Nutrition Care in Chronic Kidney Disease – An Overview Terry Banerjea, MS, RD, LDN Barbara Edgar, RD, LDN

Nutrition Care in Chronic Kidney Disease – An Overview

Terry Banerjea, MS, RD, LDNBarbara Edgar, RD, LDN

Objectives:

•Understand goals of MNT for patients with CKD•Recognize renal related labs and their goal values•Become familiar with dialysis medications and their functions

Medical Nutrition Therapy• Protein• Calories• Potassium• Phosphorus• Calcium• Sodium• Fluid• Vitamins• Minerals

Protein

• The backbone of the diet• Essential for growth, muscle building, boosting

the immune system, preventing infection, anemia

• Important for wound healing• Measured as ALBUMIN in the blood• Albumin goal is >=4.0 to live longer and

healthier

Protein/Calorie Malnutrition

• 40% of hemodialysis patients are thought to have protein/calorie malnutrition.

• Dialysis population has a two-fold increase in mortality risk for those with albumin <3.8 g/dl vs. those with albumin > 3.8 g/dl

Some Potential Reasons for Low Albumin

Loss of metabolic function in the failing kidney leads to build up of waste products leading to:•Anorexia•Decrease in nutrient intake•Changes in hormones and metabolismInsulin resistanceIncreased hepatic glucagon sensitivityExcessive parathyroid hormone secretionChange in the rate of protein/amino acid turnoverAcidosis: loss of protein and muscle massIncreased cytokine activation (pro-inflammatory response)

Some Potential Reasons for Low Albumin

• Use of multiple medications• Multiple co-morbidities• Loss of amino acids in dialysate• Reduced ability to synthesize albumin in the

elderly leads to slight albumin decrease• Liver failure decreases albumin synthesis• Fluid overload leads to dilution of the serum

(would falsely lower albumin and BUN)

Calories/ Protein in CKD

Appetite and intake may be poor due to:•Aging•Frequent illness, hospitalizations•Institutional food•GI problemsGastroparesis and diabetesConstipation due to CaCO3, iron, narcotics, other medications, low fluid, low fiber, limited exerciseDiarrhea due to C. difficile with antibiotic therapy

Calories/Protein in CKD

Appetite is made worse by CKD and dialysis due to:•Anorexia caused by uremiaNausea, vomiting, diarrheaDysgeusia due to uremia, zinc deficiency•Peritoneal Dialysis patients: feeling of fullness from dialysate or sugar content of dialysate•Hemodialysis: Interferes with regular meal pattern

Evaluating Protein Intake • Check Urea Reduction Rate (URR) or KT/V - URR

should be >70% and KT/V should be >1.2These measure dialysis adequacy and low values

may adversely affect intake• Check nPCR Normalized protein catabolic rate is determined

from urea generation. It is an indicator of available protein. If patient is stable the nPCR indicates dietary protein as g/kg/EDW. nPCR will be low if protein intake is low or patient is anabolic

Evaluating Protein Intake

• Check BUN 40-100 mg/dlUrea derived from protein will decline if

intake is poor or patient is anabolic• Check albumin (BCG) >=4.0Albumin will decline if patient has trauma,

infection, intake is poor, or if dialysis is inadequate

High Quality vs. Low Quality Protein

• Dialysis patients should get 50% of their diet from HIGH BIOLOGICAL VALUE PROTEIN (animal products)

• LOW BIOLOGICAL VALUE protein generally come from plants

• Vegetarians can still maintain acceptable albumin levels by combining plants sources with the use of supplements

How Much Protein Does a Person on Dialysis Need?

• Hemodialysis patients need 1.2 or more grams/kg• Peritoneal patients need 1.3 or more grams/kgGreater protein losses in dialysateAppetite loss due to fullness experienced while

the dialysate fluid in peritoneumEffect of glucose when using higher

concentration dialysate• These recommendations are based on K/DOQI

guidelines.

Inadequate Protein Intake

• Muscle Wasting• Lack of Energy• Weight Loss• Poor Wound Healing• Albumin </=3.5 considered protein

malnutrition (Goal >/=4.0)• Low albumin can make it hard to dialyze fluid

off of a patient

Evaluating Calorie Intake

• Check EDW (Estimated Dry Weight)• Check IDWG (Interdialytic Weight Gain)• Check labsPoor intake indicated by:Low BUNLow AlbuminLow KLow PO4

How Many Calories Does a Person on Dialysis Need?

