Nutritional Assessment in Hemodialysis

Patient

Haneen Nabeel Molla  M.Sc.

Clinical Dietitian King Khalid University Hospital

There are five stages of kidney disease. It based on the presence of kidney

damage and the glomerular filtration rate (GFR)

The treatment is based on the stage of kidney disease.

Stages of Kidney Disease

Stage

Description Glomerular Filtration Rate (GFR)*

1 Kidney damage (e.g., protein inthe urine) with normal GFR

90 or above

2 Kidney damage with milddecrease in GFR

60 to 89

3 Moderate decrease in GFR 30 to 59

4 Severe reduction in GFR 15 to 29

5 Kidney failure Less than 15

Stages of Kidney Disease

Inability to excrete waste products , maintain fluid and electrolyte balance and produce hormones.

End Stage Renal Disease ( ESRD ) :

Kidneys no longer remove enough wastes and fluid from the blood

When only 10 to 15 percent of the kidney function left.

When is Dialysis Needed?

Symptoms such as nausea, vomiting, swelling and fatigue.

A high level of wastes in their blood that may be toxic to their body.

When is Dialysis Needed?

Diet is an important part in hemodialysis patient overall care.

We will go over some of the important points in the patient diet which include : Getting the right amount of calories and protein Staying at a healthy body weight Important nutrients in the diet• Potassium • phosphorus • sodium and fluids • calcium

Diabetic – Renal Diet

Nutrition and Hemodialysis

Prevent nutrients deficiencies Control edema and serum electrolytes Provide an attractive healthy diet

The Goals of the Nutritional Management in Dialysis

Weight kg High cm Body mass index (BMI ): Weight (Height)2

Underweight 16.0 to 18.5

Normal (healthy weight) 18.5 to 25

Overweight 25 to 30 Obese Class I (Moderately obese) 30 to 35 Obese Class II (Severely obese) 35 to 40 Obese Class III (Very severely obese) over 40

Anthropometric Measurement

adjusted body weight (AIBW) = (Actual weight – IBW) x 0.32 + IBW women x 0.38 + IBW men

Ideal body weight (IBW) : (Height)2 x 22.4 men x 22.1

women

% of IBW: Actual Weight x 100 IBW

Anthropometric Measurement

To the patients overall health and helps to give them energy to do their normal activities .

Calories come from all the foods they eat , and are important because : Give the body energy Help to stay at a healthy body weight Help the body use protein for building

muscles and tissues.

Getting the Right Amount of Calories

Will keep the patients from losing weight.

The amount of calories recommended will depend on the individual needs.

Getting the Right Amount of Calories

Energy 35 kcal/kg of body weight for <60 years; 30 to 35 kcal/kg of body weight for >60 years

In pre-dialysis patients have to be on a low-protein diet.

During dialysis patients will need diet with more protein.

It is important for overall health and how well they feel.

Body needs the right amount of protein for: Building muscles Repairing tissue Fighting infections.

Getting the Right Amount of Protein

Protein is found in 2 types of foods:

Protein

Animal sources Plant sources

poultry , meat , eggs, seafood , milk and cheese

nuts, seeds , legumes, soy and tofu

Some of these protein-rich foods may also contain lots of phosphorus, which need to be controlled in their diet.

Protein : 1.2- 1.3 g/kg of body weight, >50% HBV protein

Protein

Potassium is an important mineral found in food.

Potassium helps the muscles and heart work properly.

Healthy kidneys helps to keep the right amount of potassium in the body.

Potassium

Too much or too little potassium level in the blood can be dangerous.

With hemodialysis, patients need to limit their intake of high-potassium foods.

Potassium

Soaking the vegetables after cutting it and cooking it helps to remove high amount of potassium

Potassium : 2 to 3 g/day; or 40mg/kg IBW

Potassium

High-Potassium Fruit

Apricot, raw (2 medium)dried (5 halves)

Avocado (¼ whole)Banana (½ whole)CantaloupeDates (5 whole)Dried fruitsFigs, driedGrapefruit JuiceHoneydewKiwi (1 medium)

(>200 mg / portion) The portion size is ½

cup

Mango(1 medium)Nectarine(1 medium)Orange(1 medium)Orange JuicePapaya (½ whole)Pomegranate (1 whole)Pomegranate JuicePrunesPrune JuiceRaisins

High-Potassium Vegetables

ArtichokeBaked BeansSquashBeets, fresh then boiledBlack BeansBroccoli, cookedBrussels SproutsChinese CabbageCarrots, rawLentilsDried Beans and Peas

(>200 mg / portion) The portion size

is ½ cup

LegumesMushrooms, cannedOkraParsnipsPotatoes, white and sweetPumpkinRutabagasSpinach, cookedTomatoes/Tomato productsVegetable Juices

Other High Potassium Foods

Bran/Bran productsChocolate (1.5-2 ounces)GranolaMilk, all types (1 cup)Molasses (1 Tablespoon)Yogurt

(>200 mg / portion) The portion size

is ½ cup

Low-Potassium Fruit

Apple (1 medium)Apple JuiceApplesauceBlackberriesBlueberriesCherriesCranberriesFruit CocktailGrapefruit (½ whole)

(<200 mg/ portion) The portion size is

½ cup

Grapes, Grape Juice

Raspberries

Plums (1 whole)

