Renal Diets.

Niamh Bourke, 31763005.

(i) Dietary Principles Weight/Lifestyle: This patient is in the normal weight category (Figure 1) according to the WHO (1998), therefore, there is no need to restrict fat in his diet. However, in renal patients it is recommended that monounsaturated fatty acids (MUFAs) are used as opposed to saturated fats. This is due to the fact that they can be at an increased risk of cardiovascular disease (CVD) due to hypertension. As his energy intake should be ~2,300kcal/day (Figure 5), fortification of the diet may be required in order to sustain his weight. Statins may be required to further reduce the risk of CVD (CREST, 2006a). We are unaware of this patients lifestyle, however, it would be recommended that CKD patients stop smoking and increase physical activity (CREST, 2006a). Hypertension: Hypertension is the most common cause of Chronic Kidney Disease (CKD) (Thomas, 2007). It is a well-known risk factor for a faster progression of kidney failure (Krzesinski & Cohen, 2007). One of the main aims this patient will have is to reduce his blood pressure by both dietary and medical means and therefore, potentially reduce the risk of the CKD worsening. Blood pressure should be less than 130/80 mmHg in CKD patients (CREST, 2006a). CKD is irreversible so reducing symptoms and the risk of it developing further are important approaches to be taken. Sodium restriction is one major dietary way of controlling hypertension. It is also restricted in CKD because as the kidney losses its ability to function, less sodium will be excreted and therefore sodium will build up in the body (Thomas, 2007). Excess sodium can be problematic as it increases thirst and some CKD patients may also be on a fluid restriction. No Added Salt (NAS) diets are the best method of controlling sodium intakes as 40mmol and 22mmol/d intakes are very restricted and not recommended after discharge from hospital (Thomas, 2007). This restricts sodium intake to ~80100mmol a day. Chronic Kidney Disease (CKD): In patients with CKD, specific nutrients need to be considered: Protein: There is a risk of protein intake declining as CKD progresses as the patient may be feeling unwell and therefore, poor intakes of protein and other nutrients can occur (Ikizier et al. 1995). There is much debate over how much protein should be included in the CKD diet. Traditionally it was kept to <0.6g/kg/day as a means of slowing the progression of CKD and delaying the need for dialysis (Giovannetti & Maggiore, 1964; Addis, 1948). However, adhering to a low protein diet is very demanding and there is evidence that compliance is reduced in some patients (Levey et al. 1996). Recently studies show that a higher protein diet may be more beneficial. In Study A of the MDRD trial, the low-protein diet group had significantly lower energy intakes, body weight and biochemical nutritional markers (Kopple et al. 1997). This study shows the importance of protein in the diet of a CKD patient in preventing malnutrition. The Renal Association (1997) therefore recommended a protein intake of 0.8-1.0g/kg ideal body weight (IBW)/day. It is recommended that 70% of the protein comes from a high biological value (HBV) source (Thomas, 2007). As this patient is elderly and is at a risk of malnutrition, a 1.0g/kg IBW/day protein will be used. Estimations of protein requirements and high and low biological values are shown in figures 3 & 4 respectively.

