Todays Topics

Nutritional Management of Chronic Kidney Disease

Theresa Kuracina, MS, RD, CDE Department of Health and Human Services U.S. Public Health Services Indian Health Service Albuquerque Indian Health Center April 29, 2009
U.S. Department of Health and Human Services National Institute of Health

The perfect diet The right diet for HTN, DM, high blood cholesterol The right diet for chronic kidney disease (CKD) The first steps Sodium Blood sugar Protein

The next steps Phosphorus Potassium

What is the Perfect Diet?

What is the Perfect Diet?

Servings sizes Standardized amounts Diet therapy Labels Portion sizes How much you eat

What Is the Right Diet?

Understanding the Nutrition Facts Label

High blood pressure Sodium Diabetes Total carbohydrates Total fat Food groups vary Serving sizes vary

High blood cholesterol Total fat Saturated fat Trans fats Cholesterol

Refer for Medical Nutrition Therapy

USDA, 2004

Chronic Kidney Disease

What is the Right Diet for CKD?

There is not one right diet: CKD diet needs differ Diet changes as kidney function changes No specific eGFR to recommend changes Monitor trends Medical nutrition therapy is recommended

Why the CKD Diet is Important

How the Kidneys Function

Delays progression to kidney failure Maintains nutritional status Prevents malnutrition

Regulate composition and volume of blood Remove wastes from blood into the urine Source for 1,25-dihydroxycholecalciferol (Active vitamin D), erythropoietin, renin Involved in metabolism and catabolism

As eGFR Declines

The Diet Changes for CKD

Decreased excretion of waste products Nitrogen, phosphorus, potassium Less vitamin D is activated Less calcium is absorbed Less erythropoietin is produced At risk for anemia

The First Steps Sodium Blood sugar Protein The Next Steps Phosphorus Potassium Education Tools Nutrition Facts label Ingredient list National Kidney Disease Education Program (NKDEP) web site-tools in development

Long Term Diet Goal: Prevent Malnutrition

Causes of Malnutrition

Nutrition status strongly predicts morbidity/mortality in CKD Spontaneous decrease in intake Severity increases as GFR declines Accumulation of uremic toxin(s) Appetite improves with renal replacement therapy Starts early in the course of CKD

Metabolic acidosis Inflammation Hormonal derangements Altered taste and smell Anorexia, nausea, vomiting Dietary restrictions

Carrero, 2009 Bossola, 2009

Carrero, 2009 Bossola, 2009

The First Steps in Diet Intervention

The First Steps: Sodium

Sodium Blood sugar Protein

Check serving size

20% Daily Value (or more) is HIGH

Sodium in the Diet

Sodium in Selected Foods

4500 4000 3500 3000

mg/day 2933 2400

4178 1 teaspoon salt * Beef soup

1500
Table Seasoned Garlic
Bouillon cube Broth Canned

2500 2000 1500 1000 500 0

1500

Adequate Intake Daily Value Women * Men *

2500 2000 1500 1000 500 0

1 cup tomatoes

1000 500 0

1500 1000
*What We Eat in America, 2005 2006 Institute of Medicine, 2004 USDA, 2008 FDA, 1999

300
Fresh Stewed Sauce Juice

Oatmeal
Cooked

200 100 0

Instant Instant, flavored

500 0

*Pennington, 2005 USDA, 2008

Sodium in Selected Foods

Take Home Message: Sodium

1000 800 600 400 200 0

Beef
85% Lean Corned, canned Stew, canned

Daily Value of 20% or more is high Prepare fresh food at home more often Use less salt in cooking and at the table Try lower sodium versions: canned soups, canned vegetables, convenience foods

Dairy

500 400 300 200 100 0

Cream cheese Fat free cream cheese Amer, 1 oz. Cottage cheese 1% milk Buttermilk

Fast foods

1500 1000 500 0

USDA, 2008
Double cheeseburger Single cheeseburger Taco salad

The First Steps: Blood Sugar

Control Blood Sugar (Diabetes)

Target A1c < 7% Avoid hyperglycemia Avoid hypoglycemia Increased risk with declining eGFR Decreased clearance of insulin and oral medications Less gluconeogenesis by the kidneys

NKF, 2007

The Diet Changes for Diabetics with CKD

Take Home Message: Blood Sugar

Avoid high protein diet Any kind of juice can treat hypoglycemia As GFR declines, refined grains help manage phosphorus and potassium levels May need to add more fats/carbohydrates in diet Needed for calories Diet will change as eGFR declines Intake of protein, carbohydrates and fats may need to be adjusted regularly Hypoglycemia risk increases with declining eGFR

