrient analyses for the diet recall. The second row from the bottom shows the totals. Her caloric intake was about 1,300 calories, with about 80 grams of protein, 104 grams of carbohydrate and about 62 grams of fat. Sodium intake was almost 2,300 milligrams, phosphorus intake was 1,377 milligrams, and potassium intake was only 1,554 milligrams. The bottom row shows recommended intake. Her current weight was used for estimating protein and caloric needs. Due to obesity, 23 calories per kilogram was used for weight loss. Nutrient prescription is about 1,800 calories, 64 grams protein, 230 grams carbohydrate, 61 grams fat, and 1,500 milligrams sodium. Her intake of protein, sodium, and phosphorus exceed recommended intakes. Maria’s potassium intake is inadequate. Module_5_4-26
  • So where do you start? Here is a list of potential nutrition diagnoses. LDL is elevated because she eats butter and fried foods. Carbohydrate intake is inconsistent because she skips lunch and carbohydrate content of her breakfasts varies widely. Food and medication interaction is a high priority as medication compliance is an issue. She misses evening doses of the statin, so LDL is elevated. She takes 70/30 insulin at bed time, so A1C is elevated at 10.1%. She is obese based on a BMI of 31.2 She has undesirable food choices at times, no planned exercise, and limited access to food due to income constraints. Module_5_4-26
  • The number one priority is food and medication interaction. She does not take insulin correctly and experiences hypoglycemia in the middle of the night. The second issue is inconsistent carbohydrate intake. The third issue is fat intake and LDL is high. Module_5_4-26
  • The intervention focused on the timing of evening insulin injections. She needs to take the second dose of 70/30 insulin before supper, not at bed time. A consistent carbohydrate intake and lowering saturated fat would also help. She agrees to take her medications as prescribed. Module_5_4-26
  • A phone follow-up shows she made a few changes. She takes evening meds more regularly and no longer takes 70/30 insulin at bed time. She eats school lunch. Her family is accepting two-percent milk. Fast food intake has decreased. Module_5_4-26
  • Maria missed multiple appointments and returns in December 2007. Weight is about the same. Her blood pressure is 131/74. Glucose is down to 75. A1C is higher at 11.3 percent. LDL is down to 111. BUN is 13. Her creatinine is the same, 1.1, and eGFR is 54. Sodium, potassium, bicarbonate, and phosphorus are still within range. Her corrected calcium is 9.8. Serum albumin is now down to 2.6. The UACR is higher, at 7,986. Module_5_4-26
  • High levels of urine albumin are associated with kidney damage and more rapid progression of kidney disease. Module_5_4-26
  • Maria has significant albuminuria and her kidney function declines quite rapidly in the next year or so. Module_5_4-26
  • As her eGFR declined, Maria’s blood pressure was harder to control. In the summer of 2008, she was told she has rapidly progressing kidney disease. She was very upset about the diagnosis. You may recall that her mother is on dialysis. When she came back in December 2008, she said she was eating like she did not have any diseases, meaning following an unrestricted diet. The doctor increased blood pressure medications. Module_5_4-26
  • Maria needed less insulin to help control diabetes and blood glucose levels. Even though she was eating like she did not have any diseases, both the insulin dose and A1C decreased. Module_5_4-26
  • Maria’s serum phosphorus increased as her eGFR decreased. The physician prescribed a phosphorus binder. Decreasing protein, phosphorus, and binders were discussed. Module_5_4-26
  • Maria’s 25-hydroxy vitamin D level was low and she was not always taking her vitamin D supplement. You may recall vitamin D and PTH are inversely related to each other. As her vitamin D level increased, her iPTH decreased. Module_5_4-26
  • One of the potential side effects of vitamin D supplementation is an increase in absorption of phosphorus and hyperphosphatemia. Maria’s phosphorus level increased when she restarted vitamin D. Module_5_4-26
  • We discussed the mineral and bone disorder in module 3. Maria’s vitamin D and iPTH are shown on the left. Serum calcium and phosphorus are shown on the right. Both calcium and phosphorus are increasing. Module_5_4-26
  • We discussed correcting calcium for low serum albumin in the last module. Her corrected calcium is within range, as shown in the left hand graph, in red. Module_5_4-26
  • Maria’s serum bicarbonate level decreased. The physician prescribed sodium bicarbonate. When she restricted dietary protein, she reduced dietary acid intake as well. Module_5_4-26
  • Maria’s potassium increased but not until her eGFR was quite low. Module_5_4-26
  • Maria developed anemia, and she still menstruates. This may account for her occasional low levels of hemoglobin. Module_5_4-26
  • Maria was iron deficient and started on an iron supplement, ferrous sulfate, 325 milligrams twice a day. Her ferritin and percent transferrin saturation increased. She did not receive an injectable erythropoiesis-stimulating agent. Module_5_4-26
  • This case study shows how diet and medication changes can impact CKD and its complications. Every person you work with is different and recommendations are individualized. Patient goals should be realistic. Self-management of any disease is based on patient priority and willingness to change. If the patient is not concerned about their diagnosis, provide limited information about why the diagnosis is concerning. If they want to change everything, help them pick one or two changes they can make and be successful. Module_5_4-26
  • Now we will discuss menus and food changes. You will see a healthy breakfast, a healthy lunch, a healthy supper, and possible changes for CKD. We have discussed the steps before. Not everyone will follow the steps in the same order. Prioritize changes based on lab results and patient concerns. Module_5_4-26
  • Menus used here were adapted from the American Dietetic Association Nutrition Care Manual for type 2 diabetes. Although total fiber content is not shown, a high fiber breakfast is considered healthy. This menu provides about 300 calories, 19 grams protein, 58 grams carbohydrate, 10 grams fat, 429 milligrams sodium, 489 milligrams phosphorus, and 919 milligrams potassium. Bran flakes and whole wheat bread have more fiber than cereal without bran and white bread. The cereal and bread provide most of the sodium in this meal. Whole grains contain more phosphorus and potassium than refined grains. Milk accounts for half of the total phosphorus and over a third of the total potassium. Module_5_4-26
  • If serum potassium is elevated, two-thirds of a cup of blueberries is better than half of a banana. A high potassium fruit such as banana could fit if the portion is small. A low potassium food may become a source of potassium if the portion is too large. Module_5_4-26
  • A cereal other than bran cereal will decrease sodium, phosphorus, or potassium intake. The red bars show sodium, gold bars show phosphorus, and blue bars show potassium contents. Low sodium corn flakes contain the least sodium, phosphorus, and potassium of the cereals shown. The regular corn flakes may be fortified with calcium and phosphorus, as the phosphorus level is higher. The processed whole grain cereals shown on the right add to sodium, phosphorus, and potassium intakes. Module_5_4-26
  • Convenience foods such as instant hot cereals may be higher in sodium, as shown here. Once again, the whole grains such as whole wheat and oatmeal add to phosphorus and potassium intake. Phytates in the whole grains may limit the amount of phosphorus that is absorbed. Module_5_4-26
  • Milk and soy milk add to sodium, phosphorus, and potassium intakes. Protein-fortified milk is higher in all three nutrients. Brands of soymilk vary in nutrient content due to fortification. Of the choices shown, rice milk is the low potassium choice. Module_5_4-26
  • Yeast bread and other breads add to daily sodium intake. Whole wheat bread has the highest phosphorus and potassium content of the yeast breads shown. Corn tortillas are very low in sodium, however they are a source of phosphorus. Module_5_4-26
  • As you can see, egg whites are lower in sodium, potassium, and phosphorus compared to egg substitute. Remember, egg white is the exception to the general rule that protein-rich foods are rich in phosphorus. Module_5_4-26
  • Coffee and tea add to potassium intake. Brewed has more potassium than instant versions. You already know that certain brands of iced tea may have added phosphorus and potassium. Module_5_4-26
  • This table summarizes possible changes in breakfast choices. Check Nutrition Facts labels of cereals for sodium. Fortified cereals may also contain added phosphorus. Whole grains have more phosphorus and potassium than refined grains. Start with portion control for milk. Avoid protein-fortified milk due to higher sodium, phosphorus, potassium and protein content. Read the Nutrition Facts label and ingredient list when choosing non-dairy beverages, such as soy or rice milk. Wheat bread and tortillas have less phosphorus than those made with cornmeal. Egg whites are lower in sodium, phosphorus, and potassium than egg substitutes. Modify fruit choice if potassium restriction is indicated. As mentioned earlier, instant coffee and tea tend to have less potassium than brewed versions. Module_5_4-26
  • The lunch menu is adapted from the American Dietetic Association Nutrition Care Manual type 2 diabetes vegetarian meal plan. A vegetarian lunch may be good for the heart. Vegetable proteins are low in saturated fat and are a source of phytochemicals. You know that beans and legumes are rich in protein, phosphorus, and potassium and certain vegetarian items may be a source of sodium. This menu contains 427 calories, about 26 grams protein, 53 grams carbohydrate, 13 grams fat, 1,350 milligrams sodium, 358 milligrams phosphorus, and 1,367 milligrams potassium. Convenience foods are used here to emphasize sodium content. As you look down the sodium column, notice one tablespoon of reduced fat Italian dressing has 161 milligrams of sodium. The reduced sodium vegetable soup has almost 500 milligrams of sodium. The garden burger, also a convenience food, adds to total sodium. People can use the Nutrition Facts label to find lower sodium products. Module_5_4-26
  • Salad greens differ in potassium content. Not all greens are shown here. Per one cup, red leaf lettuce has the least and spinach has the most potassium. Module_5_4-26
  • Salad dressing may be a significant source of dietary sodium. Serving size shown is one tablespoon. Homemade salad dressing is generally lower in sodium than store bought or restaurant dressing. Two tablespoons is generally the serving size of fat-free salad dressings. Module_5_4-26
  • Beans and legumes are rich in phosphorus and potassium. Canned beans, although high in sodium, may be lower in potassium than beans prepared at home. Some potassium leaches out of the product and into the water. They are still a significant source of potassium. Module_5_4-26
  • In module 4, you checked sodium and potassium content in specific canned vegetable soups. Not every low or reduced sodium soup will have potassium chloride in place of sodium chloride. The reduced-sodium tomato soup on the far right has the same amount of potassium as the regular tomato soup. Use the ingredient list to check for added potassium chloride in lower sodium products. Module_5_4-26
  • Although the lunch menu did not include fast foods, many people routinely eat out for lunch. This discussion would not be complete if we didn’t address fast foods and restaurant foods. Salad dressing packets offered at fast food restaurants are larger than a one tablespoon serving. The smaller single-size items are still high in sodium, although certainly a better choice than the double burgers or three or four tacos. Double meat means more sodium, phosphorus, and potassium. You can check the Case Western Reserve University Web site shown here for information about certain fast food chains and phosphorus additives in their products. Module_5_4-26
  • On the left side, you see sodium content of a side salad and different salad dressings from a fast food chain. The salad dressing packets are two fluid ounces and contribute significant amounts of sodium. On the right, you see phosphorus and potassium contents in those products. Milk-based products have more phosphorus and potassium. Module_5_4-26
