NUTRITION INTERVENTION FOR END STAGE RENAL DISEASE DIALYSIS
PATIENTS Tara Greenley
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OBJECTIVES Understand the different types of dialysis and
effective nutrition intervention for each Identify important
nutrients that need to be monitored Understand the importance of
the role of the dietitian in ESRD patient care Recognize abnormal
lab values associated with ESRD
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STAGES OF CHRONIC KIDNEY DISEASE
http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm
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RENAL DIALYSIS TREATMENTS Hemodialysis- Uses a dialysis machine
Nocturnal Home In-center Video
http://www.kidney.org/atoz/content/hemodialysis.cfm
PREVALENCE: Statistics for 2007 23 million people 20 and above
evidence of chronic kidney disease 16.6% of the US population
527,283 under treatment 368,544 received dialysis 157.3 deaths per
1,000 patients 87,812 total deaths 1,783,000 worldwide ESRD
patients on treatment National Institute of Diabetes and Digestive
and Kidney Diseases. (2010). Retrieved from
http://nkdep.nih.gov/
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ASSOCIATED DISEASES Diabetes: 197,037 Most common cause of CKD
Hypertension: 127,935 Glomuerulonephritis: 81,599 Cystic Kidney:
24,828 Urologic Diseases:13,139 National Institute of Diabetes and
Digestive and Kidney Diseases. (2010). Retrieved from
http://nkdep.nih.gov/
ROLE OF THE RD Monitoring lab values Monitoring dietary intake
Appetite assessments Calculating dietary nutrient needs Prevent
protein-energy malnutrition Consider modes of nutrition
intervention Escott-Stump S., (2008) 808-812. Nutrition and
Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams
& Wilkins.
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IMPORTANT LAB VALUES Lab Test for Kidney FunctionNormal Levels
Serum CreatinineMen: 0.5-1.5 mg/dL Women: 0.6-1.2 mg/dL Creatinine
ClearanceMen: 97-137 mL/min Women: 88-128 mL/min Glomerular
Filtration Rate (GFR)Healthy Adults: 140 mL/min/1.73m2 Normal:
Greater than 90 GFR less than 15: Kidney failure Urine AlbuminLess
than 30 mg/day in 24 hrs MicroalbuminariaHealthy people: Less than
150 mg/L of albumin Blood Urea Nitrogen (BUN)Adults: 7-20 mg/dL
Children: 5-18 mg/dL
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IMPORTANT LAB VALUES Lab Tests for AnemiaNormal Levels
Hematocrit (Hct)Men: 40-50% Women: 36-44% Hemoglobin (Hgb)Men: 14
to 18 g/dL Women: 12 to 16 g/dL Lab Tests for Diabetes Control
Normal Levels Hemoglobin A1C (HgbQA1C) Less than 6.5%
GlucoseFasting: 65-110 mg/dL
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MNT Protein Hemodialysis 1.2 g PRO/kg/d; at least 50% from
high-biological value sources For children, base RDA plus an
increment of 0.4 g/kg/d Peritoneal Dialysis 1.2-1.3 g PRO/kg/d; at
least 50% from high-biological value sources Children, base RDA
plus anticipated loss Escott-Stump S., (2008) 808-812. Nutrition
and Diagnosis Related Care. Baltimore, Maryland:
Lippincott-Williams & Wilkins.
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MNT Energy Hemodialysis 35 kcal/kg/d for patients who are 60
years of age Children; follow RDA levels by age Peritoneal Dialysis
Same as hemodialysis only include dialysate kcals Children; follow
RDA levels by age Escott-Stump S., (2008) 808-812. Nutrition and
Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams
& Wilkins.
