1. Renal Research Project Chelsea Cordes

2. Chronic Kidney Disease Function of the kidneys: Excretory Acid Base Balance Endocrine Fluid and Electrolyte Balance Causes of the disease: Cancer Hereditary Uncontrolled DM and HTN Treatment: Transplant Hemodialysis Peritoneal Dialysis

3. Nutrition Implications of CKD Protein: Needs dependent on stage of disease Phosphorus Potassium Sodium H2O

4. Purpose of Research Scholarly project observing PO intake of hospitalized CKD pts in comparison to pts on a liberal diet. Objective: Determine if there is a significant difference in PO intake. Necessity: Practicality of the renal diet is unclear. Diagnostic significance of undernutrition is widely understood.

5. Protein Energy Wasting PEW: abnormally low levels/excessive losses of body protein mass and energy reserves. More frequently CKD patients are exhibiting signs of PEW in the early to moderate stages of the disease. Affects >20-25% of CKD population. Result of: hyper-catabolic state, declining appetite, and activation of pro-inflammatory cytokines. Study suggest PEW in CKD results in adverse clinical consequences.

6. Issues with the Renal Diet Patient Compliance (leads to decline in quality of life). Further exacerbations of PEW. Pts feel: depressed, frustrated, uncertain about what meal plan is ideal. Renal diets are considered “difficult to integrate into daily life, especially in regard to family and social occasions”.

7. Downside of Liberalization Many still oppose the idea of liberalization: The therapeutic approach to liberalizing protein/phosphorus intake is young and lacks significant supporting evidence. Potential toxic components of high protein diet are of concern.

8. Why Research is Necessary Relevance to the VA Many veteran CKD patients are categorized as undernourished with prominent PEW. Many veterans have issues with diet compliance as they are financially and physically dependent on others for care.

9. Goal of Research 1. Asses the PO intake of CKD diet patients verses liberal diet patients. 2. Compare overall patient satisfaction both pre and post implementation of a one week menu cycle of each group.

10. Methods Prospective Quality Initiative Study aiming to inspire quality improvement in the current HD/Renal Diet at the MVAMC. Goal: Prove liberal diet pts eat more than CKD diet pts due to being more satisfied with NFS. Data Collection: Plate Waste Study of 25 CKD pts and 25 Liberal Diet pts. Variables: anthropometrics, co-morbidities, length of stay, and difference in feeding behaviors. Limitations: pt dentition, pt mental status, pt ability to self feed, secondary symptoms (N/V/C). Baseline pt satisfaction pre and post implementation of 1 week menu cycle in both groups.

11. Subjects 25 MVAMC pts on CKD diets ages 65 or older 25 MVAMC pts on liberal diets ages 65 or older

12. Data Analysis Plate Waste will be main means a data collection. Plate waste carried out by subjective judgement of one surveyor. Results were recorded in increments of 25% Pt satisfaction will be determined on a scale from 1 to 5 based on 3 phrases: “My meals taste good” “My meals look good” “My overall rating of Nutrition and Food Services is excellent”

13. Patient Satisfaction Survey

14. Results Post 1 week cycle implementation results showed: “My meals taste good”: CKD 2.92 vs Liberal 3.48 “My meals look good”: CKD 3.4 vs Liberal 4.36 Overall Satisfaction: CKD 3.88 vs Liberal 4.36

15. Results of Pt Satisfaction Survey Statements Rating

16. Plate Waste Results CKD patients ate on average 42% of their mid-day meal. Liberal diet patients ate on average 62% of their mid-day meal.

18. Patient Comments “Rice and noodles are too hard” “I wish I had something other than juice to drink” “This food doesn’t agree with me” “Some changes need to be made to this diet” “Needs more flavor” “Don’t know what the complaining is about, tastes fine”

19. Discussion CKD nutrition requirements: 30 to 35 kcal/kg. Current Renal diet provides 2000 kcal, current HD diet provides 2600 kcal. At 42% typical consumption, pts only getting 840-1092 kcal and 22-38 g of protein per day.

20. Example Pt 5’10” male renal pt weighing and ideal wt of 166 lbs Meeting 37% of his kcal needs (2263 kcal lower end) Meeting 49% of his protein needs (45 g lower end) This caloric deficit could lead to unintentional wt loss of greater than 2 lbs per week of lean muscle mass.

21. Solutions Conducting more valuable conversations/test trays on the renal/HD diet. Utilizing/adapting recipes to renal friendly ones such as those found on the Davita website. Considering expanding from a 1 week cycle to a greater length for CKD pts to offer more variety. Chicken Fajitas with Pineapple Salsa Diet types: Dialysis Diabetes Portions: 4 Serving size: 2 fajitas and 2 tablespoons salsa Ingredients ■8 flour tortillas, 6" size ■2 tablespoons canola oil ■12 ounces boneless, skinless chicken breast ■1/4 teaspoon black pepper ■2 teaspoons chili powder ■1/2 teaspoons cumin ■2 tablespoons lemon juice ■1/4 cup chopped green pepper ■1/4 cup chopped red pepper ■1/2 cup chopped onion ■1/2 cup chopped cilantro ■1/2 cup Pineapple SalsaPineapple Salsa Renal and renal diabetic food choices ■3 meat ■2 starch ■1 vegetable, low potassium ■1/2 fruit, low potassium http://www.davita.com/recipes/

22. Example HD Menu

23. Limitations Length of stay Variance in mid-day meal recorded Small sample size Variance in meal prep Lack of an objective tool for measuring plate waste Possible bias, all aspects of research by one source Variables such as: anthropometrics, co-morbidities, feeding behavior, patient dentition, patient mental status, patients ability to self feed, and secondary symptoms present

24. Conclusions Pts on liberal diets eat 20% more of their mid-day meal than pts on CKD diets. Examination of pt satisfaction results suggest this deficit may possibly be related to patient satisfaction. It could be assumed that CKD patients are generally less satisfied and are consuming less in total due to the changes from a 3 week menu cycle to a 1 week menu cycle and the resulting limited variety of food choices offered on the CKD diets.

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