Potassium: Hyperkalaemia which is high potassium in the blood is a major concern due to potential cardiac effects (Thomas, 2007). Due to continued deterioration in the kidney, there is difficulty in controlling the potassium in the body. Usually potassium isnt restricted in CKD patients initially until there is a serum potassium level above 5.5mmol/l (Thomas, 2007). We are unsure whether this patient has a restriction or not. If dietary intervention is required, the goal is to restrict potassium intake to 1mmol/kg body weight daily so therefore, this patient would require ~70mmol/day (Thomas, 2007). If the patient is hyperkalaemic, then drugs such as ACE inhibitors, Beta blockers and digoxin should be stopped immediately. Haemodialysis may also be required in drug therapy is unsuccessful (CREST, 2006b). Phosphate: There is a small proportion of inorganic phosphate in the serum that is regulated by the kidneys. When the kidney function deteriorates to below 25-30ml/minute (moderate/severe) (CREST, 2006a), then phosphate retention will occur. We are unsure what stage this patients CKD is at. Hyperphosphataemia can lead to secondary hyperparathyroidism and without dietary intervention; high levels of circulating parathyroid hormone can lead to renal bone disease (Thomas, 2007). Therefore, it is important to monitor phosphate carefully in order to prevent this. Restriction is recommended if serum phosphate is >1.6mmol. Phosphate in the diet is usually associated with protein-containing food so careful interpretation and close monitoring needs to be carried out. An average of 60-80% of the phosphorus intake is absorbed in the gut in a CKD patient. If phosphate binders are taken, the phosphorus absorbed from the diet may be reduced to 40% (Takeda et al. 2007). Some commonly used phosphate binders are calcium carbonate (e.g. Calcichew, Adcal), calcium acetate (e.g. Phosex), sevelamer hydrochloride (e.g. Renagel). However, more recently another substance has raised interest as a phosphate binder: lanthanum carbonate (Savica et al. 2006). Energy: It is important to ensure adequate energy intake to ensure protein is not used for energy and to prevent muscle wasting and weight loss occurring. Energy intake in a patient with CKD is similar to that of a healthy adult so approximately 35kcal/kg IBW/day should be recommended (Thomas, 2007). Due to the fact that this patient is 75 years old and has an estimated energy requirement of 2,330kcal/day, it may not be possible for him to obtain all these calories from his diet, especially if his appetite is poor due to feeling unwell and effects of medication. In this case, his meal provides ~1,900kcal so therefore, it falls short of ~430kcal. Supplements can be added to make up for this deficit. Recommended supplements would be a carbohydrate based supplement such as Maxijul Super Soluble Powder, Polycal Powder or Polycose, a fat based supplement such as Calogen or Liquigen or a fat and carbohydrate based supplement such as Duocal Super Soluble Powder or Duocal MCT Powder. Fluid: Fluid isnt usually restricted unless there is an overload of fluid in the body which may result in pulmonary oedema (which is an accumulation of fluid in the lungs) and a shortness of breath. Where fluid restriction is indication, there should also be a sodium restriction to ensure there is no excess desire for fluid. Fluid restriction can often be problematic as CKD patients are normally on quiet a few drugs several times a day. Ice-cubes are useful to prolong any allowances. Micronutrients: Anaemia can be a problem in CKD as the kidney produce erythropoietin which is required to make red blood cells. It can be given artificially; however, supplementation of iron may also be necessary to ensure it works effectively. There is no evidence that CKD patients require

supplementation of micronutrients, however, due to the restricted diet and especially if restricting potassium, supplementation of vitamins C, B1, B2 and B6 may be necessary (Thomas, 2007). Lives alone and does his own cooking: This patient lives alone and does his own cooking so therefore, he may be more likely to buy ready prepared meal and take-away food for convenience. Due to the fact that he is 75 years, he may be quiet set in his ways and consume a very traditional diet with potatoes, vegetables and meat been the main components. Trying to get him to change to pasta and rice as opposed to potatoes at this stage in his life may be quiet difficult if he is not use to them, however attempts should be made. Therefore, practical advice about cooking food and adding flavouring should be given to this patient in order to try to reduce the amount of salt, phosphate and possibly potassium in his diet. As he is 75 years, he may not be able to consume large amount and portion sizes should be keep relatively small. Foods which are easy and quick to cook such as boiling vegetable, rice or potatoes should be consider and quickly stir-frying meat as he may not enjoy cooking. Convenient, easy to purchase foods that are cheap and easy to but at the local corner shop are best as we are unaware of where this patient lives and he may not have assess to large supermarkets regularly. (iii) Practical Dietary Advice Providing practical information of how to avoid certain foods in the diet is essential as they add greatly to the intake of that nutrient. This patient may not be aware of the practical ways of eliminating these nutrients and therefore, this information would be very useful for him. How to avoid salt: Practical ways of avoiding salt in the diet include: not adding salt at the table, using herbs and spices in stead of salt when cooking, avoid processed foods which would be high in salt, e.g. pizzas, bacon, sausages, burger, stock cubes, ready meals, tinned vegetables, packet or tinned soup and salted snack (e.g. crisps, nuts). Also try to avoid take-away foods and foods that have been smoked or picked as much as possible as these foods contain a lot of salt. Meat brought from delicatessen is likely to be lower in salt than meat in a packet. Bread should be keep to a maximum of 4 slices a day and cheese should not exceed 3 small portions per week. Alternative flavourings that could be included in the diet include: mustard, herbs (parsley, mint) and lemon juice. How to avoid potassium: Avoid salt alternatives as they can be high in potassium. Foods which are rich in potassium and should be avoided include: chocolate, crisps, chips, coffee, malted drinks, wine, beer, dried fruit (including cereals and cakes), mushrooms, parsnip and baked beans. One small serving of fruit (e.g. apple, pear, orange, 2 plums) and a maximum of two small serving of vegetable (e.g. broccoli, carrots, peas, onions) can be included. Just one portion of milk and dairy products should be consumed daily. A small serving daily of boiled or mashed potatoes can be included. How to avoid phosphate: Cheese is a rich source of phosphate and should be avoided. Milk is also a rich source and should be kept to an intake of 250ml daily. Offal (e.g. liver, kidney and sweetbreads) and certain types of fish (e.g. herring, kippers, mackerel, trout, crab, prawns) should also be avoided. Chocolate, toffee, malted milk drinks, nuts and baking powder are also all rich sources of phosphate. How to avoid excess protein: Protein isnt restricted as strictly as it once was. Avoid large portion of meat and diets based on meat as this is the main source of protein in the diet. Cheese and milk are also high in protein but are usually restricted anyway due to their high phosphate and potassium levels.

