Escolar Documentos
Profissional Documentos
Cultura Documentos
Dr Lina Johansson
Lead Renal Dietitian / NIHR Clinical Lecturer
Glomerulus
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)
Volhard, 1918
Volhard, 1918
(Handbuch der Inneren Medizin)
(Handbuch der Inneren
Medizin)
What do you think about restricted protein
diets?
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 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
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
Female
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?