Renal Research Project

Chelsea Cordes

Chronic Kidney Disease

Function of the kidneys:

Excretory

Acid Base Balance

Endocrine

Fluid and Electrolyte Balance

Causes of the disease:

Cancer

Hereditary

Uncontrolled DM and HTN

Treatment:

Transplant

Hemodialysis

Peritoneal Dialysis

Nutrition Implications of CKD

Protein: Needs dependent on stage of disease

Phosphorus

Potassium

Sodium

H2O

Purpose of ResearchScholarly project observing PO intake of hospitalized CKD pts in comparison to pts on a liberal diet.

Objective: Determine if there is a significant difference in PO intake.

Necessity:

Practicality of the renal diet is unclear.

Diagnostic significance of undernutrition is widely understood.

Protein Energy WastingPEW: abnormally low

levels/excessive losses of body protein mass and energy reserves.

More frequently CKD patients are exhibiting signs of PEW in the early to moderate stages of the disease.

Affects >20-25% of CKD population.

Result of: hyper-catabolic state, declining appetite, and activation of pro-inflammatory cytokines.

Study suggest PEW in CKD results in adverse clinical consequences.

Issues with the Renal Diet

Patient Compliance (leads to decline in quality of life).

Further exacerbations of PEW.

Pts feel: depressed, frustrated, uncertain about what meal plan is ideal.

Renal diets are considered “difficult to integrate into daily life, especially in regard to family and social occasions”.

Downside of Liberalization

Many still oppose the idea of liberalization:

The therapeutic approach to liberalizing protein/phosphorus intake is young and lacks significant supporting evidence.

Potential toxic components of high protein diet are of concern.

Why Research is Necessary

Relevance to the VA

Many veteran CKD patients are categorized as undernourished with prominent PEW.

Many veterans have issues with diet compliance as they are financially and physically dependent on others for care.

Goal of Research

1. Asses the PO intake of CKD diet patients verses liberal diet patients.

2. Compare overall patient satisfaction both pre and post

implementation of a one week menu cycle of each group.

MethodsProspective Quality Initiative Study aiming to inspire quality improvement in the current HD/Renal Diet at the MVAMC.

Goal: Prove liberal diet pts eat more than CKD diet pts due to being more satisfied with NFS.

Data Collection: Plate Waste Study of 25 CKD pts and 25 Liberal Diet pts.

Variables: anthropometrics, co-morbidities, length of stay, and difference in feeding behaviors.

Limitations: pt dentition, pt mental status, pt ability to self feed, secondary symptoms (N/V/C).

Baseline pt satisfaction pre and post implementation of 1 week menu cycle in both groups.

Subjects

25 MVAMC pts on CKD diets ages 65 or older

25 MVAMC pts on liberal diets ages 65 or older

Data AnalysisPlate Waste will be main means a data collection.

Plate waste carried out by subjective judgement of one surveyor.

Results were recorded in increments of 25%

Pt satisfaction will be determined on a scale from 1 to 5 based on 3 phrases:

“My meals taste good”

“My meals look good”

“My overall rating of Nutrition and Food Services is excellent”

Patient Satisfaction Survey

ResultsPost 1 week cycle implementation results showed:

“My meals taste good”: CKD 2.92 vs Liberal 3.48

“My meals look good”: CKD 3.4 vs Liberal 4.36

Overall Satisfaction: CKD 3.88 vs Liberal 4.36

Results of Pt Satisfaction

Survey Statements

Rati

ng

Plate Waste Results

CKD patients ate on average 42% of their mid-day meal.

Liberal diet patients ate on average 62% of their mid-day meal.

Patient Comments

““Rice and Rice and noodles are too noodles are too

hard”hard”

““I wish I had I wish I had

something something

other than juice other than juice

to drink”to drink”

““This food doesn’t This food doesn’t agree with me”agree with me”

““Some changes need Some changes need to be made to this to be made to this

diet”diet”

““Needs Needs more more

flavor”flavor”

““Don’t know Don’t know what the what the

complaining is complaining is about, tastes about, tastes

fine”fine”

DiscussionCKD nutrition requirements: 30 to 35 kcal/kg.

Current Renal diet provides 2000 kcal, current HD diet provides 2600 kcal.

