Renal nutrition
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This document provides an overview of renal nutrition for non-renal dietitians. It discusses the basics of kidney function including measurement of glomerular filtration rate and stages of chronic kidney disease. Prevalence of CKD and end stage renal disease are noted. The roles and responsibilities of renal dietitians are outlined. Guidelines for protein and fluid intake at different stages of CKD are presented. Management of complications like potassium levels, edema and malnutrition are covered. A case study is provided to demonstrate application of renal nutrition principles.
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Renal nutrition
- 1. Renal nutrition (for non-renal dietitians) Dr Lina Johansson Lead Renal Dietitian / NIHR Clinical Lecturer 30th September 2015
- 2. overview • Basics – Measurement and stages – Prevalence – Functions of the kidney – Symptoms • Nutrition – Role of renal dietitian – Protein – Potassium – Fluid – Malnutrition • Case study
- 3. DOH LTCs Compendium of Information, 2012
- 4. Measuring Kidney Function Glomerular Filtration Rate (GFR) Glomerulus Normal GFR: ~120mls/min =~ 180L/day
- 5. eGFR- progression • Abnormally declining eGFR – >5ml/min/yr – or >10ml/min in 5 years
- 6. Stages of Renal Disease Dialysis/ transplantation needed for survival (there is no cure) Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Normal function Mild decrease Moderate decrease Severe decrease End stage renal disease 130mls/min 90mls/min 60mls/min 30mls/min 15mls/min 0 Screen for CKD risk factors •Hypertension •Diabetes •Obesity CKD risk factor reduction •Lower bp •Control diabetes •Weight loss Treat complications of CKD •Uraemia •Manage anaemia •Prevent malnutrition Prepare or undergo replacement •Uraemia •Manage bp and fluid volume •Control diabetes •Control mineral imbalances •Prevent and treat malnutrition
- 7. UK prevalence CKD 3-5
- 8. Prevalence of dialysis 2005 2013 20635 27348 UK trend of people on dialysis 87% on haemodialysis (HD) 13% on peritoneal dialysis (PD) Renal Registry Reports 2006-2014 https://www.renalreg.org/publications-reports/
- 9. What causes end stage renal disease? Primary renal diagnosis % distribution in incident Renal Replacement Therapy 2013 Diabetes 25.4 Glomerulonephritis 14.4 Pyelonephritis 6.9 Hypertension 7.6 Polycystic kidneys 7.6 Renal vascular disease 5.4 Other 18.3 Uncertain aetiology 14.5 https://www.renalreg.org/reports/2014-seventeenth-annual-report/ (Chapter 1)
- 10. Question What are the consequences of reduced kidney function within the body?
- 11. Impaired kidney function Uraemia and accumulation of waste products Raised blood pressure/ fluid retention Anaemia Raised potassium levels Low serum calcium Metabolic acidosis
- 12. • What are the symptoms of advanced chronic kidney disease/ renal failure?
- 14. Uraemic symptoms • Loss of appetite • Nausea/vomiting • Diarrhoea • Weakness • Oedema • Taste changes • Insomnia • Fatigue • Decreased concentration • Muscle cramps • Itching
- 15. What is the role of the renal dietitian? • Improve nutritional status • Improve electrolyte balance • Improve fluid balance • Communication • Symptom control • Educators: support self-mgt • Support non-renal dietetic colleagues
- 16. Minimise uraemic symptoms ” in patients with chronic renal failure it is possible to postpone the increase of serum urea concentration for a long time, reducing the nitrogen intake to 3-5 g. Sometimes we have succeeded in reducing considerably high serum urea concentrations. Consequently the first uremic symptoms disappeared.” Volhard, 1918 (Handbuch der Inneren Medizin) Volhard, 1918 (Handbuch der Inneren Medizin)
- 17. What do you think about restricted protein diets? What are the guidelines for protein in chronic kidney disease in the UK?
- 18. Protein intake: recommendations for stages 4-5 (not on dialysis) Recommended Protein intake 0.75 g/kg IBW/day for patients with stage 4-5 not on dialysis Rationale • Prevent malnutrition (risk highlighted in MDRD study) • Improve symptoms of uraemia • Aid compliance (challenging to follow very low protein diets) Renal Association 2010 Nutrition guidelinesAverage protein intake for men and women g/kg/d 0 0.2 0.4 0.6 0.8 1 1.2 Men average daily protein intake g/kg/d Women average daily protein intake g/kg/d Proteinintakeg/kg/d Recommended protein intake for CKD 0.75g/kg IBW/d
- 19. Protein intake: recommendations for dialysis Recommended Protein intake 1.2g/kg IBW/day for patients on dialysis Rationale • Protein loss through dialysis : peritoneal and haemodialysis
- 20. Haemodialysis v Peritoneal Dialysis • What are key differences between these two modes of dialysis that will affect: – Interpretation of clinical signs and biochemistry – Nutritional management
- 22. Potassium • Hyperkalaemia can be present in CKD, HD and PD patients, can lead to sudden death • Targets for potassium • Normal range – CKD (no dialysis) • 3.5-6.0mmol/L haemodialysis • 3.5-5.5mmol/L peritoneal dialysis • Recommended intake • RNG (1998) 1mmol/kg/IBW • EDTNA/ERCA (european renal guidelines 2002) 50-65 mmols/d
- 24. Potassium Causes of hyperkalaemia Acidosis Fall in plasma bicarbonate as GFR decreases. Can lead to hyperkalaemia Diet Excess K intake Medications Ace Inhibitors e.g. enalapril Angiotension II receptor antagonists e.g. candesartan Potassium sparing diuretics e.g. Spironolactone Constipation K reabsorbed from stools Blood transfusion Blood is K rich Poor diabetic control Can lead to hyperkalaemia
- 25. Medications and potassium • ACEI/ARBs: – Hyperkalaemia known complication. Serum K levels increase by 0.4-0.6mmol/L during ACEI/ARB treatment. – 1 to 1.7% develop K >6.0mmol/L. – Not normally start ACEI/ARB if K above normal range.
