Nutrition Therapy For CKD: A Case Study Approach


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Presented to fifteen clinical dietitians from the Northshore University Health System during clinical rotation

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  • The purpose of diet therapy for CKD is to maintain good nutritional status, slow progression of CKD, and treat complications. The key diet components to slowing progression of CKD are: controlling BP by reducing sodium intake, reducing protein intake, if excessive, and managing diabetes. As dietetic professionals, it is our job to be sure that CKD patients are well-versed in these areas in order to be successful.
  • Chronic kidney disease is classified based on the glomerular filtration rate (GFR). These tables show the ranges used to determine CKD stage based on glomerular filtration rate. Symptoms of CKD may not appear until over 75% of kidney function is lost. As GFR declines, complications become more common and more severe. The table to the right provides a list of clinical side effects of CKD.   Source: Rolfes SR, Pinna K, Whitney E.  Understanding Normal and Clinical Nutrition, p 881.  Wadsworth: Belmont, CA, 2009. 
  • As GFR declines, appetite may decline and taste may be altered. This is a physiological response to increasing toxins in the blood – a survival mechanism. Patients with CKD often develop protein-energy malnutrition and wasting.  Clinical studies have suggested that renal patients may have inadequate protein and energy intakes, even during the early stages of disease.  Anorexia is thought to contribute to poor food intake and may result from hormonal disturbances, nausea and vomiting, restrictive diets, uremia and medications.  Nutrient losses also contribute to malnutrition and may be a consequence of vomiting, diarrhea, GI bleeding and dialysis.  In addition, many of the illnesses that lead to chronic kidney disease can induce a catabolic state that contributes to protein losses.   Source: Rolfes SR, Pinna K, Whitney E.  Understanding Normal and Clinical Nutrition, p 881.  Wadsworth: Belmont, CA, 2009. 
  • See Nutrition Recommendations Form for specific nutrient calculations
  • In the Nurses Health Study, the risk of losing kidney function in women with mild kidney insufficiency was related primarily to animal meat intake Regardless of the level of protein intake, 50% to 75% of the protein should be of high biological value, derived predominantly from lean poultry, fish, and soy- and vegetable-based proteins. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease, Guideline 5: Nutritional Management in Diabetes and Chronic Kidney Disease.
  • Tomson, CRV. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrol. Dial. Transplant. (2001) 16 (8): 1538-1542.
  • In the past, people on dialysis have been told to soak potatoes overnight to lower the potassium. Research shows there is a better (and faster!) way to remove some potassium. These steps will help decrease the amount of potassium in these vegetables by about a third, but it will not take away all of the potassium. These vegetables should still be considered a high-potassium food. Burrowes JD. Leaching potassium from tuberous root vegetables. Renal Nutrition Forum, Summer 2007, Vol. 26, No. 3
  • Phosphorus additives are added to convenience and fast foods for many reasons. Unlike phosphorus that naturally occurs in meats, dairy products, whole grains and nuts, phosphorus from additives is completely absorbed by the body. Sullivan C, Sayre SS, Leon JB et al. Effect of Food Additives on Hyperphosphatemia Among Patients with End-Stage Renal Disease: A Randomized, Controlled Trial. JAMA, 301(6): 629-635, 2009.
  • Sullivan C, Sayre SS, Leon JB et al. Effect of Food Additives on Hyperphosphatemia Among Patients with End-Stage Renal Disease: A Randomized, Controlled Trial. JAMA, 301(6): 629-635, 2009.