• Hemodialysis patients need 30-35 kcal/kg >60 years old, 35 kcal < 60 years old

• Obese dialysis patients 25 kcal/kg regardless of age

• Peritoneal dialysis patients have the same calorie requirements however the calories from the dialysate need to be included

Suggestions for Improving Intake

• Encourage patient to not miss meals even when they are not hungry

• Small, frequent meals• If a patient is eating poorly and K and PO4 are low-

liberalize diet• If dysgeusia is present- eggs or cottage cheese may be

better tolerated than meat, meat at room temperature Consider zinc supplement• Send lunch with patient to hemodialysis treatment if

clinic allows or send supplement


• Protein recommendations are not a restriction

• Do not sacrifice protein intake in order to lower PO4 intake

• Help patient with fluid/sodium restrictionAvoid large fluid weight gains• Encourage physical activity to maintain muscle

mass


• Protein: may need to increase portion size if standards are used

Serve HBVP at 2 meals/day minimumServe at least 2+ ounces HBVPServe 4-6 ounces HBVP at large mealInclude a HBVP with snackConsider supplements

Snacks for Dialysis• Many dialysis patients miss 3 meals per week due to

dialysis schedule so it is important to replace this meal with a protein rich snack

• If patients do not wish to eat a sandwich or if it is not allowed, send a supplement as a meal replacement

• Snack Ideas: Egg salad, tuna salad, chicken salad, turkey or roast beef

sandwich Cheese stick and a piece of fruit Greek yogurt A peeled hard boiled egg• Binders should be sent with the bag meal

Potassium

• Absorbed in small intestine1.90% in cells2.8% in bones3.<1% in circulation• Excretion1.80-95% in urine2.5-20% in stools

Potassium

Primary Roles of Potassium:•Maintains fluid balance within cells•Conduction of nerve impulses•Muscle contraction

Potassium (K)

• Normal serum potassium values:3.5-5.1mEq/L• Goal range for dialysis patients:3.5-6.0mEq/L• Serum level is dependent on urine output• K is usually WNL if producing >1000cc/day• May be altered by diuretics and

antihypertensive medications

Causes of High Potassium (Hyperkalemia)

• Excessive potassium intake• Inadequate dialysis1.Inadequate treatment time or missed

treatments2.Low blood flow rate, recirculation3.Metabolic acidosis-causes K to shift from cell

to serum


• Dehydration-hyperosmolar state impairs cellular uptake of K+

• Insulin deficiency-cellular uptake of K+ requires insulin

• Blood transfusions-old packed cells will break down and release K+

• Hemolysis (incorrect handling of specimen)-release of K+ from RBC into serum


• Catabolism due to tissue breakdown:1. Infection and ischemia (bowel)2. Starvation3. Trauma surgery4. GI Bleed

• Chewing tobacco• Use of illicit drugs• Some forms of pica• Constipation• Medications-ACE Inhibitors and ARBS (Angiotensin receptor

blockers) which are commonly used for blood pressure control

Symptoms of Hyperkalemia

• Muscle weakness• Numbness and tingling of extremities• Slow pulse rate• Heart attack

Diet Recommendations for Potassium

• Hemodialysis – 2-3 grams/day• Peritoneal Dialysis – 3-4 grams/day however

often times a restriction is not needed– A high K+ usually indicates treatments are not

being done

High Potassium Fruits

High Potassium Vegetables

Diet Recommendations

• High potassium foods may be allowed in small amounts depending on frequency in meal plan– EXAMPLE: ¼ cup of tomato sauce on noodles– Consult with renal dietitian

DIALYSIS PATIENTS SHOULD NEVER EAT STAR FRUIT

If K+ is high:

• Check URR (urea reduction rate) or KT/V (clearance of volume over time)

• Check BS and HgbA1C for lack of insulin• Check Hgb and transferrin saturation for the

possibility of a GI bleed• Check potassium if specimen was hemolyzed• Check medication list – Captopril, Enalapril,

Accupril, Lisinopril • Diet review

If K+ is high due to a non-dietary cause:

