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(CKD)
(CKD)

Medical Nutrition Therapy (MNT) for Chronic Kidney Disease

(CKD) Medical Nutrition Therapy (MNT) for Chronic Kidney Disease By: Mr. Rosli Mohd Sali, Dietitian, Ipoh

By: Mr. Rosli Mohd Sali, Dietitian, Ipoh Hospital

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MNT for CKD

 

INTRODUCTION

INTRODUCTION  Pt diagnosed with CKD in Malaysia are an important group of clients for Dietitians

Pt diagnosed with CKD in Malaysia are an important group of clients for Dietitians because the no. of pts with CKD requiring RRT increased from 1,985 in 1994

(1 st National Renal Registry Report) to 9,995 in 2003 (11 th Malaysian Dialysis & Transplant Registry). In tandem with

this, the dialysis prevalence rate per million population also increased from 107 in 1995 to 391 in 2003.

Protein-calorie malnutrition is a common complication of

CKD (Kopple et al, 2000)

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INTRODUCTION

 INTRODUCTION In 2003, 66% of HD pt and almost 88% of CAPD pt had serum

In 2003, 66% of HD pt and almost 88% of CAPD pt had serum Alb < 40 g/dl. Nutritional markers such as ↓serum Alb,↓ BMI and ↓serum chol level have been identified as independent factors for death in Malaysian dialysis pt.

(11 th Malaysian Dialysis & Transplant Registry)

Appropriate medical nutrition therapy (MNT) provided by a dietitian can help reduce the burden of nutrition - related problems as MNT has an important role slowing in the progression of CKD while maintaining optimal nutrition (Levey et al. 1996) In addition, MNT reduces the risk for CKD in individuals with diabetes and hypertension

(Delahanty et al. 1998)

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Stage of CKD

(Source : K/DOQI 2003)

 

Stage

 

Description

GFR* (ml/min/1.73m³)

Medical action plan

1

Kidney damage with normal or high GFR

90

Diagnosis and treatment, treatment of co-morbid conditions, slowing progression, CVD risk reduction

2

Kidney with mild, reduced GFR

60-89

Estimating progression

 

3

Moderate reduced GFR

30-59

Evaluating and treating complications

 

4

Severe reduced GFR

15-29

Preparation for kidney replacement therapy

5

Kidney failure

<15 (dialysis)

Replacement therapy

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CKD

Modifiable risk factors for progression of CKD:
Modifiable risk factors for
progression of CKD:

Control of BP (Jafar et al. 2003)

Control of proteinuria or albuminuria (JNC-7,

2003)

Control of HbA1c (DCCT, 1993)

Cessation of smoking, reduction in dyslipidemia and increase in physical activity promote organ blood flow and potentially

reduce CKD damage (Beto & Bansal 2004)

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Prevailing Causes of primary CKD:
Prevailing Causes of primary
CKD:

Diabetes (51%) Unknown causes (30%) Glomerulonephritis (5%) Obstructive nephropathy (3%) Polycystic kidney disease (1%) Miscellaneous (8%)

*(11 th Malaysian Dialysis & Transplant Registry)

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Objectives of Nutrition Management
Objectives of Nutrition
Management
  

A. Early Chronic Kidney Disease (Stage 1&2)

Treatment of co-morbid conditions such as DM, HTN, and other chronic diseases to slow the progression of renal failure

Reduce the risk for CVD such as hyperlipidaemia

Providing regular nutritional counseling based on an individualized plan of care in order to promote good quality of life

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Objectives of Nutrition Management B. Pre-Dialysis (Stage 3&4)
Objectives of Nutrition
Management
B. Pre-Dialysis (Stage 3&4)

To delay the progression of kidney failure

Maintain good nutritional status in preventing malnutrition by:

  • i) giving adequate protein and energy

ii)

ensuring sufficient nutrients such as Ca, Fe, and other vitamins and mineral

Minimize electrolyte and mineral disturbances such as PO4, K+, Ca, Na+ and fluids to manage co-morbidities (anemia, bone disease, HTN)

Encourage physical activity according to patient’s condition and ability.

