CKD MNT Module 5: The Transition from Chronic Kidney Disease to Kidney Failure

Module 5: The Transition from Chronic Kidney Disease (CKD)

to Kidney Failure

The Diet Changes as CKD Develops and Progresses to Kidney Failure.

1. Use biochemical data to assess and monitor CKD

2. Recommend diet changes for CKD

3. Identify the four treatment options for kidney failure

4. Differentiate between the diet requirements for hemodialysis, peritoneal dialysis, and kidney transplantation

Participants will be able to:

Maria is a 41-year-old woman who was diagnosed with type 2 diabetes at age 30; she has a history of gestational diabetes at age 27.

She lives with her husband and 13-year-old son.

Maria works full time as teacher’s aide.

Putting it all together

Referred for medical nutrition therapy

Type 2 diabetes

Dyslipidemia

- Reference 12/06Weight (kg) - 80

BP - 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 -

Creatinine 0.8–1.3 -

eGFR > 60 -

Na 135–145 -

K 3.5–5.0 -

CO2 21–32 -

Phos 2.7–4.6 -

Ca (Corrected) 8.5–10.2 -

Alb 3.4–5.0 -

Urine Dipstick - -

UACR < 30 -

- Reference 12/06

Weight (kg) - 80

BP - 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 -

Creatinine 0.8–1.3 -

eGFR > 60 -

Na 135–145 -

K 3.5–5.0 -

CO2 21–32 -

Phos 2.7–4.6 -

Ca (Corrected) 8.5–10.2 -

Alb 3.4–5.0 -

Urine Dipstick - -

UACR < 30 -

Initial impression (ABCs for diabetes)

A1C and blood glucose HIGH

Blood pressure OK

Cholesterol (LDL) HIGH

- Reference 12/06

Weight (kg) - 80

BP - 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 20 H

Creatinine 0.8–1.3 1.1

eGFR > 60 56

Na 135–145 -

K 3.5–5.0 -

CO2 21–32 -

Phos 2.7–4.6 -

Ca (Corrected) 8.5–10.2 -

Alb 3.4–5.0 -

Urine Dipstick - >300

UACR < 30 -

Now assess kidney function and kidney damage

Check kidney function

‒ eGFR 56

Check kidney damage

‒ UACR not available, dipstick > 300

Request UACR

- Reference 12/06

Weight (kg) - 80

BP - 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 20 H

Creatinine 0.8–1.3 1.1

eGFR > 60 56

Na 135–145 135

K 3.5–5.0 4.2

CO2 21–32 23.9

Phos 2.7–4.6 2.9

Ca (Corrected) 8.5–10.2 8.0 L (9.36)

Alb 3.4–5.0 2.7 L

Urine Dipstick - >300

UACR < 30 7,443

Briefly review for any other abnormal parametersBUN slightly above reference range

Creatinine slightly elevated, reflected in lower eGFR

Potassium, CO2, and phosphorus within reference ranges

Hypoalbuminemia

UACR results are very HIGH 7,443

- Reference 12/06

Weight (kg) - 80

BP - 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 20 H

Creatinine 0.8–1.3 1.1

eGFR > 60 56

Na 135–145 135

K 3.5–5.0 4.2

CO2 21–32 23.9

Phos 2.7–4.6 2.9

Ca (Corrected) 8.5–10.2 8.0 L (9.36)

Alb 3.4–5.0 2.7 L

Urine Dipstick - >300

UACR < 30 7,443

Reference 12/06

Weight (kg) 80

BP 120/67

Glucose 70–100 305 H

A1C < 7.0 10.1

LDL < 100 146

BUN 7–18 20 H

Creatinine 0.8–1.3 1.1

eGFR > 60 56

Na 135–145 135

K 3.5–5.0 4.2

CO2 21–32 23.9

Phos 2.7–4.6 2.9

Ca (Corrected) 8.5–10.2 8.0 L (9.36)

Alb 3.4–5.0 2.7 L

Urine Dipstick >300

UACR < 30 7,443

If we just look at the ABCs, we miss the CKD

UACR results are very HIGH 7,443

Food and beverage intake

Breakfast: 1 cup (c.) oatmeal, ½ c. whole milk, 2 eggs fried in 1 teaspoon (t.) butter, 2 slices wheat toast, 2 t. butter, 16 ounces coffee OR yogurt. Skips lunch. Supper: fast food; 2 pieces fried chicken, biscuit, coleslaw; or large burger, fries. Doesn’t add salt.

Diet experience Diet controlled gestational diabetes, did “everything they told me.” Nutrition instruction when first diagnosed with type 2 diabetes. Buys fruit and vegetables, son gets them first.

Medications 70/30 insulin 40 units twice a day (BID), 850 milligrams (mg) metformin BID, 10 mg lisinopril daily, 20 mg simvastatin daily. Takes evening medications when she remembers, maybe twice a week. May take 70/30 insulin at bedtime instead of before supper.

Physical activity No planned exercise. Walks a lot at summer weekend flea market.

