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Nutritional Recommendations for Renal Disease and Diabetes

Alexis Chettiar ACNP-BC, PhD

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Overall prevalence among adults in the U.S. is estimated to be ~ 14%1

• More than 1/2 of people with chronic kidney disease (CKD) may be undiagnosed2

Diabetes mellitus (DM) is the primary cause of CKD in the U.S.

• More than half of people with CKD have DM1

CKD most commonly occurs in the context of multi-morbidity

• Presence of CKD worsens prognosis for co-morbid illnesses

• CKD increases risk for cardiovascular disease (CVD) and increases morbidity/mortality associated with CVD

• CKD is described as a ‘disease multiplier’

Chronic Kidney Disease (CKD) as a Public Health Issue

1. National Institutes of Health. Kidney Disease Statistics for the United States. http://www.niddk.nih.gov/health-information/health-statistics/Pages/kidney-disease-statistics-united-states.aspx. Accessed Nov 1, 2017.2. Ryan TP, Sloand JA, Winters PC, Corsetti JP, Fisher SG. Chronic kidney disease prevalence and rate of diagnosis. Am J Med. 2007;120(11):981-986. doi:10.1016/j.amjmed.2007.05.012.

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Measurement of Kidney Function

Serum Creatinine (S Cr)

• Byproduct of protein metabolism that is removed by the kidneys

• Increased S Cr indicates decreased renal filtration capacity

• Varies with age, race, gender, nutritional status and muscle mass

Estimated glomerular filtration rate (eGFR)

• Calculated from S Cr

• Accounts for age, race, and gender

• Roughly equivalent to percent of residual kidney function

Stages of Chronic Kidney Disease

Stage Description eGFR (mL/min/1.73 m2)

1 Kidney damage* with normal or increased eGFR ≥ 90

2 Kidney damage* with mildly decreased eGFR 60-89

3 Moderately decreased eGFR 30-59

4 Severely decreased eGFR 15-29

5 Kidney failure <15 or dialysis

*Kidney damage is defined as UACR persistently ≥30 mg/g Cr or other abnormalities on pathological, urine, blood or imaging tests. Adapted from Levey et al. (4).

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Measurable decrease in renal filtering capacity occurs ~ 15 years after onset of DM

• Subsequently, eGFR declines 3-5 mil/min per year

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Pre-CKD Nutritional Recommendations

Achieve and maintain optimal BMI

• Avoid calorie-dense foods

Increase lean protein consumption

Limit carbohydrates

• Select complex carbs

• Avoid simple carbs

Reduce cholesterol

• No saturated fats

Maximize consumption of low-carb vegetables

Low dietary sodium

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A. Yes

B. No

Polling QuestionHave you treated a person with CKD 1 or 2?

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CKD 3

Goals of care

• Forestall CKD progression

• Manage underlying conditions

• DM

• Hypertension (HTN)

• Minimize cardiovascular risk

Nutritional recommendations

• Optimize glycemic control

• Individualized Hgb A1c targets

• Low sodium

• Low cholesterol

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A. 15%

B. 30%

C. 50%

D. 75%

Polling QuestionWhat percentage of the U.S population has a diagnosis of CKD?

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A. 15%

B. 30%

C. 50%

D. 75%

Polling QuestionWhat is the estimated prevalence of CKD among the U.S. population?

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CKD 4

• Management of medical conditions becomes increasingly complex

• People must adjust to new limitations

• Health status is more fragile

• Pill burden increases

15 90CKD 3

CKD 2CKD 4

CKD 5 If d

am

age; C

KD

1

30 60

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CKD 4:Management Challenges

Blood pressure (BP) regulation becomes more difficult

• Increased sensitivity to sodium consumption

• More fragile intravascular volume status

Malnutrition

• Uremia

• Protein aversion

• Anorexia

• Gastroparesis

• Gut edema

Hyperkalemia due to

• ACEi/ARB

• Beta blockers

Nutritional recommendations conflict with prior education

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CKD 4:Goals of Care

DM management

• Achieve and maintain target A1c

• Avoid hypoglycemia

• Increased risk for hypoglycemia due to impaired renal metabolism and excretion of insulin

Control BP to prescribed goal

• Individualized for patients over age 60

Slow development of vascular calcifications

• Serum phosphorous (PO4) <5 mg/dL

• Corrected serum calcium (Ca) at the low end of normal

Serum potassium 3.5-5 mEq/L

Serum albumin ≥ 4 g/dL

Prepare for end-stage renal disease (ESRD)

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CKD 4:Goals of Care

Medical management of anemia and acidemia

• Anemia

• Hgb 10-12 g/dL

• Serum iron sat (T-sat) 20%-40%

• Low T-sat treated with oral or IV iron

• Acidemia

• Venous bicarb ≥ 24 mEq/L

• Low bicarb treated with oral sodium bicarbonate

Prepare for ESRD

• Educate patients about dialysis-related restrictions

• Diet

• Fluids

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CKD 4:Nutritional Recommendations

