Here are the answers to the questions: 1. CKD 3 2. C 3. B 4. B 5. A 6. B

1. In
&
Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital
(international)
ISN Educational Ambassador
Dr. Doaa Hamed
Lecturer of clinical nutrition
National Nutrition Institute
Instructor in Egyptian Fellowship of
Clinical Nutrition

2. Diet Planning
In
CKD & HD
Nutrition Care Process
in renal diseases

3. Nutrition Care Process
in renal diseases

4. Question 1
Nutritional monitoring started in
stage :-
 CKD 1
 CKD 2
 CKD 3
 CKD 4

5. Question 2
Frequency of screening for under
nutrition in CKD for inpatient:-
A. Weekly
B. 2 weeks
C. Monthly
D. Every tow months

6. Question 3
Incidence of PEM in ESRD:-
A. 10 % - 20 %
B. 20 % - 35 %
C. 40 % - 70%
D. 60 % - 80 %

7. Question 4
If Actual BW > 30% IBW use :-
A. Standard Body Weight (SBW)
B. Adjusted Body Weight (ABW)
C. Body Mass Index (BMI)
D. Interdialytic Weight Gain (IDWG)

8. Question 5
Clinically significant weight loss :-
A. 5% or > within 1 month
B. 5% or > within 3 month
C. 7.5% or > within 1 months
D. 10% or > within 1 months

9. Question 6
IDWG General recommendation in HD:-
A. + 1.5 kg
B. + 2 kg
C. + 2.5 kg
D. + 3 kg

10. Objective
1.Integrated renal care .
2.Importance of renal diet .
3.Nutritional counseling
4.Nutrition Care Process
Steps:-
Assessment
 Diagnosis
 Intervention
Monitoring and Evaluation

11. Stages of Chronic Kidney Disease
Stage CKD I CKD II CKD III CKD IV CKDV
Description Kidney Damage
with Normal or
↑GFR
Mild ↓GFR Moderate ↓ GFR Severe ↓ GFR Kidney Failure
GFR
(ml/min/1.73 m2 )
> 90 60 -89 30 -59 15 -29 < 15 or Dialysis
Stage
dependent
Actions
Prevent complications
Mineral metabolism
Nutritional monitoring
Anemia prevention

12. Care process Requires
A psychotherapist / motivation speaker
A diabetes educator
A renal specialist dietitian
A combination of:-
 Nephrologist
 Nurse
 pharmacist
 Social Worker
 patient's best friend

13. What we
should to eat?

14. What is the role of ?
 Trained & experienced in Renal nutrition
 Implementation of many guidelines concerning
nutritional assessment
Anthropometry, SGA, dietary interviews
 Plan for nutritional management & therapy
 Counseling the patient & the family
 Educational activities

15. Why there are for ?
All patients should receive nutritional counselling based
on an individualized plane of care.(Evidence Level C)
Nutrition in peritoneal dialysis Guidelines 2005
Nephrol DialTransplant (2005) 20 ( Suppl 9) : ix28-ix33
Clinicians use several strategies, but there are barriers to
nutritional counseling which include:-
skepticism about the effectiveness of nutritional interventions
lack of specific knowledge and training about therapeutic
nutrition
 lack of specialty clinics, absence of guidelines, and an
inadequate number of dietitians

16. screening
CKD
 We recommend that screening should be performed (1D)
o for inpatients
o for outpatients with eGFR <20 but not on dialysis
o of commencement of dialysis then 6-8 weeks
later
 Screening may need to occur more frequently if risk of
undernutrition is increased (for example by intercurrent illness)

17. screening
HD
 Stable and well-nourished haemodialysis patients should be
interviewed by a qualified dietitian every 6–12 months or
every 3 months if they are over 50 years of age or on
haemodialysis for more than 5 years (Evidence level III).
 Malnourished haemodialysis patients should undergo at
least a 24-h dietary recall more frequently until improved
(Opinion).
UK Renal Association, March 2010

18. CKD HD
 Clinical studies have shown that renal patients may
have inadequate dietary intakes during early stages
 40 - 70 % of patients with end-stage renal disease are
malnourished
 Protein–energy malnutrition should be avoided in
maintenance hemodialysis because of poor patient
outcome (Evidence III).
 Tow types of malnutrition I & II has been described
in CKD patients
(ESPEN 2008)

19. PEW
Kidney International (2013) 84, 1096–1107

20. Beto’s PAGE System
Pediatrics • Growth / development
Adults • Promote health ( Prevention)
Geriatric • Maintain health ( Holding pattern)
End of Life • Minimaze aging effects
CKD Key Focus on…
Quality of life