Height & weight Height 63”, weight 176 pounds (lb.) (80 kilograms [kg]), Body Mass Index (BMI) 31.2. Previous weight 81 kg (in July)

Biochemical data A1C 10.1, LDL 146, eGFR 56, albumin 2.7, dipstick protein > 300, UACR 7,443

Physical findings Poor dentition, states not a problem for her.

Referred for Medical Nutrition Therapy: Uncontrolled type 2 diabetes, dyslipidemiaAssessment (December 2006)

Personal history

41 years old, lives with husband and 13-year-old son in a condo.

Patient/family history

Diabetes (DM): mother, father, paternal grandfather. Mother on hemodialysis.

Grandfather with left foot amputation due to DM. Not planning pregnancy, using birth control. Denies polyuria, polydipsia, fatigue, or blurred vision. Checks fasting glucose about once a week, “usually 150 to 180.” Notes nocturnal lows when takes 70/30 insulin at bedtime. Denies mid-day lows. Refuses to change type of insulin, prefers only 2 shots/day.

Social history Teacher’s aide; hard to come for appointments unless summer or school break. Husband not working now; son doing great in school. His evening activities make meal time and medication use erratic.

Assessment continued (December 2006)

http://www.nal.usda.gov/fnic/foodcomp/search/

ALL of the nutrient analyses are from the USDA nutrient analyses

library website:

* Used current weight of 80 kg to estimate protein needs (0.8 g/kg), used 23 kcal/kg for obesity

Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg)

K (mg)

1 c. oatmeal (regular) 166 5.94 28.08 3.56 9 180 164

½ c. whole milk, vitamin D 74 3.84 5.86 3.96 52 102 161

2 eggs (large, fried) 180 12.5 0.76 13.65 190 198 140

3 t. butter 102 0.12 0.01 11.52 101 3 3

2 slices wheat toast (2 oz.) 177 7.35 31.62 2.42 346 107 126

16 oz. brewed coffee 9 0.57 0 0.09 9 14 232

½ c. fast-food coleslaw 138 0.87 14.95 8.25 180 19 134

1 fried chicken breast & leg- Removes breading

18570

33.9910.52

0.220.04

5.463.06

596210

31689

38609

1 biscuit (no butter) 185 3.77 22.11 9.07 548 305 60

21 oz. diet cola 10 0.53 0.15 1.41 39 44 39

TOTALS (% cal) 1,296 80 g (24.7%)

103.78 g (32.0%)

62.45 g (43.3%)

2,280 1,377 1,554

Recommended intake or DRI (% cal)

1,840 64 g*(20 %)

230 g(50 %)

61 g(< 30 %)

1,500 700 4,700

Inappropriate intake of fats (LDL 146, diet history)

Inconsistent carbohydrate intake (skips meals)

Food-medication interaction − Alterations in biochemical tests (not taking evening

meds. consistently: LDL 146, A1C 10.1)

Overweight/obesity (BMI 31.2)

Undesirable food choices (LDL 146, A1C 10.1)

Physical inactivity (no planned exercise)

Limited access to food (limited variety)

Where do you start?

Reference: International Dietetics & Nutrition Terminology, 2011

3. Inappropriate intake of fats (LDL 146, diet hx)

2. Inconsistent carbohydrate intake (skips meals)

1. Food-medication interaction − Alterations in biochemical tests (not taking evening meds

consistently: LDL 146, A1C 10.1)

Overweight (BMI 31.2)Undesirable food choices (LDL 146, A1C 10.1)Physical inactivity (no planned exercise)Nutrition-related knowledge deficit Limited access to food (limited variety)

Prioritizing NCP diagnoses (12/06)

Nutrition-related medication management− Review medications, particularly insulin timing.

− Take 70/30 insulin before breakfast and supper, not at bedtime.

Recommended modifications− Have consistent carbohydrate intake and do not skip

meals.

− Reduce saturated fat intake (1% milk, fast foods).

PLAN: Take medications as prescribed.

Intervention (12/06)

Taking evening meds more regularly now− Still not 100%, but improved

− Not taking 70/30 insulin at bedtime any longer

Eating school lunch; eats vegetables & fruit

Family accepting 2% milk

Still working on reducing fast foods, but it’s hard

Follow-up phone call shows some changes made (2/07)

Multiple missed appointments Needs new medication prescriptions

- Reference

12/06 12/07

Weight (kg) - 80 79.2

BP - 130/67 131/74

Glucose 70–100 305 H 75

A1C < 7.0 10.1 11.3

LDL < 100 146 111

BUN 7–18 20 H 13

Creatinine 0.8–1.3 1.1 1.1

eGFR > 60 56 54

Na 135–145 135 141

K 3.5–5.0 4.2 3.7

CO2 21–32 23.9 22.2

Phos 2.7–4.6 2.9 3.7

Ca (Corrected) 8.5–10.2 8.0 L (9.36) 7.9 L (9.82)

Alb 3.4–5.0 2.7 L 2.6 L

Urine dipstick >300 -

UACR < 30 7,443 7,986

Blood PressureOK

A1CHIGH

Cholesterol LDLHIGH

eGFR Stable

Hypoalbuminuria

UACR Still Very HIGH

High levels of urine albumin are associated with kidney

damage and more rapid progression

of kidney disease.

