Kidney Disease2 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

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What do they do?• Remove waste products and extra fluid

fromthe blood by forming urine

• Keep blood chemicals in balance• Produce some of the body’s hormones to

control anemia, blood pressure, and bonehealth

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Causes ??? Diabetes and high blood pressure are theleading 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

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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

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Diet with CKD – Early StagesProtein: 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.

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PhosphorusPhosphorus restriction is recommended as

soon as an elevated blood level is seenSome experts think 800-1000mg of

phosphorus daily is adequate

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PotassiumIf 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.

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That was the early stages of CKD

Any questions?

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Treatment for Stage 5A 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 toreplace kidney function

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Types of treatmentHome therapy : Peritoneal dialysis,

Hemodialysis In center HemodialysisNocturnal hemodialysis Self-care hemodialysisTransplant Conservative treatment

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

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Hemodialysis• Blood circulates through a filter (dialyzer)

toremove 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 nocturnalhemodialysis

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Role of the Dietitian Assess nutritional status

Determine appropriate interventionsand recommendations

Provide nutrition educationand counseling

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Davita Inc.

Role of the DietitianInterpret blood test results and review with

patientsMonitor outcomesMineral and Bone Disorder SpecialistMember of Health Care Team

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Objectives of Nutritional Management

Achieve optimal nutritional statusPrevent tissue breakdownManage co-existing conditionsPrevent complicationsEnhance quality of life and outcome

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Optimal Nutritional StatusIndicated by:

Albumin > 4.0Stable, desirable dry weightAdequate fat stores and muscle massAppropriate appetite and intake

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Medical Nutrition Therapy

CaloriesProteinFluidsSodiumPotassium

PhosphorusCalciumVitamins

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CaloriesCalorie 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

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ProteinEssential for growth, maintenance, preventing

infection, and anemia

Important for wound healing and repair

Inadequate Protein Intake

Muscle wastingLack of energyEdemaWeight lossPoor wound healingLow or declining albumin

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Foods High in Protein

Protein Requirements1.2 to 1.5 gm/kg Adjusted Body Weight per day

50% to 60% high biological valueIncreased needs in catabolic statesAdequate calories for protein sparing

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SupplementsProtein Powder

Procel, Egg/Pro, Beneprotein

Liquid Protein

Pro-Stat, ProSource

Liquid Nutritional

Ensure, Boost, Enlive

Calorie DenseEnsure Plus, Boost Plus

Renal SpecificNepro, Novasource Renal,

Nutren Renal. ReGen

SodiumHelps regulate body fluid volume and balance

Limiting sodium helps to prevent:Excessive thirstFluid retention Elevated blood pressure

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Sodium Allowance2.0 to 3.0 gm (2000 to 3000 mg)/day

May be higher for patients with residual renal function and those on peritoneal dialysis

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Foods High in Sodium

FluidsFluidsFluid accumulates in the body between dialysis

treatments Interdialytic weight gain3 to 5% of EDW

Excess fluid can cause: EdemaShortness of breathHypertensionCongestive heart failure

Fluid accumulates in the body between dialysis treatments Interdialytic weight gain3 to 5% of EDW

Excess fluid can cause: EdemaShortness of breathHypertensionCongestive heart failure

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Fluid AllowanceFluid 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

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PotassiumMineral required for muscle

contraction and nerve function

Goal: Maintain levels between 3.5 and 5.5 mEq/L

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PotassiumSymptoms of elevated potassium or

hyperkalemia are:Muscle weaknessNumbness and tingling of extremitiesDecreasing pulse rateCardiac arrest

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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

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Foods High in Potassium

PhosphorusMineral widely available in many foods

85-90% found in bones & teeth

Vital to energy production and storageGoal:

Maintain levels between 3.5 and 5.5 mg/dl

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Hyperphosphatemia(high phosphorus)

Symptoms:

ItchingBone damageIncreased risk for soft tissue calcification

(including heart and blood vessels)

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Foods High in Phosphorus

Phosphorus Allowance 800 – 1000 mg

½ cup milk ~100 mg1 ounce cheese 100 – 290 mg½ beans (pinto, lima) = 125 mg3 ounces meat = 195 mg1 ounce nuts = 120 mg 2 tablespoons peanut butter = 120 mg

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CalciumMineral needed for:

healthy bonesmuscle contraction & relaxationproper nerve functioning

Goal: Maintain level between 8.5 – 9.5 mg/dl

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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)

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Calcium Allowance 2000 mg

Sources to limit: Dairy products (milk, cheese, yogurt, ice cream) Fortified foods Medications

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Mineral and Bone Disorder (MBD) Management

Involves:Maintaining Calcium and Phosphorus balanceControlling Parathyroid Hormone (PTH) levels

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MBD Management Requires:

DialysisDietAdditional Therapies

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MBD Management Additional Therapies:

Phosphate Binders PhosLo, Tums Renagel, Renvela, Fosrenol

Vitamin D therapy IV: Zemplar, Hectoral, Calcitriol Oral: Rocaltrol, Hectorol

Calcimimetics Sensipar

Vitamins Water soluble

Supplemented due to diet restrictions and dialysis losses

Fat soluble

Not removed by dialysis, therefore supplementation not recommended

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Nutrition and Renal-Related Laboratory Measures

Healthy Stage 5 CKD

BUN mg/dl <25 50 – 100

Creatinine mg/dl <1.6 10 – 18

Albumin g/dl >4.0 ≥4.0

Hg g/dl 14 – 18 11 – 12

Iron Saturation % >25 25 – 50

Ferritin ng/ml 12 – 300 100 – 500

Potassium mEq/l 3.5 – 5.0 3.5 – 5.5

Corrected Calcium mg/dl 8.5 – 10.5 8.4 – 9.5

Phosphorus mg/dl 2.5 – 4.5 3.5 – 5.5

Intact PTH pg/ml <100 150 - 300