  • There are three main types of vascular access: Fistula Graft Catheter A fistula is made by sewing an artery to a vein, usually in the arm. A fistula is the best type of access for two reasons: 1. Your veins and arteries are part of your body, so a fistula is less prone to infections or blood clots than other types of access. 2. Your veins and arteries self-heal after each needle stick, so a fistula can last a long time. A graft is like a fistula, because it hooks a vein and an artery together. The difference is that a graft uses a piece of tubing to bridge the two. Compared to a fistula, a graft is more likely to: 1. Become infected and/or clotted, because the synthetic material is foreign to your body 2. Develop holes, because the synthetic material does not self-heal after needle punctures The third type of vascular access is a central venous catheter . A catheter is a plastic tube that is surgically placed in the neck, chest, or groin, and connected to a "central" vein. The other end of the tubing is outside the skin and used for hooking up to the dialysis tubing. Of the three types of vascular access (fistula, graft, catheter), the catheter is the poorest option because: 1. Blood flow rates are often poor, so it is hard to get enough dialysis to feel your best. 2. It extends outside of the body, so it is the most prone to infection—and it is so close to the heart that infections can be serious. 3. Catheters are very likely to clot. Source:
  • Due to the complexity of the diet for CKD, patients may benefit from more than one education session during the hospital stay in addition to an outpatient referral. The initial encounter for this patient was followed by a refresher that included his wife several days later. The patient was also urged to schedule an appointment with the outpatient dietitian. The Medicare benefit for MNT is underutilized, at least in part because clinicians including RDs feel inadequately educated on the topic. Currently, Medicare coverage for CKD MNT includes 3 hours in the first year and 2 hours in each subsequent year.
  • Serum phosphorus may not rise until the late stages of kidney disease. Some nephrologists recommend using fractional excretion of phosphorus in the urine. A normal level is less than 12%. When the level reaches 20%, it suggests that phosphorus excretion is decreasing. This would be an opportune time to start phosphorus binders whether the serum phosphorus has increased beyond normal levels or not.
  • The renal diet is difficult to adhere to. To find helpful, printable handouts for patients, look at the National Kidney Foundation and NKDEP (National Kidney Disease Education Program).
  • Nutrition Therapy For CKD: A Case Study Approach

    1. 1. Nutrition Therapy for CKD: A Case Study Approach
    2. 2. Objectives <ul><li>Describe the goals of nutrition therapy for patients with CKD </li></ul><ul><li>Describe nutrient recommendations for patients with CKD </li></ul><ul><li>Recommend nutrition interventions for patients with CKD </li></ul>
    3. 3. Nutrition Therapy for CKD <ul><li>Purpose: </li></ul><ul><ul><li>Maintain good nutritional status </li></ul></ul><ul><ul><li>Slow progression </li></ul></ul><ul><ul><li>Treat Complications </li></ul></ul><ul><li>Components: </li></ul><ul><ul><li>Control blood pressure by reducing sodium intake </li></ul></ul><ul><ul><li>Reduce protein intake, if excessive </li></ul></ul><ul><ul><li>Manage diabetes </li></ul></ul>NKDEP, 2011.
    4. 4. <ul><li>Normal GFR: 125ml/min </li></ul>Rolfes et al, 2009.
    5. 5. Complications of CKD <ul><li>Malnutrition </li></ul><ul><li>Metabolic acidosis due to reduced acid excretion </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Anemia </li></ul><ul><li>CVD </li></ul><ul><li>CKD-MBD – Mineral and Bone Disorder (calcium, phosphorus, and vitamin D) </li></ul>
