1. Nutrition Therapy and Dialysis Melinda S. Leone, MS, RD St. Joseph's Regional Medical Center Division of Nephrology Paterson, NJ 07503 leonem@sjhmc.org

2. Objectives  Participant will be able to describe the importance of nutrition intervention in patients with ESRD  Participant will be able to identify the components of a nutritional assessment  Participant will be able to identify the components of the renal diet and the role of the dietitian

3. Does Nutrition Status Matter? YES!  Nutritional indicators can be directly linked to patient status and outcome Protein-Energy Malnutrition (PEM) 1 BMI 2 Albumin 3, 4 Potassium Phosphorus 5 Calcium

4. Renal Osteodystrophy  Hyperphosphatemia Vascular and non-vascular calcification 5  Hypocalcemia  Secondary Hyperparathyroidism  Bone Disease Low bone mass and density Osteitis fibrosa cystica

5. Protein Energy Malnutrition 6 PEM  Malnutrition  PEM: marasmus-kwashiorkor muscle/fat wasting weight loss  Marasmus: Inadequate nutrient intake  Kwashiorkor: Inadequate protein intake  Cachexia

6. Causes of Malnutrition  Uremic Syndrome Malaise Weakness Nausea and vomiting Muscle cramps Itching Metallic taste Neurologic impairment  Hospitalizations  Co-morbidities Diabetes Infections Amputations Cancer  Inflammation

7. Protein–energy wasting syndrome in kidney disease 7

8. Nutrition Assessment Anthropometric Data  Height  Weight status  Frame size  Arm anthropometrics  Appearance  Amputations

9. Nutrition Assessment Weight Status Evaluation  Standard Body Weight (SBW)  Body Mass Index (BMI)  Ideal Body Weight (IBW)  Adjusted Body Weight  Usual Body Weight (UBW)

10. Nutrition Assessment 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 Attitude toward changes Goals for weight changes

11. Nutrition Assessment 6 Interdialytic Weight 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

12. Nutrition Assessment Diet History  Appetite/Intake  Food preferences  Allergies/Intolerance  Taste changes  Acute or chronic GI concerns  Swallowing/Chewing concerns  Urine output  Pica  Religious/Cultural Restriction  Supplement intake  Homeopathic Treatments  Nutrition Knowledge

13. Nutrition Assessment Diet History  Shopping and Cooking Abilities Facilities  Medication Side Effects Compliance  Physical limitations Psychosocial problems Emotional support Economic limitations  Depression Adjustment to disease Treatment Compliance

14. Nutrition Assessment Diet History  Food Records 24 Hour Recall 3 Day Food Record 3 Day Calorie Count Food Frequency Questionnaire  Diet Assessment Calories Protein Carbohydrates Fat/Cholesterol Sodium Potassium Phosphorus Fluid Vitamins Minerals

15. Nutrition Assessment Laboratory Analysis 6 Monthly  Albumin: 4.0g /dL or >  Potassium: 3.5-5.3 mEq/L  Phosphorus: 3.5-5.5 mg/dL  Calcium: 8.4-10.2 mg/dl  Glucose <200 mg/dL Non-fasting  Product: < 55  URR: >65%  Hgb: 10-12 g/dL Quarterly  Hemoglobin A1C: < 7%  PTH: 150-600 pg/mL  Lipid Panel Chol < 200 mg/dL HDL > 40mg/dL LDL <100mg/dL Triglycerides <200 mg/dL

16. Nutrition Assessment: Subjective Global Assessment 6  Protein-energy nutritional status measurement Valid and reliable 8 KDOQI recommended 9  Medical history and physical exam  Body composition focus on nutrient intake  Subjective rating: 7 point scale 6 Well-nourished Mild to moderately malnourished Severely malnourished