  • The size of a cheeseburger makes a difference. On the far left, the plain regular cheeseburger has over 500 milligrams of sodium. Sodium content goes up as condiments, vegetables, and portion size increase. The double meat cheeseburger, shown on the far right, has the most sodium, phosphorus, and potassium. Keep in mind, some of the sodium is from the bun and cheese. Module_5_4-26
  • On the far left, you see the small fast food bean burrito has almost 500 milligrams of sodium. Beans, cheese, and meat add to sodium, phosphorus, and potassium in fast foods. Module_5_4-26
  • One slice of thin crust cheese pizza is the lowest sodium choice shown here. Added pepperoni increases sodium and, of course, fat, which is not shown. Module_5_4-26
  • Nuts have protein; most protein-rich foods have phosphorus and potassium. One tablespoon of any of these products adds to phosphorus and potassium intakes. The reduced fat peanut butter has more sodium than the other peanut butters shown. Module_5_4-26
  • This slide summarizes possible changes for lunch. As you look down the sodium column, regular salad dressing is generally a source of sodium. Lower sodium versions may have added potassium. Raw fresh vegetables are low in sodium. Regular canned or pickled vegetables add sodium to any salad. No-added-salt canned vegetables have less sodium than regular canned vegetables. Soup made from scratch usually has less sodium than canned, dried, instant, or restaurant soup. Restaurant and fast food sandwiches are higher in sodium. Protein-rich foods such as meat, cheese, beans and peas, nuts, and seeds add to phosphorus and potassium intakes. A few tips for lunch are included at the bottom. Have salad dressing on the side, dip the fork into the dressing, and then into the salad. Take leftovers for lunch instead of going out. Eat out once a week or less. Module_5_4-26
  • This menu is adapted from the American Dietetic Association Nutrition Care Manual type 2 diabetes meal plan. A variety of foods provides a variety of nutrients. This meal has almost 500 calories, 36 grams protein, 56 grams carbohydrate, 14 grams fat, 451 milligrams sodium, 575 milligrams phosphorus, and over 1,600 milligrams of potassium. Look down the sodium column; the rotisserie chicken is the biggest source of sodium. The skim milk provides the most phosphorus and potassium. Module_5_4-26
  • You checked the nutrient content of enhanced pork tenderloin in module 4. Poultry products may also be enhanced with added sodium and phosphorus. Stewed chicken has the lowest amount of sodium, phosphorus, and potassium here. The broth from the stewed chicken or meat may contain some phosphorus and potassium. Removing the breading from fast food chicken lowers sodium intake to some degree. Module_5_4-26
  • Boiling potatoes removes potassium. As you can see, the skin of the potato contains some potassium. The baked potato with skin has the most potassium. Peeling and boiling any type of potato, including sweet potatoes, lowers potassium content. As you recall from module 4, leaching or soaking potatoes in water prior to boiling is not necessary. Peeling, cutting or shredding into small pieces and immediate boiling effectively removes some of the potassium from potatoes and many tubers. Module_5_4-26
  • One half cup of boiled green beans has less potassium than one half cup of microwaved green beans. This applies to both fresh and frozen green beans. Some potassium leaches out into the water during boiling. Module_5_4-26
  • Salted margarine and salted butter, as their names imply, contain sodium. You see those on the left. The graph on the right shows saturated fat and trans fat content. Hydrogenation of liquid oil increases trans fat content. Butter is a significant source of saturated fat, with over 7 grams in one tablespoon. Module_5_4-26
  • Brown and wild rice contain more phosphorus and potassium than refined white rice. Potatoes are a significant source of dietary potassium regardless of preparation. Module_5_4-26
  • One half cup of raw spinach on a salad or sandwich is not a significant source of potassium. However, one half cup of cooked spinach is a significant source. When we consider how much spinach “shrinks” during cooking, one half cup of cooked spinach is a much larger amount of total spinach. Some potassium leaches out of canned spinach. Module_5_4-26
  • Processed cheese has more sodium, phosphorus, and potassium. Read the ingredient list to check for added sodium, phosphorus, or potassium. Module_5_4-26
  • Portion size matters when considering potassium in fruit. A small peach has less potassium than a medium, large, or extra-large peach. Canned peaches are “soaking” in liquid and some potassium leaches out of the fruit. Avoid drinking the juice from the canned fruit if restricting potassium. Dried fruit tends to be high in potassium. Peach nectar is similar to cranberry juice cocktail in that it has added sugar. Module_5_4-26
  • You already know about the nutrient content of certain beverages. This graph summarizes some of the products you checked in module 4. Recommend light colored soda pop instead of dark colas to reduce phosphorus. Sports drinks vary in sodium, phosphorus, and potassium content. The fitness drink has the highest amount of phosphorus in the beverages shown. Module_5_4-26
  • Changes for supper include preparing food at home using ingredients without food additives. Use less salt. Cook with liquid vegetable oil instead of solid fats. Use less meat, poultry, and fish in soup and stew. This not only stretches the food dollar, it reduces nitrogen, phosphorus, potassium, and acid load. Rice and noodles are lower in potassium than potatoes. Module_5_4-26
  • You have heard about changes that can be made. Where do you start? Module_5_4-26
  • Start with the steps discussed throughout this program. Step one, choose and prepare foods with less salt and sodium. Step two, eat the right amount and the right type of protein. Step three, choose foods that are healthy for your heart. Module_5_4-26
  • Step four, choose foods with less phosphorus. Step five, choose foods that have the right amount of potassium. Module_5_4-26
  • At follow-up visits when you need to focus on one specific nutrient, use these individual factsheets. These were developed based on recommendations from dietitians. Module_5_4-26
  • Use the Nutrition Facts label to identify foods lower in sodium. Module_5_4-26
  • Read ingredient lists to identify foods with added phosphorus and potassium. Avoid those products if possible. Module_5_4-26
  • Use “Your Kidney Test Results” to show changes in lab results. You may find this helps you remember measurement and lab data used to monitor kidney disease and the associated complications. Module_5_4-26
  • The guide summarizes what you have heard in an easy to read chart. This tool includes assessment, management and treatment for patients with kidney disease who are not on dialysis. Module_5_4-26
  • The next portion of this module will include a description of the treatment choices for patients requiring renal replacement therapy.   Module_5_4-26
  • Kidney failure is defined as an estimated GFR of less than 15 milliliters per minute. Many patients with GFR less than 15 require dialysis for continued health, but some patients can tolerate very low levels of kidney function. However, at some point, all patients will reach a level of kidney function where their kidneys are unable to maintain homeostasis, and they will experience fluid, electrolyte, and hormonal imbalances as well as metabolic abnormalities. End-stage renal disease is an administrative term, which describes patients receiving treatment with dialysis or kidney transplant. Module_5_4-26
  • People with kidney failure have the same complications previously discussed in association with CKD. These include anemia, hyperkalemia, hypoalbuminemia, metabolic acidosis, and bone disease. For people who are on dialysis, the management may be somewhat different. Anemia is often treated with erythropoiesis-stimulating agents and with intravenous iron. Hyperkalemia is prevalent but may be less so in certain individuals and in people on peritoneal dialysis. Hypoalbuminemia is often a reflection of co-existing inflammation and malnutrition. Metabolic acidosis is often managed with dialysis, and bone disease is managed through a variety of complex regimens. Module_5_4-26
  • It’s important to know, while preparing patients with chronic kidney disease for eventual renal replacement therapy, that Medicare now has a kidney disease education benefit. It is available for Medicare beneficiaries with an estimated GFR less than 30 who are covered under Medicare Part B. Qualified providers of this educational benefit include physicians, physician assistants, nurse practitioners, and clinical nurse specialists. As currently defined, unfortunately, dietitians are not included as qualified providers for this educational benefit. The benefit covers up to six sessions. Module_5_4-26
  • The topics which must be covered in this curriculum include physiology, diet, prescription, drugs, and treatment options. To meet Medicare requirements, the educational program must be customized to help the patient manage their kidney disease and comorbidities and to prevent complications. Module_5_4-26
  • We know that an informed patient is better prepared, that consistent messages are more helpful to the patient, and that educational efforts like this may help patients be more successful in self-management. Module_5_4-26
  • We encourage you to discuss renal replacement therapy early in the course of progressive kidney disease. Coming to terms with kidney failure and the treatment choices takes a great deal of time. The treatment is complicated and patient fear and anxiety make comprehension more difficult. As a result, it often takes a long time for patients to come to terms with their prognosis and to understand their treatment options. So, it is prudent to discuss options early with patients with progressive kidney disease to give them time to prepare. If you have a patient, for example, who is middle aged with an eGFR of 30 and is otherwise likely to survive long enough to reach dialysis, early discussion of kidney failure may be of great benefit to the patient. People diagnosed with kidney failure may go through a grieving process and that takes time and support. If possible, it’s wise to include family members, if that’s acceptable to the patient. It’s also important to convey that the dietary instruction you give them will change as kidney function changes and will also be affected by the renal replacement modality that they choose. Module_5_4-26
  • One of the best resources for helping patients understand their treatment modalities is this booklet, which is available from the National Kidney and Urologic Disease Information Clearinghouse. Module_5_4-26
  • There are four options for treating kidney failure. Three options involve renal replacement therapy, or kidney replacement therapy, including hemodialysis, which can be in-center or at home, three or more times a week; peritoneal dialysis, which is a daily treatment performed at home; or kidney transplantation. There’s also conservative management when the patient wishes to receive medical support but does not want to consider dialysis or a transplant. Module_5_4-26
  • Dialysis, whether it’s hemodialysis or peritoneal dialysis, involves the diffusion of substances across a semi-permeable membrane which replaces the kidney. In hemodialysis, it is the dialyzer; in peritoneal dialysis, it is the peritoneum. Substances move down a gradient from high-concentration to low-concentration. The efficiency of the process is affected by the surface area across which the diffusion takes place and by the size of the diffusing substance. A large surface area membrane is more efficient than one with small surface area. Protein-bound substances, which are very large, cannot be dialyzed well. Module_5_4-26
  • Hemodialysis can occur in two settings: in-center hemodialysis, the most common type, is usually performed three times a week, sometimes four; and home hemodialysis, which may be performed three times a week or more, up to daily. Home hemodialysis gives the patient more control, but generally, will require assistance from a family member. Module_5_4-26
  • The process of hemodialysis is shown schematically here. Blood is removed from the body though the red line and propelled by a blood pump, which is, essentially like a rolling pin on the outside of the tube. The blood passes through the dialyzer and then is returned to the body through the blue line. Along the way, there are blood pressure monitors and detectors to ensure that the procedure is safe. The blood, while it does pass outside of the body, remains inside the tubes or in the dialyzer and does not actually go inside the hemodialysis machine.