Providing regular nutritional counseling based on individualized plan of care in order to promote good QOL

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Objectives of Nutrition Management
Objectives of Nutrition
Management
  • C. Haemodialysis (HD) and Continuous Ambulatory Peritoneal Dialysis (CAPD) (Stage 5)

Maintain or improve nutritional status in order to prevent malnutrition by:

  • i) giving adequate protein and energy

ii)

ensuring sufficient nutrients such as Ca, Fe, and other

vitamins and mineral

Minimize electrolyte and mineral disturbances such as PO4, K+, Ca, Na+ and fluids.

Control fluids intake

Prevent and manage co-morbidities such as CVD, anemia, bone disease and DM

Encourage physical activity according to patient’s condition and ability.

Providing regular nutritional counseling based on individualized

plan of care in order to promote good QOL

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The Need for Nutrition Assessment GFR of less than 60ml/min is associated in laboratory parameters of
The Need for Nutrition
Assessment
GFR of less than 60ml/min is associated in laboratory
parameters of serum albumin, hemoglobin, serum
bicarbonate, decreases in body weight and dietary

intake of protein and energy (Kopple et al. 1989; Ikizler et al. 1995)

It has been shown that dialysis patients with BMI above 25 had a 28% less risk of death compared to patients

with BMI less than 18.5 (11 th

Transplant Registry)

Malaysian Dialysis &

However, body composition is also important. BMI of CAPD patients are higher than HD patients but CAPD patients are more prone to protein malnutrition (K/DOQI

2003)

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 Therefore, all CKD patients should undergo nutrition assessment to evaluate protein calorie malnutrition followed with

Therefore, all CKD patients should undergo nutrition assessment to evaluate protein calorie malnutrition followed with appropriate intervention.

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Nutrition Assessment and Monitoring
Nutrition Assessment and
Monitoring

Anthropometric Assessment : Height, Weight; post-dialysis (HD)/post drainage (CAPD), body composition (bioimpedance, BIA), triceps skinfold or mid-arm circumference (MAC), SGA

Nutrition Assessment and Monitoring    Anthropometric Assessment : Height, Weight; post-dialysis (HD)/post drainage (CAPD),

Biochemical Assessment : Serum albumin, Na+, Ca, PO4, creatinine / urea, microalbumin, serum lipids, FBS / HbA1c, Hb, Kt/V, BP.

Dietary Assessment : Nutrient intake & meal plan, food/supplement intake, eating out, smoking/alcohol, recipe modification & food preparation, food label, physical activity/functional status Activity of Daily Living

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Nutrition Prescription
Nutrition Prescription

A. Calories

Stage 1-4, Hemodialysis, CAPD and Peritonitis :

35 Kcal/kg body weight if < 60 years of age 30 – 35 Kcal/kg if > 60 years of age

(Includes calories from dialysate due to glucose absorption)

Adequate energy intake is important to maintain neutral nitrogen balance, to promote higher serum albumin concentrations and more normal anthropometric parameters and to improve protein utilization (Kopple et

al 1986)

Approximately 60 – 70% of dialysis fluids glucose may be absorbed during a 6 hr dwell (Bannister DK et al 1987)

Caution: Monitor weight gain in CAPD patients.

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Nutrition Prescription

A. Calories

Nutrition Prescription A. Calories  Energy expenditure of patients undergoing maintenance HD is similar to that

Energy expenditure of patients undergoing maintenance HD is similar to that normal, healthy individuals (K/DOQI 2000)

Acutely ill maintenance dialysis patients are generally inactive physically and their energy needs will be diminished by the extent to which their physical activity has been decreased. Thus energy intakes of 30 – 35 kcal/kg BW are recommended (K/DOQI 2000)

The recommended total daily energy intake, including both diet and energy intake derived from the glucose absorbed from peritoneal dialysate should be 35kcal/kd/d (K/DOQI 2000)

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Nutrition Prescription

B. Protein (Stage 1&2)

0.8 g/kg BW

The requirement for protein is

Nutrition Prescription B. Protein (Stage 1&2)   0.8 g/kg BW The requirement for protein is

unchanged in well control DM, but in hyperglycemic individuals, protein synthesis is decreased and protein breakdown increased, leading to a negative nitrogen balance. This suggests that during periods of hyperglycemia or weight loss, somewhat higher protein intakes are required to achieve nitrogen balance, but whether this alone will correct the abnormality is

unknown (Dikow et al 2002)

