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

MNT for CKD

INTRODUCTIONPt 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 (1st National Renal Registry Report) to 9,995 in 2003 (11th 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)

MNT for CKD

INTRODUCTIONIn 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. (11th 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)

MNT for CKD

Stage of CKD (Source : K/DOQI 2003)

MNT for 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)

MNT for CKD

Prevailing Causes of primary CKD:

Diabetes (51%)Unknown causes (30%)Glomerulonephritis (5%)Obstructive nephropathy (3%)Polycystic kidney disease (1%)Miscellaneous (8%)*(11th Malaysian Dialysis & Transplant Registry)

MNT for CKD

Objectives of Nutrition ManagementA.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 failureReduce the risk for CVD such as hyperlipidaemiaProviding regular nutritional counseling based on an individualized plan of care in order to promote good quality of life

MNT for CKD

Objectives of Nutrition Management B. Pre-Dialysis (Stage 3&4)To delay the progression of kidney failureMaintain good nutritional status in preventing malnutrition by:i) giving adequate protein and energyii) ensuring sufficient nutrients such as Ca, Fe, and other vitamins and mineralMinimize 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 patients condition and ability.Providing regular nutritional counseling based on individualized plan of care in order to promote good QOL

MNT for CKD

Objectives of Nutrition ManagementC. 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 energyii) ensuring sufficient nutrients such as Ca, Fe, and other vitamins and mineralMinimize electrolyte and mineral disturbances such as PO4, K+, Ca, Na+ and fluids.Control fluids intakePrevent and manage co-morbidities such as CVD, anemia, bone disease and DMEncourage physical activity according to patients condition and ability.Providing regular nutritional counseling based on individualized plan of care in order to promote good QOL

MNT for CKD

The Need for Nutrition AssessmentGFR 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 (11th Malaysian Dialysis & Transplant Registry)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)

MNT for CKD

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

MNT for CKD

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

MNT for CKD

Nutrition PrescriptionA. CaloriesStage 1-4, Hemodialysis, CAPD and Peritonitis : 35 Kcal/kg body weight if < 60 years of age30 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.

MNT for CKD

Nutrition PrescriptionA. CaloriesEnergy 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)

MNT for CKD

Nutrition PrescriptionB. Protein (Stage 1&2)0.8 g/kg BWThe 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)

MNT for CKD

Nutrition PrescriptionB. 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 proteinLow 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)

MNT for CKD

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

MNT for CKD

Nutrition PrescriptionB. Protein (HD patients)

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.

MNT for CKD

Nutrition PrescriptionB. Protein (CAPD Patients)

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.

MNT for CKD

Nutrition PrescriptionC. Carbohydrate (Stage 1 5)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 intakeComplex 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.

MNT for CKD

Nutrition PrescriptionD. Fats (Stage 1 5)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)

MNT for CKD

Nutrition PrescriptionD. FatsIn 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.

MNT for CKD

Nutrition PrescriptionE. 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.

MNT for CKD

Nutrition PrescriptionE. Sodium (Stage 3&4)Low sodium intake (less than 2.4 g/d) (K/DOQI 2003) *Gradual reduction is recommended to max. tolerance and acceptanceNa+ excretion is inadequate in advanced renal failureNa+ intake extra cellular volume and Na+ imbalanceNa+ intake limits the efficacy of anti-hypertensive medication (Mailloux et al, 1998)

MNT for CKD

Nutrition PrescriptionE. 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 controlShould be individualized based on BP and wt (ADA 2002)No added salt diet is recommended.

MNT for CKD

Nutrition PrescriptionF. 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 dehydrationFluid retention require individualized adviceMust take into consideration environmental temperature and activity level of the pt.Aware all signs of fluid overload and dehydration

MNT for CKD

Nutrition PrescriptionF. Fluids (HD Patients)750 to 1000 ml/dayFluid balance affected by:Fluid intakeFluid removal from dialysisNa+ intake 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

MNT for CKD

Nutrition PrescriptionF. Fluids (CAPD Patients)up to 1500 ml/dayFluid balance affected by:Fluid intakeUltrafiltration capacity of peritoneal membranceNa+ intakeUltrafiltration 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 inrisk of obesityHypertriglyceridemiaDamage to peritoneal membrane (EDTNA/ERCA 2002)

MNT for CKD

Nutrition PrescriptionG. PotassiumStage 1-4 : no restriction unless blood potassium level is elevatedHD : 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 elevatedHyperkalemia cardiac arrhythmias / cardiac arrestConsider non-dietary causes of hyperkalemia (Bansal 1992)Loss of residual renal function, acidosis, catabolism, inadequate dialysis, dialysate K concentration too high, drug induced.

MNT for CKD

Nutrition PrescriptionH. PhosphateStage 1-2 : no restriction unless indicatedStage 3-5 : 800 1000 mg/d (adjust for dietary protein needs)HyperPO4 and the associated conditions begin to appear as GFR declines

Nutrition PrescriptionH. PhosphateA limited removal of PO4 occurs with dialysisThe 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.

MNT for CKD

Nutrition PrescriptionI. CalciumStage 1&2 : should meet RDIStage 3 - 5 : total calcium provided by calcium-based phosphate binder should not exceed 1500 mg/dCalcium from diet + PO4 binder should not exceed 2000 mg/d (K/DOQI 2003) J. IronStage 1 - 5 : should meet RDI. Achieve with supplementation of 200mg elemental iron (K/DOQI 2003)

MNT for CKD

Nutrition PrescriptionK. Water Soluble VitaminsStage 1 5 : supplement to meet recommended daily intake requirementsFor Vitamin C; supplement up to 60 100 mg/dL. Fat Soluble Vitamins Stage 1 5 : Intake should meet recommended daily requirements.For CAPD pt, may be given active Vitamin D therapy by physician.

MNT for CKD

Special TopicsA. Vegetarian DietsIndian-styled vegetarians various dhals and legumes incorporated into gravies, stews and snacks, milk and milk product eg yoghurtChinese-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+

MNT for CKD

Special TopicsGuidelines 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.

MNT for CKD

Special TopicsB. 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.

MNT for CKD

Special TopicsC. Use of herbal supplements:

Ref : McCann (2002)

MNT for CKD

Special TopicsD. Diabetics with kidney failure:Ensure protein and energy intake is adequate to prevent malnutritionTotal CHO intake should be monitored and use of simple sugars should be limited to improve glycemic controlEnsuring 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.

MNT for CKD

Enteral FormulaCalorically dense 2 Kcal/mlLow in Protein (7.1 g / serving)Each can provides at least 25% of recommended levels of vitamins / minerals for pre-dialysis patients.Contraindications : Chronic oracute kidney failure notreceiving dialysis

MNT for CKD

Enteral FormulaCalorically dense 2 Kcal/mlModerate in Protein (16.6 g / serving)Each can provides at least 25% of recommended levels of vitamins / minerals for dialysis patients.Contraindications : Chronic oracute kidney failure requiringdialysis

MNT for CKD

MNT for CKD