    6. 7. Drug Therapy to Control Complications of CKD <ul><li>Hypertension </li></ul><ul><ul><li>Important to slow progression of disease </li></ul></ul><ul><ul><ul><li>ACE Inhibitors – can reduce proteinuria </li></ul></ul></ul><ul><li>Anemia </li></ul><ul><ul><li>Epogen or Aranesp – IV, stimulates RBC </li></ul></ul><ul><ul><li>Iron – oral for CKD, IV for dialysis </li></ul></ul><ul><ul><li>Renal Vitamin with Folic acid and B12 due to restricted diet and dialysis losses </li></ul></ul><ul><li>Acidosis </li></ul><ul><ul><li>Sodium Bicarbonate </li></ul></ul>
    7. 8. <ul><li>Hyperphosphatemia </li></ul><ul><ul><li>#1 problem associated with calcification </li></ul></ul><ul><ul><li>Phosphorus binders should be taken with meals and snacks to bind Phos while food is in the stomach. </li></ul></ul><ul><ul><ul><li>Calcium : Tums, PhosLo, generic calcium acetate </li></ul></ul></ul><ul><ul><ul><li>Non-Calcium : Renvela/Renagel, Fosrenol </li></ul></ul></ul><ul><ul><ul><li>Avoid Calcium Citrate and Aluminum binders – “ Dialysis Dementia Syndrome ” </li></ul></ul></ul>Drug Therapy to Control Complications of CKD
    8. 9. Drug Therapy to Control Complications of CKD <ul><li>Secondary Hyperparathyroidism </li></ul><ul><ul><li>25-OH Vitamin D for Vitamin D Deficiency: Oral </li></ul></ul><ul><ul><li>1,25-OH “active” Vitamin D to reduce PTH </li></ul></ul><ul><ul><ul><li>Calcitriol, Zemplar, Hectorol </li></ul></ul></ul><ul><ul><ul><li>Oral for PD and CKD </li></ul></ul></ul><ul><ul><ul><li>IV at dialysis for HD </li></ul></ul></ul><ul><ul><li>Sensipar: Oral; side effect may be low calcium </li></ul></ul>
    9. 10. CKD Nutrient Recommendations <ul><li>Protein </li></ul><ul><li>Sodium and Fluid </li></ul><ul><li>Potassium </li></ul><ul><li>Phosphorus </li></ul>
    10. 11. Protein <ul><li>Limiting dietary protein in CKD stage 3 and 4 will slow decrease in kidney function and progression of albuminuria and may prevent CKD Stage 5. (KDOQI) </li></ul><ul><li>Vegetable or soy protein sources may be kidney-sparing compared with red-meat sources </li></ul><ul><li>   </li></ul><ul><li>Kidney Sparing Kidney Stressing </li></ul>Plant Protein Fish, Eggs Turkey, Chicken Beef, Lamb, Pork
    11. 12. Sodium and Fluid <ul><li>Fluid Restriction: 1 Liter for anuric patient on HD. Includes soup, popsicles, gelatin, ice cream. </li></ul><ul><li>Focus on limiting sodium to reduce thirst and drinking only when thirsty </li></ul><ul><li>Other suggestions: </li></ul><ul><ul><li>Chew gum </li></ul></ul><ul><ul><li>Suck on hard candy </li></ul></ul><ul><ul><li>Rinse mouth with water but don’t swallow it </li></ul></ul><ul><ul><li>Use small cups and glasses for beverages </li></ul></ul><ul><ul><li>Take medications with mealtime beverages or applesauce instead of using additional fluid </li></ul></ul>
    12. 13. Potassium <ul><li>High Potassium Foods </li></ul><ul><ul><li>Potatoes </li></ul></ul><ul><ul><li>Tomatoes </li></ul></ul><ul><ul><li>Oranges </li></ul></ul><ul><ul><li>Bananas </li></ul></ul><ul><ul><li>Nuts and Nut Butters </li></ul></ul><ul><ul><li>Dried Beans </li></ul></ul><ul><li>Low Potassium Foods </li></ul><ul><ul><li>Apple </li></ul></ul><ul><ul><li>Berries (1/2 cup) </li></ul></ul><ul><ul><li>Grapes </li></ul></ul><ul><ul><li>Zucchini </li></ul></ul><ul><ul><li>Carrots </li></ul></ul><ul><ul><li>Green Beans </li></ul></ul>
    13. 14. Improved Method for Leaching Potatoes <ul><li>Cut vegetable into thin slices or small cubes. </li></ul><ul><li>Place vegetables into a large pot of room temperature water. There should be two times the amount of water as vegetables. </li></ul><ul><li>Bring the water to a boil. </li></ul><ul><li>Discard the water. Replace with room temperature water. </li></ul><ul><li>Bring the water to boil a second time. Boil until vegetables are tender. </li></ul><ul><li>Prepare vegetables as desired. </li></ul>Burrowes JD, 2007.