17. Nutrient Needs KDOQI Guidelines 9 HDPD Protein (>/= 50% HBV protein) HD: 1.2 g/kg PD: 1.2-1.3 g/kg HD: 1.2 g/kg PD: 1.2-1.3 g/kg Energy35 kcal/kg 60 years 35 kcal/kg <60 years 30-35 kcal/kg > 60 years Phosphorus10 – 12 mg/g protein 800-1000 mg/day Adjust to meet protein needs 10 – 12 mg/g protein 800-1000 mg/day Adjust to meet protein needs Potassium2-3 g Monitor serum levels3-4 g Monitor serum levels FluidOutput + 1000 ml Limit IDWG Maintain fluid balance Sodium2 g2-3 g : Monitor fluid balance Calcium<2g including binder load Maintain Serum WNL <2g including binder load Maintain Serum WNL Vitamins/MineralsNext Slide Fiber20-25 g

18. Nutrient Needs KDOQI Guidelines 9 HDPD Vitamin C60-100 mg B62 mg Folate1-5 mcg B123 mcg Vitamin E15 IU Zinc11-15 mg IronIndividualize Vitamin DIndividualize B11.1-1.2 mg1.5-2 mg OtherRDA Vitamins and Minerals

19. Nutrition Therapy Goals  Provide an attractive and palatable diet  Control edema and serum electrolytes  Prevent nutritional deficiencies  Prevent renal osteodystrophy  Prevent cardiovascular complications

20. Dialysis Diet  Diet Order 2000 calorie, 80 g protein, 2 g Na+, 2 g K+, 1 g PO4, 1500 ml fluid restriction  Meal Planning Individualize diet for patient’s lifestyle Assistance programs Nursing Homes National Renal Diet: American Dietetic Association 10

21. Dialysis Diet  Adequacy and Balance Calories Protein Variety  Actual intakes of HD patients 11 23 kcals/kg/day Less than 1 g/kg/day

22. Albumin  Controversial key nutrition status measure 12  Depressed values PEM, fluid overload, chronic liver/pancreatic disease, steatorrhea, inflammatory GI disease, infection, catabolism r/t surgery, abnormalities in protein metabolism, acidosis 6  Elevated Values Dehydration, high dietary protein intake 6

23. Albumin  Dialysis Treatment HD: 10-12 g free amino acids lost 13 Losses increase with glucose free dialysate PD: 5 to 15 g protein lost 9, 14 Lost as albumin

24. Protein  1.2-1.3 g protein/kg SBW 9 Average patient: 80 g Protein  50% HBV protein foods  HBV Proteins Beef, poultry, fish, shell fish, fresh pork, turkey, eggs, cottage cheese, soy 6 to 10 ounces daily  Protein Alternatives protein bars, protein powders, supplement drinks

25. Potassium  2-3 g daily 9 - adjust per serum levels Dialysis bath concentrations  Stricter diet restrictions Insulin deficiency, metabolic acidosis, beta blocker or aldosterone antagonists treatments, hypercatabolic state  Non-diet causes Hyperkalemia Hemolysis, high glucose, insulin deficiency, inadequate dialysis, incorrect dialysate potassium concentration, starvation, catabolism, sickle cell anemia, Addison's disease, long-term constipation 15

26. Potassium 10  Avoid Highest Foods Oranges/Juice Banana Potato Plantains Mango Melon Avocado Tomato Nuts  Fruits & Vegetables Low: 20-150 mg Medium: 150-250 mg High: 250-550 mg  Portion size is essential  Avoid Salt Substitutes  Dairy 1 cup 380-400 mg High phosphorus foods

27. Phosphorus  Dietary intake ~800 to 1000 mg/day <17 mg/kg SBW  HD removes ~500-1000 mg/treatment  PD removes ~400 mg/treatment  50% dietary phosphorus removed by binders 16  Control = Binders + Diet + Adequate dialysis

28. Phosphate Binders Generic NameBrand NameEstimated Binding Capacity Calcium acetate 667 mg PhosLo30 mg Sevelamer HCL 800 mg Renagel, Renvela64 mg Calcium carbonate 500-600 mg TUMS, Os-Cal, Calci-Chew, Caltrate 20-24 mg Lanthanum carbonate 1000 mg Fosrenol320 mg

