Kidney Disease-What You Need to Know Mary Ann Vespignani RD LDN

WHAT DOES THE KIDNEY DO? Remove Waste Products from the body Remove Drugs from body Balance the body’s fluids Release hormones that regulate blood pressure Produce an active form Vit D that promotes strong healthy bones Control production of red blood cells

What is the Dietitian’s/CDM role? To educate and advise people on diet To provide support through treatment To work with Renal RD to review monthly labs and adjust diet as needed To provide support for non-renal staff

National Kidney Foundation Outcomes Quality Initiative KDOQI’s evidence-based clinical practice guidelines are updated on an ongoing basis, as new evidence becomes available. KDOQI also provides timely commentary on the applicability of the global KDOQI guidelines in the US clinical and regulatory environment.

KDOQI Goals Albumin 4.0 or greater Potassium 3.5-5.5 Phosphorus 3.5-5.5 Calcium 8.5-9.5

OVERVIEW What the tests measure Why they are important URR Albumin Calcium, Phosphorus, Potassium Why they are important What to do when the results are outside the acceptable range Summary

Why do you need to understand the Patient Report Card? So you can answer patients’ questions So you can reinforce the dietary changes the patient needs to make So we can work as a team …so we can provide better patient care… \

Urea Reduction Ratio Tells us if the treatments are are doing a good enough job of cleaning the blood. Formula Pre dialysis BUN – Post dialysis BUN x 100 Pre dialysis BUN Goal: Greater than or equal to 65 (> 65)

Urea Reduction Ratio URR < 65 means that the person’s blood is not being cleansed well enough. The person may have: Poor appetite Nausea / vomiting Bad taste in mouth Weight loss

ALBUMIN An important protein in the blood Indicator of person’s nutritional status Infection/Inflammatory response affects Albumin The single most important indicator of a person’s mortality Goal: 4.0 – 5.4 g/Dl

Albumin  Albumin may mean Malnutrition Increased risk for illness and death (long term) Over hydration/fluid overload  Albumin makes it difficult for dialysis to remove fluid

What factors affect Albumin Poor appetite Not eating enough protein-rich foods Meat, fish, poultry or eggs Fluid overload Illness / infection Liver problems Other health problems

CALCIUM Needed for healthy bones muscle contraction & relaxation proper nerve functioning Normal range on “Report Card” is 8.5 – 9.5

CALCIUM Hypercalcemia (Ca > 10.2): Hypocalcemia: nausea confusion coma  risk for heart disease Hypocalcemia: numbness seizures painful muscle spasms osteoporosis

What to do if calcium levels are too high or too low? Hypercalcemia ( calcium) Patient should decrease calcium intake STOP PhosLo, Tums, etc Doctor will D/C active form of Vit D3 (Calcijex or Zemplar

What to do if calcium levels are too high or too low? Hypocalcemia ( calcium) Patient may need Calcijex, or Zemplar additional dietary/supplemental calcium May be due to low albumin levels

Phosphorus (“P”) or Phosphate (PO4) Needed for healthy bones & teeth energy metabolism (ATP) When the kidneys fail, phosphorus levels usually  Hemodialysis does not remove phosphorus from the blood very well Protein-rich foods are high in P Very challenging for patients to maintain optimal P levels

Phosphorus Normal ranges currently on “report card” are 2.5 –5.5 Hyperphosphatemia ( phosphorus) itching bone damage  risk for soft tissue calcification (including heart and blood vessels) Hypophosphatemia ( phosphorus) rare muscle weakness coma patient needs to stop PO4 binders (PhosLo, Renagel

Phosphorus to HIGH Patient needs to decrease intake of P-rich food and/or take PO4 binders as prescribed(Binders must be taken with meals)

Phosphorus rich foods Beans, peas, lentils (“legumes”) Nuts (peanut butter), seeds Chocolate, cocoa Cheese (pizza), milk, yogurt Whole grains (whole wheat bread) Bran cereals Coke, Pepsi & other sodas with “phosphoric acid”

Guidelines for Phosphorus Most patients need to limit their phosphorus intake to 800 – 1000 mg per day ½ cup milk = ~100 mg What about skim milk? 124 mg What about heavy cream? 74 mg

Potassium-Function Allows nerves and muscles (including the heart) to work properly Too much or too little can cause sudden death Normal range on “report card” is 3.5 to 6.0 some doctors prefer 3.5 to 5.5

Elevated Potassium Hyperkalemia (high potassium level) can cause muscle weakness the heart to stop

