Download Nutrition Care in Chronic Kidney Disease – An Overview

Nutrition Care in Chronic Kidney
Disease – An Overview
Terry Banerjea, MS, RD, LDN
Barbara 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
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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 metabolism
 Insulin resistance
 Increased hepatic glucagon sensitivity
 Excessive parathyroid hormone secretion
 Change in the rate of protein/amino acid turnover
 Acidosis: loss of protein and muscle mass
 Increased cytokine activation (pro-inflammatory response)
Some Potential Reasons for Low
Albumin
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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 problems
 Gastroparesis and diabetes
 Constipation due to CaCO3, iron, narcotics, other
medications, low fluid, low fiber, limited exercise
 Diarrhea due to C. difficile with antibiotic therapy
Calories/Protein in CKD
Appetite is made worse by CKD and dialysis due to:
• Anorexia caused by uremia
 Nausea, vomiting, diarrhea
 Dysgeusia 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 >1.2
 These 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/dl
Urea derived from protein will decline if intake
is poor or patient is anabolic
• Check albumin (BCG) >=4.0
Albumin 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/kg
 Greater protein losses in dialysate
 Appetite loss due to fullness experienced while
the dialysate fluid in peritoneum
 Effect of glucose when using higher concentration
dialysate
• These recommendations are based on K/DOQI
guidelines.
Inadequate Protein Intake
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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 labs
Poor intake indicated by:
Low BUN
Low Albumin
Low K
Low 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 lowliberalize 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
Suggestions for Improving Intake
• Protein recommendations are not a
restriction
• Do not sacrifice protein intake in order to
lower PO4 intake
• Help patient with fluid/sodium restriction
Avoid large fluid weight gains
• Encourage physical activity to maintain muscle
mass
Suggestions for Improving Intake
• Protein: may need to increase portion size if
standards are used
Serve HBVP at 2 meals/day minimum
Serve at least 2+ ounces HBVP
Serve 4-6 ounces HBVP at large meal
Include a HBVP with snack
Consider 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 intestine
1. 90% in cells
2. 8% in bones
3. <1% in circulation
• Excretion
1. 80-95% in urine
2. 5-20% in stools
Potassium
Primary Roles of Potassium:
• Maintains fluid balance within cells
• Conduction of nerve impulses
• Muscle contraction
Potassium (K)
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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 dialysis
1. Inadequate treatment time or missed
treatments
2. Low blood flow rate, recirculation
3. Metabolic acidosis-causes K to shift from cell
to serum
Causes of High Potassium
(Hyperkalemia)
• 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
Causes of High Potassium
(Hyperkalemia)
• Catabolism due to tissue breakdown:
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Infection and ischemia (bowel)
Starvation
Trauma surgery
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
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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
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Avocados
Bananas
Kiwi
Mango
Melons
Nectarines
Orange/juice
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Papaya
Pomegranate
Prunes/juice
Raisins
Rhubarb
High Potassium Vegetables
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Artichokes
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Asparagus- fresh
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Brussels sprouts
Dried beans and peas •
Lima beans
Mushrooms
Potato-white/sweet
Pumpkin
Tomatoes and tomato
products
Winter squash
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 Phosphorus
Dietary 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
Binders
Calcium Carbonate – Tums, Oscal, Caltrate
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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
Binders
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Renagel (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
Binders
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Fosrenol (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
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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 Hypercalcemia
 Weakness
 Headache
 Drowsiness
 Nausea/Vomiting
 Dry Mouth
 Constipation
 Muscle pain/Bone pain
 Metallic Taste
Calcium
• Symptoms of hypocalcemia:
Paresthesia
Chvostek’s sign
Trousseau’s sign
Tetany
Seizures
Bronchospasm 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-suppression
Adynamic bone disease occurs with low
parathyroid hormone (PTH)
Extraskeletal calcification may occur
Sodium and Fluids
Roles of Sodium
Principle electrolyte in extracellular fluid
involved in the maintenance of normal osmotic
pressure and water balance
Acid base balance
Osmotic equilibrium
Sodium and Fluids
• Normal serum value is 136-145 mEq/L for the
general population and dialysis patients
• A high serum level indicates dehydration
 Severe diarrhea
 Vomiting
 Diuretics
• A low serum level indicates fluid overload
 Low fluid intake
 Edema
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 skin
Water vapor expired from lungs
Fecal losses or ostomy output
Fever
Sodium and Fluids
• Diet Recommendations for Fluids:
• Hemodialysis – 1000-1500 cc/day or
 1000 cc + urine output/day
 1000 cc if anuric
• Peritoneal dialysis – to maintain balance
 Patients 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 thirst
 High sodium intake
 High serum glucose
 High urea
 Medications-antihypertensives, antiinflammatories, decongestants, diuretics,
sedatives, antianxiety, anti-depressant, antidiarrhea, 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 EDW
 Goal over the weekend – no more than 5% of
EDW
• Peritoneal dialysis - check whether patient
 Reaches target weight
 May 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, mindful
 Watch sodium intake
 Take medications with meal beverages when
possible or applesauce
 Use only 4-8 ounce beverage containers
 Avoid bedside water containers
Fluid Management in Dialysis
• Suggestions for thirst control:
• Suck on lemon wedge or add lemon to watercitric 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 dialysis
 B Vitamins
o Biotin- low levels are thought to result in restless
leg syndrome
o Folic Acid, B12, B6 – low levels thought to be
associated with homecysteinemia
 Vitamin C
 Zinc
 Iron
Vitamins and Minerals
• 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
Vitamins and Minerals
• 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)
Vitamins and Minerals
• Other vitamins and minerals accumulate and may
be toxic:
 Vitamin A
 Vitamin D
 Potassium
 Calcium
 Phosphorus
 Iron
• Therefore OTC vitamins are not recommended
Vitamins and Minerals
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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
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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 calcification
 High turnover bone disease (osteitis fibrosa
cystica)
o Good bone is replaced with poorly formed bone
and fibrous tissue
o 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
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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 calciumbased 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 disease
Low rates of bone formation
Decreased 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 restriction
Lack of exercise
Medications
Calcium carbonate, oral iron supplements,
narcotics
Fiber
• Low Fiber Intake:
Restriction of fruits and vegetables due to the
high potassium content of them
Self restriction of fruit and vegetables due to
GI problems or food preferences
Poor 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 suds
 Fleets should not be used
Factors to Consider in Choosing a
Nutritional Supplement
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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
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Serving size
Calories
Carbohydrates
Fat
Protein
Sodium
Potassium
Calcium
Phosphorus
Renal Supplements
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Per 8 ounces:
400-500 calories
>15 grams of protein
<200 mg sodium
<300 mg potassium
<350 mg calcium
<200 mg phosphorus
Renal Supplements
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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
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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
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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
Vegetarian Diet for Dialysis Patients
• 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 Patients
Phosphorus
• 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 Patients
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Potassium
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
Vegetarian Diet for Dialysis Patients
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:
Diet
Medications
Inadequate dialysis
Inadequate intake
Lab error
Constipation
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 infection
Review BP medication – Accupril
Adjust 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 foods
Send appropriate supplements if solid foods
are not allowed by clinic or not desired by
patient
Have nursing send phosphate binders with
bag lunch
Nursing Home Considerations
• For Diabetics:
Send food to clinic to treat hypoglycemia
Avoid use of orange juice
Nursing Home Considerations
• 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 health
Maintain blood chemistries WNL
Decrease their risk of morbidity
Questions