  • This schematic shows how dialysis actually occurs. Blood enters at the top of the dialyzer, in this case, and is forced into multiple, very thin hollow filaments made of a semi-permeable membrane. Each filament is about the size of a human hair. As blood passes through those hollow filaments, dialysis solution, which is colored blue, passes in the opposite direction on the outside of these filaments. In the less than one second that it takes for the blood to pass from the top of the dialyzer to the bottom, waste products are able to diffuse into the dialysate and then be carried off. Remember, efficiency of diffusion is based on size. Protein-bound substances are usually not removed. Some amino acids, glucose, and water-soluble vitamins are removed. Module_5_4-26
  • The nutrient losses during dialysis do need to be replaced. More dietary protein is needed to replace the losses during dialysis, and vitamins formulated for dialysis patients may be used to compensate for the losses of water-soluble vitamins during dialysis. Generally, these vitamins are taken after treatment to avoid loss during dialysis. Module_5_4-26
  • The hemodialysis prescription is individualized, like all treatments. The goal is to maintain homeostasis in the patient. Adequate dialysis requires adjustment of several dynamic factors including the type and size of the dialyzer, the blood flow rate, the dialysate composition, and the time during which dialysis occurs. Longer treatment time, larger dialyzer, and higher blood and dialysate flow rates are all associated with higher levels of clearance of waste products. There are a number of individual patient factors which must be taken into account, including body size and diet. Module_5_4-26
  • Hemodialysis removes substances that accumulate between treatments including fluid, nitrogenous wastes, and potassium. Acidemia is treated with bicarbonate absorbed from the dialysate. The levels of these substances improve over the three or four hour dialysis treatment and then gradually accumulate again until the next treatment. Module_5_4-26
  • It’s important to remember that dialysis, even highly efficient dialysis, replaces only a fraction of normal kidney function. Remember that a normal kidney works 24 hours a day, seven days a week, and even a damaged kidney with a GFR of 20 works constantly, although at a reduced level. The artificial kidney in hemodialysis only works for a few hours, three or four times a week. More frequent dialysis, which can involve dialysis for six to seven hours, five to six nights a week, comes much closer to maintaining patients’ status at a normal level. However, it still does not approximate normal kidney function. Module_5_4-26
  • In order to perform hemodialysis, vascular access must be created. Blood flows in dialysis are usually around 400 milliliters of blood per minute. Withdrawing blood at that rapid rate from any native peripheral vein would collapse that vein. What’s required is a blood vessel from which blood can be drawn at a high rate without causing collapse. This can be accomplished by creating an artificial connection between an artery and a vein where some of the blood is diverted towards the vein. The resulting high blood flow through the vein causes it to dilate and thicken. A direct connection between the artery and the vein is called an arteriovenous or AV fistula. When it is not possible to create a fistula, a piece of synthetic tubing may be interposed between the artery and the vein. When dialysis must be performed emergently, temporary access may be placed. That is usually a catheter placed in a central vein. Permanent access is usually placed in the non-dominant arm. It’s important to advise patients with chronic kidney disease to protect the blood vessels in both arms. A large IV, such as a PICC line, placed in a peripheral vein can destroy that vein for any future use in dialysis. Patients with chronic kidney disease should be encouraged to avoid venepuncture or IV catheter placement above the wrist in either arm, if that is possible. Module_5_4-26
  • An AV fistula is the preferred permanent vascular access. It’s created when a direct connection is made between the artery and the vein. It takes many weeks to mature. Maturation involves dilation and thickening of the vein which occurs as a result of increased blood flow. When the fistula is mature, it’s possible to access high blood flow for dialysis through a percutaneous needle stick. Of the different methods of obtaining vascular access, fistulas are the least likely to become infected or clot.
  • The second choice is an AV graft which is placed when a direct connection between an artery and vein cannot be made due to small vessel size or other mechanical problems. Placing a graft involves making a connection between the artery and the vein with a synthetic tube. Compared to a fistula, a graft requires less time to heal before it’s ready to use, but is more likely to become infected or clot.
  • Temporary access is a catheter, usually placed in the neck and used for emergency treatments. It is not a permanent solution for vascular access. Catheters are associated with inadequate dialysis, increased infection rate, increased clotting, and inflammation.
  • In-center hemodialysis is a scheduled procedure. Most patients will receive a scheduled time for their treatment on Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday. The treatment itself will last three to four hours, but the entire process takes longer because patients have to arrive and check in, generally wait before treatment and briefly after treatment to make sure they’re doing well. Module_5_4-26
  • Home hemodialysis is an option that’s becoming more popular. It does require training and support. It may be done three times per week like conventional dialysis but there are other options. These include daily home dialysis done for two to three hours, five to six times per week, and nocturnal dialysis, which may be done for six to eight hours, three or more days per week. More frequent home dialysis appears to be associated with significant benefits to the patient. Module_5_4-26
  • The advantages of in-center hemodialysis are that facilities are found throughout the country and the staff does the work. The patients, if they wish to, can be relatively passive. Needles are placed by the staff, the treatment is monitored, and equipment is maintained by the staff. The other advantage is that many people with end-stage renal disease, like other people with chronic diseases, may find themselves a bit socially isolated and may enjoy the social setting of the dialysis unit. They spend three to four hours, three times a week with the same relatively small group of people and providers. The disadvantages are that the dietary restrictions may be more stringent. Patients have to follow a schedule over which they have no control. They must travel to and from the unit. They are never at equilibrium. They’re experiencing either a gradual increase in waste products and fluid between dialysis treatments, or a rapid decrease during treatment. These rapid up and down cycles may leave them feeling fatigued. In addition, some nutrients are removed during hemodialysis. Module_5_4-26
  • Home hemodialysis has a different set of advantages and disadvantages. Patients have control over their schedule, they don’t have to travel to the unit, the newer machines are small and easier to use, and, if it’s done more frequently, there are less severe ups and downs. Also, diet may be less restrictive. The disadvantages are that a partner to assist at home is usually required. This may cause stress for the patient or the partner. Space is needed for the machine and supplies. Either the patient or the partner need to insert the needles, and it may be necessary to take time off from work for the initial training which is not offered everywhere. Module_5_4-26
  • The nutrition prescription for in-center hemodialysis is shown here. Amino acids are removed during treatment and protein requirements are higher. Sodium, phosphorus, potassium, and fluid intakes are restricted. The most difficult parts of this diet for patients are the phosphorus and fluid restrictions. Phosphorus binding medications should be taken with meals. Module_5_4-26 Shiro-Harvey, 2002
  • Home hemodialysis may include more frequent treatments, and the patient may have fewer dietary restrictions. Phosphate binders may be less necessary and sometimes are not needed at all. Protein requirements are higher due to protein losses during treatment. Module_5_4-26
  • Another treatment modality, peritoneal dialysis or PD, works well for many patients. Module_5_4-26
  • There are several options for peritoneal dialysis. CAPD is a manual treatment that is performed four to five times during the day. CCPD involves a mechanical cycler and can often be performed at night. Some patients may need a combination of both. In peritoneal dialysis, the peritoneal membrane serves as the filter, or the artificial kidney. Patients using PD may not require any vascular access, but they’ll still have to have minor surgery to have a PD catheter placed. Some patients experience body-image concerns associated with the catheter. Peritoneal dialysis is continuous therapy. Patients reach an equilibrium at which they remain, avoiding the up and down cycles of hemodialysis. Module_5_4-26
  • In peritoneal dialysis, the peritoneal membrane is the semi-permeable filter, replacing the kidney. Dialysis solution flows into the peritoneal space. Waste products move by diffusion down the concentration gradient from the blood into the dialysis fluid. The efficiency of this clearance is determined by the concentration gradient, the size of the solute, and the permeability of the peritoneal membrane, which can vary over time. The dialysate includes an osmotic agent which pulls fluid into the peritoneal cavity, removing water and producing some additional clearance by bulk flow. Module_2_4-26 POST EDITING
  • In peritoneal dialysis, the peritoneal membrane is the substitute kidney. This diagram shows schematically what happens during a cycle of dialysis or exchange. The blue bag is a two to three liter bag of dialysate, a physiologic solution with added dextrose. Dialysate flows into the peritoneal cavity. The solution remains for a prescribed period of time, known as the dwell time, during which solutes and fluid pass from the capillaries in the peritoneum into the peritoneal cavity. This is represented here by a darkening of the solution. During the dwell, dextrose also passes in the other direction, and may raise blood sugar. At the end of the exchange, the solution is drained and discarded, and another cycle is begun.