The First Steps: Protein

Protein in the Diet

120 100 80
g/day 102

70 56 42 50 For CKD 0.8 g/kg

60 40 20 0

RDA women RDA men Daily Value Women * Men *

RDA 0.8 g/kg

*What We Eat in America, 2005-2006 USDA, 2008 Institute of Medicine, 2002 FDA, 1999

Protein

Sources of Protein

Quality matters High biological value: at least 50% of total Low biological value Quantity matters Less is better Lower protein may slow progression and reduce proteinuria No storage for extra nitrogen (N) urea Fewer nephrons increased blood urea N

High Biological Value (g) Egg Egg white 1 oz. poultry, meat or fish 8 oz. milk 1 c. soybeans 1 c. soy milk 6 3.6 ~7 8 14 8

Low Biological Value (g) c. Legumes 1 oz. Nuts Bread /grains Vegetables Fruit 7 4 2-4 2-3 0-1

USDA, 2008

Breakfast and Protein

The Diet Changes for Protein

Breakfast menu: 2 eggs 3 slices bacon 2 wheat toast Soft margarine 1 cup potatoes 2 cups coffee

Protein 12 7 6 0 5 0 30 g

Alternative menu: 2 egg whites 2 wheat toast Soft margarine cup potatoes 1 cup strawberries 2 cups coffee

Protein 7 6 0 2 1 0 16 g

Start with portion control, if needed Deck of cards = portion size ~ 3 ounces (21 grams protein) As eGFR declines and BUN elevates What can you eat? What kinds of protein taste good?

USDA, 2008

Take Home Message: Protein

The Next Steps

Most of us eat more protein than we need Start with portion control: About size of deck of cards (3 ounces) Fill only plate with these foods

Phosphorus Potassium

The Next Steps: Phosphorus

Phosphorus in the Diet

1800 1600 1400 1200

mg/day 1000 1000 700 1148

1600

800 600 400 200

RDA Daily Value Women * Men *

Read Ingredient List for PHOSPH

0
*What We Eat in America, 2005-2006 USDA, 2008 FDA, 1999 Institute of Medicine, 1997

Phosphorus

Phosphorus Balance

Bones can get soft Blood vessels & soft tissues can calcify

Involves: Vitamin D Calcium Parathyroid hormone NEW Fibroblastic Growth Factor 23 (FGF-23)

~ 60% absorbed due to passive absorption Increases to ~ 75% with vitamin D High intakes of phosphorus stimulate FGF-23

FGF-23 works at the kidneys to shut off phosphorus reabsorption ( phosphaturia) FGF-23 turns off enzyme in kidneys that activates Vitamin D (less P absorbed) Serum P levels normal

Gutierrez, 2005

Institute of Medicine, 1997 Gutierrez, 2005

FGF-23 Helps Maintain Serum Phosphorus Levels

Sources of Phosphorus

Organic phosphorus ~ 60% absorbed Dairy products Meat, poultry, fish Soy (soy milk, tofu)* Nuts and seeds* Dried beans and peas* Whole grains*

Inorganic phosphorus ~90 100 % absorbed Food additives Any phosph in the ingredient list

X FGF-23 decreases phosphorus absorption

FGF-23 increases phosphaturia

*Less absorbed due to phytic acid

Gutierrez, 2005 Knochel, 2007 Institute of Medicine, 1997

Phosphorus Intake Has Increased

Phosphorus: How the Food is Prepared Matters

Both extent of usage of phosphate salts as additives and the amount per serving have increased substantially over the past 20 years, and the nutrient databases may not reflect these changes..phosphorus intake may be underestimated for certain individuals who rely heavily on processed foods. these data suggest a substantial increase in phosphorus consumption, in the range of 10 to 15 percent, over the past 20 years.

250 200 150 100 50 0

600 500 400 300 200 100 0

Biscuit
Homemade Refrigerated Dough Fast Food

Cornbread

One Pancake

Homemade recipe (green) is lowest in phosphorus.

