Nutrition Therapy and Dialysis
Melinda S. Leone, MS, RD
St. Joseph's Regional Medical Center
Division of Nephrology
Paterson, NJ 07503
leonem@sjhmc.org
Objectives
 Participant will be able to describe the
importance of nutrition intervention in
patients with ESRD
 Participant will be able to identify the
components of a nutritional assessment
 Participant will be able to identify the
components of the renal diet and the role of
the dietitian
Does Nutrition Status Matter?
YES!
 Nutritional indicators can be directly linked to
patient status and outcome
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Protein-Energy Malnutrition (PEM)
BMI
Albumin
Potassium
Phosphorus
Calcium
2
3, 4
5
1
Renal Osteodystrophy
 Hyperphosphatemia
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Vascular and non-vascular calcification
 Hypocalcemia
 Secondary Hyperparathyroidism
 Bone Disease
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Low bone mass and density
Osteitis fibrosa cystica
5
Protein Energy Malnutrition6
PEM
 Malnutrition
 PEM: marasmus-kwashiorkor
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muscle/fat wasting
weight loss
 Marasmus: Inadequate nutrient intake
 Kwashiorkor: Inadequate protein intake
 Cachexia
Causes of Malnutrition
 Uremic Syndrome
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Malaise
Weakness
Nausea and vomiting
Muscle cramps
Itching
Metallic taste
Neurologic impairment
 Hospitalizations
 Co-morbidities
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Diabetes
Infections
Amputations
Cancer
 Inflammation
Protein–energy wasting syndrome in kidney disease7
Nutrition Assessment
Anthropometric Data
 Height
 Weight status
 Frame size
 Arm anthropometrics
 Appearance
 Amputations
Nutrition Assessment
Weight Status Evaluation
 Standard Body Weight (SBW)
 Body Mass Index (BMI)
 Ideal Body Weight (IBW)
 Adjusted Body Weight
 Usual Body Weight (UBW)
Nutrition Assessment
Weight Status Evaluation
 Weight changes
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Intentional vs. unintentional weight loss
Dry weight changes vs. fluid shifts
Clinically significant weight loss
5% or > within 1 month
 7.5% or > within 3 months
 10% or > within 6 months
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Attitude toward changes
Goals for weight changes
Nutrition Assessment6
Interdialytic Weight Gain (IDWG)
 General recommendation +2 kg
 >5% fluid gains
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Excessive fluid intake
Weight gain
 <2% fluid gain
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Inadequate fluid and/or food intake
Weight Loss/Decreased body mass
Nutrition Assessment
Diet History
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Appetite/Intake
Food preferences
Allergies/Intolerance
Taste changes
Acute or chronic GI
concerns
 Swallowing/Chewing
concerns
 Urine output
 Pica
 Religious/Cultural
Restriction
 Supplement intake
 Homeopathic
Treatments
 Nutrition Knowledge
Nutrition Assessment
Diet History
 Shopping and Cooking Psychosocial problems
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Abilities
Facilities
 Medication
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Side Effects
Compliance
 Physical limitations
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Emotional support
Economic limitations
 Depression
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Adjustment to disease
Treatment Compliance
Nutrition Assessment
Diet History
 Food Records
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24 Hour Recall
3 Day Food Record
3 Day Calorie Count
Food Frequency
Questionnaire
 Diet Assessment
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Calories
Protein
Carbohydrates
Fat/Cholesterol
Sodium
Potassium
Phosphorus
Fluid
Vitamins
Minerals
Nutrition Assessment
Laboratory Analysis6
Monthly
Quarterly
 Albumin: 4.0g /dL or >
 Hemoglobin A1C: < 7%
 Potassium: 3.5-5.3 mEq/L
 PTH: 150-600 pg/mL
 Phosphorus: 3.5-5.5 mg/dL
 Lipid Panel
 Calcium: 8.4-10.2 mg/dl
 Glucose <200 mg/dL
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Non-fasting
 Product: < 55
 URR: >65%
 Hgb: 10-12 g/dL
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Chol < 200 mg/dL
HDL > 40mg/dL
LDL <100mg/dL
Triglycerides <200 mg/dL
Nutrition Assessment:
Subjective Global Assessment6
 Protein-energy nutritional status measurement
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Valid and reliable8
KDOQI recommended9
 Medical history and physical exam
 Body composition focus on nutrient intake
 Subjective rating: 7 point scale6
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Well-nourished
Mild to moderately malnourished
Severely malnourished
Nutrient Needs
KDOQI Guidelines9
HD
PD
Protein
(>/= 50% HBV protein)
HD: 1.2 g/kg
PD: 1.2-1.3 g/kg
HD: 1.2 g/kg
PD: 1.2-1.3 g/kg
Energy
35 kcal/kg <60 years 30-35 kcal/kg >
60 years
35 kcal/kg <60 years
30-35 kcal/kg > 60 years
Phosphorus
10 – 12 mg/g protein
800-1000 mg/day
Adjust to meet protein needs
10 – 12 mg/g protein
800-1000 mg/day
Adjust to meet protein needs
Potassium
2-3 g Monitor serum levels
3-4 g Monitor serum levels
Fluid
Output + 1000 ml
Limit IDWG
Maintain fluid balance
Sodium
2g
2-3 g : Monitor fluid balance
Calcium
<2g including binder load
Maintain Serum WNL
<2g including binder load
Maintain Serum WNL
Vitamins/Minerals
Next Slide
Next Slide
Fiber
20-25 g
20-25 g
Nutrient Needs
KDOQI Guidelines9
Vitamins and Minerals
HD
PD
Vitamin C
60-100 mg
60-100mg
B6
2 mg
2 mg
Folate
1-5 mcg
1-5 mcg
B12
3 mcg
3 mcg
Vitamin E
15 IU
15 IU
Zinc
11-15 mg
11-15 mg
Iron
Individualize
Individualize
Vitamin D
Individualize
Individualize
B1
1.1-1.2 mg
1.5-2 mg
Other
RDA
RDA
Nutrition Therapy Goals
 Provide an attractive and palatable diet
 Control edema and serum electrolytes
 Prevent nutritional deficiencies
 Prevent renal osteodystrophy
 Prevent cardiovascular complications
Dialysis Diet
 Diet Order
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2000 calorie, 80 g protein, 2 g Na+, 2 g K+, 1 g PO4,
1500 ml fluid restriction
 Meal Planning
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Individualize diet for patient’s lifestyle
Assistance programs
Nursing Homes
National Renal Diet: American Dietetic Association10
Dialysis Diet
 Adequacy and Balance
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Calories
Protein
Variety
 Actual intakes of HD patients11
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23 kcals/kg/day
Less than 1 g/kg/day
Albumin
 Controversial key nutrition status measure12
 Depressed values
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PEM, fluid overload, chronic liver/pancreatic
disease, steatorrhea, inflammatory GI disease,
infection, catabolism r/t surgery, abnormalities in
protein metabolism, acidosis6
 Elevated Values
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Dehydration, high dietary protein intake6
Albumin
 Dialysis Treatment
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HD: 10-12 g free amino acids lost13
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Losses increase with glucose free dialysate
PD: 5 to 15 g protein lost 9, 14
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Lost as albumin
Protein
 1.2-1.3 g protein/kg SBW9
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Average patient: 80 g Protein
 50% HBV protein foods
 HBV Proteins
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Beef, poultry, fish, shell fish, fresh pork, turkey,
eggs, cottage cheese, soy
6 to 10 ounces daily
 Protein Alternatives
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protein bars, protein powders, supplement drinks
Potassium
 2-3 g daily9 - adjust per serum levels
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Dialysis bath concentrations
 Stricter diet restrictions
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Insulin deficiency, metabolic acidosis, beta blocker or
aldosterone antagonists treatments, hypercatabolic state
 Non-diet causes Hyperkalemia
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Hemolysis, high glucose, insulin deficiency, inadequate
dialysis, incorrect dialysate potassium concentration,
starvation, catabolism, sickle cell anemia, Addison's
disease, long-term constipation15
Potassium10
 Fruits & Vegetables
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Low: 20-150 mg
Medium: 150-250 mg
High: 250-550 mg
 Portion size is essential
 Avoid Salt Substitutes
 Dairy
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1 cup 380-400 mg
High phosphorus foods
 Avoid Highest Foods