    14. 15. Phosphorus <ul><li>High Phosphorus Foods </li></ul><ul><ul><li>Dairy Products </li></ul></ul><ul><ul><ul><li>Milk, Ice Cream, Yogurt, Cottage Cheese </li></ul></ul></ul><ul><ul><ul><li>Limit to no more than ½ cup daily </li></ul></ul></ul><ul><ul><ul><li>Cheese, Pizza, Macaroni and Cheese </li></ul></ul></ul><ul><ul><li>Nuts and Peanut Butter </li></ul></ul><ul><ul><li>Dried Beans and Peas </li></ul></ul><ul><ul><li>Chocolate and Cocoa </li></ul></ul><ul><ul><li>Pancakes, Waffles and Biscuits </li></ul></ul>
    15. 16. Hidden Phosphorus <ul><li>Phosphorus is frequently added to convenience, ready-to-eat and processed foods. Look for “phos” on ingredient lists </li></ul>Dicalcium Phosphate Hexametaphosphate Monocalcium Phosphate Phosphoric Acid Pyrophosphate Sodium Acid Pyrophosphate Sodium Phosphate Sodium Tripolyphosphate Tricalcium Phosphate Sullivan et al, 2009.
    16. 17. Hidden Phosphorus <ul><li>Some products using phosphorus additives: </li></ul><ul><li>Restructured meats (chicken nuggets, hot dogs) </li></ul><ul><li>Processed and spreadable cheeses </li></ul><ul><li>Instant products (puddings and sauces) </li></ul><ul><li>Refrigerated bakery products (biscuits, snack cakes) </li></ul><ul><li>Beverages (colas, flavored waters, fruit drinks) </li></ul>
    17. 18. Case Study 1- JM <ul><li>AV Graft placed for dialysis </li></ul><ul><li>Nutrition Screen: Poor PO Intake > 2 weeks </li></ul><ul><li>Nutrition Consult: Renal, ADA, Cardiac diet education </li></ul><ul><li>2000-Calorie ADA Cardiac Renal Pre-Dialysis Diet with PO Intakes of 75-100% </li></ul><ul><li>PMH: CKD 4, HTN, DM2 </li></ul><ul><li>BMI: 57.66 </li></ul><ul><li>Labs: </li></ul><ul><ul><li>NA: 137 </li></ul></ul><ul><ul><li>K: 4.4 </li></ul></ul><ul><ul><li>BUN: 56 H </li></ul></ul><ul><ul><li>CREAT: 7.9 H </li></ul></ul><ul><ul><li>CA: 8.3 L </li></ul></ul><ul><ul><li>ALB: 3.4 L </li></ul></ul><ul><ul><li>Phos: 3.4 (1 wk ago) </li></ul></ul><ul><ul><li>Glu: 105 </li></ul></ul>
    18. 19. Now What? <ul><li>Patient eating well on current diet. K in target. Phos level > 1 week ago. Medications include insulin; no phos binders or vitamin </li></ul><ul><li>Recommend renal vitamin; check phosphorus </li></ul><ul><li>Diet Education: </li></ul><ul><ul><li>Manage Diabetes: Plate Method Handout </li></ul></ul><ul><ul><li>Reduce sodium: NKDEP Handout </li></ul></ul><ul><ul><li>Decrease protein: limit red meat, review portion sizes. NKDEP handout </li></ul></ul><ul><ul><li>Limit High Potassium Foods: Handout with Photos </li></ul></ul><ul><li>Refer to Outpatient Dietitian </li></ul>
    19. 20. Case Study 2- PG <ul><li>Admitted for pleural effusion </li></ul><ul><li>Hemodialysis x 1 year </li></ul><ul><li>Patient requested renal diet education </li></ul><ul><li>PMH: HTN, ESRD, GERD, CAD </li></ul><ul><li>Labs: </li></ul><ul><ul><li>NA: 134 </li></ul></ul><ul><ul><li>K: 4.7 (goal 3.5-5.5) </li></ul></ul><ul><ul><li>BUN: 61 H (goal 60-80) </li></ul></ul><ul><ul><li>CREAT: 5.2 H </li></ul></ul><ul><ul><li>CA: 8.6 </li></ul></ul><ul><ul><li>ALB: 3.6 (goal > 3.5) </li></ul></ul><ul><ul><li>Phos: 5.2 H (goal 3.5-5.5) </li></ul></ul><ul><ul><li>Glu: 154 H </li></ul></ul>