- 26. What to do if referred a CKD patient with a raised potassium? • Check trend of potassium – Is it increasing and hovering around upper limit? – Have there been high potassium results in past? • Check diet – What is the baseline diet like? – Identify high potassium foods and offer suitable alternatives – Make diet achievable. • Follow up – If high potassium, then need to re-check bloods – Allow patient to contact you for further questions – Get support from renal dietitians
- 27. potassium • High potassium foods Fruit juices Coffee Potato or veg based crisps Bananas Chocolate Dried fruit and nuts or foods containing these Mushrooms Spinach
- 28. potassium • Cooking methods for vegetables
- 29. Breakfast: Glass of orange juice All Bran with milk and sugar 1 slice of wholemeal toast with butter and marmalade Mug of coffee with milk Mid Morning: Mug of tea with milk and 2 chocolate digestives Lunch: Wholemeal cheese and tomato sandwich Packet of crisps and a banana Mug of tea with milk Mid Afternoon: Orange with glass of fruit squash Evening Meal: Lamb chop with boiled potatoes and peas Fruit yoghurt Mug of tea with milk Supper: Mug of ovaltine 1. Identify high potassium foods from 24 hour recall 2. Suggest suitable alternatives
- 30. Potassium exercise - answers Breakfast: Glass of orange juice All Bran with milk and sugar 1 slice of wholemeal toast with butter and marmalade Mug of coffee with milk Mid Morning: Mug of tea with milk and 2 chocolate digestives Lunch: Wholemeal cheese and tomato sandwich Packet of crisps and a banana Mug of tea with milk Mid Afternoon: Orange with glass of fruit squash Evening Meal: Lamb chop with boiled potatoes and peas Fruit yoghurt Mug of tea with milk Supper: Mug of ovaltine
- 31. • peripheral oedema • pulmonary oedema Oedema
- 32. Fluid managment • 500ml/24hr plus previous day’s urine output if on haemodialysis • If not requiring dialysis then unlikely to be restricted (unless nephrotic)- guided by Drs • Poor DM control and salt intake contribute to thirst
- 33. Fluid balance in HD http://www.kidneypatientguide.org.uk/fluid.php Just before HD session Just after HD session= normally hydrated weight
- 34. Malnutrition: Nutritional intake as renal function declines: stage 4-5 Decreasing renal function Decreasing renal function Male Female Male Female Protein Intake Calorie Intake Kopple, Kid Int, 57:1688-1703, 2000
- 35. Decreasing renal function Male Female BMI Decreasing renal function associated with spontaneous reduction of protein and calorie intake and BMI reduction. Kopple, Kid Int, 57:1688-1703, 2000 Malnutrition: Nutritional intake as renal function declines: stage 4-5
- 36. Treatment of malnutrition Enteral – Modified food first advice – Oral nutritional supplements – Tube feeding e.g. nasogastric/ gastrostomy Parenteral – Intra Dialytic Parenteral Nutrition (IDPN) – HD only (only supplementary nutrition equivalent to ~420 kcals/ day, SMOFKABIVEN 8 EF) – Total Parenteral Nutrition (TPN)- Home service
- 37. Modified Food First Advice What do you have to consider in food first advice in patients with advanced CKD?
- 38. Enteral Nutritional Support • Renal considerations – Volume • are restrictions necessary? – Electrolytes • are phosphate and potassium levels raised? – Protein • how much protein does the patient need depending on their type of dialysis treatment and stage of CKD?
- 39. ONS – Which one to choose Product Volume Kcal Protein Potassium Phosphate Build Up 85g/200ml 270 15 21.8 14 Fortified Milk 300ml 323 22.6 24.8 20 Calshake 87g/240ml 598 11.9 20.7 14.1 Nepro HP 220ml 400 17.8 5.4 4.4 Fresubin Energy 200ml 300 11.2 6.6 5.4 Fresubin protein energy 200ml 300 20 6.6 7.8 Fresubin 2kcal 200ml 400 20 8 7.6 Fresubin Jucy 200ml 300 8 0.4 0.8 Fresubin creme 125g 231 12.5 5.3 5.1 Fresubin 5kcal shot 30ml 150 0 0 0
- 40. Case study Mr Remoh Nospmis Type 2 diabetic Overweight CKD stage 4, eGFR 20mls/min 3 children Works in a nuclear power plant Weight 95kgs, height 1.7m, BMI 32.9kg/m2
- 41. Questions?