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Oranges/Juice
Banana
Potato
Plantains
Mango
Melon
Avocado
Tomato
Nuts
Phosphorus
 Dietary intake ~800 to 1000 mg/day
<17 mg/kg SBW
 HD removes ~500-1000 mg/treatment
 PD removes ~400 mg/treatment
 50% dietary phosphorus removed by binders16
 Control = Binders + Diet + Adequate dialysis
Phosphate Binders
Generic Name
Brand Name
Calcium acetate
667 mg
Sevelamer HCL
800 mg
Calcium carbonate
500-600 mg
PhosLo
Estimated
Binding Capacity
30 mg
Renagel, Renvela
64 mg
Lanthanum
carbonate
1000 mg
Fosrenol
TUMS, Os-Cal,
20-24 mg
Calci-Chew, Caltrate
320 mg
Phosphorus Balance
Phos Intake
+1000 mg/day
+7000 mg/wk
Absorption Binding
~60%
~50%
-300 mg/day
(10 Phoslo)
+4200 mg/wk -2100 mg/wk
+600 mg/day
Dialysis
Removal
HD
-700 x 3 =
-2100 mg/wk
PD
-400 x 7 =
-2800 mg/wk
Weekly Phosphorus Balance
+ 4200 (diet) – 2100 (Binders) – 2100( HD) = Balance
Phosphorus10
High Phosphorus Foods
 Dairy products
 Beans & Nuts
 Processed meats
 Chocolate
 Pancakes, waffles,
biscuits, cakes
 Sardines
 Whole wheat, bran
cereals
Lower Phosphorus Foods
 Fresh meat products
 Homemade baked goods
 Nondairy creamer
 Unenriched rice milk
 Cream cheese
 White flour products
 Rice cakes
Phosphorus Additives
 Inorganic Phosphorus absorbed easily
 Phosphorus binders ineffective with many additives
 READ THE INGREDENTS LABEL!!
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Phosphoric acid
Sodium hexametaphosphate
Calcium phosphate
Disodium phosphate
Trisodium triphosphate
Monosodium phosphate
Sodium tripolyphosphate
Tetrasodium pyrophosphate
Potassium tripolyphosphate
Calcium
 Use corrected calcium (adjusted calcium) for albumin <46
Calculation: [ (4-albumin) x 0.8] + Ca++]
 Diet: Less than 2 g daily
 Hypercalcemia
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Ca++ based binders, supplements
Vitamin D analogs/treatment
Diet, fortified foods
Dialysate calcium levels
 Hypocalcemia
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Vitamin D, Calcijex
Supplement between meals
Parathyroid Hormone (PTH)
 Vitamin D is activated in the kidney to calcitriol, or
vitamin D31
 Vitamin D3 levels fall with kidney failure
Calcium absorption ↓ and phosphorus excretion ↓
PTH increases => bone disease
 Vitamin D3 therapy helps prevent renal bone disease
 Ca and Phosphorus precipitate and calcify soft tissue
 Ca x Phos product goal range with treatment
Fluid
 HD
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Urine Output + 1000 ml
Limit IDWG
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2-5% Estimated Dry weight
 PD
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Maintain fluid balance
Vary dextrose concentrations in dialysate
Restrict if fluid balance not obtained without
frequent hypertonic exchanges
Sodium1,6
 ≥ 1 L fluid output: 2-3 g Na and 2 L fluid
 ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid
 Anuria: 2 g Na and 1 L fluid
 Individualize
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IDWG, blood pressure, residual renal functions
 Increased Restrictions if ↑ IDWG, CHF, edema,
HTN
 PD: liberalize restriction to 2-4 grams sodium
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High sodium intake may increase thirst
Lipids10
 Increased risk of lipid disorders
 Recommended fat intake
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Total Fat <30% of calories
Saturated fat <10%
Cholesterol <300 mg/day
 Difficult restrictions to achieve
 Omega 3 supplements for elevated triglycerides
 Optimum fiber intake 20-25 g/day
Micronutrients1,6
 Renal Multivitamin containing water soluble
vitamins17
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Dialyzable – take after dialysis
 Vitamin C in renal vitamin
Limit total vitamin C 60-100 mg
↑ Vitamin C → ↑ oxalate → calcification of soft
tissues and kidney stones
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 Individualize: Fe++, Vitamin D, Ca++, Zinc
Specific PD Concerns
 Higher protein needs
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Lose 5-15 grams of protein a day 9, 14
 Weight Gain1
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Include dialysate calories in total intake
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May absorb as much as 1/3 (500-800 kcals) of daily energy needs