Maria has significant albuminuria; her kidney function declined rapidly

As eGFR declined, blood pressure was harder to control

Maria needed less insulin to control her blood glucose levels

December 2007 Discontinue metformin

Increase 70/30 insulin to 45 units BID (from 40 units)

July 2008 Decrease 70/30 insulin to

35 units BID

November 2008 Decrease 70/30 insulin to

30 units BID

Maria’s serum phosphorus increased;phosphorus binder added 11/08

Vitamin D may lower iPTH

Reference: *IOM, 2011

Vitamin D increased phosphorus absorption

Reference: *IOM, 2011

Complex interactions between vitamin D and iPTH affect P and Ca

Correcting calcium for hypoalbuminemia is worthwhile when assessing calcium levels

Maria’s bicarbonate level decreased, medication was added, and

dietary protein was restricted

Maria’s potassium increased when her eGFR was quite low

Maria developed anemia

Iron supplement improved anemia

Individualize− Small steps− Realistic changes

Emphasize self-management − What is their priority?− What can they live with?

Prioritize changes based on laboratory data

Where do you start?

Let’s work through the meals

A high fiber breakfast may be good for many people

Reference: Adapted from Nutrition Care Manual type 2 diabetes meal planhttp://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf

Food Kcal Pro (g)

Carb (g)

Fat (g)

Na (mg)

P (mg)

K (mg)

½ banana, medium 53 0.64 13.48 0.19 1 13 211

½ c. bran flakes 64 1.89 16.16 0.44 147 102 124

1 c. skim milk 83 8.26 12.15 0.2 103 247 382

1 slice whole wheat toast

76 4.07 12.79 1.02 146 76 82

1 tbsp. peanut butter (reduced Na)

94 3.84 3.49 7.98 32 51 120

TOTALS 301 18.7 58.07 9.83 429 489 919

If potassium is high, choose blueberries instead of banana on the cereal

May need to recommend different cold cereal to lower Na, P, or K in CKD

Phosphorus in plant foods not completely absorbed

Some instant hot cereals may be higher in Na

What is on the cereal may add Na, P, and K in CKD

(use ½ cup milk as place to start)

Yeast bread contributes 7% of sodium in U.S. diet

Bread: Frequent consumption of lower sodium foods adds to daily totals

Reference: Dietary Guidelines for Americans, 2010

Egg whites are lower in Na, K, and P than egg substitutes

Breakfast beverage may make a difference in P or K

Phosphorus from food additives is 90–100% absorbed

Breakfast choices at a glance

* Read labels to compare brands

Food Sodium Phosphorus Potassium

Hot cereal Regular < instant

Corn, rice, wheat < oat

Corn, rice, wheat < oat

Cold cereal Refined < bran*

Refined < branUnfortified <fortified*

Refined < bran

Milk (1/2 cup)

Protein-fortified has more

Protein-fortified has more

Protein-fortified has more

Nondairy Rice < soy * Rice < soy < cow’s Check label for phos

Rice < soy < cow’s

Bread Wheat < rye * Wheat < corn White < whole wheat

Egg Egg white < egg sub.

Egg white < egg sub. Egg white < egg sub.

Fruit - - Lower K fruits if needed

Hot beverage - - Instant < brewed

A vegetarian lunch may be good for the heart

Reference: Adapted from Nutrition Care Manual type 2 diabetes vegetarian meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type%202%20Diabetes%20Nutrition%20Therapy%20for%20Vegetarians.pdf

Food Kcal Pro (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg)

1 c. green leaf lettuce 5 0.49 1.03 0.05 10 10 70

1/3 c. tomato chopped 11 0.52 2.31 0.12 3 14 141

1 tbsp. reduced fat Italian salad dressing

11 0.07 0.69 0.96 161 2 13

1 c. reduced sodium vegetable soup

83 2.78 15.33 1.14 491 58 549

1 garden burger, frozen 124 10.99 9.99 4.41 398 144 233

1 mixed grain bun 113 4.13 19.18 2.58 197 52 69

1 c. soymilk, added Ca, unsweetened

80 6.95 4.23 3.91 90 78 292

TOTALS 427 25.93 52.76 13.17 1,350 358 1,367

Salad greens differ in K content

Vinegar/oil or low-sodium salad dressing aids 1,500 mg Na budget

Salt added to cooking may still mean less sodium than canned.Eat small portions of beans and peas when serum potassium is high.

Canned beans may be a little lower in K, but still very high in Na

Read ingredient list for KCl in lower sodium canned soups

CKD patients should limit sodium to 1,500 mg per day.

Salad dressing packets tend to be large.

Smaller, single items are still high in sodium.

Double meat means more Na, P, and K.

