‫Nutritional aspects in CKD management pptx

Category: Education

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presented by Aisha Eljazwee Dietitian at Nephrology & Hemodialysis division at Benghazi Medical Center .


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Aisha Abd Alsttar Eljazwee Dietitian at Nephrology & Hemodialysis Division Benghazi Medical Center


One in ten people has Chronic Kidney Disease . CKD is typically a progressive disease . There are five stages of chronic kidney disease (CKD), based on glomerular filtration rate (GFR ) . Early detection can help prevent the progression of kidney disease to kidney failure. High risk groups for CKD include those with diabetes, hypertension, glomerular diseases and family history of kidney disease . Delaying the onset of dialysis and stabilizing CKD is a major issue . CHRONIC KIDNEY DISEASE

What is the Dietitian’s role?:

To educate and advise patients on diet . To work with Nephro team to review monthly labs and adjust diet as needed . To provide nutritional information for non-renal staff. The dietitian is an important member of the healthcare team ,dietitian will work with pt to design a tasty, daily eating plan that will give him the right kinds and amounts of food to meet his nutritional needs, try to slow the loss of kidney function and help him stay as healthy as possible. What is the Dietitian’s role?

Goals of Renal Diet Therapy:

Maintain normal biochemistry levels . Minimise symptoms . Prevent malnutrition and unintentional weight loss . Improve / preserve nutritional status . Optimize functional status . Compensate/adjust diet for illness, catabolic events . Improve quality of Life . Goals of Renal Diet Therapy

Factors that influence dietary advice:

Stage of CKD . Biochemistry levels . Medications . Treatments e.g. Conservative, Dialysis . Other medical conditions e.g. Diabetes , HTN. Lifestyle (social, psychological aspects ) . Factors that influence dietary advice

Why is good nutrition important for people with kidney disease? :

Making healthy food choices is important to us all, but it is even more important if you have chronic kidney disease (CKD). Why ? Good nutrition gives you energy to: Do your daily tasks. Prevent infection . Build muscle . Help maintain a healthy weight . Keep your kidney disease from getting worse . Why is good nutrition important for people with kidney disease?

CKD: Medical Nutrition Therapy:

Referral for MNT should be initiated at diagnosis of CKD, in order to : maintain adequate nutritional status , minimizes the impact of other comorbidities on the progression of kidney disease (e.g., diabetes , obesity, hypertension and disorders of lipid metabolism) and delay renal replacement therapy (RRT) . MNT should be initiated at least 12 months prior to the anticipation of RRT (dialysis or transplant). CKD: Medical Nutrition Therapy

CKD: Frequency of Medical Nutrition Therapy:

Depending on the care setting and the initiation of MNT, the RD should monitor the nutritional status of individuals with CKD every one to three months and more frequently if there is inadequate nutrient intake, protein-energy malnutrition, mineral and electrolyte disorders or the presence of an illness that may worsen nutritional status . CKD: Frequency of Medical Nutrition Therapy

Which nutrients do we focus on for kidney disease?:

Calories . Protein . Phosphorus . Potassium . Sodium . Fluids . Fats and cholesterol . Which nutrients do we focus on for kidney disease ?


Typical Dietary Recommendations for Chronic : Kidney Disease Patients Protein: 0.6-0.8   g/kg/day. Sodium :< 2 g/day (<6 g/day of salt ) . Potassium: 2 - 3 g/day . Phosphate: 800-1000   mg/day . Calcium: 1400-1600  mg/day (not to exceed 2000 mg/day ) . Free water (in excess of urine output): 1.5 - 2   L/day .

