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NUTRITION INTERVENTION FOR END STAGE RENAL DISEASE DIALYSIS PATIENTS Tara Greenley

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OBJECTIVES Understand the different types of dialysis and effective nutrition intervention for each Identify important nutrients that need to be monitored Understand the importance of the role of the dietitian in ESRD patient care Recognize abnormal lab values associated with ESRD

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STAGES OF CHRONIC KIDNEY DISEASE http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm

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RENAL DIALYSIS TREATMENTS Hemodialysis- Uses a dialysis machine Nocturnal Home In-center Video http://www.kidney.org/atoz/content/hemodialysis.cfm

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Dialysis Treatments Peritoneal Dialysis www.kidney.org/atoz/pdf/nutri_pd.pdf

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PREVALENCE: Statistics for 2007 23 million people 20 and above evidence of chronic kidney disease 16.6% of the US population 527,283 under treatment 368,544 received dialysis 157.3 deaths per 1,000 patients 87,812 total deaths 1,783,000 worldwide ESRD patients on treatment National Institute of Diabetes and Digestive and Kidney Diseases. (2010). Retrieved from http://nkdep.nih.gov/

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ASSOCIATED DISEASES Diabetes: 197,037 Most common cause of CKD Hypertension: 127,935 Glomuerulonephritis: 81,599 Cystic Kidney: 24,828 Urologic Diseases:13,139 National Institute of Diabetes and Digestive and Kidney Diseases. (2010). Retrieved from http://nkdep.nih.gov/

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COMPLICATIONS Infection Vaccines Peritonitis Malnutrition Anemia Kidney.niddk.nih.gov

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ROLE OF THE RD Monitoring lab values Monitoring dietary intake Appetite assessments Calculating dietary nutrient needs Prevent protein-energy malnutrition Consider modes of nutrition intervention Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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IMPORTANT LAB VALUES Lab Test for Kidney FunctionNormal Levels Serum CreatinineMen: 0.5-1.5 mg/dL Women: 0.6-1.2 mg/dL Creatinine ClearanceMen: 97-137 mL/min Women: 88-128 mL/min Glomerular Filtration Rate (GFR)Healthy Adults: 140 mL/min/1.73m2 Normal: Greater than 90 GFR less than 15: Kidney failure Urine AlbuminLess than 30 mg/day in 24 hrs MicroalbuminariaHealthy people: Less than 150 mg/L of albumin Blood Urea Nitrogen (BUN)Adults: 7-20 mg/dL Children: 5-18 mg/dL

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IMPORTANT LAB VALUES Lab Tests for AnemiaNormal Levels Hematocrit (Hct)Men: 40-50% Women: 36-44% Hemoglobin (Hgb)Men: 14 to 18 g/dL Women: 12 to 16 g/dL Lab Tests for Diabetes Control Normal Levels Hemoglobin A1C (HgbQA1C) Less than 6.5% GlucoseFasting: 65-110 mg/dL

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MNT Protein Hemodialysis 1.2 g PRO/kg/d; at least 50% from high-biological value sources For children, base RDA plus an increment of 0.4 g/kg/d Peritoneal Dialysis 1.2-1.3 g PRO/kg/d; at least 50% from high-biological value sources Children, base RDA plus anticipated loss Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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MNT Energy Hemodialysis 35 kcal/kg/d for patients who are 60 years of age Children; follow RDA levels by age Peritoneal Dialysis Same as hemodialysis only include dialysate kcals Children; follow RDA levels by age Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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MNT Carbohydrate and Fat Hemodialysis After protein is calculated, assess patient needs and calculate percentages accordingly Peritoneal Dialysis Limit simple sugars and saturated fat Extra 300-450 kcal of glucose Fluid Hemodialysis >1L fluid output = 2 L fluid needed

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MNT Phosphorus Hemodialysis Use 800-1000 mg or

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MNT Sodium Hemodialysis Limit unless large losses in dialysate or through vomiting or diarrhea 2-4 g Peritoneal Dialysis Liberal intake 2-4 g; some need no restriction Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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MNT Vitamins Hemodialysis Use water-soluble vitamin supplements to replace dialysate losses Children follow DRI levels Common Recommendations Folic acid: 1 microgram Vitamin B6: 1.3-1.7 mg Vitamin C: 75-90 mg Vitamin B12: 2.4 micrograms Vitamin D: Monitor and replace at recommended levels Avoid excess Vitamin A Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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MNT Vitamins Peritoneal Dialysis Water-soluble vitamins Especially vitamin B6 and folic acid Vitamin D should be monitored and replaced as recommended Minerals Hemodialysis Calcium varies per individual Magnesium: 0.2-0.3 g Zinc: 8-11 mg Avoid excess vitamin A Peritoneal Dialysis Same as hemodialysis Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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MNT Omega-3 Fatty Acids Hemodialysis and Peritoneal Dialysis Fish oil Reduce prostaglandin synthesis Improve hematocrit levels Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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SAMPLE DIET BREAKFAST 1/2 cup (4 ounces) orange juice 1 English muffin or 2 slices bread At least one tablespoon margarine with jelly Coffee or tea with non-dairy creamer and sugar LUNCH 2 slices white bread At least 2 tablespoons mayonnaise with lettuce and tomato 1 ounce chicken (such as a small thigh) or 1 hard boiled egg 2 canned peach halves in heavy syrup 7-UP, lemonade or Hawaiian Punch DINNER 3-4 ounces steak (weigh after cooking, without bone), saut in tablespoons olive oil 1 small baked potato with at least 2 tablespoons margarine 1/2 cup fresh green beans, carrots or broccoli with margarine Lettuce, onions, cucumbers, green pepper At least 2 tablespoons olive oil with vinegar or lemon /8 apple or cherry pie with 1/2 cup fruit sorbet (this is not sherbet) Iced tea with sugar and lemon or Sprite http://www.kidney.org/patients/kidneykitchen/sample_meal_plan.cfm