• Consult MD for changes:– Blood pressure medications– Possible use of Kayexalate– Change dialysis bath (3K to a 2K)– Discontinue potassium supplement (KCl) if

prescribed

Phosphorus

• Primary Roles of Phosphorus:– Bone and Teeth Formation– Energy Metabolism– Acid-Base Balance

Phosphorus

• Normal serum phosphorus level:2.6-4.5mg/dL• Goal range for dialysis patients:3.0-5.5mg/dL• Three ways to control phosphorus:– Diet restriction is nearly always necessary– Phosphate binders– Dialysis – 800mg/treatment is removed at each

hemodialysis treatment and 300-315mg/day for peritoneal dialysis

Symptoms of High Phosphorus (Hyperphosphatemia)

• Itching• Blood shot eyes• Bone pain

Effects of High Phosphorus

• Combines with calcium to form deposits in and joints– CVD, PVD– Calcification of soft tissue– Calciphylaxis

• Causes parathyroid hormone to increase– Decalcification of bones– Bone pain, high risk of fractures

Relative Mortality Risk by Serum Phosphorus Levels

Dietary Recommendations for Phosphorus

• 800-1000mg/day, adjust to meet protein needs (10-12mg/gram of protein) for hemodialysis and peritoneal dialysis

High Phosphorus Foods

• Dairy products – milk, cheese, ice cream, yogurt

• Beans – dry beans and legumes• Peanut butter and nuts• Chocolate products• Cola beverages• Bran – bran muffins and cereals• Whole grains – whole wheat bread, cheerios

Treatment of High PhosphorusDietary recommendations

•Limit milk/dairy to ½ cup per day•Limit use of non-dairy high phosphorus foods:– Nuts– Legumes

•Limit foods that contain phosphorus additives:– Processed and spreadable cheeses– Instant products-puddings and sauces– Cola, some flavored waters and fruit drinks (Hawaiian

punch)•90% of the phosphorus in additives are absorbed vs. 50% in natural foods

Phosphate Binders

• Must be taken with meals and snacks to be effective

• The active component of the phosphate binder combines with the digested phosphorus, forming a compound that is eliminated in the stool

• Patients should also take a binder with the protein supplements

BindersCalcium Carbonate – Tums, Oscal, Caltrate

– OTC so not costly– Many different pleasant flavors to choose from– Chewable– May cause hypercalcemia – May cause constipation, gas, nausea– Strength vary from regular Tums (500mg tab which provides

200mg of elemental calcium) to Tums EX (750mg tab which provides 300 mg of elemental calcium) to Ultra Tums (1000mg tab which provides 400mg of elemental calcium)

– Typical dose is 1-3 tablets per meal– Should be limited to 7-8 regular Tums per day– Absorb 20-30% of calcium

Binders

Phoslo – calcium acetate– Capsule is 667mg which is 169mg of elemental

calcium– Typical dose is 1-3 capsules per meal, should be

limited to 9 per day– Easy to swallow– May cause hypercalcemia– Generic is calcium acetate which is either a capsule or

tablet– Less calcium absorbed than calcium carbonate– 21% calcium absorbed with meals, 40% absorbed in

between meals

Binders

• Phoslyra- calcium acetate oral solution– Can be used in tube feedings– Can be used for patients with swallowing issues– Black cherry/menthol flavor – Single dose is 5ml– Typical dose is 5ml-15ml per meal

BindersRenagel (sevelamer hydrochloride)

Renvela (sevelamer carbonate)•Tablet 400mg and 800mg dose for Renagel, 800mg dose for Renvela•Renagel lowers cholesterol due to binding with bile acids•Renagel lowers serum bicarbonate•Typical dose is 3 tablets per meal though some patients require more•Non-calcium based binder so is used for patients that have issues with hypercalcemia•Renvela comes in a powder form of 800mg or 2.4g that is mixed with 2 ounces of water for patients with swallowing issues•Renagel and Renvela may cause some n/v, diarrhea or gas

BindersFosrenol (Lanthanum Carbonate)

•Chewable tablet of 500mg, 750mg, 1000mg•Typical dose is 1000mg tablet per meal•Maximum dose is 4500mg per day•Non-calcium based binder so is used for patients that have issues with hypercalcemia•Tablet must be completely chewed, can not swallow whole pieces•Tablet must be taken after meal is completed, not before or during•Chalky flavor•0.00003% lanthanum is absorbed

