%E2%80%ABNutritional aspects in CKD management pptx

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

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  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 .

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  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

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 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

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  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

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 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

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 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

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 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

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

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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 .

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 can calories Adequate 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

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  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

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 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

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  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 10mg to 12mg phosphorus per gram of protein . Phosphorus

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  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

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 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

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  Common high K+ foods include many fruits and vegetables:  Prunes and Prune juice .  Orange and Orange juice .  Bananas \ apricot .  Dried fruits .  Potato / chips / fried / sweet.  Tomato products juices sauces paste.  Brussels sprouts .  Spinach .  Beets .  Milk Milk products .  Large quantities of low potassium foods . Potassium

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

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 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 2000mg sodium .  Most of us eat 3000-6000mg of sodium /day  Low sodium ≤140mg/serving .  Do not buy a food that has 150-350mg sodium/serving . SODIUM

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 or his blood cardiovascular disease If patient have such as — is high unhealthy fats cholesterol 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

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 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

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 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

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 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 – GoldenrodJuniper berries and parsley .  Can effect blood thinning agents: garlic cinnamon and Ginger.  Do not use in CKD-Ginseng . HERBAL SUPPLEMENTS

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 1. Weight Management - activity/lifestyle current intake food preferences cooking methods food labeling alcohol. 2. DM Control - meds regular meals starchy CHOs low sugar fruit veg. 3. Lipid Control – ↓saturated fats ↑mono fats oily fish fruit veg. 4. Salt Intake - at table in cooking convenience foods . 5. Low Appetite Depressed Symptomatic – small frequent meals energy dense and moderate protein foods. 6. High Potassium Level – cooking methods food choices frequencies of high K foods. 7. Hypertension – salt intake . 8. Phosphate Level –Need to evaluate binders and when they are taken. Binders need to be taken with meals . Dietary advices

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  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

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  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

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When a patient has a diagnosis of renal failure their nutritional needs are complex—Levels of Protein Calories Fluid Sodium Potassium Calcium Phosphors need to be regularly monitored and make changes based on pt’s needs. It is important to continuously monitor their labs intake provide or offer nutritional supplements encourage dietary and medication compliance . SUMMERY

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There is no single kidney diet that fits everyone with kidney disease because the individual diet is determined by existing kidney function lab values nutritional status and health history . Nutrition and physical activity can also influence each other and closely interact both in healthy and in CKD population . Summery

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

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 Correct answer…  Apple - 1 medium62 mg .  Broccoli - 1/2c 127mg .  Pineapple - 1/2c 150mg .  Banana - medium451mg.  Potato- medium 926 mg. Q A

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 What are the foods high in Phosphorus  Pizza Cheese and meat .  Chicken .  Yogurt .  Cream Cheese .  Cottage Cheese .  Oatmeal . Q A

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  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

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 References 1 A Clinical Guide to Nutrition Care in Kidney Disease American Dietetic Association 2004 . 2 The National Kidney Disease Education Program NKDEP 2011 . 3 Renal Diet ABC’s of Nephrology Sobha Malla RDCSR 2011 . 4 Update on Nutrition and Chronic Kidney Disease. Medscape. Matthew D. Beekley PhD 2007 . 5 Executive Summary of Recommendations Academy of Nutrition and Dietetics A.N.D. 2014. 6 Adamasco Cupisti Claudia D’Alessandro Giordano Fumagalli Valentina VigoMario Meola Caterina Cianchi Maria F. EgidiNutrition and Physical Activity in CKD patients Kidney Blood Press Res 201439:107-113.

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 7 Chronic Kidney Disease CKD-Diet Guidelines2013. 8 Martin E. Lascano Martin J. Schreiber Saul NurkoChronic Kidney Disease2014. 9 ChronicKidney DiseaseCKDandDiet Assessment Management and Treatment 2011. 10 Herbal Supplements and Kidney DiseaseNational kidney Foundation 2015. 11 Nutrition and chronic kidney disease kidney Foundation of Canada2009. 12 Chronic kidney disease evidence-based nutrition practice guideline American Dietetic Association 2010 . References

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 13 Diet and Nutrition Goals for People with Stage 3 Chronic Kidney Disease 2014 . 14 Nutrition and Chronic Kidney Disease Stages 1–4 National Kidney Foundation2010 . 15 Protein restriction and progression of chronic kidney diseaseup to date2015 . References