Transcript Dietary Considerations in Renal Failure

DIETARY CONSIDERATIONS IN RENAL
FAILURE
Eileen Duff, Renal Dietitian
Fiona Chawke, Renal Dietitian
7th Aug 2015

AIMS
1. To highlight the risk of malnutrition in patients
with renal disease.
 2. To outline the different dietary requirements of
patients at each stage of renal failure.
 3. To provide practical tips about how to meet the
different nutritional requirements of these
patients.

AIMS OF DIETETIC INTERVENTION…
(WHAT WE DO!)
1. To optimise nutritional status
2. To keep renal biochemistry within safe limits
•
•
K+
PO4-
3. To prevent fluid overload & aid BP control
4. To make dietary advice as practical as
possible to aid compliance
DIET AND RENAL DISEASE
Nutritional Assessment
•1. Anthropometry

Body weight/Dry weight

Weight history
•2.
Biochemistry
•3. Clinical condition
•
•
•4.
Stage or RRT
Symptoms affecting dietary
intake
Diet & diet history
•5. Social aspects
Diet will vary with:
• Biochemistry
• Nutritional
status
• RRT
Diet is important throughout the
‘patient journey’
:
MALNUTRITION
ESTIMATES OF 20-70% IN CKD/HD/PD
WHY… ?
Restrictions to diet
Catabolism
(Dialysis &
acidosis, AKI)
Travel time =
missed meals
Frequent hosp
admission
Mood &
depression
Nutrient
losses
(Dialysis)
•Protein
•Vits & mins
Co-morbidities:
•Cancer
•Diabetes
(gastroparesis)
Factors
contributing to
risk of
malnutrition
Socio-economic factors:
• Lack of food prep. skills
•Low budget ?employment
Anaemia
& fatigue
Infection
e.g. peritonitis
Uraemia:
•Sickness
•Taste changes
•Reduced appetite
ORAL NUTRITIONAL SUPPLEMENTS
Milk-style:




Fresubin Energy = 300kcal, 11g protein
Fresubin Protein Energy = 300 kcal, 20g protein
Fresubin 2Kcal = 400Kcal, 20g protein
While in hospital – various ‘homemade’ milkshakes
Juice-style:

Fresubin Jucy = 300kcal, 8g protein
Dessert-style:

Fresubin Crème/FresYocreme = 225kcal, 12.5g protein
Shot-style:
Fresubin 5kcal 30 ml tds – 450kcal, 0 protein
 ProCal 40 ml tds – 400 kcal, 8 g protein
Also, powders & liquid energy modular supplements

ENTERAL & PARENTERAL NUTRITION
Enteral tube feeding –

often require low electrolyte, fluid restricted feeds for
dialysis patients e.g. Nutrison Concentrate.
Parenteral feeding –

often require ‘scratch or tailored’ bags for electrolyte
flexibility and low volume. Ordered by dietitian and
pharmacist with Medical approval.
Energy
(calories)
Renal Minerals
(potassium &
phosphate)
Diet in Kidney
Disease
Protein
Fluid & salt
(sodium)
Micronutrients:
vitamins &
minerals
FOCUS ON PROTEIN
Pre-Dx (LCC)
HD
PD
Protein
required:
0.75g/kg IBW
≥1.1g/kg IBW
≥1.2g/kg IBW
For 70kg

~53g protein/day =
~30g HBV protein =
~5oz/125g meat or
equivalent daily
≥77g protein/day =
~54g HBV protein =
~9oz/225g meat or
equivalent daily
≥84g protein/day =
~59g/day HBV protein =
~10oz/250g meat or
equivalent daily
Example
meal plan:
Bk = Cereal & toast (1/3
pint milk/d only - ?rice
milk on cereal)
Bk = Cereal & Toast
(1/2 milk/d if low K+ diet)
Bk = 2 Grilled bacon or
sausage on toast
(1/2 milk/d if low K+ diet)
L = S/w (1 thin slice
meat or ¼ tin
tuna/salmon)
EM = Pasta with
vegetables in tomato
sauce (3 rasher bacon)
OR 4oz chicken breast
(if cream cheese at
lunch) No milk pudds
L = S/w (2-3 slice meat
or ½ tin tuna/salmon)
EM = Pasta with
vegetables in tomato
sauce 5oz chicken
breast OR ¼ 500g beef
mince pack in bolognese
+/- cheese on top, or
milk pud (if po4- & fluid
allows)
L = S/w (2-3 slice meat or
½ tin tuna/salmon)
EM = Pasta with
vegetables in tomato
sauce 5oz chicken breast
OR ¼ 500g beef mince
pack in bolognese
+/- cheese on top, or milk
pud (if po4- & fluid allows)
QUIZ…IDENTIFY THE HIGH K FOODS
Carrot
 Tomatoes
 Avocado
 Oranges
 Spinach
 Coconut
 Dried fruit
 Beef
 Pate