Binders• Velphoro (Sucroferric Oxyhydroxide)• Chewable tablet of 500mg• Typical dose is 1 tablet per meal• May require 2 tablets with a large meal or a meal

that contains a high PO4 food• Tablet must be completely chewed, can not

swallow whole pieces• Non-calcium based binder so is used for patients

that have issues with hypercalcemia• May cause dark stools

Calcium

Primary roles of calcium:•Bone strength•Teeth formation•Catalyst in the conversion of prothrombin to thrombin•Involved in transmission of nerve impulses and relates to muscle contractions•Activates several enzymes such as lipase

Calcium

• Normal serum calcium level: 8.4-10.2• Normal serum calcium level for dialysis

patients: 8.4-10.2• Calcium is corrected for an albumin <4.0 (4.0-albumin level X .8)

Calcium

Causes of Hypercalcemia•Addison’s disease•Cancer•Medications•Calcium enriched foods

Calcium• Symptoms of HypercalcemiaWeaknessHeadacheDrowsinessNausea/VomitingDry MouthConstipationMuscle pain/Bone painMetallic Taste

Calcium

• Symptoms of hypocalcemia:ParesthesiaChvostek’s signTrousseau’s signTetanySeizuresBronchospasm and laryngospasm

If Calcium is High: High Calcium levels can lead to calcification• Evaluate binder – Change to a non-calcium based

binder if on a calcium based binder• Evaluate Vitamin D analog– hold or decrease

dose May need to start Sensipar which decreases PTH

and calcium • Make sure calcium bath is 2.25• Counsel on avoiding calcium fortified foods

Calcium

• Receive calcium from diet, supplements, phosphate binders and dialysate

• K/DOQI guidelines limit p.o. calcium to 2000mg from all sources

• Limit calcium from phosphate binders and calcium supplements to 1500mg/day

• Do not give calcium with iron or zinc supplements

• Renal RD works with MD to change dialysis bath, phosphate binders as appropriate

Calcium

• Possible Problems for the Elderly:• Decreased absorption due to achlorhydria• Calcium citrate may increase aluminum

absorption• Calcium with a meal will decrease phosphorus

(hence the calcium based phosphate binders)• Decrease response to Vitamin D• Immobility increases calcium loss

Calcium

• Drawbacks of Excess Calcium:Parathyroid over-suppressionAdynamic bone disease occurs with low

parathyroid hormone (PTH)Extraskeletal calcification may occur

Sodium and Fluids

Roles of SodiumPrinciple electrolyte in extracellular fluid involved in the maintenance of normal osmotic pressure and water balanceAcid base balanceOsmotic equilibrium

Sodium and Fluids

• Normal serum value is 136-145 mEq/L for the general population and dialysis patients

• A high serum level indicates dehydrationSevere diarrheaVomiting Diuretics• A low serum level indicates fluid overloadLow fluid intakeEdema

Sodium and Fluids

• A high sodium intake results in:• Thirst and increased fluid intake• Fluid drawn into interstitial space causing

edema• High blood pressure• Shortness of breath when fluid is in lungs

Sodium and Fluids

• Difficult Treatments:• Sudden drop in blood pressure when large

volumes are removed• Cramping when sodium in interstitial spaces is

holding fluid which then cannot be removed • Nausea• A generally miserable treatment

Diet Recommendations for Sodium

• Hemodialysis: 2-3 grams per day• Peritoneal Dialysis: 2-4 grams per day• Should be most strict when patient has CHF or

is a cardio-renal patient and on weekends due to 3 day interval

• Avoid law sodium products with KCl added• Give salty foods as a special treat

Sodium and Fluids

• Fluid Losses (non-urinary):Perspiration from skinWater vapor expired from lungsFecal losses or ostomy outputFever

Sodium and Fluids

• Diet Recommendations for Fluids:• Hemodialysis – 1000-1500 cc/day or 1000 cc + urine output/day1000 cc if anuric• Peritoneal dialysis – to maintain balancePatients should not push fluids but drink only to

quench thirst• If a patient has residual renal function they can

have more fluids.