Reading labels: It would be useful to give this patient basic information on how to read a label. Showing him where the ingredient list is to look for baking powder would be useful and explaining to him, that the higher up the list, the more baking powder there is in the product. Although potassium and phosphate are not included in the nutritional information, sodium often is. Explaining that sodium levels and salt levels are actual different values and that salt is 2.5 times the value of sodium, may help him realise more clearly how much salt he is including in his diet. Cooking: The best method of cooking vegetables and potatoes for this patient when he has CKD is boiling, as the potassium in the foods will leach into the liquid. It is important to remember not to use this liquid for gravies or soups. General healthy eating guidelines and recommendations: It is often difficult to give dietary information to patient with CKD who have been following healthy eating guidelines for a number of years. This is especially true for this patient as due to his hypertension, he would be at an increased risk of CVD and therefore, should have been recommended to follow healthy eating guidelines where there would have been a big emphasis on 5 a day. Extra care and time needs to be taken in explaining to this patient, that they are not to include the 5 a day as many fruits and vegetables are high in potassium. Monitoring: Biochemistry: Regular monitoring of urea and electrolytes and glucose is essential to prevent adverse side effect and to alter dietary habits. Serum albumin is useful in the detection of malnutrition should be measured with tranferrin, ferritin and pre-albumin to give a more reliable measure (Thomas, 2007). Anthropometry: Weight and BMI measurements are a useful indicator of malnutrition; however, care needs to be taken as oedema may alter the results. Mid-arm circumference can also be measured as loss of circumference can be an indicator of muscle wasting due to low protein diets (Thomas, 2007). Dietary: A diet history of 48 or even 24 hours can be a useful marker of nutritional intake. Where blood biochemistry is abnormal, patients may be requested to keep a 4 day or a week food dairy. Blood Pressure: Due to the fact that this patient have hypertension, blood pressure needs to be closely monitored and should be keep below 130/80mmHg (CREST, 2006a). Fluid Balance: Fluid balance chart should be keep for every patient with CKD when admitted to hospital to ensure that output is equal to input. If output is reduced, fluid restriction is essential. Glomerular Filtration Rate (GFR): This should be monitored to ensure that the patients CKD is not worsening and to implement strictly dietary or medical control. Stages of CKD are in Table 2. DEXA: Annual DEXA scans may be useful to detect early signs of renal bone disease especially in menopausal females. 12-lead ECG and cardiac monitoring: Mandatory in patients with hyperkalaemia (CREST, 2006b).

References: Addis T. (1948) Glomerular Nephritis: Diagnosis and Treatment. New York: Macmillan. CREST. (2006a) Guidelins for the treatment of chronic kidney disease in Northern Ireland. CREST. (2006b) Guidelines for the treatment of hyperkalaemia in adults. Giovannetti S & Maggiore Q. (1964) A low-nitrogen diet with proteins of high biologic value for severe chronic uraemia. Lancet, i: 10013.