Apples
 Milk
 Cake
 Nuts
 Pear
 Fresh beetroot
 Cheese
 Blackcurrant
 Toffee

LOW POTASSIUM DIET
1. Potatoes 4oz/100g boiled per day
AVOID: jackets, chips, crisps, instant mash
2. 3 -6 x 80g portions fruit and/or (boiled) vegetables /day
AVOID: avocados, bananas, blackcurrants, coconut, all
dried fruits (inc. apricots, figs, raisins)
3. Limit milk to ½ pint /day (inc. milk pudding etc)
4. Avoid/limit other high K+ foods:
• E.g. coffee, chocolate, toffee, liquorice, bran, nuts,
fruit juices, salt-substitues(Lo-salt), marmite,
ketchup, brown sauce
Written low potassium advice on the intranet:
http://pht/Departments/NutritionDietetics/default.aspx
PHOSPHATE MANAGEMENT
High
phosphate foods:
Milk allowance (½ pint daily)
 Cheese allowance (e.g. 100g/week)
 Eggs allowance (e.g. 2-3/week)
 Others include: nuts, chocolate,
products with baking powder (e.g.
scones), shellfish, bony fish, offal/pate.

Phosphate
restriction often not
necessary in hospital due to reduced
intake.
No low phosphate menu while in-pt
–choose appropriately from ‘normal’
menu as required.
PHOSPHATE BINDERS
FLUID ALLOWANCE IN DIALYSIS
1.
Reduce salt in the diet =  thirst
2. Effective control of BMs in diabetes =  thirst
3.
Include fluid from foods “liquid at room temperature”:
 Milk on cereal, soups, gravy, ice cream etc.
4.
Use small or half cups
5. Plan a routine for drinks through the day
6. Suck (sugar-free) sweets / chew gum
7. Rinse mouth or clean teeth
8. Suck ice cubes
9. Minimise fluid with meds
RENAL TRANSPLANT
Immediately post transplant:
1. High protein diet & boil drinking water
2. Food hygiene – food storage/ handling/ preparation
& high risk foods
Long term:
1. Healthy eating & weight maintenance
 5-a-day Fruit & veg
 Reduce fats/sugars
 Minimise saturated fats (choose MUFA)
 Physical activity
2. Occ. low K+ needed
3. Occ. steroid-induced diabetes
N.B. Failing transplant as per CKD/Low
clearance
RE-FEEDING SYNDROME
Re-introduce food slowly
 Thiamine and multivitamins for 10 days
(pabrinex)
 Monitor po4, k and mg daily for 10 days
 Re-feeding guidelines on the intranet

http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Refeeding
%20Syndrome%20Guideline.doc

Prolonged vomitting, diarrhoea, alcoholism,
neglect etc are high risk patients.
REASONS TO REFER TO US

New starter HD/ PD

New ‘Crash-lander’ / Catabolic AKI

K+/po4-/fluid modification

Poor intake/Dry weight loss/malnutrition

Nephrotic syndrome

Weight reduction

New transplant advice

NODAT (New onset diabetes after
transplant)
CONTACT DETAILS
Bleep 1479, 1480, 1481
 Phone 02392 286000 ext. 1016 or 1014
 Location: beside the registrars office at QA
 Eileen, Sarah, Caroline, Fiona, Clare, Miriam
 We cover G9, G7, G6 acute wards,
HD units at QA , Havant, Totton, Salisbury,
IOW, Bognor, Milford, Basingstoke and
low clearance clinic at these locations also.

ANY QUESTIONS?