NUTRITIONAL MARKERS IN

HEMODIALYSISJulie Atteritano, RD, CDE, CDN

ALBUMIN Biochemical marker reflecting

visceral protein stores Most common protein found in

the blood Produced by the liver (9-12g

/day) Life span 12-20 days

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

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

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 4.0- 4.5gm/dl

• Serum albumin 3.5- 4.0gm/dl resulted in a 2 fold increase in relative risk of death

• (Lowrie et al.)

CONSEQUENCES CONTINUED… Edema and ascites Decreased healing Increased risk of infection

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- 30-35Kcal/Kg 1.2- 1.4 gm/Kg protein

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

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

STRATEGIES TO IMPROVE ALBUMIN CONTINUED…. Intradialytic Parenteral Nutrition (IDPN) Amino acids (AA), Dextrose, and lipids

delivered directly into the blood stream during hemodialysis

POTASSIUM (K+)

Potassium is a mineral and an electrolyte

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

TARGET LEVELS FOR POTASSIUM

Low : less than 3.5mg/dlGoal :3.5mg/dl – 5.5mg/dlHigh : 5.6mg/dl – 6.0mg/dl

Unsafe: > 6.0mg/dl

HYPERKALEMIA 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

CONSEQUENCES OF HYPERKALEMIA Nausea Weakness Numbness and tingling Irregular heart beat Heart failure Sudden death

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 512-694mg Tomato (1 cup canned) 1098mg

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

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

HYPOKALEMIA K+ < 3.5mg/dl Causes: - Decreased po intake - Excessive diarrhea or vomiting - Certain medications (ex-

diuretics) - Need for K+ bath change

(3K+,4K+)

CONSEQUENCES OF HYPOKALEMIA Muscle weakness and cramping Fatigue Confusion Problems with muscle coordination Irregular heart beat Heart failure

Dietary intervention: Liberalization

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

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)

TARGET LEVELS FOR PHOSPHORUS

Low: less than 3.5mg/dl Goal: 3.5mg/dl – 5.5mg/dl

High: greater than 5.5mg/dl

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

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

DIETARY STRATEGIES TO IMPROVE HYPERPHOSPHATEMIA Lower PO4 diet Goal for intake 800- 1,000mg 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

DIETARY STRATEGIES CONTINUED… Phosphorus binders - Calcium Carbonate: TUMS - Calcium Acetate: Phoslo - Sevelamar Hydrochloride: Renvela - Lanthanum Carbonate: Fosrenol

Greatest limitation is Compliance!!

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

PATHWAY OF CKDMINERAL AND BONE DISORDER

Decreased Renal Function

Decreased 1,25 (OH) Vitamin D Phosphate Retention

PTH Ca+ PO4

Secondary Hyperparathyroidism

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

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

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)

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

CONSEQUENCES OF HYPERCALCEMIA

CALCIFICATION

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

CONSEQUENCES OF HYPOCALCEMIA

Paresthesia, bronchospasm, laryngospasm, tetany, and

seizures

PUTTING IT ALL TOGETHER…

How can we work together as a health care team to promote

patient compliance and improve patient outcome??

THANK YOU!!!!

Thank you so much for your time and attention!!

Hope you all learned a new thing or two!!