Renal Diet ABC’s of Nephrology

Sobha Malla RD,CSR9/17/11

ObjectivesNursing staff will understand the basic

premise of a renal dietUnderstand the nutritional needs Hemo and

Peritoneal Dialysis patients

CHRONIC KIDNEY DISEASEOne in nine Americans has Chronic Kidney

Disease.Early detection can help prevent the

progression of kidney disease to kidney failure. High risk groups for CKD include those with

diabetes, hypertension and family history of kidney disease.

Groups with increased risk include African Americans, Hispanics, Pacific Islanders, Native Americans and the elderly.

CHRONIC RENAL FAILUREProgressive and irreversible loss of function

that occurs over many months or yearsCauses include diabetes, hypertension and

glomerular diseasesSome form of renal replacement therapy is

needed for life

STAGES OF CHRONIC KIDNEY DISEASE

STAGE

GFR (mL/min/1.73m2) EFFECT ON HOMEOSTASIS

1 ≥ 90 Minimal; excretory and secretory functions intact.

2 60 - 89 Usually no symptoms, but may have high BP, anemia & disturbance in Ca+ & Phos+ metabolism.

3 30 - 59 May have fatigue, anemia, swelling, high BP &/or Ca+ & Phos+ disturbance.

4 15 - 29 Usually symptomatic. Prepare for renal replacement therapy.

5 < 15 Unable to maintain homeostasis without dialysis or transplant.

Goals of the Patient Specific Renal DietImprove/preserve nutritional statusOptimize functional statusMaintain patient safetyPrepare for transplantCompensate/adjust diet for illness,

catabolic events

Subjective Global AssessmentRecognized by KDOQI as a useful measure of PEMProvides a nutritional score based on 2 components

Medical history: history of wt. loss (6 months), eating habits, GI symptoms, physiological functions and metabolic stress

Physical assessment: visual assessment of loss of subcutaneous fat and muscle mass

Patient is scored on a 7–point scale (1)

6-7 well nourished3,4,5 mild to moderately nourished1 or 2 severely malnourished

Renal diet for Dialysis patients consists of individualized modifications

CaloriesProteinSodiumPotassiumPhosphorusCalciumFluidCarbohydrates Fat/Cholesterol

CALORIESAdults on Hemo Dialysis and Peritoneal

Dialysis

< 60 years old 30-35Kcals / Kg SBW

> 60 years old or obese 30 Kcals / Kg SBW

KDOQI recommends NHANES II Data for assessing SBW

Protein

• 1.2 grams of protein per Kg SBW for Hemo Dialysis

• 1.2 - 1.3 grams of protein per Kg SBW with for PD

ProteinImportant for growth and maintenance of body

tissueProvides energy and fights infectionKeep fluid balance in the blood2 types of Protein

High Biological Value (HBV) or animal protein-meat, fish, poultry, eggs, tofu, soy milk, and dairy

Low Biological Value (LBV) or plant protein – breads, gains, vegetables, dried beans and peas and fruits

ProteinThe following list contains foods and their

protein content:

▪ 1 egg=7 g protein▪ 1-2 ounce (oz) chicken thigh=14 g protein▪ 8 oz skim milk=8 g protein▪ 1 slice of bread=2 g protein▪ 1 cup (C) cooked rice=4 g protein▪ ½ C corn=2 g protein

Phosphorus• A mineral found in almost all foods. • Normal kidneys will balance the amount of

phosphorus in our bodies. When the kidneys fail the phosphorus increases in the blood.

• It is necessary to limit and/or avoid high-phosphorus foods.

• Control of phosphorus is often difficult for kidney failure patients.

• Dietary goal is 1-1.5gms/day• Normal range <5.5

PhosphorusFoods high in

phosphorus include:Dairy productsDried beans and peasNutsPeanut butterBran cerealsWhole wheat breadMeatsFood Additives

Potassium• Dietary Goal is usually 2 - 3 gms/day

• Potassium is a mineral , plays a role in regulating your heartbeat; so, too much can result in heart problems.

• Explore with patient high or low serum potassium levels

• Monitor residual renal function, changes in appetite for dietary adjustments

Low Potassium foodsApplesGrapesBerriesPineappleTangerineCabbageGreen BeansCauliflowerEggplant

PotassiumCommon high K+ foods include many

fruits and vegetables:

Prunes and Prune juice Orange and Orange juice Bananas Dried fruits Potatoes Tomatoes Brussels sprouts Spinach Beets Milk

SodiumHD 2-4 gm/d

PD usually more liberal

Too much sodium in the blood is related to high blood pressure and congestive heart failure.

Foods high in sodium include:• Processed meats• Canned soups• Salty snack foods• Deli meats

Sodium1 Tsp salt =

2000mg sodiumMost of us eat

3,000-6,000mg of sodium /day

Low sodium = ≤140mg/serving

Do not buy a food that has 150-350mg sodium/serving

FluidsHemo Dialysis: Fluid individualized to accommodate

fluid gains, blood pressure control, residual renal function.