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MNT Carbohydrate and Fat Hemodialysis After protein is
calculated, assess patient needs and calculate percentages
accordingly Peritoneal Dialysis Limit simple sugars and saturated
fat Extra 300-450 kcal of glucose Fluid Hemodialysis >1L fluid
output = 2 L fluid needed
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MNT Phosphorus Hemodialysis Use 800-1000 mg or
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MNT Sodium Hemodialysis Limit unless large losses in dialysate
or through vomiting or diarrhea 2-4 g Peritoneal Dialysis Liberal
intake 2-4 g; some need no restriction Escott-Stump S., (2008)
808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland:
Lippincott-Williams & Wilkins.
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MNT Vitamins Hemodialysis Use water-soluble vitamin supplements
to replace dialysate losses Children follow DRI levels Common
Recommendations Folic acid: 1 microgram Vitamin B6: 1.3-1.7 mg
Vitamin C: 75-90 mg Vitamin B12: 2.4 micrograms Vitamin D: Monitor
and replace at recommended levels Avoid excess Vitamin A
Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related
Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.
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MNT Vitamins Peritoneal Dialysis Water-soluble vitamins
Especially vitamin B6 and folic acid Vitamin D should be monitored
and replaced as recommended Minerals Hemodialysis Calcium varies
per individual Magnesium: 0.2-0.3 g Zinc: 8-11 mg Avoid excess
vitamin A Peritoneal Dialysis Same as hemodialysis Escott-Stump S.,
(2008) 808-812. Nutrition and Diagnosis Related Care. Baltimore,
Maryland: Lippincott-Williams & Wilkins.
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MNT Omega-3 Fatty Acids Hemodialysis and Peritoneal Dialysis
Fish oil Reduce prostaglandin synthesis Improve hematocrit levels
Escott-Stump S., (2008) 808-812. Nutrition and Diagnosis Related
Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.
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SAMPLE DIET BREAKFAST 1/2 cup (4 ounces) orange juice 1 English
muffin or 2 slices bread At least one tablespoon margarine with
jelly Coffee or tea with non-dairy creamer and sugar LUNCH 2 slices
white bread At least 2 tablespoons mayonnaise with lettuce and
tomato 1 ounce chicken (such as a small thigh) or 1 hard boiled egg
2 canned peach halves in heavy syrup 7-UP, lemonade or Hawaiian
Punch DINNER 3-4 ounces steak (weigh after cooking, without bone),
saut in tablespoons olive oil 1 small baked potato with at least 2
tablespoons margarine 1/2 cup fresh green beans, carrots or
broccoli with margarine Lettuce, onions, cucumbers, green pepper At
least 2 tablespoons olive oil with vinegar or lemon /8 apple or
cherry pie with 1/2 cup fruit sorbet (this is not sherbet) Iced tea
with sugar and lemon or Sprite
http://www.kidney.org/patients/kidneykitchen/sample_meal_plan.cfm
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NUTRITION SUPPORT Drinks Nutren Renal Nepro NovaSource Enteral
Nutrition Parenteral Nutrition Escott-Stump S., (2008) 808-812.
Nutrition and Diagnosis Related Care. Baltimore, Maryland:
Lippincott-Williams & Wilkins.
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POSITIVE EFFECT OF SOY IN ESRD PATIENTS? Double blind, random
2:1 ratio 25 subjects 15 in soy group 10 in control group Possible
benefits from isolflavone-rich foods Fanti, P., Asmis, R.,
Stephenson, T.J., Sawaya, B.P., & Franke, A.A. (2006). Positive
effect of dietary soy in esrd patients with systemic
inflammation-correlation between blood levels of the soy
isoflavones and the acute-phase reactants. Nephrology Dialysis
Transplantation, 21, 2239-2246.
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EXERCISE CAPACITY AS A PREDICTOR OF SURVIVAL AMONG AMBULATORY
ESRD PATIENTS 6 month trial Assessment at beginning, 3 months, end
Measured VO2 Patients from two clinical trials 33-59 years old On
dialysis 26 months- 56 months 23 deaths 7 due to cardiovascular
issues 7 due to infection 2 Cancer Sietsema, K.E., Amato, A.,
Adler, S.G., & Brass, E.P. (2004). Exercise capacity as a
predicator of survival among ambulatory patients with end-stage
renal disease. Kidney International, 65, 719-724.