Calories :

Adequate calories  can either prevent weight loss if the pt is at a desirable weight or provide extra calories for weight gain if the pt is underweight or help the pt to attain desirable body weight . Making changes in patient`s diet may cause weight loss, so energy supply must equal, or even overcome the energy requirement if the pt is under wt or has desirable body wt . Calories


Important for growth and maintenance of body tissue. Provides energy and fights infection . Keep fluid balance in the blood . 2 types of Protein : High Biological Value (HBV) or animal protein:- meat , fish, poultry, eggs, tofu, and dairy products . Low Biological Value (LBV) or plant protein :– breads, gains, vegetables, legumes and fruits . Protein


Current K/DOQI guidelines suggest a protein intake of 0.6-0.8 (g/kg/d) for patients in stages 1-4 of CKD This means that, CKD patients in stages 1-4 need dietary counseling to reduce their protein intake by about half . The severity of protein restriction depends on the level of the residual renal function . Basically, reduction of protein intake reduces protein synthesis but also reduces protein catabolism, so nitrogen balance is maintained in equilibrium . Protein


A mineral found in almost all foods. Normal kidneys will balance the amount of phosphorus in our bodies. When the kidneys fail the phosphorus increases in the blood . Serum phosphorus levels are difficult to control with dietary restrictions alone . Most patients need to limit their phosphorus intake to 800 – 1000 mg per day or 10 mg to 12 mg phosphorus per gram of protein . Phosphorus

Phosphorus rich foods :

Beans, peas, lentils (“legumes ”). Nuts (peanut butter), seeds . Chocolate, cocoa . Cheese (pizza), milk, yogurt ( dairy products). Whole grains (whole wheat bread ) . Bran cereals . Coke , Pepsi & other sodas with “phosphoric acid ”. Meats & fish . Food Additives . Phosphorus rich foods

Potassium :

Dietary Goal is usually 2 - 3 gms /day . Potassium is a mineral , plays a role in regulating the heartbeats; so, too much can result in heart problems. A high potassium level is typically related to potassium-sparing diuretics, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prescribed to reduce protein in the urine or other blood pressure management medications . Potassium


Common high K+ foods include many fruits and vegetables : Prunes and Prune juice . Orange and Orange juice . Bananas \ apricot . Dried fruits . Potato / chips / fried / swee t. Tomato products (juices, sauces, paste). Brussels sprouts . Spinach . Beets . Milk & Milk products . Large quantities of “low potassium” foods . Potassium

Low Potassium foods:

Apples . Grapes . Berries . Pineapple . Tangerine . Cabbage . Green Beans . Cauliflower. Eggplant . Onion. Pepper . Low Potassium foods


According to K/DOQI guidelines, in CKD patients stage 1-4, sodium is restricted to 2000 mg/d, based on blood pressure, fluid balance and the presence of other diseases that may affect sodium requirements . Foods high in sodium include: Processed meats. Canned soups . Salty snack foods . Deli meats . 1 Tsp salt = 2000 mg sodium . Most of us eat 3,000-6,000 mg of sodium /day Low sodium = ≤ 140 mg/serving . Do not buy a food that has 150-350 mg sodium/serving . SODIUM

Fats and cholesterol :

If patient have cardiovascular disease  or his blood cholesterol  is high, unhealthy fats — such as saturated fats and trans-fats — should be replaced by poly- and monounsaturated fats from vegetable oil, canola oil and olive oil. A limit on high cholesterol foods is recommended. Fats and cholesterol


Is not restricted in stages of CKD unless the patient experience fluid retention. Signs of fluid retention include sudden weight gain; shortness of breath; swelling in the feet, hands and face; and high blood pressure. These symptoms may indicate a decline in kidney function and decreased urine output . Fluid

Physical activity :

Regular physical activity coupled with adequate nutritional support is a therapeutic intervention able to prevent the loss of lean body mass in CKD patients , and the perception of well-being of CKD patients and may Facilitate the anabolic effects of nutritional interventions . Physical activity


NEED CAREFUL CHECK AS THEY MAY INTERACT WITH OTHER MEDICATIONS : Can affect K levels-alfalfa, Dandelion , Licorice root, Noni fruit/juice and St John’s wort . Has diuretic properties/electrolyte imbalance – Goldenrod,Juniper berries and parsley . Can effect blood thinning agents: garlic ,cinnamon and Ginger. Do not use in CKD-Ginseng . HERBAL SUPPLEMENTS

Dietary advices :