  • A dialysis exchange describes one complete fill and drain cycle. Module_5_4-26
  • As with hemodialysis and all other treatments, the peritoneal dialysis prescription is individualized. Generally, dextrose solutions are used as the osmotic agents. Depending on how much fluid must be removed, different concentrations of dextrose will be used. Of course, as the dextrose concentration is increased, more fluid will be removed but also more dextrose will be absorbed and the blood sugar will be elevated. Exchanges are generally two to three liters in volume. The dwell times and number of exchanges vary depending on the individual and the characteristics of the peritoneal membrane. Module_5_4-26
  • CAPD is a manual process that generally involves three to four exchanges per day.
  • CCPD involves use of a cycler, a small appliance, which performs the exchanges automatically. Many patients are able to do enough dialysis during the night while they sleep so that they don’t have to do additional exchanges during the day. Some patients do one or two additional manual exchanges during the day in order to get adequate clearance. Most patients on peritoneal dialysis now use the cycler.
  • The advantages of peritoneal dialysis include better preservation of residual renal function, the remaining kidney function when people start dialysis. Because the blood pressure doesn’t rise and fall as occurs in hemodialysis, peritoneal dialysis may preserve that residual renal function better than hemodialysis. This is important because even a small amount of residual kidney function can make a big difference in survival. Peritoneal dialysis can be done by the individual. It’s under the patient’s control, including time and location of treatment. It’s easy to travel, and it’s not necessary to transport a large machine. There’s no need to go to the dialysis unit, and treatments are done daily, so patients have a fairly constant biochemical status. The disadvantages include space required for supplies, which are usually delivered monthly. Treatment is daily and must be performed as prescribed. It’s necessary to follow a strict protocol to avoid infection. Supplies must be transported when patients travel. Weight gain may result from the absorption of dextrose, and absorption of dextrose may make it hard to control diabetes. Module_5_4-26
  • For most people on peritoneal dialysis, potassium restriction may not be as strict as hemodialysis. However, amino acids lost during the exchanges must be replaced and dietary protein needs are higher. Absorbed dextrose may add weight and people with diabetes are never really fasting. Glucose levels may be harder to control. It is possible to add insulin to the dialysis solution. Module_5_4-26
  • Here is the nutrition prescription for peritoneal dialysis. Protein requirements are higher due to daily losses. Sodium and potassium restrictions are still required, but may not be as strict as hemodialysis. Daily treatment means daily removal of toxins. Phosphorus is still restricted and binders are still required. Caloric intake guidelines must compensate for calories absorbed from the dialysis solution. Module_5_4-26 Shiro-Harvey,2002
  • The calories in the dialysis solution vary according to the dextrose concentration and the size of the bag. In CAPD, 60 to 70 percent of the dextrose is absorbed. The longer the dwell time, the more dextrose in absorbed. In CCPD, where the cycle times are shorter, 40 to 50 percent of the dextrose is absorbed. Module_5_4-26 McCann,2009
  • Here is an estimate of the caloric gain associated with a typical peritoneal dialysis prescription. Assuming 60 to 70 percent absorption, 250 to 290 calories are absorbed daily. Module_5_4-26
  • More information about peritoneal dialysis dose and adequacy is available from this publication from the National Kidney and Urologic Disease Information Clearinghouse. Module_5_4-26
  • The final option for renal replacement therapy that we’ll discuss is kidney transplantation. Transplantation is well described in this booklet, also available from the National Kidney and Urologic Disease Information Clearinghouse. Module_5_4-26
  • It’s important to bear in mind that kidney transplantation is a treatment, not a cure. Transplants work very well but eventually they do fail. Donor kidneys come from deceased and living donors. Generally it’s necessary for donor and recipient to be ABO blood type compatible. It’s also helpful to find the best match for transplant antigens. Pre-transplant evaluation can take several months and eligibility varies from center to center. Some centers are more willing to transplant patients with high BMI than others. The transplant procedure is major surgery, and maintaining the transplanted kidney requires taking medications daily and getting routine follow-ups. Module_5_4-26
  • The transplanted kidney is generally placed in the groin. The native kidneys are usually not removed unless they’re infected or very large due to cysts. The transplanted kidney is transplanted with donor blood vessels which are attached to the inguinal blood vessels. The donor kidney ureter is attached to the recipient’s bladder.
  • The advantages of kidney transplant include that the recipient has a normal functioning kidney, doesn’t need dialysis, may eat a near normal diet, and may live longer and have a better quality of life. The disadvantages are that it takes a long time to get a kidney if waiting for a deceased donor kidney. In many states the waiting time is three to seven years. Transplant does require major surgery. There is always the risk of rejection although this has decreased with advances in treatment. It is necessary to take anti-rejection medicines, which suppress the immune system and increase the risk of infection and malignancy. There may be weight gain, and diabetes may be harder to control. Module_5_4-26
  • There is no one nutrition prescription for the patient with a transplant, but certainly whatever other co-existing medical problems the patient has which could affect the kidney, such as diabetes or hypertension, need to be managed as well as possible to avoid recurrent disease in the transplanted kidney. The patient may need to follow a sodium restriction, to follow a calorie-reduced diet, and to avoid weight gain that may be associated with some medications. Module_5_4-26
  • The final treatment choice is conservative management, which is active medical management for patients who do not wish to receive transplant or undergo dialysis. Many complications can be treated, but there’s no non-dialysis treatment to replace the loss of clearance of uremic toxins. Eventually, the patient will become uremic. Medications usually are continued and can be adjusted. It’s important to provide comfort and palliative care. For patients who are declining renal replacement therapy, it’s important that they and their families understand that eventually, without renal replacement therapy, the patient will die from uremia. This needs to be presented to the patient in a way that doesn’t question their decision but that ensures that this life and death decision is an informed one. Module_5_4-26
  • To summarize treatment options, discuss treatment options early in the course of CKD, and let the patient know the diet will change depending on the chosen option. Hemodialysis requires the most dietary restrictions. Keep in mind the calories in the dextrose solutions used in peritoneal dialysis may cause weight gain and make diabetes harder to control. Transplant requires daily immunosuppressant therapy for the duration of the transplant. Module_5_4-26
  • As discussed, Maria was upset when she heard she had progressive chronic kidney disease. She has a vascular access in place and is waiting for a kidney transplant. Module_5_4-26
  • Maria had significantly elevated albuminuria, and kidney disease rapidly progressed to kidney failure. Dietary interventions included protein, sodium and phosphorus restrictions. Now she needs to restrict dietary potassium as her serum level is elevated to 5.0. The diet will change once she begins dialysis. At that time, she will be instructed to eat more protein to help replace amino acids removed during treatments. Sodium, phosphorus, and potassium restrictions will continue. Fluid restriction will be required. Module_5_4-26
  • As we conclude, let’s summarize the content of this CKD curriculum. Module_5_4-26
  • Use eGFR and UACR to identify and monitor CKD. An eGFR less than 60 is considered CKD. We discussed that eGFR declines with age, but not all elderly patients with a lower eGFR will have progressive kidney disease. High levels of albuminuria, measured as UACR, are associated with more rapid progression, cardiovascular disease, and mortality. Module_5_4-26
  • We discussed blood pressure and interventions. Sodium restriction is key. ACE inhibitors and ARBs are used to control blood pressure and reduce albuminuria, but they increase the risk of hyperkalemia. Review medication lists, and monitor serum potassium levels when these medications are prescribed. When it comes to diabetes, the A1C goal is individualized in CKD. Consider age, co-morbid conditions, and frequency of hypoglycemia when setting the goal. An improvement in diabetes control without a change in medication, diet, or exercise may indicate CKD is progressing. A juice low in potassium will be a better choice for treating hypoglycemia when the serum potassium level is elevated. Light-colored soda pop is lower in phosphorus and is a better choice than dark cola when used to treat low glucose levels in CKD. Module_5_4-26
  • As discussed, high levels of urine albumin may be associated with more rapid progression of CKD. Interventions include ACEi and ARBs, lower sodium and protein, planned weight loss, and tobacco cessation. Non-traditional risk factors for CVD include anemia, albuminuria, abnormal calcium, and phosphorus metabolism. Module_5_4-26
  • Complications include anemia, hyperkalemia, and hypoalbuminemia. Hypoalbuminemia is associated with inflammation as well as inadequate intake of protein and calories. Treating infection reduces inflammation and may result in an increase in serum albumin. Module_5_4-26
  • Metabolic acidosis and bone disease are complications which should be assessed and treated. Decreasing protein intake reduces acid load. The physician may prescribe supplemental bicarbonate to treat low serum bicarbonate levels. As you know, bone disease associated with CKD is complex. Phosphorus binding medication and supplemental vitamin D may be prescribed. Remember that vitamin D increases the absorption of both calcium and phosphorus, and its use increases the risk of hypercalcemia and hyperphosphatemia. Module_5_4-26
  • Throughout this program, you have heard that the diet will change as CKD progresses and with the development of kidney failure. There are no standardized norms for assessing weight in CKD. Not every patient will need 30 to 35 kilocalories per kilogram. Limit sodium to 1,500 milligrams per day. Provide adequate, not excessive protein. Phosphorus and potassium may be restricted as CKD advances. Patients on dialysis will need more protein due to losses during treatment. They will still need to limit sodium. Most will continue to take phosphorus binders. Remember that protein-rich foods are generally rich in phosphorus. Potassium restriction varies based on chosen modality. Module_5_4-26
  • Food groups vary in nutrient content. Restricting protein means less phosphorus and potassium. Egg whites are low in phosphorus. Refined grains may be better than whole grains. Boiling potatoes removes some potassium and leaching is not required. Module_5_4-26
  • Protein-rich foods are a source of nitrogen, phosphorus, and potassium. Animal protein is a source of metabolic acid. Choose products without food additives, if possible. Absorption of phosphorus varies based on food source. Phosphorus that is added is readily absorbed. Module_5_4-26
  • Lower protein foods may be a source of sodium, phosphorus, and potassium. Foods that are consumed frequently, such as yeast bread, add to daily sodium intake. Bran and whole grains have more phosphorus and potassium. Low potassium fruit and vegetables can become a source of potassium based on the quantity consumed. Small amounts of high potassium fruit and vegetables can be incorporated into meals. Heart-healthy fats are preferred. Module_5_4-26
  • Kidney failure is an eGFR less than 15. The treatment options include hemodialysis, peritoneal dialysis, transplantation, and conservative management. The nutrition prescriptions will vary by chosen modality. Sodium will be restricted. Protein requirements for dialysis are higher, as amino acids are removed during treatment. Daily dialysis generally means higher protein needs as amino acids are removed every day. Daily dialysis removes potassium and phosphorus every day. Potassium may not need to be restricted if it is removed daily. The diet for conservative management is similar to the diet for CKD. Module_5_4-26

Transcript

  • 1. Module 5: The Transition from Chronic Kidney Disease (CKD) to Kidney Failure The Diet Changes as CKD Develops and Progresses to Kidney Failure.