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CONT. 2 due to transplant complications 7 unknown Shows VO2 as
a significant predictor of survival among a stable cohort of
hemodialysis patients Sietsema, K.E., Amato, A., Adler, S.G., &
Brass, E.P. (2004). Exercise capacity as a predicator of survival
among ambulatory patients with end-stage renal disease. Kidney
International, 65, 719-724.
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FOOD ADDITIVES AN UNRECOGNIZED RISK? 36 uncooked meat and
poultry products Tested the amount of potassium and phosphorus
Phosphorus 28.4% higher Potassium 8.4% higher Significant evidence
proves need for monitoring Sherman, R.A., & Mehta, O. (2009).
Phosphorus and potassium content of enhanced meat and poultry
products: implications for patients who receive dialysis. Clin J Am
Soc Nephrol, 1(4), 1370-1373.
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GOODBYE TO FAST FOOD? 194 randomly selected patients 44
hemodialysis facilities in NE Ohio 81 subjects One meal in four
days at fast food restaurants Kcals increased from 18.9 to 26.1
Higher serum phosphorus levels Butt, S., Leon, J., David, C.,
Chang, H., Sehgal, A., & Sidhu, S. (2007). The prevalence and
nutritional implications of fast food consumption among
hemodialysis patients. National Institute of Health, 17(4),
264-268.
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DRUG THERAPY ACE inhibitors Antidepressants Carnitine Growth
hormone Insulin Iron supplements Lipid-lowering medications and
statins Phosphate binders Potassium excretion Ruboxistaurin
Water-soluble vitamins and vitamin D3 Escott-Stump S., (2008)
808-812. Nutrition and Diagnosis Related Care. Baltimore, Maryland:
Lippincott-Williams & Wilkins.
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COST In 2006 cost to Medicare $49 billion If 5% percent more
did at home Peritoneal Dialysis could potentially save $295 million
HD cost Medicare $69,758 pppy PD cost Medicare $50,847 pppy Neil,
N., Guest, S., Wong, L., Inglese, G., Gehr, T., Walker, D., Golper,
T., & Bhattacharyya, S. (2009). The financial implications for
Medicare of greater use of peritoneal dialysis. Clinical
Therapeutics, 31(4), 880-888. Just, P.M., Riella, M.C., Tschosik,
E.A., Noe, L.L., Charro, F.D., & Bhattacharyya, S.K. (2001).
Economic evaluations of dialysis treatment modalities. Science
Direct, 86(2008), 163-180.
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REIMBURSEMENT Medicare will pay for the following services:
Inpatient dialysis treatments Outpatient dialysis treatments Home
dialysis equipment and supplies Home support services Certain drugs
for home dialysis Outpatient doctor and other related services as a
part of the dialysis treatment Medicare does not pay for: Paid
dialysis aides to help with home dialysis Lost pay to you and your
helper during self-dialysis training A place to stay during
treatment Blood or packed red blood cells for home self-dialysis
unless it is part of a doctors service or is needed to prime the
dialysis equipment Transportation to a dialysis facility Medicare
covers 80% of their approved amount, you are responsible for the
remaining amount. Medicare.gov
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ETHICAL ISSUES Right to choose or suicide? Religious views
Black market for obtaining organs Donation About 14,000 kidney
transplants are performed each year Just over one third of
transplanted kidneys are from living donors. About 55,000 people
are on the waiting list for a kidney transplant. Each year over
3,000 people die while waiting for a kidney transplant One-year
survival rate for kidney transplant recipients is about 95%
http://www.nytimes.com/2004/05/23/world/organ-trade-global-black-market-tracking-
sale-kidney-path-poverty-hope.html
http://www.organdonor.gov/student/access/organs.asp
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CONCLUSION Role of the Dietitian Nutrients to closely monitor
Phosphorus Potassium Calcium Protein Sodium