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NUTRITION SUPPORT Drinks Nutren Renal Nepro NovaSource Enteral Nutrition Parenteral Nutrition Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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POSITIVE EFFECT OF SOY IN ESRD PATIENTS? Double blind, random 2:1 ratio 25 subjects 15 in soy group 10 in control group Possible benefits from isolflavone-rich foods Fanti, P., Asmis, R., Stephenson, T.J., Sawaya, B.P., & Franke, A.A. (2006). Positive effect of dietary soy in esrd patients with systemic inflammation-correlation between blood levels of the soy isoflavones and the acute-phase reactants. Nephrology Dialysis Transplantation, 21, 2239-2246.

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EXERCISE CAPACITY AS A PREDICTOR OF SURVIVAL AMONG AMBULATORY ESRD PATIENTS 6 month trial Assessment at beginning, 3 months, end Measured VO2 Patients from two clinical trials 33-59 years old On dialysis 26 months- 56 months 23 deaths 7 due to cardiovascular issues 7 due to infection 2 Cancer Sietsema, K.E., Amato, A., Adler, S.G., & Brass, E.P. (2004). Exercise capacity as a predicator of survival among ambulatory patients with end-stage renal disease. Kidney International, 65, 719-724.

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CONT. 2 due to transplant complications 7 unknown Shows VO2 as a significant predictor of survival among a stable cohort of hemodialysis patients Sietsema, K.E., Amato, A., Adler, S.G., & Brass, E.P. (2004). Exercise capacity as a predicator of survival among ambulatory patients with end-stage renal disease. Kidney International, 65, 719-724.

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FOOD ADDITIVES AN UNRECOGNIZED RISK? 36 uncooked meat and poultry products Tested the amount of potassium and phosphorus Phosphorus 28.4% higher Potassium 8.4% higher Significant evidence proves need for monitoring Sherman, R.A., & Mehta, O. (2009). Phosphorus and potassium content of enhanced meat and poultry products: implications for patients who receive dialysis. Clin J Am Soc Nephrol, 1(4), 1370-1373.

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GOODBYE TO FAST FOOD? 194 randomly selected patients 44 hemodialysis facilities in NE Ohio 81 subjects One meal in four days at fast food restaurants Kcals increased from 18.9 to 26.1 Higher serum phosphorus levels Butt, S., Leon, J., David, C., Chang, H., Sehgal, A., & Sidhu, S. (2007). The prevalence and nutritional implications of fast food consumption among hemodialysis patients. National Institute of Health, 17(4), 264-268.

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DRUG THERAPY ACE inhibitors Antidepressants Carnitine Growth hormone Insulin Iron supplements Lipid-lowering medications and statins Phosphate binders Potassium excretion Ruboxistaurin Water-soluble vitamins and vitamin D3 Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

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COST In 2006 cost to Medicare $49 billion If 5% percent more did at home Peritoneal Dialysis could potentially save $295 million HD cost Medicare $69,758 pppy PD cost Medicare $50,847 pppy Neil, N., Guest, S., Wong, L., Inglese, G., Gehr, T., Walker, D., Golper, T., & Bhattacharyya, S. (2009). The financial implications for Medicare of greater use of peritoneal dialysis. Clinical Therapeutics, 31(4), 880-888. Just, P.M., Riella, M.C., Tschosik, E.A., Noe, L.L., Charro, F.D., & Bhattacharyya, S.K. (2001). Economic evaluations of dialysis treatment modalities. Science Direct, 86(2008), 163-180.

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REIMBURSEMENT Medicare will pay for the following services: Inpatient dialysis treatments Outpatient dialysis treatments Home dialysis equipment and supplies Home support services Certain drugs for home dialysis Outpatient doctor and other related services as a part of the dialysis treatment Medicare does not pay for: Paid dialysis aides to help with home dialysis Lost pay to you and your helper during self-dialysis training A place to stay during treatment Blood or packed red blood cells for home self-dialysis unless it is part of a doctors service or is needed to prime the dialysis equipment Transportation to a dialysis facility Medicare covers 80% of their approved amount, you are responsible for the remaining amount. Medicare.gov

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ETHICAL ISSUES Right to choose or suicide? Religious views Black market for obtaining organs Donation About 14,000 kidney transplants are performed each year Just over one third of transplanted kidneys are from living donors. About 55,000 people are on the waiting list for a kidney transplant. Each year over 3,000 people die while waiting for a kidney transplant One-year survival rate for kidney transplant recipients is about 95% http://www.nytimes.com/2004/05/23/world/organ-trade-global-black-market-tracking- sale-kidney-path-poverty-hope.html http://www.organdonor.gov/student/access/organs.asp

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CONCLUSION Role of the Dietitian Nutrients to closely monitor Phosphorus Potassium Calcium Protein Sodium