Individualize and prioritize goals

• Consider quality of life and prognosis

Moderate protein intake; 1-1.5 gms/kg/day

• Lean, low-phosphorous proteins such as chicken, fish, eggs

Reduce dietary PO4 if serum PO4 >5 mg/dL

• Avoid nuts, legumes, processed meats and whole grains

• PO4 binders are off-label in CKD 4

Reduce dietary potassium if serum potassium is >5 mEq/L

• Avoid high-potassium fruits and vegetables

• Avoid potassium-based salt substitutes

Reduce dietary calcium if serum Ca is >9 mg/dL

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Teaching Strategies

• Focus on what people can eat, not what they can’t eat

• Recognize the difficulty of what people are asked to do

• Patients are adults, and have the right to make choices that are not consistent with medical recommendations

• Our job is to inform and educate, not judge or criticize

• Balance health goals with impact on quality of life

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A. Cardiovascular risk reduction

B. Slowed CKD progression

C. Control of underlying disease processes

D. All of the above

Polling QuestionWhat are the primary goals of nutritional counseling for people with renal disease and diabetes?

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CKD 5:Challenges of Management

Choosing ESRD treatment modality

• Dialysis

• Transplant

• Medical management

Impact of medical therapies on quality of life

Complexity of medical regimen

Increased number of dietary restrictions

• Recommendations frequently conflict with previous education

• E.g. reduce consumption of nuts, legumes, whole grains and leafy greens

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CKD 5:Goals of Care

All patients

• Avoid protein-calorie malnutrition

People who initiate hemodialysis

• Compensate for limitations of dialytic therapy

• Maintain lab indicators in target range‣ Albumin

‣ Potassium

‣ Hemoglobin

• Limit fluid consumption‣ Maintain euvolemia

• Slow progression of vascular calcifications and bone mineral metabolism

• Phosphorous

• Calcium

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Fluid Restriction for People with ESRDTreated with HemodialysisGoals

• 1-1.5 L/day total fluid consumption

• ≤ 5% of body weight gained between dialysis treatments

Fluids include

• Anything liquid at room temp such as jello, popsicles, ice

• Moisture-rich foods such as fruits, vegetables, soup

Reducing sodium consumption reduces thirst

Fluid restriction/fluid removal with dialysis is first line treatment for HTN

Substitutes

• Hard candy

• Frozen water bottles

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Managing Phosphorus for People with ESRD Treated with Hemodialysis

PO4 is not adequately removed by dialysis

High serum PO4 drives increased intact parathyroid hormone (iPTH) levels,

worsening bone mineral metabolism disorder (BMMD)

Side effect of high serum PO4 develop over the long term (months)

• Vascular calcifications

• Increased CV risk

• Bone demineralization

PO4 is found primarily in proteins, whole grains and preserved foods

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Managing Phosphorus for People with ESRD Treated with HemodialysisHigh Phosphorus Foods (avoid/limit)

• Proteins

• Dairy products (cheese, milk, yogurt, ice cream), beans, nuts, shellfish, cured meats

• Carbohydrates

• Corn, potatoes, whole grains (brown rice, oatmeal, whole-wheat products, bran etc.)

• Other

• Chocolate, beer, mushrooms, peas, dark colas, packaged and preserved foods

Low Phosphorus Substitutes (encourage)

• Proteins

• Chicken, fish, eggs, low PO4 dairy-like foods (cream cheese, Coffee-Mate, rice milk, popsicles, sorbet)

• Carbohydrates

• White bread, pasta, white rice, grits/cream of wheat, pretzels, saltines (low sodium)

• Other

• White chocolate, white cake (angel food), clear sodas, low-potassium fruits and vegetables in moderation

*Note: Phosphorus is often added to processed or packaged foods. Look for “phos” on ingredient label, such as pyrophosphate. Examples of foods with added phosphorus: chicken nuggets, baking mixes, frozen baked goods, cereals, instant puddings.

