Julie Atteritano, RD, CDE, CDN
 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
 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
Stabilized serum albumin equal to or
greater than the lower limit of the
normal range.
Approximately 4.0mg/dl
K/DOQI
 Increased
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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 4.04.5gm/dl
Serum albumin 3.5- 4.0gm/dl resulted in a 2
fold increase in relative risk of death
(Lowrie et al.)
Edema
and ascites
Decreased healing
Increased risk of infection
 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
 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
 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
 Intradialytic
Parenteral Nutrition (IDPN)
Amino acids (AA), Dextrose, and lipids
delivered directly into the blood stream
during hemodialysis
Potassium
is a mineral and an
electrolyte
 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
Low : less than 3.5mg/dl
Goal :3.5mg/dl – 5.5mg/dl
High : 5.6mg/dl – 6.0mg/dl
Unsafe: > 6.0mg/dl
 K+
levels > 5.5mg/dl
Causes of Hyperkalemia include:
 Dietary
 K+
indiscretion
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
 Nausea
 Weakness
 Numbness
and tingling
 Irregular heart beat
 Heart failure
 Sudden death
 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
 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
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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
 K+
< 3.5mg/dl
 Causes:
- Decreased po intake
- Excessive diarrhea or vomiting
- Certain medications (ex- diuretics)
- Need for K+ bath change (3K+,4K+)
 Muscle
weakness and cramping
 Fatigue
 Confusion
 Problems with muscle coordination
 Irregular heart beat
 Heart failure
 Dietary
intervention: Liberalization
 Phosphorus
is a mineral
 Most abundant after Calcium (Ca+)
 85% found in bones
 14% spread throughout soft tissue
 1% in blood and extracellular fluid
 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)
Low: less than 3.5mg/dl
Goal: 3.5mg/dl – 5.5mg/dl
High: greater than 5.5mg/dl
 PO4
> 5.5mg/dl
 As kidney function diminishes
(decreased GFR), the kidney loses the
ability to excrete PO4
 Leading to elevated serum PO4 levels
 Calcium-
phosphorus deposits
- heart
- skin
- lungs
- blood vessels
 Red eyes
 Bone disease
- bone and joint pain
- weak brittle bones
 Increased risk of mortality
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
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 Phosphorus
-
binders
Calcium Carbonate: TUMS
Calcium Acetate: Phoslo
Sevelamar Hydrochloride: Renvela
Lanthanum Carbonate: Fosrenol
 Greatest
limitation is Compliance!!
 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
Decreased Renal
Function
Decreased 1,25 (OH)
Vitamin D
PTH
Phosphate Retention
Ca+
Secondary Hyperparathyroidism
PO4
 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
 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
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)
 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
CALCIFICATION
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

Paresthesia,
bronchospasm,
laryngospasm, tetany, and
seizures
 How
can we work together as a
health care team to promote patient
compliance and improve patient
outcome??
 Thank
you so much for your time
and attention!!
 Hope you all learned a new thing or
two!!