USDA, 2008

Institute of Medicine, 1997

Boxed Mix

Read Ingredient Labels For PHOSPH

Additives with Phosphorus

Dipotassium phosphate (buffer) Disodium phosphate (texturizer, emulsifier) Monocalcium phosphate (leavening, chip surface) Monosodium phosphate (color) Phosphoric acid (acidulant) Potassium tripolyphosphate (retain moisture)

Turkey Breast & Gravy INGREDIENTS: TURKEY BREAST (TURKEY BREAST MEAT, WATER, SALT, BROWN SUGAR, SODIUM PHOSPHATE, DEXTROSE, MODIFIED FOOD STARCH, VEGETABLE OIL), GRAVY

International Food Additives Council, 2007

Additives with Phosphorus

Hidden Phosphorus

Sodium acid pyrophosphate (leavening, color) Sodium hexametaphosphate (emulsifier) Sodium tripolyphosphate (flavor enhancer) Tetrasodium pyrophosphate (retain moisture) Tricalcium phosphate (calcium fortification) Trisodium phosphate (antimicrobial, emulsifier)

Baked goods Baking powder Cake mixes Cake donuts Refrigerated dough Beverages Some soft drinks including cola, iced teas, fruit punch Flavored milk Ca-fortified orange juice

Cereals Cooked ( cooking time, Ca fortified) Extruded dry: Ca fortified Dairy /Cheese Cottage cheese, dips/ sauces, imitation cheese slices, starter cultures, ice cream

International Food Additives Council, 2007

International Food Additives Council, 2007

More Hidden Phosphorus

Protein Foods Have Phosphorus

Imitation dairy Non-dairy creamer Whipped topping Egg products Egg substitutes Meat /poultry products Enhanced Pasta cooking time

Potatoes Baked chips Fries, hash browns, potato flakes Desserts Instant pudding Cake mixes Seafood shrimp, canned crab/tuna, surimi

400 300 200 100 0

Dairy

Cream cheese Fat free cream cheese American Cottage cheese Buttermilk

150 100 50 0

Egg
White Substitute Yolk

300 200 100 0

Various Proteins
Ground beef Salmon Peanuts Pinto beans

300 200 100 0

Fast Foods
Double cheeseburger Single cheeseburger Taco salad

International Food Additives Council, 2007

USDA, 2008

Take Home Message: Phosphorus

The Next Steps: Potassium

Additives with phosphorus increase total phosphorus intake Read ingredient lists for phosph Less dietary protein means less phosphorus Refined grains are lower in phosphorus However, 100% is not absorbed 1. Monitor trends in serum potassium levels 2. Consider restricting dietary potassium if trending up 3. Potassium-sparing medications

Potassium in the Diet

Potassium in Foods

5000 4500 4000 3500 3000

mg/day 2500 3500 2366 3174 4700

Salt substitutes have potassium in place of sodium (600 3,200 mg / teaspoon) Most food groups have some potassium Fruits and vegetables have the most variation (low/medium /high) Whole grains have more than refined grains

2000 1500 1000 500 0

Adequate Intake Daily Value Women * Men *

*What We Eat in America, 2005-2006 Institute of Medicine, 2004 USDA, 2008 FDA, 1999 Edwards, 2008

Potassium in Selected Foods

Potassium In Juice (4 ounces)

Proteins

800 600 400 200 0

Ground beef Salmon Peanuts Pinto beans

500 400 300 200 100 0

Cereals
Corn flakes Wheat bran flakes Bran Oatmeal

8 ounce Milk/Substitutes

300
Milk Choc. Soy

250 200
Potassium per serving

400 300 200 100 0

100 80 60 40 20 0

6 ounce Coffee/Tea

150 100

Coffee, brewed Coffee, instant Tea

Cranberry Apple Grape Pineapple Grapefruit Orange Tomato

50 0

USDA, 2008

USDA, 2008

Potassium in Selected Vegetables

Take Home Message: Potassium

Green, canned, cup

400 300 200 100 0

Yellow/Orange, canned, cup
Green beans Peas Spinach

800 600 400 200 0

1 Potato
Flesh, baked Skin, baked Boiled, peeled Fries (10)

Salt substitutes are high in potassium Fruits and vegetables can be low/medium/high in potassium content Refined grains are lower in potassium Hypoglycemia can be treated successfully with low potassium juice (cranberry or apple)

Salad greens, 1 cup

300 200 100 0

Carrots Corn Pumpkin Wax beans

200 150 100 50 0

USDA, 2008
Green leaf Iceberg Romaine Spinach

Renal Replacement Therapy

Medical Nutrition Therapy (MNT)

Individualize

Hemodialysis (In center 3 times per week) >1.2 g/kg 30 35 kcal 1,000 3,000 mg 800-1000 mg 2,000 3,000 mg Urine output + 1,000 mL