  • 2. 1. Use biochemical data to assess and monitor CKD 2. Recommend diet changes for CKD 3. Identify the four treatment options for kidney failure 4. Differentiate between the diet requirements for hemodialysis, peritoneal dialysis, and kidney transplantation Participants will be able to:
  • 3.  Maria is a 41-year-old woman who was diagnosed with type 2 diabetes at age 30; she has a history of gestational diabetes at age 27.  She lives with her husband and 13-year-old son.  Maria works full time as teacher’s aide. Putting it all together
  • 4. Referred for medical nutrition therapy Type 2 diabetes Dyslipidemia - Reference 12/06 Weight (kg) - 80 BP - 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 - Creatinine 0.8–1.3 - eGFR > 60 - Na 135–145 - K 3.5–5.0 - CO2 21–32 - Phos 2.7–4.6 - Ca (Corrected) 8.5–10.2 - Alb 3.4–5.0 - Urine Dipstick - - UACR < 30 -
  • 5. - Reference 12/06 Weight (kg) - 80 BP - 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 - Creatinine 0.8–1.3 - eGFR > 60 - Na 135–145 - K 3.5–5.0 - CO2 21–32 - Phos 2.7–4.6 - Ca (Corrected) 8.5–10.2 - Alb 3.4–5.0 - Urine Dipstick - - UACR < 30 - Initial impression (ABCs for diabetes) A1C and blood glucose HIGH Blood pressure OK Cholesterol (LDL) HIGH
  • 6. - Reference 12/06 Weight (kg) - 80 BP - 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 20 H Creatinine 0.8–1.3 1.1 eGFR > 60 56 Na 135–145 - K 3.5–5.0 - CO2 21–32 - Phos 2.7–4.6 - Ca (Corrected) 8.5–10.2 - Alb 3.4–5.0 - Urine Dipstick - >300 UACR < 30 - Now assess kidney function and kidney damage Check kidney function ‒ eGFR 56 Check kidney damage ‒ UACR not available, dipstick > 300  Request UACR
  • 7. - Reference 12/06 Weight (kg) - 80 BP - 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 20 H Creatinine 0.8–1.3 1.1 eGFR > 60 56 Na 135–145 135 K 3.5–5.0 4.2 CO2 21–32 23.9 Phos 2.7–4.6 2.9 Ca (Corrected) 8.5–10.2 8.0 L (9.36) Alb 3.4–5.0 2.7 L Urine Dipstick - >300 UACR < 30 7,443 Briefly review for any other abnormal parameters BUN slightly above reference range Creatinine slightly elevated, reflected in lower eGFR Potassium, CO2, and phosphorus within reference ranges Hypoalbuminemia
  • 8. UACR results are very HIGH 7,443 - Reference 12/06 Weight (kg) - 80 BP - 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 20 H Creatinine 0.8–1.3 1.1 eGFR > 60 56 Na 135–145 135 K 3.5–5.0 4.2 CO2 21–32 23.9 Phos 2.7–4.6 2.9 Ca (Corrected) 8.5–10.2 8.0 L (9.36) Alb 3.4–5.0 2.7 L Urine Dipstick - >300 UACR < 30 7,443
  • 9. Reference 12/06 Weight (kg) 80 BP 120/67 Glucose 70–100 305 H A1C < 7.0 10.1 LDL < 100 146 BUN 7–18 20 H Creatinine 0.8–1.3 1.1 eGFR > 60 56 Na 135–145 135 K 3.5–5.0 4.2 CO2 21–32 23.9 Phos 2.7–4.6 2.9 Ca (Corrected) 8.5–10.2 8.0 L (9.36) Alb 3.4–5.0 2.7 L Urine Dipstick >300 UACR < 30 7,443 If we just look at the ABCs, we miss the CKD UACR results are very HIGH 7,443
  • 10. Food and beverage intake Breakfast: 1 cup (c.) oatmeal, ½ c. whole milk, 2 eggs fried in 1 teaspoon (t.) butter, 2 slices wheat toast, 2 t. butter, 16 ounces coffee OR yogurt. Skips lunch. Supper: fast food; 2 pieces fried chicken, biscuit, coleslaw; or large burger, fries. Doesn’t add salt. Diet experience Diet controlled gestational diabetes, did “everything they told me.” Nutrition instruction when first diagnosed with type 2 diabetes. Buys fruit and vegetables, son gets them first. Medications 70/30 insulin 40 units twice a day (BID), 850 milligrams (mg) metformin BID, 10 mg lisinopril daily, 20 mg simvastatin daily. Takes evening medications when she remembers, maybe twice a week. May take 70/30 insulin at bedtime instead of before supper. Physical activity No planned exercise. Walks a lot at summer weekend flea market. Height & weight Height 63”, weight 176 pounds (lb.) (80 kilograms [kg]), Body Mass Index (BMI) 31.2. Previous weight 81 kg (in July) Biochemical data A1C 10.1, LDL 146, eGFR 56, albumin 2.7, dipstick protein > 300, UACR 7,443 Physical findings Poor dentition, states not a problem for her. Referred for Medical Nutrition Therapy: Uncontrolled type 2 diabetes, dyslipidemia Assessment (December 2006)
  • 11. Personal history 41 years old, lives with husband and 13-year-old son in a condo. Patient/family history Diabetes (DM): mother, father, paternal grandfather. Mother on hemodialysis. Grandfather with left foot amputation due to DM. Not planning pregnancy, using birth control. Denies polyuria, polydipsia, fatigue, or blurred vision. Checks fasting glucose about once a week, “usually 150 to 180.” Notes nocturnal lows when takes 70/30 insulin at bedtime. Denies mid-day lows. Refuses to change type of insulin, prefers only 2 shots/day. Social history Teacher’s aide; hard to come for appointments unless summer or school break. Husband not working now; son doing great in school. His evening activities make meal time and medication use erratic. Assessment continued (December 2006)
  • 12. http://www.nal.usda.gov/fnic/foodcomp/search/ ALL of the nutrient analyses are from the USDA nutrient analyses library website:
  • 13. * Used current weight of 80 kg to estimate protein needs (0.8 g/kg), used 23 kcal/kg for obesity Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg) 1 c. oatmeal (regular) 166 5.94 28.08 3.56 9 180 164 ½ c. whole milk, vitamin D 74 3.84 5.86 3.96 52 102 161 2 eggs (large, fried) 180 12.5 0.76 13.65 190 198 140 3 t. butter 102 0.12 0.01 11.52 101 3 3 2 slices wheat toast (2 oz.) 177 7.35 31.62 2.42 346 107 126 16 oz. brewed coffee 9 0.57 0 0.09 9 14 232 ½ c. fast-food coleslaw 138 0.87 14.95 8.25 180 19 134 1 fried chicken breast & leg - Removes breading 185 70 33.99 10.52 0.22 0.04 5.46 3.06 596 210 316 89 386 09 1 biscuit (no butter) 185 3.77 22.11 9.07 548 305 60 21 oz. diet cola 10 0.53 0.15 1.41 39 44 39 TOTALS (% cal) 1,296 80 g (24.7%) 103.78 g (32.0%) 62.45 g (43.3%) 2,280 1,377 1,554 Recommended intake or DRI (% cal) 1,840 64 g* (20 %) 230 g (50 %) 61 g (< 30 %) 1,500 700 4,700
  • 14.  Inappropriate intake of fats (LDL 146, diet history)  Inconsistent carbohydrate intake (skips meals)  Food-medication interaction − Alterations in biochemical tests (not taking evening meds. consistently: LDL 146, A1C 10.1)  Overweight/obesity (BMI 31.2)  Undesirable food choices (LDL 146, A1C 10.1)  Physical inactivity (no planned exercise)  Limited access to food (limited variety) Where do you start? Reference: International Dietetics & Nutrition Terminology, 2011
  • 15. 3. Inappropriate intake of fats (LDL 146, diet hx) 2. Inconsistent carbohydrate intake (skips meals) 1. Food-medication interaction − Alterations in biochemical tests (not taking evening meds consistently: LDL 146, A1C 10.1) Overweight (BMI 31.2) Undesirable food choices (LDL 146, A1C 10.1) Physical inactivity (no planned exercise) Nutrition-related knowledge deficit Limited access to food (limited variety) Prioritizing NCP diagnoses (12/06)
  • 16.  Nutrition-related medication management − Review medications, particularly insulin timing. − Take 70/30 insulin before breakfast and supper, not at bedtime.  Recommended modifications − Have consistent carbohydrate intake and do not skip meals. − Reduce saturated fat intake (1% milk, ↓ fast foods).  PLAN: Take medications as prescribed. Intervention (12/06)
  • 17.  Taking evening meds more regularly now − Still not 100%, but improved − Not taking 70/30 insulin at bedtime any longer  Eating school lunch; eats vegetables & fruit  Family accepting 2% milk  Still working on reducing fast foods, but it’s hard Follow-up phone call shows some changes made (2/07)
  • 18.  Multiple missed appointments  Needs new medication prescriptions - Referenc e 12/06 12/07 Weight (kg) - 80 79.2 BP - 130/67 131/74 Glucose 70–100 305 H 75 A1C < 7.0 10.1 11.3 LDL < 100 146 111 BUN 7–18 20 H 13 Creatinine 0.8–1.3 1.1 1.1 eGFR > 60 56 54 Na 135–145 135 141 K 3.5–5.0 4.2 3.7 CO2 21–32 23.9 22.2 Phos 2.7–4.6 2.9 3.7 Ca (Corrected) 8.5–10.2 8.0 L (9.36) 7.9 L (9.82) Alb 3.4–5.0 2.7 L 2.6 L Urine dipstick >300 - UACR < 30 7,443 7,986 Blood Pressure OK A1C HIGH Cholesterol LDL HIGH eGFR ∼ Stable Hypoalbuminuria UACR Still Very HIGH
  • 19. High levels of urine albumin are associated with kidney damage and more rapid progression of kidney disease.