29. Phosphorus Balance Phos Intake +1000 mg/day +7000 mg/wk Absorption ~60% +600 mg/day +4200 mg/wk Binding ~50% -300 mg/day (10 Phoslo) -2100 mg/wk Dialysis Removal HD -700 x 3 = -2100 mg/wk PD -400 x 7 = -2800 mg/wk Weekly Phosphorus Balance + 4200 (diet) – 2100 (Binders) – 2100( HD) = Balance

30. Phosphorus 10 High Phosphorus Foods  Dairy products  Beans & Nuts  Processed meats  Chocolate  Pancakes, waffles, biscuits, cakes  Sardines  Whole wheat, bran cereals Lower Phosphorus Foods  Fresh meat products  Homemade baked goods  Nondairy creamer  Unenriched rice milk  Cream cheese  White flour products  Rice cakes

31. Phosphorus Additives  Inorganic Phosphorus absorbed easily  Phosphorus binders ineffective with many additives  READ THE INGREDENTS LABEL!! Phosphoric acid Sodium hexametaphosphate Calcium phosphate Disodium phosphate Trisodium triphosphate Monosodium phosphate Sodium tripolyphosphate Tetrasodium pyrophosphate Potassium tripolyphosphate

32. Calcium  Use corrected calcium (adjusted calcium) for albumin <4 6 Calculation: [ (4-albumin) x 0.8] + Ca++]  Diet: Less than 2 g daily  Hypercalcemia Ca++ based binders, supplements Vitamin D analogs/treatment Diet, fortified foods Dialysate calcium levels  Hypocalcemia Vitamin D, Calcijex Supplement between meals

33. Parathyroid Hormone (PTH)  Vitamin D is activated in the kidney to calcitriol, or vitamin D3 1  Vitamin D3 levels fall with kidney failure Calcium absorption ↓ and phosphorus excretion ↓ PTH increases => bone disease  Vitamin D3 therapy helps prevent renal bone disease  Ca and Phosphorus precipitate and calcify soft tissue  Ca x Phos product goal range with treatment

34. Fluid  HD Urine Output + 1000 ml Limit IDWG 2-5% Estimated Dry weight  PD Maintain fluid balance Vary dextrose concentrations in dialysate Restrict if fluid balance not obtained without frequent hypertonic exchanges

35. Sodium 1,6  ≥ 1 L fluid output: 2-3 g Na and 2 L fluid  ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid  Anuria: 2 g Na and 1 L fluid  Individualize IDWG, blood pressure, residual renal functions  Increased Restrictions if ↑ IDWG, CHF, edema, HTN  PD: liberalize restriction to 2-4 grams sodium High sodium intake may increase thirst

36. Lipids 10  Increased risk of lipid disorders  Recommended fat intake Total Fat <30% of calories Saturated fat <10% Cholesterol <300 mg/day  Difficult restrictions to achieve  Omega 3 supplements for elevated triglycerides  Optimum fiber intake 20-25 g/day

37. Micronutrients 1,6  Renal Multivitamin containing water soluble vitamins 17 Dialyzable – take after dialysis  Vitamin C in renal vitamin Limit total vitamin C 60-100 mg ↑ Vitamin C → ↑ oxalate → calcification of soft tissues and kidney stones  Individualize: Fe++, Vitamin D, Ca++, Zinc

38. Specific PD Concerns  Higher protein needs Lose 5-15 grams of protein a day 9, 14  Weight Gain 1 Include dialysate calories in total intake May absorb as much as 1/3 (500-800 kcals) of daily energy needs Limit sodium and fluid to minimize hypertonic exchanges Hypertonic agents such as Icodextrin (Extraneal)  High Triglycerides 6 Modify intake of sugars/carbohydrates Limit intake of fats, saturated fats