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Nutrition Prescription B. Protein (Stage 3&4; Pre-dialysis)  0.6 g/kg BW, if severe malnourish, use 0.75
Nutrition Prescription
B. Protein (Stage 3&4; Pre-dialysis)
0.6 g/kg BW, if severe malnourish, use 0.75 g/kg
BW (K/DOQI 2000) at least 50% HBV protein
Low protein will maintain nutritional status (Kopple et al

1973, Walser 1993, Tom et al 1995, Kopple et al 1997,

Fleischmann et al 1998) particularly if they receive higher energy intake (ie. 35 kcal/kg/d)

Low protein diet reduces the generation of nitrogenous waste and inorganic ions which causes many of the clinical and metabolic disturbances characteristic of uremic individuals (K/DOQI 2000)

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Nutrition Prescription

B. Protein (Stage 3&4; Pre-dialysis)

Nutrition Prescription B. Protein (Stage 3&4; Pre-dialysis)  HBV has an amino acid composition that is

HBV has an amino acid composition that is similar to human protein, is likely to be animal protein and tends to be utilized more efficiently by human to conserve body proteins individuals (K/DOQI 2000)

Caution: if patient is planning to undergo dialysis, a higher protein intake may be warranted and ensure energy intake is adequate.

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Nutrition Prescription

B. Protein (HD patients)

Nutrition Prescription B. Protein (HD patients)    1.2 g/kg BW , if severe malnourish

1.2 g/kg BW, if severe malnourish and acute illness (if increase intensity in dialysis, use 1.3 g/kg BW with at least 50% HBV protein (Acchiardo et al 1990)

Studies show that protein intake less than 1.2 g/kg/d are associated with lower serum albumin levels and higher morbidity in HD patients.

Protein intakes greater than 1.2 or 1.3 g/kg/d may also benefit the catabolic, acutely ill HD patients.

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Nutrition Prescription

B. Protein (CAPD Patients)

Nutrition Prescription B. Protein (CAPD Patients)   1.2 – 1.3 g/kg BW , if acute

1.2 – 1.3 g/kg BW, if acute illness use 1.3 g/kg BW with at least 50% HBV protein (Shilling et al 1985)

Hypoalbuminemia is more to occur when the protein intake is less than 1.3 g/kg/d and significantly associated with an increased incidence of peritonitis and more prolonged hospital stay.

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Nutrition Prescription

C. Carbohydrate (Stage 1 – 5)

Nutrition Prescription C. Carbohydrate (Stage 1 – 5)     50 – 60% of

50 – 60% of energy intake; but for DM patients, follow diabetic diet guidelines. Fiber 20 – 30 g per day.

CHO should be utilized to make up the balance of the required energy intake

Complex CHO is recommended & dietary fiber for good glycemic control in diabetic patients (Beto 1995)

Incorporating low protein CHO food sources and simple sugars can assist in meeting energy requirements of pt on low protein diet.

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Nutrition Prescription

D. Fats (Stage 1 – 5)

Nutrition Prescription D. Fats (Stage 1 – 5)  25 – 35% of total kcal; emphasize

25 – 35% of total kcal; emphasize reduced SFA less than 7% total kcal, PUFA up to 10% of total kcal, MUFA up to 20% of total kcal, cholesterol < 200 mg/day.

Encourage daily regular physical activity whenever possible. If dietary intervention is inadequate, drug therapy should be started after 3 months (K/DOQI 2003)

Patients are considered at highest risk for CVD (K/DOQI

2003)

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Nutrition Prescription

D. Fats

Nutrition Prescription D. Fats    In non-diabetic pre-dialysis pt, hypertryglyceridaemia can be reduced by

In non-diabetic pre-dialysis pt, hypertryglyceridaemia can be reduced by both increasing the dietary PUFA:SFA ratio and reducing the CHO content of the diet.

Pt with other coronary risk factors (smoking, HTN, obesity and lack of exercise) should be encourage to modify their behavior + modified lipid diet

Management of lipid abnormalities by dietary CHO and fat restriction alone has been reported to be effective in dialysis pt. However, additional dietary restriction is difficult to achieve in the already fluid and protein restricted pt, and the limited of diet is counterbalanced by the risk of malnutrition in these pts.