Sodium and Fluids• Causes of High Interdialytic Weight Gains:• Increase in intake of fluid due to excessive thirstHigh sodium intakeHigh serum glucoseHigh ureaMedications-antihypertensives, anti-

inflammatories, decongestants, diuretics, sedatives, antianxiety, anti-depressant, anti-diarrhea, anti-histamines

Lack of saliva

Fluid Management in Dialysis

• Assessing Fluid Retention• Hemodialysis – check interdialytic weight gain Goal during the week –no more than 3% of EDWGoal over the weekend – no more than 5% of

EDW• Peritoneal dialysis - check whether patientReaches target weightMay need a higher strength dialysate• Typically no fluid restriction required

Fluid Management in Dialysis• Any beverage or food that is fluid at room

temperature is considered fluid (fruits and vegetables are not counted as fluid)

• Fluid guidelines:Measure, monitor, mindfulWatch sodium intakeTake medications with meal beverages when

possible or applesauceUse only 4-8 ounce beverage containersAvoid bedside water containers

Fluid Management in Dialysis• Suggestions for thirst control:• Suck on lemon wedge or add lemon to water-

citric acid increases saliva• Eat sour candy or mints• Chew gum• Rinse mouth with cold water or mouth wash• Eat frozen grapes, pineapple chunks, etc.• Brush teeth more often to feel refreshed• Use breath spray• Use Biotene mouthwash and other products

Vitamins and Minerals

• Some nutrients are lost during dialysisB Vitaminso Biotin- low levels are thought to result in restless

leg syndromeo Folic Acid, B12, B6 – low levels thought to be

associated with homecysteinemiaVitamin CZinc Iron


• Fat soluble vitamins are stored in the body and not removed during dialysis so supplementation is not needed (Vitamin A,D,E,K)

• Schedule renal multivitamin at bedtime to prevent removal at dialysis treatment


• Supplements are prescribed:Renavite, Renaplex, Nephrovite, Nephrocaps,

Renal Caps, Prorenal, Triphocaps, Diatx, Dialyvite

Oral iron is used mainly for peritoneal patients IV iron may be provided in-center (Venofer,

Ferrlecit)


• Other vitamins and minerals accumulate and may be toxic:

Vitamin AVitamin DPotassiumCalciumPhosphorus Iron• Therefore OTC vitamins are not recommended

Vitamins and Minerals• Vitamin D: 1,25 dihydroxy Vitamin D- calcitriol 25, hydroxy Vitamin D - calcidol Vitamin D2 – ergocalciferol Vitamin D3 – cholecalciferol• Normal value is 30-100ng/ml

• Vitamin D analogs: Hectorol Zemplar Calcitriol Available IV for hemodialysis patients and oral for peritoneal

patients –used to manage parathyroid hormone (PTH) levels

Parathyroid Hormone (PTH)• Maintains calcium and phosphorus balance in the

blood• Kidneys turn the active form of Vitamin D (from

the sun and food/supplements) to the active form

• When the kidneys do not work, PTH increases and active Vitamin D in the form of the Vitamin D analog is given to suppress PTH

• Normal serum PTH – 14-72pg/ml• Goal range for dialysis patients 150-600pg/ml

Parathyroid Hormone (PTH)

• Parathyroid gland becomes less sensitive to calcium and Vitamin D

• A high PTH can lead to: Increase risk for extraskeletal calcificationHigh turnover bone disease (osteitis fibrosa

cystica)o Good bone is replaced with poorly formed bone

and fibrous tissueo Also increases phosphorus

Parathyroid Hormone (PTH)

• Treatment of Hyperparathyroidism:• Vitamin D analogs:Zemplar (paricalcitol)Hectorol (doxercalciferol)Calcijex and Rocaltrol (calcitriol)• Parathyroidectomy: If PTH > 1000• Calciminetics - Sensipar

Sensipar

• PTH, calcium and phosphorus decrease• Doses are 30mg, 60mg, 90mg, 120mg and 180mg• PTH is monitored monthly until goal range is met• Dose of sensipar is increased until goal range is

met• Patients continue to receive Vitamin D analogs• Hypocalcemia can be a problem so calcium level

is monitored closely

Parathyoidectomy• Calcium level drops• Patients will need calcium supplements, usually 1-2 gm

tid between meals• May need to change from a non-calcium based binder

(Renvela, Renagel, Fosrenol, Velphoro) to a calcium-based binder (calcium carbonate or calcium acetate)