Hyperkalemia What to do? Alert doctor immediately if > 7.0 Review symptoms with patient Kayexalate may be needed Review diet with patient

High Potassium Foods Orange / juice Tomato / sauce / juice Bananas/apricots Potato / chips / french fried / sweet Prune juice Large quantities of “low potassium” foods Fresh Fruit

Summary We reviewed the following lab values: What they mean URR Albumin Calcium Phosphorus Potassium What they mean Why they are important What to do when they are above or below the acceptable range

Dietary advice Energy Protein Salt Potassium Phosphate Fluid

Goals of Diet Therapy Maintain normal biochemistry levels Minimise symptoms Prevent malnutrition and unintentional weight loss Improve quality of Life

Factors that influence dietary advice Stage of CKD Biochemistry levels (trends) Medications Treatments e.g. Conservative, Dialysis Other medical conditions e.g. Diabetes Lifestyle (social, psychological aspects)

Dietary advice Weight Management - activity/lifestyle, current intake, food preferences, cooking methods, food labelling, alcohol. DM Control - meds, regular meals & starchy CHOs, low sugar, fruit & veg. Lipid Control – ↓saturated fats, ↑mono fats, oily fish, fruit & veg. Salt Intake - at table, in cooking, convenience foods.

Dietary advice: Low Appetite, Depressed & Symptomatic – small & frequent meals, energy dense and high protein foods. High Potassium Level – cooking methods, food choices & frequencies of high K foods. Hypertension – salt intake Phosphate Level –Need to evaluate binders and when they are taken. Binders need to be taken with meals Factors Considered by Dietitian: Family situation / recent loss of love one/other medical conditions Culture – Asian diet & cooking methods Future ‘life changing’ treatments – Hemodialysis

Dietary Guidelines Protein Intakes of 1.2 gm/kg body weight 30-35 Kcals/kg body weight Fluid weight gains between treatments of 2-3 kg Sodium intakes = 2.5 grams/day Phosphorus =800 -1200mg/day Calcium intakes <1200 mg/day Potassium intakes <3200 mg/day

Medications Phosphate Binders Iron- Calcium- Renal Vitamins- PhosLo,Renzela and Fosrenol-these must be taken with meals and snacks to be effective!!!!! Iron- Epogen/Procrit often provided at Dialysis center. Calcium- Renal Vitamins- Common names Nephrovite, Nephrocaps, Renaltab, Diatex

Medication Alerts!! Dialysis patients are not to be given Milk of Mag,Citracal or calcium citrate, PeptoBismol; KCL supplements or PRN calcium or aluminum based antacids Renal patients are normally taken off Lasix, Bumex or other diuretics when starting HD

Interactions: HERBAL SUPPLEMENTS NEED CAREFUL CHECK AS THEY MAY INTERACT WITH OTHER MEDICATIONS Can affect K levels-alfalfa, Dandelion, Licorice root, Noni fruit/juice and St John’s wort Has diuretic properties/electrolyte imbalance –Goldenrod,Juniper berries and parsley Can effect blood thinning agents: garlic and Ginger Do not use in CKD-Ginseng

Questions

Contact Details Binik, Y., Devins, G., Barre, P., Guttman, R., Hollomby, D and Mandin, H. et al (1993) Live and learn: Patient education delays the need to initiate renal replacement therapy in end-stage renal disease Journal of Nervous and Mental Disease 181(pp 371 - 376 Christensen, A. and Ehlers, S (2002) Psychological factors in end-stage renal disease: and emerging context for behavioural medicine research Journal of Consulting and Clinical Psychology 70 (3) pp 712 - 724 Hener, T., Weisenberg, M. and Har-Evan, D. (1996) Supportive versus cognitive-behavioural intervention programs in achieving adjustment to home peritoneal kidney dialysis Journal of Consulting and Clinical Psychology 64 pp 731 - 741 Kimmel, P. (2002) Depression in patients with chronic renal disease: What we know and what we need to know. Journal of Psychosomatic Research 53 (pp 951 – 956) Leake, R., Friend, R. and Wadhwa, N (1999) Improving adjustment to chronic illness through strategic self presentation: an experimental study on a renal dialysis unit Health Psychology 18 (pp 54 – 62) Petrie K (1997) Renal failure, dialysis and transplantation. In Baum, A., Newman, S., Weinman, J., West, R. and McManus, C (Eds) Cambridge Handbook of Psychology, Health and Medicine. Pp 573 – 574 Cambridge University Press