Ikizier TA, Green JH, Wingerd RI, Parker RA & Hakim RM.(1995) Spontaneous Dietary Protein Intake During the Progression of Chronic Renal Failure. Journal of the American Society of Nephrology, 6:1386-91. Kopple JD, Levey AS, Greene T, Chumlea WC, Gassman JJ, Hollinger DL, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR & Zimmer GS. (1997) Effect of dietary protein restriction on nutritional status in the Modification of Diet in Renal Disease Study. Kidney International, 52: 77891. Krzesinski JM & Cohen EP. (2007) Hypertension and the Kidney. Acta Clinica Belgica, 62(1): 5-14. Levey AS, Adler S, Caggiula AW, England BK, Greene T, Hunsicker L, Kusek JW, Roger NL & Teschan PE. (1996) Effects of dietary protein restriction on the progression of moderate renal disease in the modification of diet in renal disease study. Journal of the American Society of Nephrology, 7: 2616-2626. Renal Association. (1997) Treatment of Adults and Children with Renal Failure. Standard and Audit Measures. London: Royal College of Physicians. Savica V, Calo LA, Monardo P, Santoro D & Bellinghieri G. (2006) Phosphate binder and management of hyperphosphateaemia in end stage renal disease. Nephrology Dialysis Transplantation, 21:2065-68. Takeda E, Yamamoto H, Nishida Y, Sato T, Sawada N & Taketani Y. (2007) Phosphate restriction in the diet. Contributions to Nephrology, 155:113-24. Thomas B & Bishop J. (2007) Manual of Dietetic Practice; Fourth Edition. Blackwell Publishing, Oxford. World Health Organisation (WHO). Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity, Geneva, 3-5 June 1997. Geneva: WHO, 1998.

Appendix: Table 1. Menu, exchanges and calories. Menu: Exchanges: Breakfast: Bowl of porridge made up with whole Bowl of cornflakes-1 exchanges milk and a teaspoon of honey of LBV Cup of tea with whole milk Calories: Cornflakes-150kcal Milk-150kcal Honey-40kcal Apple-50kcal

Small apple Morning Snack: 2 slices of wholegrain toast with flora and jam Cup of tea with whole milk Lunch: Wholegrain bread with roast beef, lettuce and flora 1 pot of yogurt Glass of water Afternoon Snack: Two digestives biscuits with flora Dinner: Rice, chicken breast, peppers and sweetcorn with a wholegrain mustard sauce Glass of water Supper: 1 slice of wholemeal toast with flora and jam

2 slices of toast-2 exchanges of LBV

Bread-2 exchanges of LBV Beef-1 exchanges of HBV Yogurt-1 exchange of HBV Biscuits-1 exchange of LBV Rice-1 exchange of LBV Chicken-3 exchanges of HBV

1 slice of toast-1 exchanges of LBV 1 exchange of HBV protein for the milk 1 exchange of LBV protein for the fruit and vegetables. 6 HBV exchanges 10 LBV exchanges

Total-390kcal Toast-150kcal Flora-40kcal Jam-80kcal Milk-20kcal Total-290kcal Bread-150kcal Beef-100kcal Flora-40kcal Yogurt-150kcal Total-415kcal Biscuits-140kcal Flora-40kcal Total-180kcal Rice-220kcal Chicken-180kcal Mustard sauce-30kcal Oil-30kcal Total-460kcal Toast-75kcal Flora-20kcal Jam-40kcal Total-135kcal

Total:

1,895kcal

Table 2. Stages of CKD. Stages Description 1 CKD with normal or increased GFR and urinary abnormalities 2 Milk CKD 3 Moderate CKD 4 Severe CKD 5 Established renal failure (Source: CREST Guidelines for CKD in NI, 2006) BMI: Weight(kg) = 70kg = 70kg = Height(m) (1.7m) 2.89m 24.22kg/m

eGFR (ml/min/1.73m) >90 60-89 30-59 15-29 <15 or on dialysis

Figure 1. Body Mass Index (BMI) of the patient. BMI: Weight(kg) = Weight(kg) = Weight(kg) = 23kg/m, Height(m) (1.7m) 2.89m

Therefore, Weight(kg) = 23 X 2.89 Weight = 66.5kg Figure 2. Ideal Body Weight (IBW) Using an ideal body weight of 23kg/m and the reference range 0.8-1.0g/kg IBW/day (Renal Association, 1997) 0.8(66.5) - 1.0(66.5) 53.2g - 66.5g per day. Figure 3. Protein Requirements Using the upper end of the normal range of the protein requirement to ensure adequate intake, High Biological Value (HBV) - 70% of 66.5g = 46.5g divide 7g = 6 exchanges Low Biological Value (LBV) 30% of 66.5g = 20g divide 2g = 10 exchanges Figure 4. Protein Exchanges 35kcal/kg IBW/day (Thomas, 2007) 35kcal X 66.5kg = 2,330kcal/day Figure 5. Estimation of Energy Intake.