1. Nutritional Markers in hemodialysis
Julie Atteritano, RD, CDE, CDN

2. Albumin Biochemical marker reflecting visceral protein stores
Most common protein found in the blood
Produced by the liver (9-12g /day)
Life span days

3. Role of Albumin in the Body
Maintains intravascular oncotic pressure
Transports small molecules in the blood such as billirubin, Ca+, Mg, Progesterone, and medications
Provides the body with necessary protein needed to maintain growth and repair tissue

4. Target Levels for Albumin
Stabilized serum albumin equal to or greater than the lower limit of the normal range. Approximately 4.0mg/dl K/DOQI

5. Consequences of hypoalbuminemia
Increased morbidity and mortality
Serum albumin concentrations are identified as the most powerful indicator of mortality
Risk of death in patients with serum albumin concentration < 2.5gm/dl was 20 fold than that of patients with serum albumin gm/dl
Serum albumin gm/dl resulted in a 2 fold increase in relative risk of death
(Lowrie et al.)

6. Consequences continued…
Edema and ascites
Decreased healing
Increased risk of infection

7. Reasons for hypoalbuminemia
Protein Energy Malnutrition (PEM)
Caloric and protein intake are inadequate
to meet nutrition needs
** Patients on hemodialysis have a higher Resting Energy Expenditure than patients in Stage 2 CKD
** Goal for intake Kcal/Kg
gm/Kg protein

8. Hypoalbuminemia continued…
Inflammation
Characterized by acute phase proteins
C- reactive protein (CRP), Alpha -1 acid glycoprotein (a1-AG), Ferritin, Ceruloplasm
Inflammation secondary to infection, trauma, obesity, poorly controlled DM
Hydration status
Proteinuria
Metabolic acidosis

9. Dietary strategies to improve albumin levels
Ensure adequate caloric and protein intake
Increase intake of high biological value (HBV) proteins (Chicken, turkey, fish, red meat, eggs)
Nutritional supplementation: Nepro, Liquid protein supplements (Liquacel, Prostat), whey protein powder

10. Strategies to improve albumin continued….
Intradialytic Parenteral Nutrition (IDPN)
Amino acids (AA), Dextrose, and lipids delivered directly into the blood stream during hemodialysis

11. Potassium (K+)
Potassium is a mineral and an electrolyte

12. Role of potassium in the body
Potassium is an electrolyte which means it conducts electricity in the body along with Na+, Ca+, Mg, and chloride
Responsible for skeletal and smooth muscle contraction (crucial for heart function)
Plays a role in biochemical reactions and energy metabolism
Catalyst in the synthesis of amino acids from protein sources

13. Target levels for potassium
Low : less than 3.5mg/dl Goal :3.5mg/dl – 5.5mg/dl High : 5.6mg/dl – 6.0mg/dl Unsafe: > 6.0mg/dl

14. Hyperkalemia Dietary indiscretion K+ levels > 5.5mg/dl
Causes of Hyperkalemia include:
Dietary indiscretion
K+ shifts from intracellular to extracellular space (Caused by metabolic acidosis, NSAID’s, non-selective Beta-blockers)
K+ bath (3K+,4K+)
Non-compliance with treatment Rx

15. Consequences of hyperkalemia
Nausea
Weakness
Numbness and tingling
Irregular heart beat
Heart failure
Sudden death

16. Dietary strategies to improve hyperkalemia
Goal for intake 2,000mg K+ per day
Avoid/limit high K+ foods
Avocado (1oz) 144mg
Banana (small) 422mg
Cantaloupe/honeydew (1 cup) 388mg
Orange (small) 240mg
Mango/papaya 323mg
Dried fruit (ex-Apricots 10 halves:470mg)
Potato/sweet potato mg
Tomato (1 cup canned) 1098mg

17. Dietary strategies continued…
Spinach (1 cup cooked) 839mg
Winter squash (1 cup) 494mg
Dried beans and peas
(ex: kidney beans 1 cup 713mg)
Milk (1 cup) 382mg
Yogurt (8oz) 579mg
Salt substitutes

18. Low potassium choices Apples Berries (strawberries and blueberries)
Cabbage
Canned peaches and pears
Carrots
Cauliflower
Cucumber
Eggplant
Green beans
Grapes
Lettuce
Non-dairy creamer
Onion
Rice milk
Sorbet
Watermelon