Some items have PHOS additives.

http://www.case.edu/med/ccrhd/phosfoods/

Fast foods and CKD

Some fast-food salad dressings are large servings and high in sodium

Salad has 81 mg P, 356 mg K

Size and what’s on the fast food cheeseburger adds up

Even a small fast-food bean burrito has about 1/3 of the daily Na

If you’re having pizza, thin crust is a better choice

Nut butter is convenient; watch portion size if serum P or K is high

Possible changes for lunch: IndividualizeFood Sodium Phosphorus PotassiumSalad dressing

Oil/vinegar, low-Na type < regular dressing;Homemade < fast food, restaurant

Non-milk based < milk based

Read label for KCl in low-Na type

Salad Raw < pickled vegetable;No-added-salt canned < regular canned vegetables

Cheese, meat, beans, nuts, seeds add more

Potato or bean salad, meat, seeds, nuts add more; use lower K vegetables

Soup Homemade < canned, dried, instant, or restaurant

Non-dairy based < dairy based

Bean, pea, vegetable soup have more; read label for KCl in low-Na type

Sandwich Restaurant, fast food, deli meats, cheese are high

Double meat and/or cheese add more

Meat, cheese, bean, nut butter add more

TIPS:•Salad dressing on the side: dip fork in dressing, then into salad•Leftovers from food prepared from scratch •Smaller servings of protein in sandwiches and burritos •Fast foods, restaurant meals only once every other week (SODIUM)

A healthy evening meal usually includes a variety of foods

Reference: Adapted from Nutrition Care Manual type 2 diabetes meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf

Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg)

3 oz. baked chicken, rotisserie

111 21.8 0 2.62 256 192 222

1 small baked potato 73 1.53 16.81 .08 4 39 305

½ c. green beans, frozen 22 1.10 3.87 .23 2 23 132

1 tbsp. margarine-like spread w yogurt (40% fat)

46 .28 .28 4.9 88 5 9

1 ½ c. spinach/feta/ grapefruit salad

87 2.1 8.5 5.7 78 37.5 292

1 c. skim milk 83 8.26 12.15 .20 103 247 382

1 medium peach 58 1.36 14.31 0.38 0 30 285

TOTALS 480 36.43 55.92 14.1 451 573.5 1,627

Source and preparation of chicken can increase Na, P, and K

Potato preparation affects K (Boiling helps remove some K)

020406080

100120140160180200

Raw Boiled Canned Microwaved Frozen,microwaved

Frozen,boiled

K

Boiling removes more K from green beans

½ cup serving

Type of spread may add some sodium, saturated or trans fat

Type of rice can increase P or K, still a better choice than potato if K is high

Amount and processing of spinach makes a difference in K content

NAS = No Added Salt

Check ingredient list of processed cheese for additives

Size and processing of a peach makes a difference in K intake

Beverage choice can make a difference in Na, P, or K; read ingredient list

Prepare foods from scratch.

Read ingredient list to identify food additives.

Use ingredients with fewer food additives.

Use less salt than the recipe lists.

Use liquid vegetable oil instead of butter, margarine, lard, or shortening in cooking.

Use less meat, poultry, or fish in soup or stew.

If K is high, use rice not potatoes.

Possible changes for supper: Individualize

So many changes to make, so many things to consider…

Where do you start?

Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf

Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf

Reference: http://nkdep.nih.gov/

Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf

Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf

Reference: http://nkdep.nih.gov/resources/nkdep-kidney-test-results-508.pdf

Reference: http://nkdep.nih.gov/resources/nkdep-ckd-amt-guide-508.pdf

RENAL REPLACEMENT THERAPY (RRT)

OptionsDiet Considerations

Kidneys cannot maintain homeostasis.

Kidney failure is associated with fluid, electrolyte, and hormonal imbalances and metabolic abnormalities.

End-stage renal disease (ESRD) means patient is on dialysis or has a kidney transplant.

Kidney failure is an eGFR < 15

Patients with kidney failure will have the same complications

eGFR < 30

Medicare B − Individual pays 20%, deductible applies

Qualified providers: physicians, physician assistants, nurse practitioners, and clinical nurse specialists

Up to six sessions covered

Kidney disease education is a Medicare benefit

The topics include many of the ones you already know about

Consistent messages are better.

Providers should be teaching the same thing.

Education may help patients to be successful in their self-management efforts.

An informed patient is better prepared

Discuss options early with patients with progressive CKD, give them time to prepare.

Patients diagnosed with kidney “failure” or loss of kidney function may experience grief, fear, or depression.

Include family members if possible.

The “diet” will change; and changes depend on the chosen option.