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Managing Potassium for People with ESRD Treated with Hemodialysis

Potassium is removed by dialysis

Elevated serum potassium inhibits muscle contraction

• High serum potassium poses immediate risk of cardiac arrest

Rapid reduction of serum potassium, and reduction of serum potassium to below or low-normal range increases risk of fatal dysrhythmias

Potassium is found primarily in fruits, vegetables, dairy products and salt substitutes

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Managing Potassium for People with ESRD Treated with HemodialysisHigh Potassium Foods (avoid/limit)

• Fruits

• Stone fruits, avocado, banana, cantaloupe, citrus fruit, melon, kiwi, mango, pomegranate

• Vegetables

• Hard squash, tomatoes, artichoke, potatoes, sweet potatoes, beets, dark leafy greens (except kale), mushroom, okra

• Other foods

• Milk, chocolate, bran, peanut butter, chewing tobacco, salt substitutes

Low/Moderate Potassium Foods (encourage)

• Fruits

• Apples, blackberries, blueberries, cranberries, raspberries, strawberries, cherries, grapes, pears

• Vegetables

• Kale, asparagus, green beans, cabbage, carrots, cauliflower, celery, onions, peppers, summer squash, radishes, cucumber

• Other foods

• Refined bread products, pasta)

Note: Root vegetables and winter squash can be thinly sliced, soaked and drained to reduce potassium content

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Managing Calcium for People with ESRD Treated with Hemodialysis

Calcium is removed by dialysis

High serum Ca causes nausea and abdominal pain, low serum Ca can cause tetany and muscle weakness

Not all patients need to restrict dietary Ca

Found primarily in dairy products and dark-green leafy vegetables

High serum PO4 artificially reduces serum Ca

Treat based on corrected serum Ca

• Low albumin is common among ESRD patients

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CKD 5:Starfruit Intoxication, Dining Out

Numerous people with ESRD have died from consuming starfruit

• Neurotoxic, nephrotoxic

Italian restaurants offer a selection of ESRD-friendly menu options

• Choose

• Pasta with pesto, olive oil, or butter sauce

• Unsalted bread

• Bread with butter or oil

• Grilled chicken or fish

• Avoid

• Red and white sauce

• Clams, sausage, prosciutto, pepperoni and anchovies

• Olives and cheese

• Tomatoes

• Desserts with chocolate, nuts and cheese

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CKD 5:Dining Out

Thai and Chinese restaurants; can be challenging

• Choose

• Pad Thai without peanuts

• Beef or chicken kabobs

• Steamed rice

• Ask for sauce on the side

• Stir-fry dishes with: chicken, pork, beef, carrots, celery, bean sprouts, snow peas, eggplant, green pepper, onion, cabbage, water chestnuts

• Avoid

• Curry and soups

• Peanuts, cashews and coconut

• MSG, soy sauce, teriyaki sauce, fish sauce

• Bok choy, mushrooms and mung beans

• Desserts with mango or banana

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Mexican

• Choose• Burritos or tacos on wheat tortillas with

meat and lettuce

• Fajitas with sour cream

• Salsa verde (without avocado)

• Avoid• Corn tortillas and corn chips

• Guacamole, avocado

• Cheese and beans

• Tomato, red salsa

Japanese often has good low-sodium options

• Choose• Sashimi, nigiri, sushi rolls or grilled

chicken/fish• Tempura (no sweet potato or dipping sauce)

• Avoid• Sweet potato

• Soy sauce, fish sauce

• Spam

• Shellfish

CKD 5:Dining Out

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American

• Choose• Steak, grilled or broiled chicken, fish, pork

chops, plain hamburger, beef or pork roast

• Plain white rice or pasta

• Green beans, cabbage, carrots, asparagus, zucchini, cauliflower, salad with romaine lettuce

• Plain breadstick or bread

• Apple pie, strawberry shortcake

American

• Avoid• Soups, casseroles, and mixed dishes

with cheese

• Breaded and battered foods

• Ham, corned beef, bacon, sausage

• Spinach, sauerkraut, potatoes, broccoli, Caesar salad

• Beans

• Desserts with chocolate, nuts, or coconut

CKD 5:Dining Out

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Summary

Stage 1Kidney damage with

normal or higher kidney function

Stage 2Kidney damage with

mild decreasedkidney function

Stage 3Kidney damage with

mild decreasedkidney function

Stage 4Severe loss of function

Stage 5Kidney failure

*TX

*kidney transplant

GFR 130 90 60 30 15 0

Dietary recommendations vary according to CKD stage

CKD 1, 2 and 3

• Control underlying disease process

• Slow CKD progression

• Reduce CVD risk

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Summary (continued)

CKD 4

• Maintain serum potassium and phosphorous in normal range

• Keep serum calcium at low end of normal range

• Emphasize sodium restriction for improved BP control and increased efficacy of diuretics and proteinuria suppression with ACEi/ARB

CKD 5

• Maintain serum potassium and phosphorous• Restrict dietary phosphorus, potassium, and calcium as indicated

• Increase protein consumption

• Fluid restriction

General guidelines• Individualize management

• Consider quality of life

• Offer people alternatives to restricted foods

• Nutritional management in CKD is challenging

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Davita Dialysis

• www.davita.com

Fresenius Medical Care

• www.fmcna.com

National Kidney Foundation (NKF)

• www.kidney.org

NIH, National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK)

• www.niddk.nih.gov

Online peer support

• NKF• Chat rooms

Additional Resources

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