  • 20. Maria has significant albuminuria; her kidney function declined rapidly
  • 21. As eGFR declined, blood pressure was harder to control
  • 22. Maria needed less insulin to control her blood glucose levels December 2007  Discontinue metformin  Increase 70/30 insulin to 45 units BID (from 40 units) July 2008  Decrease 70/30 insulin to 35 units BID November 2008  Decrease 70/30 insulin to 30 units BID
  • 23. Maria’s serum phosphorus increased; phosphorus binder added 11/08
  • 24. Vitamin D may lower iPTH Reference: *IOM, 2011
  • 25. Vitamin D increased phosphorus absorption Reference: *IOM, 2011
  • 26. Complex interactions between vitamin D and iPTH affect P and Ca
  • 27. Correcting calcium for hypoalbuminemia is worthwhile when assessing calcium levels
  • 28. Maria’s bicarbonate level decreased, medication was added, and dietary protein was restricted
  • 29. Maria’s potassium increased when her eGFR was quite low
  • 30. Maria developed anemia
  • 31. Iron supplement improved anemia
  • 32.  Individualize − Small steps − Realistic changes  Emphasize self-management − What is their priority? − What can they live with?  Prioritize changes based on laboratory data Where do you start?
  • 33. Let’s work through the meals
  • 34. A high fiber breakfast may be good for many people Reference: Adapted from Nutrition Care Manual type 2 diabetes meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf Food Kcal Pro (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg) ½ banana, medium 53 0.64 13.48 0.19 1 13 211 ½ c. bran flakes 64 1.89 16.16 0.44 147 102 124 1 c. skim milk 83 8.26 12.15 0.2 103 247 382 1 slice whole wheat toast 76 4.07 12.79 1.02 146 76 82 1 tbsp. peanut butter (reduced Na) 94 3.84 3.49 7.98 32 51 120 TOTALS 301 18.7 58.07 9.83 429 489 919
  • 35. If potassium is high, choose blueberries instead of banana on the cereal
  • 36. May need to recommend different cold cereal to lower Na, P, or K in CKD Phosphorus in plant foods not completely absorbed
  • 37. Some instant hot cereals may be higher in Na
  • 38. What is on the cereal may add Na, P, and K in CKD (use ½ cup milk as place to start)
  • 39. Yeast bread contributes 7% of sodium in U.S. diet Bread: Frequent consumption of lower sodium foods adds to daily totals Reference: Dietary Guidelines for Americans, 2010
  • 40. Egg whites are lower in Na, K, and P than egg substitutes
  • 41. Breakfast beverage may make a difference in P or K Phosphorus from food additives is 90–100% absorbed
  • 42. Breakfast choices at a glance * Read labels to compare brands Food Sodium Phosphorus Potassium Hot cereal Regular < instant Corn, rice, wheat < oat Corn, rice, wheat < oat Cold cereal Refined < bran* Refined < bran Unfortified <fortified* Refined < bran Milk (1/2 cup) Protein-fortified has more Protein-fortified has more Protein-fortified has more Nondairy Rice < soy * Rice < soy < cow’s Check label for phos Rice < soy < cow’s Bread Wheat < rye * Wheat < corn White < whole wheat Egg Egg white < egg sub. Egg white < egg sub. Egg white < egg sub. Fruit - - Lower K fruits if needed Hot beverage - - Instant < brewed
  • 43. A vegetarian lunch may be good for the heart Reference: Adapted from Nutrition Care Manual type 2 diabetes vegetarian meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type%202%20Diabetes%20Nutrition%20Therapy Food Kcal Pro (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg) 1 c. green leaf lettuce 5 0.49 1.03 0.05 10 10 70 1/3 c. tomato chopped 11 0.52 2.31 0.12 3 14 141 1 tbsp. reduced fat Italian salad dressing 11 0.07 0.69 0.96 161 2 13 1 c. reduced sodium vegetable soup 83 2.78 15.33 1.14 491 58 549 1 garden burger, frozen 124 10.99 9.99 4.41 398 144 233 1 mixed grain bun 113 4.13 19.18 2.58 197 52 69 1 c. soymilk, added Ca, unsweetened 80 6.95 4.23 3.91 90 78 292 TOTALS 427 25.93 52.76 13.17 1,350 358 1,367
  • 44. Salad greens differ in K content
  • 45. Vinegar/oil or low-sodium salad dressing aids 1,500 mg Na budget
  • 46. Salt added to cooking may still mean less sodium than canned. Eat small portions of beans and peas when serum potassium is high. Canned beans may be a little lower in K, but still very high in Na
  • 47. Read ingredient list for KCl in lower sodium canned soups
  • 48.  CKD patients should limit sodium to 1,500 mg per day.  Salad dressing packets tend to be large.  Smaller, single items are still high in sodium.  Double meat means more Na, P, and K.  Some items have PHOS additives. http://www.case.edu/med/ccrhd/phosfoods/ Fast foods and CKD
  • 49. Some fast-food salad dressings are large servings and high in sodium Salad has 81 mg P, 356 mg K
  • 50. Size and what’s on the fast food cheeseburger adds up
  • 51. Even a small fast-food bean burrito has about 1/3 of the daily Na
  • 52. If you’re having pizza, thin crust is a better choice
  • 53. Nut butter is convenient; watch portion size if serum P or K is high
  • 54. Possible changes for lunch: Individualize Food Sodium Phosphorus Potassium Salad dressing Oil/vinegar, low-Na type < regular dressing; Homemade < fast food, restaurant Non-milk based < milk based Read label for KCl in low-Na type Salad Raw < pickled vegetable; No-added-salt canned < regular canned vegetables Cheese, meat, beans, nuts, seeds add more Potato or bean salad, meat, seeds, nuts add more; use lower K vegetables Soup Homemade < canned, dried, instant, or restaurant Non-dairy based < dairy based Bean, pea, vegetable soup have more; read label for KCl in low-Na type Sandwic h Restaurant, fast food, deli meats, cheese are high Double meat and/or cheese add more Meat, cheese, bean, nut butter add more TIPS: •Salad dressing on the side: dip fork in dressing, then into salad •Leftovers from food prepared from scratch •Smaller servings of protein in sandwiches and burritos •Fast foods, restaurant meals only once every other week (SODIUM)
  • 55. A healthy evening meal usually includes a variety of foods Reference: Adapted from Nutrition Care Manual type 2 diabetes meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg) 3 oz. baked chicken, rotisserie 111 21.8 0 2.62 256 192 222 1 small baked potato 73 1.53 16.81 .08 4 39 305 ½ c. green beans, frozen 22 1.10 3.87 .23 2 23 132 1 tbsp. margarine-like spread w yogurt (40% fat) 46 .28 .28 4.9 88 5 9 1 ½ c. spinach/feta/ grapefruit salad 87 2.1 8.5 5.7 78 37.5 292 1 c. skim milk 83 8.26 12.15 .20 103 247 382 1 medium peach 58 1.36 14.31 0.38 0 30 285 TOTALS 480 36.43 55.92 14.1 451 573.5 1,627
  • 56. Source and preparation of chicken can increase Na, P, and K
  • 57. Potato preparation affects K (Boiling helps remove some K)
  • 58. 0 20 40 60 80 100 120 140 160 180 200 Raw Boiled Canned Microwaved Frozen, microwaved Frozen, boiled K Boiling removes more K from green beans ½ cup serving
  • 59. Type of spread may add some sodium, saturated or trans fat
  • 60. Type of rice can increase P or K, still a better choice than potato if K is high
  • 61. Amount and processing of spinach makes a difference in K content NAS = No Added Salt
  • 62. Check ingredient list of processed cheese for additives
  • 63. Size and processing of a peach makes a difference in K intake
  • 64. Beverage choice can make a difference in Na, P, or K; read ingredient list
  • 65.  Prepare foods from scratch.  Read ingredient list to identify food additives.  Use ingredients with fewer food additives.  Use less salt than the recipe lists.  Use liquid vegetable oil instead of butter, margarine, lard, or shortening in cooking.  Use less meat, poultry, or fish in soup or stew.  If K is high, use rice not potatoes. Possible changes for supper: Individualize
  • 66. So many changes to make, so many things to consider… Where do you start?