Limit sodium and fluid to minimize hypertonic exchanges
Hypertonic agents such as Icodextrin (Extraneal)
 High Triglycerides6
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Modify intake of sugars/carbohydrates
Limit intake of fats, saturated fats
Nutritional Supplements
 Oral supplements: Nepro, Ensure, Boost
 Powders: Beneprotein, ProSource, Eggpro
 Modular Protein: Pro-Stat, Promod
 Cookies: NutraBalance
 Protein Bars
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Meal replacements vs. snacks
Over the counter
Evaluate potassium, phosphorus
Nutrition Support
Enteral
 Oral Supplements
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Barriers: compliance, fluid , palatability, cost
 Tube feeding
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Renal Formulas
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Nepro and Novasource Renal
Barriers: acceptance, intolerance, tube placement,
fluid intake, reimbursements, assistance
Nutrition Support
Parenteral
 IDPN
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Barriers
Oral intake is maximized without improvement in status
 Usually requires documented malabsorption diagnosis
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Benefits
Supplemented during treatment
 No additional tube/access needed
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Dialysis clinics have individual rules and criteria
Specific qualifying criteria from insurance
companies
RD Roles
Anemia and Bone Management
 Anemia Management
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APN Anemia Manager
Protocols
 Bone Management
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APN Bone Manager
Protocols
MD input as needed
RD recommendations
Resources
 www.davita.com/diethelper
 www.case.edu/med/ccrhd/phosfoods
 www.kidneyschool.org
 www.aakp.org/brochures/phosphorus
 www.aakp.org/aakp-library
 www.rd411.com
References
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1. Byham-Gray L, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease.
Chicago: American Dietetic Association; 2004.
2. Pifer TB et al. Mortality risk in hemodialysis patients and changes in nutritional
indicators: DOPPS. Kidney International. 2002;62:2238-2245.
3. Acchiardo SR, et al. Morbidity and mortality in hemodialysis patients. ASAIO Trans.
1990;46:830-837.
4. Lowrie EG et al. Death risk predictors among peritoneal dialysis and hemodialysis
patients: a preliminary comparison. Am J Kidney Dis. 1995;26:220-228.
5. Kestenbaum, B et al. Serum phosphate levels and mortality risk among people with
chronic kidney disease. JASN. 2005;16(2):520-528.
6. McCann L. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney
Disease. 4th ed. National Kidney Foundation; 2009.
7. Fouque D et al. A proposed nomencalture and diagnostic criteria for protein-energy
wasting in acute and chronic kidney disease. Kidney International. 2008;73:391-398.
8. Steibe A et al. Multicenter study of validity and reliability of subjective global
assessment in the hemodialysis population. Journal of Renal Nutrition. 2007;17(5):336342.
References
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9. NKF K/DOQI practice guidelines. Clinical practice guidelines for nutrition in chronic
renal failure. Am J Kid Dis. 2000;35:S40-S41
10. Schiro-Harvey K. National Renal Diet: Professional Guide. 2nd ed. Chicago: American
Dietetic Association; 2002.
11. Rocco et al. Nutritional status in HEMO study cohort at baseline hemodialysis. Am J
Kidney Dis. 2002;39:245-256.
12. Friedman AN, Fadem SZ. Reassessment of albumin as a nutritional marker in kidney
disease. J Am Soc Nephrol. 2010;21:223-230.
13. Ikizler, TA et al. Amino acid losses during hemodialysis. Kidney Int. 1994;46:830-837.
14. Blumenkrantz MJ et al. Metabolic balance studies and dietary protein requirements in
patients undergoing continuous ambulatory peritoneal dialysis. Kidney Int. 1982;21: 849861.
15. Beto J. Hyperkalemia: Evaluation of dietary and non-dietary etiology. J Ren Nutr.
1992;2:28-29.
16. Rocco MV et al. Handbook of Dialysis. 3rd ed. Philadelphia: Lippincott, Williams
&Wilkins; 2001.
17. Andreucci, VE et al. Dialysis outcomes and practice patterns study (DOPPS) data on
medications in hemodialysis patients. Am J Kidney Dis. 2004;44(S2):S61-S67.
Thank You
?? Questions ??