Weight Management - activity/lifestyle, current intake, food preferences, cooking methods, food labeling, alcohol. DM Control - meds, regular meals & starchy CHOs, low sugar, fruit & veg. Lipid Control – ↓ saturated fats, ↑ mono fats, oily fish, fruit & veg. Salt Intake - at table, in cooking, convenience foods . Low Appetite, Depressed & Symptomatic – small & frequent meals, energy dense and moderate protein foods. High Potassium Level – cooking methods, food choices & frequencies of high K foods. Hypertension – salt intake . Phosphate Level –Need to evaluate binders and when they are taken. Binders need to be taken with meals . Dietary advices

Monitoring and evaluation:

(RD) should monitor and evaluate various biochemical parameters in adults with chronic kidney disease , related to : Glycemic control . Protein-energy malnutrition . Kidney function . Mineral and bone disorders . Anemia . Dyslipidemia . Electrolyte disorders . . Monitoring and evaluation of the above factors is needed to determine the effectiveness of Medical Nutrition Therapy (MNT) in adults with CKD . Monitoring and evaluation

Monitoring and evaluation:

Monthly QAPI report to review the labs and discuss plan of action to correct the problem . Monthly interdisciplinary Care plan meeting to review the patient performance . Albumin to monitor intake : (Goal >3.5mg/dl) . Potassium to determine dietary restriction: (Goal 3.5-5.5mg/dl) . Phosphorus to adjust binders & compliance : (Goal <5.5 mg/dl ) . Monitoring and evaluation





Question and Answers:

Which food is highest in Potassium? Apple Pineapple Broccoli Banana Potato Question and Answers

Q & A:

Correct answer… Apple - 1 medium(62 mg ) . Broccoli - 1/2c ( 127mg) . Pineapple - 1/2c (150mg) . Banana - medium(451mg). Potato- medium (926 mg ). Q & A

Q & A:

What are the foods high in Phosphorus ? Pizza (Cheese and meat ) . Chicken . Yogurt . Cream Cheese . Cottage Cheese . Oatmeal . Q & A

Q & A:

Oatmeal ( instant, 1 cup - 176 mg PO4 , 131 mg K+, 377 mg Na ) . Cottage Cheese ( 4 oz - 152 mg Po4, 97 mg K+, 459 mg Na ) . Yogurt ( fruit 6 oz - 150 mg Po4, 310 mg K+, 100 mg Na). Pizza (1-1/8 slice -131mg Po4, 1780mg K+, 382mg Na) . Chicken (1oz-60mg po4) . Cream Cheese (1tbsp- 15 mg PO4, 17mg K+, 43 mg Na). Q & A

References :

References A Clinical Guide to Nutrition Care in Kidney Disease American Dietetic Association, 2004 . The National Kidney Disease Education Program (NKDEP) , 2011 . Renal Diet ABC’s of Nephrology , Sobha Malla RD,CSR 2011 . Update on Nutrition and Chronic Kidney Disease. Medscape. Matthew D. Beekley , PhD, 2007 . Executive Summary of Recommendations, Academy of Nutrition and Dietetics (A.N.D.), 2014 . Adamasco Cupisti Claudia D’Alessandro Giordano Fumagalli Valentina VigoMario Meola Caterina Cianchi Maria F. Egidi (Nutrition and Physical Activity in CKD patients) Kidney Blood Press Res 2014;39:107-113.


Chronic Kidney Disease (CKD)-Diet Guidelines,2013. Martin E. Lascano ,Martin J. Schreiber ,Saul Nurko ,(Chronic Kidney Disease)2014. ChronicKidney Disease(CKD) andDiet Assessment Management , and Treatment 2011 . Herbal Supplements and Kidney Disease,National kidney Foundation 2015. Nutrition and chronic kidney disease, kidney Foundation of Canada,2009 . Chronic kidney disease evidence-based nutrition practice guideline, American Dietetic Association; 2010 . References


Diet and Nutrition Goals for People with Stage 3 Chronic Kidney Disease ,2014 . Nutrition and Chronic Kidney Disease (Stages 1–4), National Kidney Foundation,2010 . Protein restriction and progression of chronic kidney disease,up to date,2015 . References