Peritoneal Dialysis (Daily at home) 1.2 1.3 g/kg 30 35 kcal/kg incl. dialysate 2,000 4,000 mg

Refer to a Registered Dietitian Medicare Part B benefit for Chronic Kidney Disease (non-dialysis): GFR 13 50 Requires physician referral Allows 3 hours of MNT in 1st calendar year Additional hours based on change in diagnosis, medical condition or treatment Covers 2 hours of MNT in subsequent years

Protein (50% HBV) Calories Sodium Phosphorus Potassium Fluid

800-1000 mg 3,000 4,000 mg As needed

Medicare, 2009 ADA, 2009

Medical Nutrition Therapy (MNT)

Patient Tips Before Referral to Dietitian

Provider Claim Form

Your diet will help treat your kidney disease Use Nutrition Facts label to choose lower sodium foods Fill of your plate with the right kinds and amount of protein Use ingredient list to find added phosphorus

Diagnosis (ICD-9) codes for MNT for CKD CKD Stage GFR ICD-9 code 3 30-59 585.3 4 15-29 585.4 5 <15 or dialysis 585.5 MNT CPT codes 97802
MNT initial assessment and intervention, individual, face-to-face, each 15 minutes

97803
MNT, reassessment and intervention, individual, face-to-face, each 15 minutes

97804
MNT, group, 2 or more individuals, each 30 minutes Medicare, 2009

In Summary

NKDEP Resources

The diet for CKD can delay progression to kidney failure First diet changes: sodium, blood sugar, protein Next diet changes: phosphorus, potassium Help patients read the nutrition facts label and ingredient list Refer to a Registered Dietitian for medical nutrition therapy

Materials designed for both health professionals and patients. Provider Materials Disease process Nutrition assessment and diet intervention Patient Materials General overview, including sample meal plans and serving sizes Laboratory assessment handout Individual nutrient handouts

Coming soon to www.nkdep.nih.gov

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References

References

American Dietetic Association. Chronic Kidney Disease (Non-Dialysis) Medical Nutrition Therapy Protocol. ADA Evidence-Based Guides for Practice. Chicago, IL: American Dietetic Association; 2002. Bossola, M, Tazza, L, and Luciani, G. Mechanisms and Treatment of Anorexia in End-Stage Renal Disease Patients on Hemodialysis. J Ren Nutr 19: 2-9, 2009. Carrero, JJ. Identification of Patients with Eating Disorders and Biochemical Signs of Appetite Loss in Dialysis Patients. J Ren Nutr 19: 10-15, 2009. Edwards, A. Salt, Salt Substitutes, and Seasoning Alternatives. J Renal Nutr. 18:e23-e25, 2008. Food and Drug Administration. Food Labeling Guide, 1999. Available at http://vm.cfsan.fda.gov/~dms/flg-7a.html. Accessed March 2009. Gutierrez, O. Fibroblast Growth Factor-23 Mitigates Hyperphosphatemia but Accentuates Calcitriol Deficiency in Chronic Kidney Disease. J Am Soc Neph 16:2005-2215. International Food Additive Council. Phosphates, 2007. Available at www.foodadditives.org/phosphates. Accessed March 2009.

Institute of Medicine (U.S.) Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. National Academy of Science, 1997. Institute of Medicine. (U.S.) Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. National Academy of Science, 2002. Institute of Medicine. (U.S.) Dietary reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. National Academy of Science, 2004. Kochel, James. Micronutrient Information Center. Oregon State University. Available at http://lpi.oregonstate.edu/infocenter/minerals/phsophorus/phospth.ht ml April, 2007. Accessed March 2009. Medicare MNT Provider Part B News for Registered Dietitians, Volume 7, Number 9. January, 2009. United States Department of Agriculture. Nutrition Facts Label, 2004. Available at www.cfsan.fda.gov/~acrobat/foodlab.pdf. Accessed March 2009.

References

Questions

National Kidney Foundation. Kidney Disease Outcomes Quality Initiative. New York, NY: National Kidney Foundation; 2007. Pennington, JA, Douglass, JS. Bowes and Churchs Food Values of Portions Commonly Used (18th ed.). Philadelphia: Lipppincott, Williams & Wilkins, 2005. U.S. Department of Agriculture, Agricultural Research Service. USDA National Nutrient Database for Standard Reference, Release 21. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl What We Eat in America: www.ars.usda.gov/ba/bhnrc.fsrg

Please contact NKDEP at nkdep@info.niddk.nih.gov with any questions or comments.

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