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Nutrition Prescription
Nutrition Prescription

E. Sodium (Stage 1&2)

Low sodium intake (less than 2.4 g/d) (K/DOQI 2003) Strict control of BP can delay renal progression and control CVD Other lifestyle modifications recommended: wt control, ↓ intake of SFA & Chol., glycemic control, limit alcohol, exercise and stop smoking.

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Nutrition Prescription
Nutrition Prescription

E. Sodium (Stage 3&4)

Low sodium intake (less than 2.4 g/d) (K/DOQI 2003) *Gradual reduction is recommended to max. tolerance and acceptance

Na+ excretion is inadequate in advanced renal failure

↑Na+ intake ↑extra cellular volume and Na+ imbalance

↑Na+ intake limits the efficacy of anti-hypertensive

medication (Mailloux et al, 1998)

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Nutrition Prescription
Nutrition Prescription

E. Sodium (Stage 5) HD : 2 – 3 g Na+ per day (ADA 2002) CAPD : 2 – 4 g Na+ per day (ADA 2002) ↑Na+ intake ↑ thirst and complicate fluid control Should be individualized based on BP

and wt (ADA 2002)

No added salt diet is recommended.

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Nutrition Prescription E. Sodium (Stage 5) HD : 2 – 3 g Na+ per day (ADA
Nutrition Prescription
Nutrition Prescription

F. Fluids (Stage 1 – 4)

Generally no restriction. Keep fluid balance to maintain hydration status (ADA 2002)

Capacity to handle water is limited must monitor fluid intake to avoid overload or dehydration

Fluid retention require individualized advice Must take into consideration environmental temperature and activity level of the pt. Aware all signs of fluid overload and dehydration

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Nutrition Prescription
Nutrition Prescription

F. Fluids (HD Patients) 750 to 1000 ml/day Fluid balance affected by:

Fluid intake Fluid removal from dialysis Na+ intake

Nutrition Prescription F. Fluids (HD Patients)  750 to 1000 ml/day  Fluid balance affected by:

↑ interdialytic wt gain among pts on HD results in ↑ mortality risk (Kimmel et al)

Maintain fluid gain between HD to less than 3% - 5% dry wt (ADA 2002) or 2 to 3kg

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Nutrition Prescription F. Fluids (CAPD Patients)  up to 1500 ml/day  Fluid balance affected by:
Nutrition Prescription F. Fluids (CAPD Patients)  up to 1500 ml/day  Fluid balance affected by:
 

Nutrition Prescription

F. Fluids (CAPD Patients) up to 1500 ml/day Fluid balance affected by:

Fluid intake Ultrafiltration capacity of peritoneal membrance Na+ intake

Ultrafiltration normally can remove 2.0 – 2.5 kg fluid per day

↑ ultrafiltration through the use of hypertonic exchanges can treat fluid overload. But hypertonic solution may risk in

↑risk of obesity Hypertriglyceridemia Damage to peritoneal membrane

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MNT for CKD

(EDTNA/ERCA 2002)

Nutrition Prescription
Nutrition Prescription

G. Potassium Stage 1-4 : no restriction unless blood potassium level is elevated HD : 2 – 3g adjust to serum levels (8-17 mg/kg body wt) CAPD : 3 – 4g adjust to serum levels (8-17 mg/kg body wt) K+ levels may be depressed or elevated Hyperkalemia cardiac arrhythmias / cardiac arrest Consider non-dietary causes of hyperkalemia (Bansal

1992)

Loss of residual renal function, acidosis, catabolism, inadequate dialysis, dialysate K concentration too high, drug induced.

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Nutrition Prescription
Nutrition Prescription

H. Phosphate

Stage 1-2 : no restriction unless indicated

Stage 3-5 : 800 – 1000 mg/d (adjust for dietary protein needs)

HyperPO4 and the associated conditions begin to appear as GFR declines <60 ml/min elevated PTH

Require early detection and treatment to prevent bone disease of chronic hyperparathyroidism, and to minimize

the increased risk for CVD (Slatopolsky E, Block et al, 1998; Ammann K et al, 1999; Block GA et al 2000)

In pre-dialysis pt, prescriptions of low protein intake has been shown to be effective to prevent or correct hyperPO4. (MDRD, 1994)

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Nutrition Prescription
Nutrition Prescription

H. Phosphate

A limited removal of PO4 occurs with dialysis

The appropriate dose of PO4 binder should be ideally based on PO4 content meals and snacks. It should be taken with meals. The type of PO4 binder usually used are calcium carbonate and calcium acetate.