    20. 21. Now What? <ul><li>Patient eating 50-100%. K, Phos, Alb in target. Medications include Folbee Plus (B-complex), Phoslo 1 cap with dinner (phos binder) </li></ul><ul><li>Diet Education: </li></ul><ul><ul><li>Consume adequate protein: NKDEP handout </li></ul></ul><ul><ul><li>Limit sodium, fluids: 1 Liter/4 cups daily (anuric) </li></ul></ul><ul><ul><li>Sample 2-Week Menus at </li></ul></ul><ul><li>F/U with dietitian at outpatient dialysis facility </li></ul><ul><li>Other possible renal topics: Potassium, Phosphorus, Function and Timing of Phosphorus Binders, Diabetes Management (CKD Diet TRUMPS DM Diet) </li></ul>
    21. 22. Potential Interventions for Patients with CKD <ul><li>Monitor PO Intake – can liberalize diet as indicated </li></ul><ul><li>Nutrition Supps - Nepro, Beneprotein. Others may be appropriate; consider K, Phos, fluids, PO intake. </li></ul><ul><li>Renal vitamin </li></ul><ul><li>Check phosphorus level </li></ul><ul><li>Add or increase phosphorus binders as indicated; may also be appropriate to decrease or stop if patient with severe hypophosphatemia </li></ul>
    22. 23. Renal Resources National Kidney Disease Education Program Free downloadable materials!!! RD Reference: CKD and Diet National Kidney Foundation Free CEUs available American Association of Kidney Patients AAKP Nutrition Counter
    23. 24. Renal Resources <ul><li>National Kidney Disease Education Program working to improve early detection and treatment of CKD </li></ul><ul><li>CKD Diet Initiative </li></ul><ul><ul><li>To provide simplified and accessible professional and patient education materials </li></ul></ul><ul><ul><li>To train general practice dietitians to counsel people with CKD </li></ul></ul><ul><ul><li>To facilitate referrals for CKD MNT from PCPs </li></ul></ul>
    24. 25. Renal Resources <ul><li>NKDEP developing CKD refresher course for RDs, and ADA to adapt training materials as online Certificate of Training in CKD </li></ul><ul><li>Expected to launch in mid 2011 through ADA Center for Professional Development </li></ul><ul><li>To include interactive activities, case studies, assessments and the CKD business case </li></ul><ul><li>Earn CEUs, Certificate of Training in CKD Diet Management at completion </li></ul>
    25. 26. References <ul><li>1. National Kidney Disease Education Program. Chronic Kidney Disease and Diet: Assessment, Management and Treatment. National Kidney Disease Education Program; 2011. </li></ul><ul><li>2. Rolfes SR, Pinna K, Whitney E.  Chronic Kidney Disease. In Understanding Normal and Clinical Nutrition.  8 th ed. Belmont, CA: Wadsworth; 2009. </li></ul><ul><li>3. National Kidney Foundation. Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. New York, NY: The National Kidney Foundation; 2007. </li></ul>
    26. 27. References <ul><li>4. Burrowes JD. Leaching potassium from tuberous root vegetables. Renal Nutrition Forum, 26(3), 2007. </li></ul><ul><li>5. Sullivan C, Sayre SS, Leon JB et al. Effect of Food Additives on Hyperphosphatemia Among Patients with End-Stage Renal Disease: A Randomized, Controlled Trial. JAMA, 301(6): 629-635, 2009. </li></ul><ul><li>6. Byham-Gray L, Wiesen K, eds. A Clinical Guide to Nutrition Care in Kidney Disease. Chicago, IL: American Dietetic Association; 2004. </li></ul><ul><li>7. McCann L, ed. Pocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease. 4 th ed. New York, NY: National Kidney Foundation Council on Renal Nutrition; 2009. </li></ul>