Discuss treatment options early

Reference: http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtreatment.pdf

Renal replacement therapy (RRT)1. Hemodialysis

• In-center or home, three times a week or more frequently

2. Peritoneal dialysis• Daily, at home

3. Kidney transplantation

No RRT4. Conservative management

• Active medical management

Four options for treating kidney failure

Concentration gradient − Flows from high to low

Area through which diffusion takes place− Large surface area of the membrane

Size of molecules− Protein-bound substances not usually dialyzed

Dialysis involves diffusion of substances across a semipermeable membrane

In-center hemodialysis− Most common type

http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/hemodialysis.pdf

Home hemodialysis− Individual has more control

− Need assistance

http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/homehemodialysis.pdf

Hemodialysis occurs in two settings

Hemodialysis

Removal is based on size.

Protein-bound substances are not usually removed.

Amino acids are removed.

Glucose is removed.

Water-soluble vitamins are removed to some degree.

Concentration gradients move substances across the semipermeable

membrane for removal

Reference: Descombes et al. Artif Organs 2000; 24(10):773–778.

More dietary protein is needed to replace losses.

Specific renal vitamin may be used.− Consider taking vitamin after treatment to avoid

removal during treatment.

Nutrient losses during dialysis need to be replaced

Maintain homeostasis Adequate dialysis

− Type and size of the dialyzer− Blood flow rate− Dialysate composition (similar to normal levels)

Sodium, potassium, calcium, bicarbonate

− Time Individual patient factors

The hemodialysis prescription is individualized

Reference: Locatelli et al. Nephrol Dial Transplant 2004; 19(4):785–796.

Levels build up between treatments; examples of these substances are:− Fluid

− Nitrogen

− Sodium

− Potassium

− Phosphorus (only to some degree)

− Hydrogen (acid)

Hemodialysis removes some substances that accumulate between treatments

A normal kidney works “24/7.”

Damaged kidneys (in CKD) still work nonstop but at a reduced level.

An artificial kidney works only during dialysis treatments.

Dialysis replaces only a fraction of normal kidney function

Arteriovenous (AV) fistula

Graft

Temporary access

Permanent access, usually placed in non-dominant arm

Protect blood vessels in both arms− Avoid venipuncture and IV catheter placement above

the wrist

A vascular access is needed for hemodialysis

Provides permanent access

Surgically connects artery to a vein− Vein grows larger due to increased

blood flow.

− Needles are inserted to access the bloodstream.

Takes time to mature− Few weeks to months

Less likely to clot

An AV fistula is the preferred access

An AV graft will work for hemodialysis

Synthetic tube connects artery and vein.

Graft takes less time to mature.

Graft is more likely to become infected or clot.

Emergency dialysis

Less than optimal blood flow

No needles

Permanent access surgery needed later

The only option when patient is not prepared and needs dialysis

A “temporary access” is just temporary

Catheter for temporary access

Treatment is three times per week.

Dialysis treatment lasts 3–4 hours.

In-center hemodialysis is scheduled

Conventional home hemodialysis− Three times per week

− Most common type of home hemodialysis

Daily home hemodialysis− 2–3 hours, 5–6 days per week

Nocturnal hemodialysis− 6–8 hours, 3 or more days per week

− Dialyze more frequently

Home hemodialysis requires training and support

Reference: http://www.homedialysis.org/

In-center hemodialysis: Pros and cons

PROS

Social setting

Facilities are found nationwide.

Staff does the work.− Placing/removing needle

− Monitoring the treatment

− Maintaining the equipment

CONS

Requires strictest diet− Substances and fluid build up

between treatments.

Have to follow set schedule

Must travel to the unit

May take more medication

May feel fatigued

Some nutrients are removed during treatment

Home hemodialysis: Pros and cons

PROS

Diet is less restrictive with more frequent treatments

Can schedule around work

No travel to the unit is needed

Newer machines are small

Fewer ups and downs occur

CONS

Must have a partner

May be stressful for partner

Need space for treatment: machine, supplies, access to water and drainage, electricity

Have to insert needles

Need time off from work for initial training

Training not offered everywhere

Protein: > 1.2 g/kg (some loss during treatment) Calories: 30–35 kcal/kg

− > 60 years old: 30 kcal/kg

Sodium: 1,000–3,000 mg

Potassium: 2,000–3,000 mg Phosphorus: 800–1,000 mg phosphorus

− Need binders

Fluid restriction: urine output + 1,000 mL (cc)− 240 cc/cup

Nutrition prescription: In-center hemodialysis

Increased frequency of treatment means fewer restrictions.

Fewer phosphate binders may be needed. Adequate protein is still needed.

Nutrition prescription: Home hemodialysis

Reference: http://kidney.niddk.nih.gov/KUDiseases/pubs/peritoneal/index.aspx

Continuous ambulatory (CAPD).

Continuous cycler-assisted (CCPD).

PD uses the peritoneal membrane as the filter.

PD still requires surgery for catheter placement.

Some people experience body-image concerns.

PD is a continuous therapy.

Peritoneal dialysis (PD) options

Dextrose is the most common osmotic agent used in the dialysate.

Osmotic gradient helps move water into the peritoneal cavity.

Clearance affected by: Concentration gradient Size Permeability of the peritoneal

membrane

The peritoneal membrane is the semipermeable “filter” in peritoneal

dialysis

The peritoneal dialysis exchange

Dialysis solution with dextrose flows into the abdominal cavity.