At 42% typical consumption, pts only getting 840-1092 kcal and 22-38 g of protein per day.

Example Pt

5’10” male renal pt weighing and ideal wt of 166 lbs

Meeting 37% of his kcal needs (2263 kcal lower end)

Meeting 49% of his protein needs (45 g lower end)

This caloric deficit could lead to unintentional wt loss of greater than 2 lbs per week of lean muscle mass.

SolutionsConducting more valuable conversations/test trays on the renal/HD diet.

Utilizing/adapting recipes to renal friendly ones such as those found on the Davita website.

Considering expanding from a 1 week cycle to a greater length for CKD pts to offer more variety.

Chicken Fajitas with Pineapple SalsaDiet types:1Dialysis2Diabetes

Portions: 4     Serving size: 2 fajitas and 2 tablespoons salsaIngredients■8 flour tortillas, 6" size

■2 tablespoons canola oil

■12 ounces boneless, skinless chicken breast

■1/4 teaspoon black pepper

■2 teaspoons chili powder

■1/2 teaspoons cumin

■2 tablespoons lemon juice

■1/4 cup chopped green pepper

■1/4 cup chopped red pepper

■1/2 cup chopped onion

■1/2 cup chopped cilantro 

■1/2 cup Pineapple Salsa

Renal and renal diabetic food choices■3 meat

■2 starch

■1 vegetable, low potassium

■1/2 fruit, low potassium

http://www.davita.com/recipes/

Example HD Menu

LimitationsLength of stay

Variance in mid-day meal recorded

Small sample size

Variance in meal prep

Lack of an objective tool for measuring plate waste

Possible bias, all aspects of research by one source

Variables such as: anthropometrics, co-morbidities, feeding behavior, patient dentition, patient mental status, patients ability to self feed, and secondary symptoms present

ConclusionsPts on liberal diets eat 20% more of their mid-day meal than pts on CKD diets.

Examination of pt satisfaction results suggest this deficit may possibly be related to patient satisfaction.

It could be assumed that CKD patients are generally less satisfied and are consuming less in total due to the changes from a 3 week menu cycle to a 1 week menu cycle and the resulting limited variety of food choices offered on the CKD diets.

SourcesKovesdy CP, Kopple JD, Kalantar-Zadeh K, Management of protein-energy wasting in non-dialysis-dependent chronic kidne disease:reconciling low protein intake with nutrition therapy. Am J Clin Nutr. 2013;97:1163-1177.

Hollingdale R, Sutton D, Hart K, Facilitating dietary change in renal disease: investigating patient’s pespective. Journal of Renal Care. 2008;34:136-142.

Shinaberger CS, Greenland S, Kopple JD, Van Wyck D, Mehrotra R, Kovesdy CP, Kalantar-Zadeh K, Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease? AM J Clin Nutr. 2008;88:1511-1518.

Haworth S, Brotherton AM, Correcting metabolic acidosis leads to an increase in dietary protein intake in patients with established chronic kidney disease. Journal of Human Nutrition and Dietetics. 2011;24:277-310.

Uribarri J, Man S, The key to halting progression of CKD might be in the produce market, not the pharmacy. Kidney International. 2012;81:7-9.

Dioguardi FS, The alanine-arginine connection: a key piece in the puzzle of protein renal toxicity, low-protein diets, and the risk of malnutrition in patients with chronic kidney disease. Nutrition Therapy & Metabolism. 2009;27:73-82.

Sigrist MK, Chiarelli G, Lim L, Levin A, Early initiation of phosphate lowering dietary therapy in non-dialysis chronic kidney disease: a critical review. Journal of Renal Care. 2009;35(s1):71-78.

Bross R, Noori N, Kovesdy CP, Murali SB, Benner D, Block G, Kopple JD, Kalandar-Zadeh K, Dietary assessment of individuals with chronic kidney disease. Seminars in Dialysis. 2010;23(n4):359-365.

Kovesday CP, George SM, Anderson JE, Kalantar-Zadeh K, Outcome predictability of biomarkers of protein energy wasting and inflammation in moderate and advanced chronic kidney disease. Am J Clin Nutr. 2009;90:407-414.