• Phosphorus usually drops as well but patients still need phosphate binder

• May supplement with calcitriol as a calcium supplement

• May change calcium bath from a 2.25 to a 3.0

Low PTH

• PTH <100• Leads to adynamic bone diseaseLow rates of bone formationDecreased numbers of osteoblasts and

osteoclasts Osteomalacia (related to aluminum or Vitamin

D deficiency

Fiber

• Constipation is a common problem in the dialysis population due to:

Fluid restrictionLack of exerciseMedicationsCalcium carbonate, oral iron supplements,

narcotics

Fiber

• Low Fiber Intake:Restriction of fruits and vegetables due to the

high potassium content of themSelf restriction of fruit and vegetables due to

GI problems or food preferencesPoor general intake

Fiber Prevention/Treatment of Constipation

•Encourage fruit and vegetable intake within limits of potassium restriction•Encourage exercise•Fiber supplements and stool softners can be used:Unifiber, Metamucil, Miralax, Colace, Senokot•Laxatives:Dolcolax, Lactulose, Sorbitol, Docusate Sodium•Enemas:Mineral Oils, Soap sudsFleets should not be used

Factors to Consider in Choosing a Nutritional Supplement

• Current Oral Intake• Recent Lab Values• Co-morbidities• Body weight• Fluid status• Recent changes in health status• Cognitive state• Patient preferences

Important Content of the Nutritional Supplement

• Serving size• Calories• Carbohydrates• Fat• Protein• Sodium• Potassium• Calcium• Phosphorus

Renal Supplements

• Per 8 ounces:• 400-500 calories• >15 grams of protein• <200 mg sodium• <300 mg potassium• <350 mg calcium• <200 mg phosphorus

Renal Supplements

• Nepro• Novasource Renal• Re/Gen• Suplena – used for pre-dialysis patients only

that need to be on a low protein diet

Non-Renal Supplements

• Can be useful when a patient’s potassium and phosphorus are well controlled

• Some patients may also find these choices more palatable

Non-Renal Supplements• Boost• Ensure• Liquacel• Pro-Stat• Procel Powder• Protein Bars• Body Quest Ice Cream• Enlive• Resource

Supplements

• Providing supplements in small amounts throughout the day i.e. a med pass program, can be useful for patients with limited appetite and to decrease fluid intake

Vegetarian Diet for Dialysis Patients

Protein•Vegetable proteins include foods such as legumes, beans, nuts, seeds, soy products such as soy milk, tofu and meat analogs•Tofu is a good protein choice because it is low in sodium, potassium and phosphorus and is very versatile•Select “regular” or “silken” tofu as they contain less potassium than “extra firm” or “firm” tofu•Legumes are a good source of protein and soluable fiber but can be a major contributor to a high potassium level in the blood•The following beans are lower in potassium:•Lupin, chickpeas, black beans, black eye peas, red kidney, pinto as well as hummus which is made from chickpeas•Meat analogs can be used in moderation if balanced with other lower sodiun foods•Consider using protein powder or other supplements depending on the type of vegetarian


• Meat analogs:• Many provide 10-24 grams of protein per

serving• They are made from soy protein with flavor

and color added so they taste and feel like real meat

• Contain a lot of sodium so check labels• Brands – Morningstar Farms, Loma Linda,

Green Giant

Vegetarian Diet for Dialysis PatientsPhosphorus

•Some of the foods that contain high levels of phosphorus include beans, nuts and whole grains•Phosphate found in vegetable protein is not absorbed as well as the phosphorus found in the animal protein•Phosphate binders are necessary to manage phsophorus levels

Vegetarian Diet for Dialysis PatientsPotassium

•Always select the lower potassium fruits and vegetables •Grains also contain potassium -the lower potassium grains would be rice and barley•Avoid quinoa, miso and naho•Avoid high potassium legumes such as lentils, soybeans, adzuki, navy and white beans


Calories•When following a renal diet it is often a challenge to consume enough calories•May need include fats as well as some sugars to meet calorie needs