39. Nutritional Supplements  Oral supplements: Nepro, Ensure, Boost  Powders: Beneprotein, ProSource, Eggpro  Modular Protein: Pro-Stat, Promod  Cookies: NutraBalance  Protein Bars Meal replacements vs. snacks Over the counter Evaluate potassium, phosphorus

40. Nutrition Support Enteral  Oral Supplements Barriers: compliance, fluid, palatability, cost  Tube feeding Renal Formulas Nepro and Novasource Renal Barriers: acceptance, intolerance, tube placement, fluid intake, reimbursements, assistance

41. Nutrition Support Parenteral  IDPN Barriers Oral intake is maximized without improvement in status Usually requires documented malabsorption diagnosis Benefits Supplemented during treatment No additional tube/access needed Dialysis clinics have individual rules and criteria Specific qualifying criteria from insurance companies

42. RD Roles Anemia and Bone Management  Anemia Management APN Anemia Manager Protocols  Bone Management APN Bone Manager Protocols MD input as needed RD recommendations

43. Resources  www.davita.com/diethelper www.davita.com/diethelper  www.case.edu/med/ccrhd/phosfoods www.case.edu/med/ccrhd/phosfoods  www.kidneyschool.org www.kidneyschool.org  www.aakp.org/brochures/phosphorus www.aakp.org/brochures/phosphorus  www.aakp.org/aakp-library www.aakp.org/aakp-library  www.rd411.com

44. References  1. Byham-Gray L, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. Chicago: American Dietetic Association; 2004.  2. Pifer TB et al. Mortality risk in hemodialysis patients and changes in nutritional indicators: DOPPS. Kidney International. 2002;62:2238-2245.  3. Acchiardo SR, et al. Morbidity and mortality in hemodialysis patients. ASAIO Trans. 1990;46:830-837.  4. Lowrie EG et al. Death risk predictors among peritoneal dialysis and hemodialysis patients: a preliminary comparison. Am J Kidney Dis. 1995;26:220-228.  5. Kestenbaum, B et al. Serum phosphate levels and mortality risk among people with chronic kidney disease. JASN. 2005;16(2):520-528.  6. McCann L. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4 th ed. National Kidney Foundation; 2009.  7. Fouque D et al. A proposed nomencalture and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney International. 2008;73:391-398.  8. Steibe A et al. Multicenter study of validity and reliability of subjective global assessment in the hemodialysis population. Journal of Renal Nutrition. 2007;17(5):336- 342.

45. References  9. NKF K/DOQI practice guidelines. Clinical practice guidelines for nutrition in chronic renal failure. Am J Kid Dis. 2000;35:S40-S41  10. Schiro-Harvey K. National Renal Diet: Professional Guide. 2 nd ed. Chicago: American Dietetic Association; 2002.  11. Rocco et al. Nutritional status in HEMO study cohort at baseline hemodialysis. Am J Kidney Dis. 2002;39:245-256.  12. Friedman AN, Fadem SZ. Reassessment of albumin as a nutritional marker in kidney disease. J Am Soc Nephrol. 2010;21:223-230.  13. Ikizler, TA et al. Amino acid losses during hemodialysis. Kidney Int. 1994;46:830-837.  14. Blumenkrantz MJ et al. Metabolic balance studies and dietary protein requirements in patients undergoing continuous ambulatory peritoneal dialysis. Kidney Int. 1982;21: 849- 861.  15. Beto J. Hyperkalemia: Evaluation of dietary and non-dietary etiology. J Ren Nutr. 1992;2:28-29.  16. Rocco MV et al. Handbook of Dialysis. 3rd ed. Philadelphia: Lippincott, Williams &Wilkins; 2001.  17. Andreucci, VE et al. Dialysis outcomes and practice patterns study (DOPPS) data on medications in hemodialysis patients. Am J Kidney Dis. 2004;44(S2):S61-S67.

46. Thank You ?? Questions ??