Tangerine (1 whole)

Strawberries

Pears(1 small) canned (½ cup)

Pineapple, Pineapple Juice

Peaches, (1 small) canned (½ cup)

Watermelon(limit to 1 cup)

Low-Potassium Vegetables

Asparagus (6 spears)Beans, green or waxCabbage, green and redCarrots, cookedCauliflowerCelery (1 stalk)Corn, fresh (½ ear) frozen (½ cup)CucumberEggplantMixed VegetablesMushrooms, fresh

(<200 mg/ portion) The portion size is ½ cup

WatercressYellow SquashZucchini SquashOnionsParsleyPeas, greenPeppersRadishKaleLettuce

Other Foods Low Potassium

Cake: angel, yellowCoffee: limit to 8 ounces ( 1

cup )Pies without chocolate or

high potassium fruitCookies without nuts or

chocolateTea: limit to 16 ounces (2

cups )

( <200 mg/ portion) The portion size is ½ cup

RiceNoodlesPastaBread and bread products:

(Not Whole Grains)

Phosphorus is a mineral found in different kind of foods.

Eating foods high in phosphorus will raise the amount of phosphorus in the blood.

When phosphorus builds up in the blood, calcium is pulled from the bones. Over time, the bones will become weak and break easily.

Dialysis cannot remove all of this phosphorus.

Phosphorus

A high level of phosphorus in the blood may also cause calcium phosphorus crystals to build up in the joints, muscles, skin, blood vessels and heart.

These crystals may cause serious problems such as• Bone pain• Damage to the heart and other organs • Poor blood circulation• Skin ulcers.

Phosphorus

To keep blood phosphorus at safe levels, patients will need to limit phosphorus-rich foods, and may need to take some medications.

Phosphorus 800 to 1,000 mg/day; or 17mg/kg IBW

Phosphorus

High Phosphorus Food

Protein Carp, sardines, beef

liver, chicken liver ,organ meats, oysters

( >150 mg/portion) The portion size is ½ cup

Dairy Products: Milk, Yogurt ,Pudding,

Custard, Ice cream and Cream soups

High Phosphorus Food

Vegetables dried beans and peas:

baked beansblack beanschick peaskidney beanslentilsnorthern beanssplit peassoy beans

Other foods

bran cerealsbrewer’s yeastnutscaramelsseedsBeveragesAle, Beerdrinks made with milkchocolate drinksCocoa, dark colas

Sodium is a mineral found naturally in foods. It is found in large amounts in table salt and in foods that have added table salt.

Eating too much sodium can make the patient thirsty and cause the body to hold onto more fluid.

Sodium

The extra sodium can cause: Swelling or puffiness around eyes, hands

or feet Fluid weight gain Shortness of breath Rise in blood pressure More work for their heart

Sodium 1 - 3 g/day

Sodium

SEASONINGS

High Sodium Sauces

Salted Snacks

MEATS PROCESSED FOODS

Table saltSeasoning saltGarlic saltOnion saltCelery salt

Barbecue Steak Soy Teriyaki Oyster

CrackersPotato chipsCorn chipsPretzelsTortilla chipsNutsPopcornSunflower seeds

Hot DogsCold cuts, PastramiSausageCorned beefSpam

Frozen prepared foodsCommercial mixesButtermilkCheeseSoupsTomato productsVegetable juicesCanned vegetables Canned raviolisChiliMacaroni & CheeseSpaghettiFast foodsPicklesOlives

Sodium

Fluid is any food or beverage that is liquid at room temperature.

Some examples are: Ice Beverages like coffee, tea, sodas, juices

and water Frozen desserts such as ice cream,

sherbet or Popsicles Gelatin Gravy and Soups

Fluids

Signs may noticed with drinking too many fluids A sudden increase in weight along with

swelling Shortness of breath A rise in the blood pressure

Fluid : output + 1000 ml

Fluids

Calcium is the mineral that is important for building strong bones.

However, foods that are good sources of calcium are also high in phosphorus.

Calcium

To prevent loss of calcium from bones • Follow a diet that limits high-phosphorus

foods• Take phosphate binders.

In some cases the physician may prescribe a special form of vitamin D to help keep calcium and phosphorus levels in balance and prevent bone disease.

Calcium

Patient on hemodialysis diet will have restrictions in foods containing high amounts of phosphorus, sodium and potassium.

Diabetic patients who are on hemodialysis will be tightly controlled the Carbohydrate intake in order to manage the blood glucose levels.

Diabetic-Renal Diet in Hemodialysis

High sugar foods and all carbohydrate containing foods, increase blood glucose levels.

The total amount of carbohydrates the patients eat will be balanced with their medication and activity level.

They could use system called

carbohydrate counting to keep their carbohydrate intake balanced.

Diabetic-Renal Diet in Hemodialysis

Take low phosphorus and low potassium foods .

Limit milk and dairy intake. Control blood sugar to help control

thirst and fluid gains. Avoid cooking with salt, salt

substitutes, or add salt at the table.

Diabetic-Renal Diet in Hemodialysis

Our goal for hemodialysis patients should be a healthy lifestyle that can be maintained in the long run, rather than a short-term "diet”. It's all about making changes that will last a lifetime--changes that are focused on smart, sensible eating.

Conclusion

Thank you