Renal nutrition

(for non-renal dietitians)

Dr Lina Johansson
Lead Renal Dietitian / NIHR Clinical Lecturer

30th September 2015

 overview
• Basics
– Measurement and stages
– Prevalence
– Functions of the kidney
– Symptoms
• Nutrition
– Role of renal dietitian
– Protein
– Potassium
– Fluid
– Malnutrition
• Case study
DOH LTCs Compendium of Information, 2012
 Measuring Kidney Function
Glomerular Filtration Rate (GFR)

Glomerulus

Normal GFR: ~120mls/min

=~ 180L/day
 eGFR- progression
• Abnormally declining eGFR
– >5ml/min/yr
– or >10ml/min in 5 years
 Stages of Renal Disease
130mls/min 90mls/min 60mls/min 30mls/min 15mls/min 0
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Normal Mild decrease Moderate Severe End stage renal

function decrease decrease disease

Screen for CKD risk CKD risk factor Treat Prepare or undergo replacement
factors reduction complications of •Uraemia
•Hypertension •Lower bp CKD •Manage bp and fluid volume
•Diabetes •Control diabetes •Uraemia •Control diabetes
•Obesity •Weight loss •Manage anaemia •Control mineral imbalances
•Prevent •Prevent and treat malnutrition
malnutrition

Dialysis/
transplantation
needed for survival
(there is no cure)
UK prevalence CKD 3-5
 Prevalence of dialysis
UK trend of people on dialysis

2005 20635

2013 27348

87% on 13% on
haemodialysis (HD) peritoneal dialysis
(PD)

Renal Registry Reports 2006-2014

https://www.renalreg.org/publications-reports/
 What causes end stage renal disease?

Primary renal diagnosis % distribution in incident

Renal Replacement Therapy
2013
Diabetes 25.4
Glomerulonephritis 14.4
Pyelonephritis 6.9
Hypertension 7.6
Polycystic kidneys 7.6
Renal vascular disease 5.4
Other 18.3
Uncertain aetiology 14.5
https://www.renalreg.org/reports/2014-seventeenth-annual-report/
(Chapter 1)
 Question
What are the consequences of reduced kidney function
within the body?
 Impaired kidney function

Uraemia and Low serum calcium

accumulation of waste
products

Raised blood pressure/ fluid Raised potassium levels

retention

Anaemia Metabolic acidosis

• What are the symptoms of advanced chronic
kidney disease/ renal failure?
 Uraemic symptoms
• Loss of appetite
• Nausea/vomiting
• Diarrhoea
• Weakness
• Oedema
• Taste changes
• Insomnia
• Fatigue
• Decreased concentration
• Muscle cramps
• Itching
 What is the role of the renal dietitian?
• Improve nutritional status
• Improve electrolyte balance
• Improve fluid balance
• Communication
• Symptom control
• Educators: support self-mgt
• Support non-renal dietetic
colleagues
 Minimise uraemic symptoms
” in patients with chronic renal failure it is possible to
postpone the increase of serum urea concentration for a
long time, reducing the nitrogen intake to 3-5 g.
Sometimes we have succeeded in reducing considerably high
serum urea concentrations. Consequently the first uremic
symptoms disappeared.”

Volhard, 1918
Volhard, 1918
(Handbuch der Inneren Medizin)
(Handbuch der Inneren

Medizin)
What do you think about restricted protein
diets?

What are the guidelines for protein in chronic

kidney disease in the UK?
 Protein intake: recommendations for
stages 4-5 (not on dialysis)
Recommended Protein intake
0.75 g/kg IBW/day for patients with stage 4-5 not on dialysis
Rationale
• Prevent malnutrition (risk highlighted in MDRD study)
• Improve symptoms of uraemia
• Aid compliance (challenging to follow very low protein diets)
Average protein intake for men and women g/kg/d Renal Association 2010 Nutrition guidelines
1.2

1
Protein intake g/kg/d

0.8

0.6
Recommended protein intake
0.4
for CKD 0.75g/kg IBW/d
0.2

0
Men average daily protein intake Women average daily protein intake
g/kg/d g/kg/d
 Protein intake:
recommendations for dialysis

Recommended Protein intake

1.2g/kg IBW/day for patients on dialysis
Rationale
• Protein loss through dialysis : peritoneal and haemodialysis
 Haemodialysis v Peritoneal Dialysis
• What are key differences between these two
modes of dialysis that will affect:
– Interpretation of clinical signs and biochemistry
– Nutritional management
• http://www.youtube.com/watch?v=IQKQ4eoK
fTg
 Potassium
• Hyperkalaemia can be present in CKD, HD and PD
patients, can lead to sudden death

• Targets for potassium

• Normal range – CKD (no dialysis)
• 3.5-6.0mmol/L haemodialysis
• 3.5-5.5mmol/L peritoneal dialysis

• Recommended intake
• RNG (1998) 1mmol/kg/IBW
• EDTNA/ERCA (european renal guidelines 2002) 50-65
mmols/d
 Potassium