The solution remains for a prescribed time period, also known as the dwell time.

Substances and fluid pass from the capillaries in the peritoneum into the solution.

Dextrose enters the blood; and substances and fluid enter the solution.

The solution is drained at the end of the dwell.

What is an “exchange”?

Dextrose solutions are used as osmotic agent.− 1.25%, 2.5%, 4.25% concentrations

Exchanges are 2–3 liters in volume.

Dwell time and number of exchanges vary.

PD prescription is individualized

CAPD requires 3–4 manual exchanges

The cycler does 3–5 exchanges during the night in CCPD

Peritoneal dialysis: Pros and Cons

PROS Better preserves residual renal

function Can do it alone Choice of times Choice of location Easier to travel, no machine No travel to unit Treatments done daily

CONS Need space for supplies which are

delivered monthly Must plan around activities Must do as prescribed to get

adequate treatment Must follow instructions to keep

risk of infection low Need to take supplies when

traveling May have weight gain May be harder to control diabetes

The diet may not be as strict.

Amino acids lost during the exchanges must be replaced, dietary protein needs are higher.

Absorbed dextrose calories may add weight.

People with diabetes are never really “fasting.”− Glucose levels may be harder to control.

− Insulin may be injected into the dialysate bags.

Peritoneal dialysis and diet

Protein: 1.2–1.3 g/kg

Calories: 30–35 kcal/kg− Includes calories from dextrose solutions

Sodium: 2,000–4,000 mg

Potassium: 3,000–4,000 mg

Phosphorus: 800–1,000 mg− Still need binders

Fluid restriction–as needed

Nutrition prescription: Peritoneal dialysis

Reference: Shiro-Harvey, 2002

Dextrose concentrations vary − 1.25%, 2.5%, 4.25%

Bag sizes vary− 2-liter, 2.5-liter, 3-liter

In CAPD, 60–70% is absorbed. The amount is higher due to longer dwell times.

In CCPD, 40–50% is absorbed.

Calories count in dextrose solutions

Reference: McCann, 2009

Four exchanges of 2-liter bags with 1.5% dextrose= 8 liters of 1.5% dextrose (grams dextrose/liter)

= 120 grams of dextrose

3.4 kcal/gram of dextrose (120 grams of dextrose) x 3.4 = 408 calories

60–70% absorbed

Total of 245–286 calories absorbed/day

Estimate of calories from CAPD

For more information about peritoneal dialysis dose and adequacy

Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritonealdose.pdf

Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant.pdf

Deceased or living donor kidney is required.− Must be ABO compatible, match for human leukocyte

antigens

The transplant workup takes time; eligibility is strict.

Requires major surgery.

Need to take medications daily, including antirejection medication.

Kidney transplantation is a treatment, not a cure

A transplanted kidney is placed in the groin area. Native kidneys usually are

not removed.

Kidney transplant: Pros and cons

PROS A transplanted kidney is a

normal, functioning kidney. Dialysis is not needed. Fewer diet restrictions are

needed. Successful transplant may

mean a longer life. Recipient may have better

quality of life.

CONS The waiting list is long for a

deceased donor. The transplant requires major

surgery. Rejection Antirejection medications

suppress the immune system. Weight gain Diabetes may be harder to

control.

Transplant is a treatment, not a cure.

May need a sodium restriction.

May need to reduce calories to avoid weight gain.

Medications may increase weight gain.

Nutrition prescription: Transplant

No non-dialysis way can replace loss of clearance of uremic toxins.

Complications can be treated.

Continue medications.

Provide comfort and palliative care.

Encourage patient to inform family.

Conservative management is active medical management with no RRT

Discuss the options early to allow time for the patient to adjust and make a decision.

The diet will change with dialysis, more protein is needed to replace the losses.

Hemodialysis has the most restrictive diet.

Peritoneal dialysis calories add up. Transplant requires daily immunosuppressant

medication.

All the options still require medications.

Summary: Treatment options

She was very upset upon hearing she had CKD.

She is now on the waiting list for a transplant.

Hemodialysis is her second choice.

She has a vascular access in place and will probably need in-center hemodialysis prior to transplant.

Maria wants a kidney transplant

The transition from CKD to ESRD can be short for someone like Maria

SUMMARY OF ALL CONTENT

Identify people with chronic kidney disease.

Assess and monitor estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). − eGFR estimates kidney function.

Persistent levels < 60 are considered CKD.

− UACR > 30 mg/g is considered as kidney damage. Patients with high levels of urine albumin are at greatest

risk of rapid progression to kidney failure.

Identify CKD

Control blood pressure.− 1,500 mg sodium

Do not replace salt with salt substitutes (KCl).− Medications that affect the renin-angiotensin-aldosterone

system (RAAS) increase risk of hyperkalemia.− Limit dietary potassium when serum level is elevated.

Control diabetes.− A1C is individualized.− Spontaneous improvement in control may mean CKD

progression.− Treat hypoglycemia appropriately.

