2. Kidney Disease 2 kidneys Each the size of your fist One on each side of your spine Weight 4-6 ounces each Nephron - the basic functioning unit of the kidney 1 million per kidney 2

3. What do they do? Remove waste products and extra fluid from the blood by forming urine Keep blood chemicals in balance Produce some of the body’s hormones to control anemia, blood pressure, and bone health 3

4. Causes ??? Diabetes and high blood pressure are the leading causes of chronic kidney disease Other conditions that may cause chronic kidney disease Glomerulonephritis Genetic diseases (e.g. polycystic kidney disease) Inflammatory conditions (e.g. lupus) Obstruction to the urinary tract Repeat urinary tract infections 4

5. Starting to feel it ….. Waste products and fluid build up in the blood causing a condition called uremia. Symptoms of uremia include: Swelling (face, hands, feet) Shortness of breath Itching Poor appetite Nausea and vomiting Trouble concentrating 5

6. Diet with CKD – Early Stages Protein: To restrict or not to restrict? For persons in stages, 1, 2,3 – protein intake is often limited to 12-15% of each day’s calorie intake or to.8 grams/kg body weight. Persons with Stage 4 CKD may be advised to reduce protein to 10% of calorie intake each day, which is.6-.75 grams protein/kg body weight. 6

7. Phosphorus Phosphorus restriction is recommended as soon as an elevated blood level is seen Some experts think 800-1000mg of phosphorus daily is adequate 7

8. Potassium If the level is high, a low potassium diet is prescribed. Restricting such foods as avocados, dried fruits (raisins, apricots, prunes), potatoes, oranges, bananas, and salt substitutes is often needed. 8

9. That was the early stages of CKD Any questions? 9

10. Treatment for Stage 5 A treatment for Stage 5 kidney disease Blood is cleaned through filtration a natural filter inside the body (peritoneal dialysis) an artificial filter outside of the body (hemodialysis) Dialysis must be done on a regular basis to replace kidney function 10

11. Types of treatment Home therapy : Peritoneal dialysis, Hemodialysis In center Hemodialysis Nocturnal hemodialysis Self-care hemodialysis Transplant Conservative treatment 11

12. Peritoneal Dialysis Removes wastes and fluid Catheter in the abdomen Several exchanges daily 12

13. Hemodialysis Blood circulates through a filter (dialyzer) to remove wastes and fluid A machine controls speed and safety factors Hemodialysis can be done in-center or at home, night or day Traditional: At a dialysis facility 3 treatments/week week 3 to 4 hours each tr Option for self-care and nocturnal hemodialysis 13

14. Role of the Dietitian  Assess nutritional status  Determine appropriate interventions and recommendations  Provide nutrition education and counseling 14 Davita Inc.

15. Role of the Dietitian Interpret blood test results and review with patients Monitor outcomes Mineral and Bone Disorder Specialist Member of Health Care Team 15

16. Objectives of Nutritional Management Achieve optimal nutritional status Prevent tissue breakdown Manage co-existing conditions Prevent complications Enhance quality of life and outcome 16

17. Optimal Nutritional Status Indicated by: Albumin > 4.0 Stable, desirable dry weight Adequate fat stores and muscle mass Appropriate appetite and intake 17

18. Medical Nutrition Therapy Calories Protein Fluids Sodium Potassium Phosphorus Calcium Vitamins 18

20. Calories Calorie requirements: 30 to 40 kcal/kg of actual or Adjusted BW/day Adjusted to maintain, decrease, or increase actual body weight as desired Individualized for carbohydrate, fat and cholesterol recommendations 20

21. Protein Essential for growth, maintenance, preventing infection, and anemia Important for wound healing and repair

22. Inadequate Protein Intake Muscle wasting Lack of energy Edema Weight loss Poor wound healing Low or declining albumin 22

23. Foods High in Protein

24. Protein Requirements 1.2 to 1.5 gm/kg Adjusted Body Weight per day 50% to 60% high biological value Increased needs in catabolic states Adequate calories for protein sparing 24