  • 67. Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf
  • 68. Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf
  • 69. Reference: http://nkdep.nih.gov/
  • 70. Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf
  • 71. Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf
  • 72. Reference: http://nkdep.nih.gov/resources/nkdep-kidney-test-results-508.pdf
  • 73. Reference: http://nkdep.nih.gov/resources/nkdep-ckd-amt-guide-508.pdf
  • 74. RENAL REPLACEMENT THERAPY (RRT) Options Diet Considerations
  • 75.  Kidneys cannot maintain homeostasis.  Kidney failure is associated with fluid, electrolyte, and hormonal imbalances and metabolic abnormalities.  End-stage renal disease (ESRD) means patient is on dialysis or has a kidney transplant. Kidney failure is an eGFR < 15
  • 76. Patients with kidney failure will have the same complications
  • 77.  eGFR < 30  Medicare B − Individual pays 20%, deductible applies  Qualified providers: physicians, physician assistants, nurse practitioners, and clinical nurse specialists  Up to six sessions covered Kidney disease education is a Medicare benefit
  • 78. The topics include many of the ones you already know about
  • 79.  Consistent messages are better.  Providers should be teaching the same thing.  Education may help patients to be successful in their self-management efforts. An informed patient is better prepared
  • 80.  Discuss options early with patients with progressive CKD, give them time to prepare.  Patients diagnosed with kidney “failure” or loss of kidney function may experience grief, fear, or depression.  Include family members if possible.  The “diet” will change; and changes depend on the chosen option. Discuss treatment options early
  • 81. Reference: http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtreatment.pdf
  • 82.  Renal replacement therapy (RRT) 1. Hemodialysis • In-center or home, three times a week or more frequently 1. Peritoneal dialysis • Daily, at home 1. Kidney transplantation  No RRT 4. Conservative management • Active medical management Four options for treating kidney failure
  • 83.  Concentration gradient − Flows from high to low  Area through which diffusion takes place − Large surface area of the membrane  Size of molecules − Protein-bound substances not usually dialyzed Dialysis involves diffusion of substances across a semipermeable membrane
  • 84.  In-center hemodialysis − Most common type http://kidney.niddk.nih.gov/kudiseases/pubs/p df/hemodialysis.pdf  Home hemodialysis − Individual has more control − Need assistance http://kidney.niddk.nih.gov/kudiseases/pubs/p df/homehemodialysis.pdf Hemodialysis occurs in two settings
  • 85. Hemodialysis
  • 86.  Removal is based on size.  Protein-bound substances are not usually removed.  Amino acids are removed.  Glucose is removed.  Water-soluble vitamins are removed to some degree. Concentration gradients move substances across the semipermeable membrane for removal Reference: Descombes et al. Artif Organs 2000; 24(10):773–778.
  • 87.  More dietary protein is needed to replace losses.  Specific renal vitamin may be used. − Consider taking vitamin after treatment to avoid removal during treatment. Nutrient losses during dialysis need to be replaced
  • 88.  Maintain homeostasis  Adequate dialysis − Type and size of the dialyzer − Blood flow rate − Dialysate composition (similar to normal levels)  Sodium, potassium, calcium, bicarbonate − Time  Individual patient factors The hemodialysis prescription is individualized Reference: Locatelli et al. Nephrol Dial Transplant 2004; 19(4):785–796.
  • 89.  Levels build up between treatments; examples of these substances are: − Fluid − Nitrogen − Sodium − Potassium − Phosphorus (only to some degree) − Hydrogen (acid) Hemodialysis removes some substances that accumulate between treatments
  • 90.  A normal kidney works “24/7.”  Damaged kidneys (in CKD) still work nonstop but at a reduced level.  An artificial kidney works only during dialysis treatments. Dialysis replaces only a fraction of normal kidney function
  • 91.  Arteriovenous (AV) fistula  Graft  Temporary access  Permanent access, usually placed in non-dominant arm  Protect blood vessels in both arms − Avoid venipuncture and IV catheter placement above the wrist A vascular access is needed for hemodialysis
  • 92.  Provides permanent access  Surgically connects artery to a vein − Vein grows larger due to increased blood flow. − Needles are inserted to access the bloodstream.  Takes time to mature − Few weeks to months  Less likely to clot An AV fistula is the preferred access
  • 93. An AV graft will work for hemodialysis  Synthetic tube connects artery and vein.  Graft takes less time to mature.  Graft is more likely to become infected or clot.
  • 94.  Emergency dialysis  Less than optimal blood flow  No needles  Permanent access surgery needed later  The only option when patient is not prepared and needs dialysis A “temporary access” is just temporary Catheter for temporary access
  • 95.  Treatment is three times per week.  Dialysis treatment lasts 3–4 hours. In-center hemodialysis is scheduled
  • 96.  Conventional home hemodialysis − Three times per week − Most common type of home hemodialysis  Daily home hemodialysis − 2–3 hours, 5–6 days per week  Nocturnal hemodialysis − 6–8 hours, 3 or more days per week − Dialyze more frequently Home hemodialysis requires training and support Reference: http://www.homedialysis.org/
  • 97. In-center hemodialysis: Pros and cons PROS  Social setting  Facilities are found nationwide.  Staff does the work. − Placing/removing needle − Monitoring the treatment − Maintaining the equipment CONS  Requires strictest diet − Substances and fluid build up between treatments.  Have to follow set schedule  Must travel to the unit  May take more medication  May feel fatigued  Some nutrients are removed during treatment
  • 98. Home hemodialysis: Pros and cons PROS  Diet is less restrictive with more frequent treatments  Can schedule around work  No travel to the unit is needed  Newer machines are small  Fewer ups and downs occur CONS Must have a partner May be stressful for partner Need space for treatment: machine, supplies, access to water and drainage, electricity Have to insert needles Need time off from work for initial training Training not offered everywhere
  • 99.  Protein: > 1.2 g/kg (some loss during treatment)  Calories: 30–35 kcal/kg − > 60 years old: 30 kcal/kg  Sodium: 1,000–3,000 mg  Potassium: 2,000–3,000 mg  Phosphorus: 800–1,000 mg phosphorus − Need binders  Fluid restriction: urine output + 1,000 mL (cc) − 240 cc/cup Nutrition prescription: In-center hemodialysis
  • 100.  Increased frequency of treatment means fewer restrictions.  Fewer phosphate binders may be needed.  Adequate protein is still needed. Nutrition prescription: Home hemodialysis
  • 101. Reference: http://kidney.niddk.nih.gov/KUDiseases/pubs/peritoneal/index.aspx
  • 102.  Continuous ambulatory (CAPD).  Continuous cycler-assisted (CCPD).  PD uses the peritoneal membrane as the filter.  PD still requires surgery for catheter placement.  Some people experience body-image concerns.  PD is a continuous therapy. Peritoneal dialysis (PD) options
  • 103.  Dextrose is the most common osmotic agent used in the dialysate.  Osmotic gradient helps move water into the peritoneal cavity. Clearance affected by:  Concentration gradient  Size  Permeability of the peritoneal membrane The peritoneal membrane is the semipermeable “filter” in peritoneal dialysis
  • 104. The peritoneal dialysis exchange
  • 105.  Dialysis solution with dextrose flows into the abdominal cavity.  The solution remains for a prescribed time period, also known as the dwell time.  Substances and fluid pass from the capillaries in the peritoneum into the solution.  Dextrose enters the blood; and substances and fluid enter the solution.  The solution is drained at the end of the dwell. What is an “exchange”?
  • 106.  Dextrose solutions are used as osmotic agent. − 1.25%, 2.5%, 4.25% concentrations  Exchanges are 2–3 liters in volume.  Dwell time and number of exchanges vary. PD prescription is individualized
  • 107. CAPD requires 3–4 manual exchanges
  • 108. The cycler does 3–5 exchanges during the night in CCPD
  • 109. Peritoneal dialysis: Pros and Cons PROS  Better preserves residual renal function  Can do it alone  Choice of times  Choice of location  Easier to travel, no machine  No travel to unit  Treatments done daily CONS  Need space for supplies which are delivered monthly  Must plan around activities  Must do as prescribed to get adequate treatment  Must follow instructions to keep risk of infection low  Need to take supplies when traveling  May have weight gain  May be harder to control diabetes
  • 110.  The diet may not be as strict.  Amino acids lost during the exchanges must be replaced, dietary protein needs are higher.  Absorbed dextrose calories may add weight.  People with diabetes are never really “fasting.” − Glucose levels may be harder to control. − Insulin may be injected into the dialysate bags. Peritoneal dialysis and diet
  • 111.  Protein: 1.2–1.3 g/kg  Calories: 30–35 kcal/kg − Includes calories from dextrose solutions  Sodium: 2,000–4,000 mg  Potassium: 3,000–4,000 mg  Phosphorus: 800–1,000 mg − Still need binders  Fluid restriction–as needed Nutrition prescription: Peritoneal dialysis Reference: Shiro-Harvey, 2002
  • 112.  Dextrose concentrations vary − 1.25%, 2.5%, 4.25%  Bag sizes vary − 2-liter, 2.5-liter, 3-liter  In CAPD, 60–70% is absorbed. The amount is higher due to longer dwell times.  In CCPD, 40–50% is absorbed. Calories count in dextrose solutions Reference: McCann, 2009
  • 113.  Four exchanges of 2-liter bags with 1.5% dextrose = 8 liters of 1.5% dextrose (grams dextrose/liter) = 120 grams of dextrose  3.4 kcal/gram of dextrose (120 grams of dextrose) x 3.4 = 408 calories  60–70% absorbed  Total of 245–286 calories absorbed/day Estimate of calories from CAPD
  • 114. For more information about peritoneal dialysis dose and adequacy Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritonealdose.pdf
  • 115. Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant.pdf
  • 116.  Deceased or living donor kidney is required. − Must be ABO compatible, match for human leukocyte antigens  The transplant workup takes time; eligibility is strict.  Requires major surgery.  Need to take medications daily, including antirejection medication. Kidney transplantation is a treatment, not a cure
  • 117. A transplanted kidney is placed in the groin area. Native kidneys usually are not removed.