Use juice low in potassium. Avoid dark colas due to phosphorus content.

Slow progression

Urine albumin is an indicator of kidney damage.− Medications that affect the RAAS may lower urine

albumin.− Lower sodium, planned weight loss, lower protein

intake, tobacco cessation may help lower albuminuria.

Cardiovascular disease is the leading cause of mortality for people with CKD.− Nontraditional risk factors are important.

Anemia Urine albumin Abnormal mineral metabolism (calcium and phosphorus)

Slow progression (continued)

Anemia− Inadequate erythropoietin and iron

− Hemoglobin and iron indices

Hyperkalemia− Limit dietary potassium when serum level is elevated.

Hypoalbuminemia− Poor oral intake (spontaneous reduction in protein)

− Inflammation

Complications

Metabolic acidosis− Maintaining serum CO2 > 22 mEq/L may be beneficial.− Animal protein is a source of metabolic acids.− Acidosis may be treated with supplemental

bicarbonate.

Bone disease in CKD− Calcium, phosphorus, vitamin D, parathyroid hormone

Use corrected calcium with hypoalbuminemia

− Vitamin D supplementation may increase risk of hypercalcemia and hyperphosphatemia.

Complications (continued)

Use clinical judgment when assessing body weight for estimating nutrient needs.

Caloric requirements are not higher.

For CKD patients limit to 1,500 mg sodium.

Diet has adequate, not excessive, protein.

Restrict phosphorus if serum level is elevated.

Restrict potassium if serum level is elevated.

Diet changes as CKD progresses

Foods rich in protein tend to be rich in phosphorus and potassium. Egg whites are an exception.

Refined grains are lower in phosphorus and potassium than whole grains.

Boiling potatoes and tubers immediately removes enough potassium. Leaching, or soaking, in water is not required.

The food groups

Fresh lean meat, poultry, and fish have K and P.

Use products that are not enhanced with Na.

Dried beans and peas are high in phosphorus and potassium; may need to limit amounts.

Dairy foods are high in sodium, protein, phosphorus, potassium, and fluid (milk).

Use foods without food additives, if possible.− Inorganic phosphorus is more readily absorbed.

The foods

Cereals and breads may be a source of Na.

Bran and whole grains have more K and P.

Fruits and vegetables vary in K content.− Canned fruit may have lower K. − Use lower sodium canned vegetables, if using canned.

Heart-healthy fats are preferred.

The foods

Kidney failure is considered as an eGFR < 15. ESRD still means many of the same complications. There are 4 options to choose from:

1. Hemodialysis More protein; restrict Na, P, K, and fluid Fewer restrictions with more frequent home hemodialysis

2. Peritoneal dialysis More protein; usually Na and P restriction

3. Transplant May need to limit sodium Other comorbidities (diabetes, hypertension)

4. Conservative management

The diet changes when the kidneys fail

This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD), especially among communities most impacted by the disease, NKDEP works in collaboration with a range of government, nonprofit, and health care organizations to:• raise awareness among people at risk for CKD about the need for testing;• educate people with CKD about how to manage their disease;• provide information, training, and tools to help health care providers better detect

and treat CKD; and• support changes in the laboratory community that yield more accurate, reliable,

and accessible test results.To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional

materials from NIDDK, please visit: http://www.niddk.nih.gov.

Meet our Presenters Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.

Ms. Kuracina is the lead author of the American Dietetic Association’s CKD Nutrition Management Training Certificate Program and NKDEP’s nutrition resources for managing patients with CKD.Ms. Kuracina has more than 20 years of experience in clinical dietetics with the Indian Health Service (IHS). She is a senior clinical consultant with the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. She also serves as a diabetes dietitian and coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico, a role in which she routinely counsels patients who have chronic kidney disease (CKD).

Meet our Presenters Andrew S. Narva, M.D., F.A.C.P.

Dr. Narva is the director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health (NIH). Prior to joining NIH in 2006, he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Via telemedicine from NIH, he continues to provide care for IHS patients who have chronic kidney disease. A highly recognized nephrologist and public servant, Dr. Narva has served as a member of the Medical Review Board of ESRD Network 15 and as chair of the Minority Outreach Committee of the National Kidney Foundation (NKF). He serves on the NKF Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Diabetes and is a member of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Expert Panel.

American Dietetic Association. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Standardized Language for the Nutrition Care Process. 3rd ed. Chicago, IL: American Dietetic Association; 2011.

American Dietetic Association. Type 2 diabetes nutrition therapy for vegetarians. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type%202%20Diabetes%20Nutrition%20Therapy%20for%20Vegetarians.pdf. 2010. Accessed June 14, 2011.

American Dietetic Association. Type 2 diabetes nutrition therapy. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf. 2010. Accessed June 14, 2011.

References

Case Center for Reducing Health Disparities. Fast food, phosphorus containing food additives, and the renal diet. Case Western Reserve University website. http://www.case.edu/med/ccrhd/phosfoods/. 2009. Accessed August 30, 2011.