25. Supplements Protein Powder Procel, Egg/Pro, Beneprotein Liquid Protein Pro-Stat, ProSource Liquid Nutritional Ensure, Boost, Enlive Calorie Dense Ensure Plus, Boost Plus Renal Specific Nepro, Novasource Renal, Nutren Renal. ReGen

26. Sodium Helps regulate body fluid volume and balance Limiting sodium helps to prevent: Excessive thirst Fluid retention Elevated blood pressure 26

27. Sodium Allowance 2.0 to 3.0 gm (2000 to 3000 mg)/day May be higher for patients with residual renal function and those on peritoneal dialysis 27

28. Foods High in Sodium

29. Fluids Fluid accumulates in the body between dialysis treatments Interdialytic weight gain 3 to 5% of EDW Excess fluid can cause: Edema Shortness of breath Hypertension Congestive heart failure Fluid accumulates in the body between dialysis treatments Interdialytic weight gain 3 to 5% of EDW Excess fluid can cause: Edema Shortness of breath Hypertension Congestive heart failure 29

30. Fluid Allowance 1.0 to 1.5 liters per day Includes all foods liquid at room temperature 1.0 to 1.5 liters per day Includes all foods liquid at room temperature 30

32. Potassium Mineral required for muscle contraction and nerve function Goal: Maintain levels between 3.5 and 5.5 mEq/L 32

33. Potassium Symptoms of elevated potassium or hyperkalemia are: Muscle weakness Numbness and tingling of extremities Decreasing pulse rate Cardiac arrest 33

34. Potassium Allowance 2.0 to 3.0 gm (2000 to 3000 mg) per day Based on lab values Allowed more if residual renal function or on peritoneal dialysis 34

35. Foods High in Potassium

37. Phosphorus Mineral widely available in many foods 85-90% found in bones & teeth Vital to energy production and storage Goal: Maintain levels between 3.5 and 5.5 mg/dl 37

38. Hyperphosphatemia (high phosphorus) Symptoms : Itching Bone damage Increased risk for soft tissue calcification (including heart and blood vessels) 38

39. Foods High in Phosphorus

40. Phosphorus Allowance 800 – 1000 mg ½ cup milk ~100 mg 1 ounce cheese 100 – 290 mg ½ beans (pinto, lima) = 125 mg 3 ounces meat = 195 mg 1 ounce nuts = 120 mg 2 tablespoons peanut butter = 120 mg 40

41. Calcium Mineral needed for: healthy bones muscle contraction & relaxation proper nerve functioning Goal: Maintain level between 8.5 – 9.5 mg/dl 41

42. Calcium  Hypercalcemia  Increased risk for heart disease  Increased risk for calcification of soft tissue  confusion (when very high)  Hypocalcemia (rare)  muscle spasms  numbness  confusion  seizures (when very low) 42

43. Calcium Allowance  2000 mg  Sources to limit:  Dairy products (milk, cheese, yogurt, ice cream)  Fortified foods  Medications 43

44. Mineral and Bone Disorder (MBD) Management Involves: Maintaining Calcium and Phosphorus balance Controlling Parathyroid Hormone (PTH) levels 44

45. MBD Management Requires: Dialysis Diet Additional Therapies 45

46. MBD Management  Additional Therapies:  Phosphate Binders  PhosLo, Tums  Renagel, Renvela, Fosrenol  Vitamin D therapy  IV: Zemplar, Hectoral, Calcitriol  Oral: Rocaltrol, Hectorol  Calcimimetics  Sensipar

47. Vitamins  Water soluble  Supplemented due to diet restrictions and dialysis losses  Fat soluble  Not removed by dialysis, therefore supplementation not recommended 47

48. . Nutrition and Renal-Related Laboratory Measures HealthyStage 5 CKD BUN mg/dl<2550 – 100 Creatinine mg/dl<1.610 – 18 Albumin g/dl>4.0≥4.0 Hg g/dl14 – 1811 – 12 Iron Saturation %>2525 – 50 Ferritin ng/ml12 – 300100 – 500 Potassium mEq/l3.5 – 5.03.5 – 5.5 Corrected Calcium mg/dl8.5 – 10.58.4 – 9.5 Phosphorus mg/dl2.5 – 4.53.5 – 5.5 Intact PTH pg/ml<100150 - 300