Case Study #1• 67 year old female who receives hemodialysis on

Mondays, Wednesdays and Fridays• Access: A-V Fistula• Fluid Status: Urine output of 75 ml/day, average

interdialytic weight gain 2-4.8kg• Medical History: ESRD due to hypertensive

nephrosclerosis• Secondary dx: CAD s/p CABG, CHF, PVD,

Hyperparathyroidism, currently has an access infection

Case Study #1• Medications: Nephrocaps, 2 Phoslo with meals,

Vitamin D, Accupril, Synthroid, Keflex• Labs: BUN 55, Cr 6.8, K 6.3, Alb 3.1 (was 4.1

previous month) KT/V 0.9, Ca 9.5, PO4 4.7, Na 140

• Nutrition/GI Issues: Anorexia, weight loss, constipation, hypocaloric intake, nausea, vomiting

• Psychosocial Factors: ride issues so misses 3 treatments per month, leg cramps due to excessive interdialytic weight gains

Case Study #1

• Potential Rationale for elevated potassium:DietMedicationsInadequate dialysisInadequate intakeLab errorConstipation

Case Study #1• Intervention:• Check dietary intake – adjust diet or review diet with

patient as needed• Repeat lab – if it was an error, repeat lab should be

WNL• Encourage patient to not miss treatments to improve

adequacy• Encourage patient to use fiber supplement or stool

softner or refer to PCP• Encourage adequate intake to prevent tissue

breakdown

Case Study #1

• Nephrologist’s interventions:Rx for access infectionReview BP medication – AccuprilAdjust treatment to improve adequacy

Case Study #2

• 78 year old male who receives dialysis on Mondays, Wednesdays and Fridays

• Fluid Status: the patient is new to dialysis and still produces quite a bit of urine

• Medical History: Type 2 DM and HTN• Labs: Alb 4.0, K 5.5, PO4 6.5, Ca 8.0

Case Study #2• 24 Hour Diet Recall:• Breakfast – A bowl of bran cereal with 2% milk on

it, 2 slices of toast with butter and low sugar jelly on them and a cup of coffee

• Lunch – A ham and cheese sandwich, an apple and 12 ounces of 2% milk

• Dinner – Meatloaf, mashed potatoes, green beans and 12 ounces of 2% milk

• HS Snack – Graham crackers and 12 ounces of milk

Case Study #2

• Recommendations for this patient:• Decrease milk intake to 4 ounces a day or

substitute rice milk in place of 2% milk • Drink a beverage other than milk with meals

(diet ginger-ale, diet sprite, sugarfree lemonade)

• Mix Unifiber, Benefiber with hot cereal or juice

Case Study #3

• 71 year old male who receives dialysis on Tuesday, Thursday and Saturday

• Medical History: Type 2 DM• He was admitted to an ECF following a hospital

admission for CHF and began dialysis at that time• Labs: Alb 3.2, PO4 3.9• EDW is 15 pounds less than his usual weight• His appetite has improved since starting dialysis

and he consumes 75-100% of meals and snacks

Case Study #3

• Second set of labs: Alb 3.5, PO4 6.0• Diet: PO4 restriction of 1000mg/day• Medications: Phoslo is ordered 2 with meals

and 1 with HS snack• Third set of labs: PO4 5.0, Ca 10.5• Medications: Phoslo is discontinued and

Renvela 2 with meals and 1 with HS snack is ordered

Nursing Home Considerations

• Check clinic policies regarding bag lunches or allowed food

Send appropriate finger foodsSend appropriate supplements if solid foods

are not allowed by clinic or not desired by patient

Have nursing send phosphate binders with bag lunch


• For Diabetics:Send food to clinic to treat hypoglycemiaAvoid use of orange juice


• Monthly communication between dietary and nursing staff at the nursing home and the dialysis dietitian is essential

• Each renal patient is different and may have different dietary needs, a standard diet may not be appropriate

• Avoid high phosphorus and potassium snacks – save them for special occasions when the nursing home is a special event

In Conclusion

• Our goals for our patients both in the dialysis clinic and in the ECF is to:

Ensure their best possible healthMaintain blood chemistries WNLDecrease their risk of morbidity

Questions

• ????

Documents

Nutrition Care in Chronic Kidney Disease – An Overview Terry Banerjea, MS, RD, LDN Barbara Edgar, RD, LDN