Descombes E, Boulat O, Perriard F, Feilay G. Water-soluble vitamin levels in patients undergoing high-flux hemodialysis and receiving long-term oral postdialysis vitamin supplementation. Artificial Organs. 2000;24(10):773–778.

Handelman GJ, Levin NW. Guidelines for vitamin supplements in chronic kidney disease patients: what is the evidence? Journal of Renal Nutrition. 2011;21(1):117–119.

References

Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.: National Academies Press; 2010. Institute of Medicine website. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx. Accessed June 14, 2011

Khanna R, Nolph KD. Chapter 4. Principles of peritoneal dialysis. In: Henrich WL, Bennet WM, eds. Atlas of Diseases of the Kidney. Vol. 5. http://www.kidneyatlas.org/book5/adk5-04.ccc.QXD.pdf. 1999. Accessed June 14, 2011.

Locatelli F, Covic A, Chazot C, Leunissen K, Luno J, Yaqoob M. Optimal composition of the dialysate, with emphasis on its influence on blood pressure. Nephrology Dialysis Transplantation. 2004;19(4):785–796.

McCann L, ed. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York: National Kidney Foundation; 2009.

References

National Kidney and Urologic Disease Information Clearinghouse. Home hemodialysis. February 2008. NIH publication 08–6232. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/homehemodialysis.pdf. Accessed June 14, 2011.

 National Kidney and Urologic Disease Information Clearinghouse.

Kidney failure: choosing a treatment that’s right for you. November 2007. NIH publication 08–2412. National Institute of Diabetes and Digestive and Kidney Disease website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtreatment.pdf. Accessed June 14, 2011.

References

National Kidney and Urologic Disease Information Clearinghouse. Peritoneal dialysis dose and adequacy. December 2006. NIH publication 07–4578. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritonealdose.pdf. Accessed June 14, 2011.

National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure hemodialysis. December 2006. NIH publication 07–4666. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/hemodialysis.pdf. Accessed June 14, 2011.

References

National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure peritoneal dialysis. May 2006. NIH publication 06–4688. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritoneal.pdf. Accessed June 14, 2011.

National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure transplantation. May 2006. NIH publication 06–4687. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant.pdf Accessed June 14, 2011.

References

National Kidney and Urologic Disease Information Clearinghouse. Vascular access for hemodialysis. February 2008. NIH publication 08–4554. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/vascularaccess.pdf. Accessed June 14, 2011.

National Kidney Disease Education Program. Chronic kidney disease (CKD) and diet: assessment, management and treatment. Treating CKD patients who are not on dialysis. An overview guide for dietitians. Revised September 2011. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-ckd-amt-guide-508.pdf. Accessed September 8, 2011.

References

National Kidney Disease Education Program. Eating right for kidney health tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://www.nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf. Accessed June 13, 2011.

National Kidney Disease Education Program. How to read a food label tips for people with chronic kidney disease. June 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf. Accessed August 30, 2011.

References

National Kidney Disease Education Program. Phosphorus tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf. Accessed August 30, 2011.

National Kidney Disease Education Program. Potassium tips for people with chronic kidney disease (CKD). September 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf. Accessed September 8, 2011.

National Kidney Disease Education Program. Protein tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf Accessed August 30, 2011.

References

National Kidney Disease Education Program. Sodium tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.pdf. Updated March 2011. Accessed August 30, 2011.

 National Kidney Disease Education Program. Your kidney test results.

Revised September 2011. NIH publication 11–7407. National Kidney Disease Education Program website. http://www.nkdep.nih.gov/resources/nkdep-kidney-test-results-508.pdf. Accessed September 8, 2011.

Palmer, BF. Chapter 2. Dialysate composition in hemodialysis and peritoneal dialysis. In: Henrich WL, Bennet WM, eds. Atlas of Disease of the Kidney. Vol. 5. http://www.kidneyatlas.org/book5/adk5-02.ccc.QXD.pdf. 1999. Accessed June 14, 2011.

References

Renal Practice Group of the American Dietetic Association. National Renal Diet Professional Guide. 2nd ed. Chicago, IL: American Dietetic Association; 2002.

Types of home dialysis. Home dialysis central. Homedialysis.org website. http://www.homedialysis.org/types. 2004. Accessed June 14, 2011.

U.S. Department of Agriculture. Agricultural Research Service. 2010. USDA National Nutrient Database for Standard Reference, Release 23. Search the USDA national nutrient database for standard reference. U.S. Department of Agriculture website. http://www.nal.usda.gov/fnic/foodcomp/search/ Accessed August 30, 2011.

References

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, D.C.: U.S. Government Printing Office, December 2010. U.S. Department of Agriculture website. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. Accessed June 14, 2011.

U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Did you know Medicare helps cover kidney disease education? March 2010. CMS product 11456. Centers for Medicare & Medicaid Services website. http://www.medicare.gov/Publications/Pubs/pdf/11456.pdf. Accessed June 12, 2011.

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