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Nutrition Prescription H. Phosphate   A limited removal of PO4 occurs with dialysis The appropriate

MNT for CKD

Nutrition Prescription
Nutrition Prescription

I. Calcium

Stage 1&2 : should meet RDI

Stage 3 - 5 : total calcium provided by calcium-based phosphate binder should not exceed 1500 mg/d

Calcium from diet + PO4 binder should not exceed 2000

mg/d (K/DOQI 2003)

J. Iron

Stage 1 - 5 : should meet RDI. Achieve with supplementation of 200mg elemental iron (K/DOQI 2003)

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Nutrition Prescription
Nutrition Prescription

K. Water Soluble Vitamins

Stage 1 – 5 : supplement to meet recommended daily intake requirements

For Vitamin C; supplement up to 60 – 100 mg/d

L. Fat Soluble Vitamins

Stage 1 – 5 : Intake should meet recommended daily requirements.

For CAPD pt, may be given active Vitamin D therapy by physician.

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Special Topics
Special Topics

A. Vegetarian Diets

Indian-styled vegetarians – various dhals and legumes incorporated into gravies, stews and snacks, milk and milk product eg yoghurt

Chinese-styled vegetarians – tofu, textured vegetable proteins (meat analogues) and soy milk.

Caution: may not protein adequacy, may also face problems of controlling K+, PO4 and Na+

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Special Topics
Special Topics

Guidelines for Planning Vegetarian Renal Diets:

Should consume a wide variety of plant foods such as cereal, legumes, nuts and seeds, fruits and vegetables.

Some vege consume milk and eggs considered. Consider that cereal foods will contribute a substantial amount of protein in the vegetarian diet.

Special Topics Guidelines for Planning Vegetarian Renal Diets:    Should consume a wide variety

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Special Topics
Special Topics

B. Nutrition Support in CKD:

Moderate protein and electrolyte levels plus added fiber products may be given. Too high protein can risk of dehydration, hypernatremia, and azotemia.

Concentrate formulas to minimize fluid overload. Monitor fluid status.

PO4 binders may need to be withheld if refeeding syndrome occurs.

Chose appropriate formulas.

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Special Topics
Special Topics

C. Use of herbal supplements:

Herb

Use

Comments/effects

Ginseng

Multiple, stress, memory, strength

Can create anxiety, increased BP, hypoglycemia, decreased anti-coagulant activity, insomnia, headache, asthma attacks. Do not use in CKD.

Garlic

Cardiac/reduce lipid levels

Side effects, bad breath, gastritis, impaired blood clotting, can effect insulin & OHA.

Gingko biloba

Memory,

Headache, anxiety, restlessness, diarrhea,

concentration

anorexia

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Ref : McCann (2002)

MNT for CKD

Special Topics
Special Topics

D. Diabetics with kidney failure:

Ensure protein and energy intake is adequate to prevent malnutrition

Total CHO intake should be monitored and use of simple sugars should be limited to improve glycemic control

Ensuring adequate fiber intake may be beneficial to improve glycemic control and prevent constipation. However, PO4 and K+ intake should be monitored especially with the use of whole grain products, beans and legumes.

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Enteral Formula
Enteral Formula

Calorically dense – 2 Kcal/ml Low in Protein (7.1 g / serving)

Each can provides at least 25% of recommended levels of vitamins / minerals for pre-dialysis patients.

Contraindications : Chronic or acute kidney failure not receiving dialysis

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Enteral Formula  Calorically dense – 2 Kcal/ml Low in Protein (7.1 g / serving) 
Enteral Formula
Enteral Formula

Calorically dense – 2 Kcal/ml Moderate in Protein (16.6 g / serving)

Each can provides at least 25% of recommended levels of vitamins / minerals for dialysis patients.

Contraindications : Chronic or acute kidney failure requiring dialysis

Enteral Formula  Calorically dense – 2 Kcal/ml  Moderate in Protein (16.6 g / serving)

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