19. Hypokalemia K+ < 3.5mg/dl Causes: - Decreased po intake
- Excessive diarrhea or vomiting
- Certain medications (ex- diuretics)
- Need for K+ bath change (3K+,4K+)

20. Consequences of hypokalemia
Muscle weakness and cramping
Fatigue
Confusion
Problems with muscle coordination
Irregular heart beat
Heart failure
Dietary intervention: Liberalization

21. Phosphorus (PO4) Phosphorus is a mineral
Most abundant after Calcium (Ca+)
85% found in bones
14% spread throughout soft tissue
1% in blood and extracellular fluid

22. Role of pO4 in the body
Responsible for the growth, maintenance, and repair of tissues and cells
Production of genetic building blocks (DNA/RNA)
Energy production: helps change protein, fat, and carbohydrates into energy
Combines with Calcium (Ca+) to form calcium phosphate (predominant mineral in bone)

23. Target levels for phosphorus
Low: less than 3.5mg/dl Goal: 3.5mg/dl – 5.5mg/dl High: greater than 5.5mg/dl

24. Hyperphosphatemia PO4 > 5.5mg/dl
As kidney function diminishes (decreased GFR), the kidney loses the ability to excrete PO4
Leading to elevated serum PO4 levels

25. Consequences of hyperphosphatemia
Calcium- phosphorus deposits
- heart
- skin
- lungs
- blood vessels
Red eyes
Bone disease
- bone and joint pain
- weak brittle bones
Increased risk of mortality

26. Dietary strategies to improve hyperphosphatemia
Lower PO4 diet
Goal for intake ,000mg per day
Avoid high PO4 foods
- Dairy products (milk, cheese, ice cream,
yogurt)
- Chocolate
- Dark cola (Coke and Pepsi)
- Nuts and nut butters
- Organ meats
- Cream soups
- Processed meats
- Whole grain bread

27. Dietary strategies continued…
Phosphorus binders
- Calcium Carbonate: TUMS
- Calcium Acetate: Phoslo
- Sevelamar Hydrochloride: Renvela
- Lanthanum Carbonate: Fosrenol
Greatest limitation is Compliance!!

28. Hypophosphatemia PO4 level < 3.5mg/dl Possible causes:
- Poor po intake
- Need for binder dosage adjustment
Consequences:
- Decreased appetite
- Confusion
Dietary Strategies:
- Dietary liberalization
- Binder dosage decrease or D/C

29. Pathway of ckd mineral and bone disorder
Decreased Renal Function
Decreased 1,25 (OH) Vitamin D
Phosphate Retention
PTH
Ca+
PO4
Secondary Hyperparathyroidism

30. Calcium (Ca+) Calcium is a mineral Most abundant mineral in the body
99% of calcium in the body is in bones and teeth
1% of calcium is found in the blood and soft tissues

31. Role of calcium in the body
Forms strong bones and teeth
Aides in muscle contraction and relaxation
Transmits nerve impulses
Aides in blood clotting
Assists in enzymatic reactions
Involved in the process of cell division and multiplication

32. Target level for calcium
Serum levels of corrected total Ca+ should be maintained within the normal range for the laboratory used, preferably toward the lower end: 8.4mg/dl – 9.5mg/dl
(K/DOQI)

33. hypercalcemia Corrected Ca+ > 10.2 mg/dl Causes:
- Increased Ca+ intake (Ca+ based binders,
Ca+ supplements or high Ca+ foods)
- Too much Hectorol/Zemplar (Active form of
Vitamin D)
Treatment:
- Avoid foods high in Ca+
- Change to non- calcium based binder
- Decrease Hectorol/Zemplar dose

34. Consequences of hypercalcemia
CALCIFICATION

35. Hypocalcemia Ca+ < 8.4mg/dl Causes: - Inadequate Ca+ intake
- Vitamin D deficiency
- High PO4 levels
- Calcimimetics
Treatment:
- Increase Ca+ intake or begin
supplementation
- Initiate or increase Hectorol/Zemplar dose
- Decrease PO4 levels to restore balance
between Ca+, PO4 and PTH

36. Consequences of hypocalcemia
Paresthesia, bronchospasm, laryngospasm, tetany, and seizures

37. Putting it all together…
How can we work together as a health care team to promote patient compliance and improve patient outcome??

38. Thank you!!!! Thank you so much for your time and attention!!
Hope you all learned a new thing or two!!