Hyperglycaemia

Causes of
Hyperkalaemia
Diet

Medications
 Potassium

Causes of hyperkalaemia
Acidosis Fall in plasma bicarbonate as GFR
decreases. Can lead to hyperkalaemia
Diet Excess K intake
Medications Ace Inhibitors e.g. enalapril
Angiotension II receptor antagonists
e.g. candesartan
Potassium sparing diuretics e.g.
Spironolactone
Constipation K reabsorbed from stools
Blood transfusion Blood is K rich
Poor diabetic control Can lead to hyperkalaemia
 Medications and potassium
• ACEI/ARBs:
– Hyperkalaemia known complication. Serum K levels
increase by 0.4-0.6mmol/L during ACEI/ARB treatment.
– 1 to 1.7% develop K >6.0mmol/L.
– Not normally start ACEI/ARB if K above normal range.
What to do if referred a CKD patient with
a raised potassium?
• Check trend of potassium
– Is it increasing and hovering around upper limit?
– Have there been high potassium results in past?
• Check diet
– What is the baseline diet like?
– Identify high potassium foods and offer suitable
alternatives
– Make diet achievable.
• Follow up
– If high potassium, then need to re-check bloods
– Allow patient to contact you for further questions
– Get support from renal dietitians
 potassium
• High potassium foods
Coffee
Bananas

Fruit juices
Spinach

Potato or veg based

crisps
Mushrooms
Chocolate
Dried fruit and nuts or foods
containing these
 potassium
• Cooking methods for vegetables
 1. Identify high potassium foods from 24 hour recall
2. Suggest suitable alternatives

Breakfast: Glass of orange juice

All Bran with milk and sugar
1 slice of wholemeal toast with butter and marmalade
Mug of coffee with milk

Mid Morning: Mug of tea with milk and 2 chocolate digestives

Lunch: Wholemeal cheese and tomato sandwich

Packet of crisps and a banana
Mug of tea with milk

Mid Afternoon: Orange with glass of fruit squash

Evening Meal: Lamb chop with boiled potatoes and peas

Fruit yoghurt
Mug of tea with milk

Supper: Mug of ovaltine

 Potassium exercise - answers
Breakfast: Glass of orange juice
All Bran with milk and sugar
1 slice of wholemeal toast with butter and marmalade
Mug of coffee with milk

Mid Morning: Mug of tea with milk and 2 chocolate digestives

Lunch: Wholemeal cheese and tomato sandwich

Packet of crisps and a banana
Mug of tea with milk

Mid Afternoon: Orange with glass of fruit squash

Evening Meal: Lamb chop with boiled potatoes and peas

Fruit yoghurt
Mug of tea with milk

Supper: Mug of ovaltine

 Oedema
• peripheral oedema
• pulmonary oedema
 Fluid managment
• 500ml/24hr plus previous day’s urine output if
on haemodialysis
• If not requiring dialysis then unlikely to be
restricted (unless nephrotic)- guided by Drs
• Poor DM control and salt intake contribute to
thirst
 Fluid balance in HD
Just after HD
session= Just before
normally HD session
hydrated
weight

http://www.kidneypatientguide.org.uk/fluid.php
 Malnutrition:
Nutritional intake as renal function declines: stage 4-5
Protein Intake Calorie Intake

Male

Male

Female

Female

Decreasing renal function Decreasing renal function

Kopple, Kid Int, 57:1688-1703, 2000
 Malnutrition:
Nutritional intake as renal function declines: stage 4-5
BMI

Male Decreasing renal function

associated with spontaneous
reduction of protein and calorie
intake and BMI reduction.

Female

Decreasing renal function Kopple, Kid Int, 57:1688-1703, 2000

 Treatment of malnutrition
Enteral
– Modified food first advice
– Oral nutritional supplements
– Tube feeding e.g. nasogastric/ gastrostomy

Parenteral
– Intra Dialytic Parenteral Nutrition (IDPN) – HD only (only
supplementary nutrition equivalent to ~420 kcals/ day, SMOFKABIVEN 8
EF)
– Total Parenteral Nutrition (TPN)- Home service
 Modified Food First Advice
What do you have to consider in food first advice in
patients with advanced CKD?
 Enteral Nutritional Support
• Renal considerations
– Volume
• are restrictions necessary?

– Electrolytes
• are phosphate and potassium levels raised?

– Protein
• how much protein does the patient need depending on their type of
dialysis treatment and stage of CKD?
 ONS – Which one to choose
Product Volume Kcal Protein Potassium Phosphate
Build Up 85g/200ml 270 15 21.8 14
Fortified Milk 300ml 323 22.6 24.8 20
Calshake 87g/240ml 598 11.9 20.7 14.1
Nepro HP 220ml 400 17.8 5.4 4.4
Fresubin Energy 200ml 300 11.2 6.6 5.4
Fresubin protein 200ml 300 20 6.6 7.8
energy
Fresubin 2kcal 200ml 400 20 8 7.6
Fresubin Jucy 200ml 300 8 0.4 0.8
Fresubin creme 125g 231 12.5 5.3 5.1
Fresubin 5kcal 30ml 150 0 0 0
shot
 Case study
Mr Remoh Nospmis
Type 2 diabetic
Overweight
CKD stage 4, eGFR 20mls/min
3 children
Works in a nuclear power plant
Weight 95kgs, height 1.7m, BMI 32.9kg/m2
Questions?