  • 118. Kidney transplant: Pros and cons PROS  A transplanted kidney is a normal, functioning kidney.  Dialysis is not needed.  Fewer diet restrictions are needed.  Successful transplant may mean a longer life.  Recipient may have better quality of life. CONS  The waiting list is long for a deceased donor.  The transplant requires major surgery.  Rejection  Antirejection medications suppress the immune system.  Weight gain  Diabetes may be harder to control.
  • 119.  Transplant is a treatment, not a cure.  May need a sodium restriction.  May need to reduce calories to avoid weight gain.  Medications may increase weight gain. Nutrition prescription: Transplant
  • 120.  No non-dialysis way can replace loss of clearance of uremic toxins.  Complications can be treated.  Continue medications.  Provide comfort and palliative care.  Encourage patient to inform family. Conservative management is active medical management with no RRT
  • 121.  Discuss the options early to allow time for the patient to adjust and make a decision.  The diet will change with dialysis, more protein is needed to replace the losses.  Hemodialysis has the most restrictive diet.  Peritoneal dialysis calories add up.  Transplant requires daily immunosuppressant medication.  All the options still require medications. Summary: Treatment options
  • 122.  She was very upset upon hearing she had CKD.  She is now on the waiting list for a transplant.  Hemodialysis is her second choice.  She has a vascular access in place and will probably need in-center hemodialysis prior to transplant. Maria wants a kidney transplant
  • 123. The transition from CKD to ESRD can be short for someone like Maria
  • 124. SUMMARY OF ALL CONTENT
  • 125.  Identify people with chronic kidney disease.  Assess and monitor estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). − eGFR estimates kidney function.  Persistent levels < 60 are considered CKD. − UACR > 30 mg/g is considered as kidney damage.  Patients with high levels of urine albumin are at greatest risk of rapid progression to kidney failure. Identify CKD
  • 126.  Control blood pressure. − 1,500 mg sodium  Do not replace salt with salt substitutes (KCl). − Medications that affect the renin-angiotensin-aldosterone system (RAAS) increase risk of hyperkalemia. − Limit dietary potassium when serum level is elevated.  Control diabetes. − A1C is individualized. − Spontaneous improvement in control may mean CKD progression. − Treat hypoglycemia appropriately.  Use juice low in potassium.  Avoid dark colas due to phosphorus content. Slow progression
  • 127.  Urine albumin is an indicator of kidney damage. − Medications that affect the RAAS may lower urine albumin. − Lower sodium, planned weight loss, lower protein intake, tobacco cessation may help lower albuminuria.  Cardiovascular disease is the leading cause of mortality for people with CKD. − Nontraditional risk factors are important.  Anemia  Urine albumin  Abnormal mineral metabolism (calcium and phosphorus) Slow progression (continued)
  • 128.  Anemia − Inadequate erythropoietin and iron − Hemoglobin and iron indices  Hyperkalemia − Limit dietary potassium when serum level is elevated.  Hypoalbuminemia − Poor oral intake (spontaneous reduction in protein) − Inflammation Complications
  • 129.  Metabolic acidosis − Maintaining serum CO2 > 22 mEq/L may be beneficial. − Animal protein is a source of metabolic acids. − Acidosis may be treated with supplemental bicarbonate.  Bone disease in CKD − Calcium, phosphorus, vitamin D, parathyroid hormone  Use corrected calcium with hypoalbuminemia − Vitamin D supplementation may increase risk of hypercalcemia and hyperphosphatemia. Complications (continued)
  • 130.  Use clinical judgment when assessing body weight for estimating nutrient needs.  Caloric requirements are not higher.  For CKD patients limit to 1,500 mg sodium.  Diet has adequate, not excessive, protein.  Restrict phosphorus if serum level is elevated.  Restrict potassium if serum level is elevated. Diet changes as CKD progresses
  • 131.  Foods rich in protein tend to be rich in phosphorus and potassium. Egg whites are an exception.  Refined grains are lower in phosphorus and potassium than whole grains.  Boiling potatoes and tubers immediately removes enough potassium. Leaching, or soaking, in water is not required. The food groups
  • 132.  Fresh lean meat, poultry, and fish have K and P.  Use products that are not enhanced with Na.  Dried beans and peas are high in phosphorus and potassium; may need to limit amounts.  Dairy foods are high in sodium, protein, phosphorus, potassium, and fluid (milk).  Use foods without food additives, if possible. − Inorganic phosphorus is more readily absorbed. The foods
  • 133.  Cereals and breads may be a source of Na.  Bran and whole grains have more K and P.  Fruits and vegetables vary in K content. − Canned fruit may have lower K. − Use lower sodium canned vegetables, if using canned.  Heart-healthy fats are preferred. The foods
  • 134.  Kidney failure is considered as an eGFR < 15.  ESRD still means many of the same complications.  There are 4 options to choose from: 1. Hemodialysis  More protein; restrict Na, P, K, and fluid  Fewer restrictions with more frequent home hemodialysis 2. Peritoneal dialysis  More protein; usually Na and P restriction 3. Transplant  May need to limit sodium  Other comorbidities (diabetes, hypertension) 4. Conservative management The diet changes when the kidneys fail
  • 135. This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD), especially among communities most impacted by the disease, NKDEP works in collaboration with a range of government, nonprofit, and health care organizations to: • raise awareness among people at risk for CKD about the need for testing; • educate people with CKD about how to manage their disease; • provide information, training, and tools to help health care providers better detect and treat CKD; and • support changes in the laboratory community that yield more accurate, reliable, and accessible test results. To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from NIDDK, please visit: http://www.niddk.nih.gov.
  • 136. Meet our Presenters Theresa A. Kuracina, M.S., R.D., C.D.E., L.N. Ms. Kuracina is the lead author of the American Dietetic Association’s CKD Nutrition Management Training Certificate Program and NKDEP’s nutrition resources for managing patients with CKD. Ms. Kuracina has more than 20 years of experience in clinical dietetics with the Indian Health Service (IHS). She is a senior clinical consultant with the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. She also serves as a diabetes dietitian and coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico, a role in which she routinely counsels patients who have chronic kidney disease (CKD).
  • 137. Meet our Presenters Andrew S. Narva, M.D., F.A.C.P. Dr. Narva is the director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health (NIH). Prior to joining NIH in 2006, he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Via telemedicine from NIH, he continues to provide care for IHS patients who have chronic kidney disease. A highly recognized nephrologist and public servant, Dr. Narva has served as a member of the Medical Review Board of ESRD Network 15 and as chair of the Minority Outreach Committee of the National Kidney Foundation (NKF). He serves on the NKF Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Diabetes and is a member of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Expert Panel.
  • 138. American Dietetic Association. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Standardized Language for the Nutrition Care Process. 3rd ed. Chicago, IL: American Dietetic Association; 2011. American Dietetic Association. Type 2 diabetes nutrition therapy for vegetarians. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type %202%20Diabetes%20Nutrition%20Therapy%20for %20Vegetarians.pdf. 2010. Accessed June 14, 2011. American Dietetic Association. Type 2 diabetes nutrition therapy. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type2Diab etesNutritionTherapy.pdf. 2010. Accessed June 14, 2011. References
  • 139. Case Center for Reducing Health Disparities. Fast food, phosphorus containing food additives, and the renal diet. Case Western Reserve University website. http://www.case.edu/med/ccrhd/phosfoods/. 2009. Accessed August 30, 2011. Descombes E, Boulat O, Perriard F, Feilay G. Water-soluble vitamin levels in patients undergoing high-flux hemodialysis and receiving long-term oral postdialysis vitamin supplementation. Artificial Organs. 2000;24(10):773–778. Handelman GJ, Levin NW. Guidelines for vitamin supplements in chronic kidney disease patients: what is the evidence? Journal of Renal Nutrition. 2011;21(1):117–119. References
  • 140. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.: National Academies Press; 2010. Institute of Medicine website. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for- Calcium-and-Vitamin-D.aspx. Accessed June 14, 2011 Khanna R, Nolph KD. Chapter 4. Principles of peritoneal dialysis. In: Henrich WL, Bennet WM, eds. Atlas of Diseases of the Kidney. Vol. 5. http://www.kidneyatlas.org/book5/adk5- 04.ccc.QXD.pdf. 1999. Accessed June 14, 2011. Locatelli F, Covic A, Chazot C, Leunissen K, Luno J, Yaqoob M. Optimal composition of the dialysate, with emphasis on its influence on blood pressure. Nephrology Dialysis Transplantation. 2004;19(4):785–796. McCann L, ed. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York: National Kidney Foundation; 2009. References
  • 141. National Kidney and Urologic Disease Information Clearinghouse. Home hemodialysis. February 2008. NIH publication 08–6232. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/homehemo dialysis.pdf. Accessed June 14, 2011. National Kidney and Urologic Disease Information Clearinghouse. Kidney failure: choosing a treatment that’s right for you. November 2007. NIH publication 08–2412. National Institute of Diabetes and Digestive and Kidney Disease website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtr eatment.pdf. Accessed June 14, 2011. References
  • 142. National Kidney and Urologic Disease Information Clearinghouse. Peritoneal dialysis dose and adequacy. December 2006. NIH publication 07–4578. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritoneald ose.pdf. Accessed June 14, 2011. National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure hemodialysis. December 2006. NIH publication 07–4666. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/hemodialy sis.pdf. Accessed June 14, 2011. References
  • 143. National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure peritoneal dialysis. May 2006. NIH publication 06–4688. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritoneal. pdf. Accessed June 14, 2011. National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure transplantation. May 2006. NIH publication 06–4687. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant. pdf Accessed June 14, 2011. References
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