Peritoneal Dialysis: Fluid individualized to patient tolerance. Strive for minimal use of hypertonic solution to maintain fluid balance.

Everything that is liquid at room temperature1500ml-2000ml~6 c-8 c /day 4 cups=32 oz=1 qt=1000ml=1 liter

FluidsChoices include all drinks and foods that are

liquid at room temperature.WaterCoffeeTeaSodasSoupsJuicesJell-O

Fluids Cont..Thirst Quenching Ideas :Suck on sour candies or chew gumEat chilled fruit, frozen grapes and berriesAdd lemon or Lime juice to waterTake pills with apple sauce instead of liquidsUse smaller cups or glasses Keep track of all liquidsLimit salty foodsIf diabetic, control blood sugars

CALCIUM Hemo Dialysis Patients Balance is determined

by:Dietary Calcium IntakeCalcium Supplements and Calcium Based

BindersDialysate Calcium LevelsVitamin D TherapyPhysician Monitoring of PTH

CARBOHYDRATECarbohydrate intake may need to be modified

for Patients with Diabetes to achieve the goal of HgAIC < 7 %

CAUTION !

HYPOGLYCEMIA

PD - HYPERGLYCEMIA / WEIGHT GAIN

FAT / CHOLESTEROL

• Cardiovascular Disease is the most frequent cause of death among patients with Renal Disease regardless of treatment modality.

• Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and individualized treatment goals

• Consider nutritional status / protein, energy deficits

SupplementsMulti Vitamins

Water solubleVitamin C

Supplementation may improve Iron availability from stores

Limit to 60-100mg/d to avoid oxalate formationIron and Zinc supplementation must be

determined individually based on labs

MonitoringMonthly QAPI report to review the labs and discuss

plan of action to correct the problem

Monthly interdisciplinary Care plan meeting to review the patient performance

Albumin to monitor intake (Goal >3.5mg/dl)

Potassium to determine dietary restriction (Goal 3.5-5.5mg/dl)

Phosphorus to adjust binders & compliance (Goal <5.5 mg/dl)

SummaryWhen a patient has a diagnosis of renal

failure, their nutritional needs are complex—Levels of Protein, Calories, Fluid, Sodium, Potassium, Calcium Phosphors need to be regularly monitored and make changes based on pt’s needs.

It is important to continuously monitor their labs , PO intake , provide or offer nutritional supplements, encourage dietary and medication compliance

Question and AnswersWhich food is highest in Potassium?ApplePineappleBroccoliBananaPotato

Q & ACorrect answer…Apple -1 medium(62 mg)Pineapple -1/2c(150mg)Broccoli -1/2c(127mg)Banana -medium(451mg)Potato- medium (926 mg)

Q & AWhat are the foods high in Phosphorus?Pizza (Cheese and meat)ChickenAmerican CheeseYogurtCream CheeseCottage CheeseOatmeal

Q &APizza (1-1/8 slice -131mg Po4, 1780mg K+, 382mg Na)

Chicken (1oz-60mg po4)

American Cheese (1oz- 211 mg Po4, 46 mg K+, 405 mg Na)

Yogurt (fruit 6 oz - 150 mg Po4, 310 mg K+, 100 mg Na)

Cream Cheese (1tbsp- 15 mg PO4, 17mg K+, 43 mg Na)

Cottage Cheese (4 oz- 152 mg Po4, 97 mg K+, 459 mg Na)

Oatmeal (instant, 1 cup - 176 mg PO4, 131 mg K+, 377 mg Na)

Q &A

Why do dialysis patients need to limit dairy and high phosphorus foods?

Q &A

Healthy kidneys get rid of Phosphorus from the body, but when kidneys fail, phosphorus builds in the blood.

High levels cause calcium to come out of the bones and make them brittle, weak and painful. It also gets deposited in soft tissues like blood vessels and heart, causing damage to them.

Q &A

How does the diet for someone on peritoneal dialysis differ from the one for hemodialysis?

A. It requires more calories B. It requires more calcium C. It requires less protein D. None of the above

Q &A A. It requires more calories B. It requires more calcium C. It requires less protein D. None of the above

Q &A

If you are on a renal diet, you most need to limit your intake of what three things? 

a. Apples, oranges, grapes.b. Carrot cake, ice cream, Coke.c. Sodium, phosphorus, potassiumd. Seafood, surf-and-turf Red Lobster entrees,

macaroni and cheese.

Q &Aa. Apples, oranges, grapes.b. Carrot cake, ice cream, Coke.c. Sodium, phosphorus, potassiumd. Seafood, surf-and-turf Red Lobster entrees,

macaroni and cheese.

References1) A Clinical Guide to Nutrition Care in Kidney

Disease American Dietetic Association, 2004

2) Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease, 4 th Edition, National Kidney Foundation, 2009

3) Core Curriculum for Nephrology Nursing, Fifth Edition. American Nephrology Nurses Association, 2008.