21.  Maintain optimal nutritional status
 Prevent protein energy malnutrition
 Slow the rate of disease progression
 Prevention/treatment of complications
and other medical conditions
 DM
 HTN
 Dyslipidemias and CVD
 Anemia
 Metabolic acidosis
 Secondary hyperparathyroidism

22. Renal diet minimizes the amount of wastes
A good meal plan choices can:
 Minimize build-up of waste products &
fluid between treatments
 Improve nutritional and functional status
 Conserve muscle mass

23. Nutrition Care Process Steps
ADIME
Nutrition
Care
Process

24. assessment
History and physical examination looking for loss
of weight and muscle wasting
Dietary history
SGA (Subjective Global Assessment)
Anthropometry
Biochemical / laboratory tests

25. Protein and energy intakes decrease as appetite decreases during the
course of CKD progression
Carrero JJ: J Renal Nutr 19: 10-15, 2009

26. S. creatinine
 The predialysis s.creatinine level will be
proportional to dietary protein intake and the
somatic (skeletal muscle) mass
 Thus, a low predialysis or stabilized
s.creatinine level an MD patient with
negligible renal function suggests
◦ Decreased skeletal muscle mass and /or a low dietary
protein intake

27. Is albumin can predicts mortality at
onset of dialysis?
Strong predictor of morbidity and mortality
(CANUSA study)
However,
Albumin is affected by non-nutritional
factors
 Infection
 Inflammation
 Co-morbidities
 Fluid overload
 Inadequate dialysis
 Blood loss
 Metabolic acidosis
Albumin may not increase in response to
nutritional intervention
There is No Single Magic Nutritional Index

28. Weight Status Evaluation
 Weight changes
◦ Intentional vs. unintentional weight loss
◦ Dry weight changes vs. fluid shifts
◦ Clinically significant weight loss
 5% or > within 1 month
 7.5% or > within 3 months
 10% or > within 6 months

29. How can we monitor and Follow-up
nutritional status?
Severely underweight Less than 16.0
Underweight From 16.0 to 18.5
Normal From 18.5 to 24.9
Overweight From 25 to 29.9
Obese Class I From 30 to 34.9
Obese Class II From 35 to 39.9
Obese Class III Over 40
Haemodialysis patients should maintain a BMI >23.0
BMI = Weight (kg) / (height [m]2)

30. Reverse epidemiology of obesity in dialysis
patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

31. Ideal Body Weight (IBW)
For men = [ (height(cm) – 152.4) x 0.91) ] + 50
For women= [ (height(cm) – 152.4) x 0.91) ] + 45.5
Adjusted Body Weight (ABW)
For men: Adjusted weight = [( actual weight- IB weight) x 0.38] + IB weight
For women: Adjusted wt = [(actual weight- IB weight) x 0.32 ] + IB weight
If Actual BW > 30% IBW
use

32. Dry Weight
 Dialysis patient’s weight
◦ neither too much nor too little fluid
 Feel well, have no excess fluid or difficulty
breathing
 Dry weight can change & must be evaluation
frequently
 Weight used to calculate how much fluid needs to
be removed with dialysis and for other nutrient
calculations

33. Estimated DryWeight
Mendenhall
,
s figure
Ascites Oedema
Minimal (kg) 2.2 1
Moderate(kg) 6 5
Severe (kg) 14 10

34. InterdialyticWeight Gain (IDWG)
 General recommendation +2 kg
 >5% fluid gains
 Excessive fluid intake
 Weight gain
 <2% fluid gain
 Inadequate fluid and/or food intake
 Weight Loss/Decreased body mass

35. Subjective Global Assessment Rating Form

36. Q & A

37. Question 1
Nutritional monitoring started in
stage :-
 CKD 1
 CKD 2
 CKD 3
 CKD 4

38. Question 2
Frequency of screening for under
nutrition in CKD for inpatient:-
A. Weekly
B. 2 weeks
C. Monthly
D. Every tow months

39. Question 3
Incidence of PEM in ESRD:-
A. 10 % - 20 %
B. 20 % - 35 %
C. 40 % - 70%
D. 60 % - 80 %

40. Question 4
If Actual BW > 30% IBW use :-
A. Standard Body Weight (SBW)
B. Adjusted Body Weight (ABW)
C. Body Mass Index (BMI)
D. Interdialytic Weight Gain (IDWG)

41. Question 5
Clinically significant weight loss :-
A. 5% or > within 1 month
B. 5% or > within 3 month
C. 7.5% or > within 1 months
D. 10% or > within 1 months

42. Question 6
IDWG General recommendation in HD:-
A. + 1.5 kg
B. + 2 kg
C. + 2.5 kg
D. + 3 kg