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Nutrition and Chronic Kidney Disease Paula Przywojski, RDN, CD, CDE Mayo Clinic Health System: Franciscan Health Care

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What does the kidney do???? • Homeostasis • Fluid • Electrolytes • Acid/base balance • Hormone production • Vitamin D activation • Erythropoietin • Regulates blood pressure • Renin-angiotensin mechanism

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Demographics  26 million Americans have chronic kidney disease  About 1 in 7 people have kidney disease  Diabetes and high blood pressure are responsible for 2/3 of the cases of chronic kidney disease

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Other Causes of Kidney Disease • Glomerulonephritis • Inherited diseases • Repeated kidney infections • Kidney stones • Congenital problems • Medications

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Chronic kidney disease (CKD) 

Abnormalities of kidney structure or function, present for > 3 months, with adverse implications for health

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Rate of progression varies

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Rate of progression partially depends on blood pressure control, blood glucose control

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Kidney’s maintain function till more than 60% of the nephrons fail

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Increased Risk for Kidney Disease  People who  Are Older  Have diabetes  Have high blood pressure  Have a family member with kidney disease  Are African American, Hispanic, Asian and Pacific Islander or American Indian  Obesity

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Stages of Chronic Kidney Disease

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Changes in GFR

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Diabetes Nephropathy • Uncontrolled high blood sugar damages both large and small blood vessels • The kidneys are made up of small blood vessels • Damage to the small blood vessels, microalbuminuria • Number of patient’s has stabalized

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Diabetic Nephropathy • Diabetes is the cause of kidney failure in 4053% of patients starting dialysis • Diabetes is the leading cause of kidney disease and kidney failure

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• Labs

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Other labs • Fasting LPA • Potassium: 3.5-5.1 mM/L • Phosphorus: 2.5-4.5 mg/dL • PTH: Parathyroid hormone 15-65 pg/mL • Vitamin D3-25 Hydroxy: greater than 20 ng/mL • Magnesium: 1.6-2.6 mg/dL • Hgb A1C: goal rang varies

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Diabetes and CKD • Blood Pressure control • Blood Sugar control: 120-180 with AIC levels 6.5-7.5 • Adequate Fluid intake • Healthy Eating plan

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Blood Sugar Control • Take medications as directed • Check blood sugars as directed • Eat balanced meals and snacks • Follow your meal plan as instructed by your diabetes education team-make appointment to see the diabetes dietitian or nurse if needed

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Nutrition and Kidneys: Salt/Sodium • Less salt/sodium has been shown to keep kidneys healthy • Less problems with fluid retention • Salt is about ½ or 50% sodium • Excessive sodium intake can lead to increased problems with high blood pressure and fluid retention • ~2000 mg per day of sodium (90 Meq) • 1 teaspoon of salt = 2300 mg of sodium ©2014 MFMER | slide-17

High Salt/Sodium Foods

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The Obvious Offenders  Potato Chips = 136 mg

 Cheese Puffs = 240 mg

 Pretzels = 385 mg ©2014 MFMER | slide-19

Nutrition Facts Label: Sodium • Less than 200 mg sodium per serving is generally a good goal to aim for • Also look at the % Daily Value: over 20%, usually a high sodium food • Whole entrée/meal: Aim for 500 mg or less

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Goal: Choose and prepare foods with Less salt and sodium • Buy fresh food more often. • Use spices, herbs and sodium-free seasoning in place of salt • Check the Nutrition Facts label for sodium • A daily value of 20% or more means the food is high in sodium • Try lower-sodium versions of frozen dinners and other convenience foods • Rinse canned vegetables, beans, meats and fish with water before eating

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Nutrition and Kidneys: Protein • Waste products of protein digestion: urea and nitrogen= BUN level • High protein diets: Hard on Kidneys • Food Sources of Protein - Dairy Products - Meats/Seafood/Poultry - Nuts and peanut butter - Eggs - Dried Beans and Peas - Whole grains ©2014 MFMER | slide-22

Protein • Needs based on weight • 0.6-1.0 grams/kg of body weight • Use adjusted ideal body weight when over 20% of their ideal body weight • CKD stage 2: 0.8-1.0 gram/kg day • CKD stage 3-4: 0.6-1.0 gram/kg day • 1serving of protein = 7- 8 grams • Example: 75 kg = 60-75 grams or 8-10 servings 45-75 grams or 6-10 servings ©2014 MFMER | slide-23

Protein • A dietary protein intake of 0.8 g/kg body weight per day, the RDA for this macronutrient, is a level that has been achieved in studies of diabetes and CKD. • Reduction in albuminuria and stabilization of kidney function have been reported with dietary protein intake at the RDA level • Nutrition surveys indicate that most people eat in excess of the RDA for dietary protein

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Eat the Right Amount of Protein • Standard portion of meat: 3 ounces-size of a deck of cards. 4 ounces raw = 3 ounces cooked • Consume High quality protein: lean meats, fish, poultry, eggs, dairy, beans and nuts • Divide throughout the day • Plant proteins better than Meat proteins? • Malnutrition: Inadequate protein intake

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Examples of “Junk” Food Protein

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Nutrition/Kidneys: Heart Health • Choose foods that are healthy for heart, blood vessels and kidneys • Prevent fat from building up in these organs • Grill, broil bake, roast or stir-fry foods, instead of deep frying • Lean cuts of meat, like loin or round cuts • Poultry without the skin • Fish, beans, vegetable, fruits • Low-fat milk, yogurt and cheese ©2014 MFMER | slide-27

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Heart Healthy Fats  Choose softer or liquid fats - Soft tub margarine-made with no hydrogenated oils - Any liquid oil-canola and olive oil Limit solid fats such as butter, stick margarine, bacon grease, shortening, lard and deep-fried foods.

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Nutrition and Kidneys: Potassium  Potassium: Mineral that regulates how muscles work  Kidneys balance this regulation • Only restrict if level is elevated • Adequate urine output typically means normal potassium levels • Adequate fluid intake

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Potassium  Certain heart and blood pressure medications can cause potassium levels to increase -”prils”: lisinopril, captopril, enalopril - “sartans”: losartan (Cozaar), valsartan (Diovan), Olmesartan (Benicar), candesartan (Atacand), irbesartan (Avapro) Potassium levels can increase with Chronic Kidney disease if on these medications = irregular heart beat/weakness

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Foods High in Potassium Fruits

Vegetables

• Bananas

• Avocados

• Oranges and Orange juice

• Beets

• Dried Fruits

• Brussels Sprouts

• Cantaloupe and Honeydew melons

• Potatoes

• Fresh pears • Prune juice • Nectarines

• Pumpkin • Sweet potatoes • Tomatoes • Winter Squash ©2014 MFMER | slide-31

Miscellaneous: High potassium • Potassium-based Salt substitutes: potassium chloride is first on the ingredient list-examples are NoSalt and Nu-Salt • Chocolate • Milk • Nuts • Seeds • Sport Drinks

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Nutrition and Kidneys: Phosphorus • Restrict if elevated • Reduced protein intake will naturally restrict phosphorus • CKD 4 : less kidney function • Meats and Dairy • High phosphorus levels: elevated PTH levels/calcium balance for bone health and heart health

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Foods High in Phosphorus • Red meats • Dairy products • Nuts and Seeds • Chocolate • Cola sodas • Whole grain breads, cereals, rice and crackers • Biscuit, waffles, pancakes from a mix or frozen

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Fluid: The Forgotten Nutrient • Kidneys need adequate fluid to function well • Every body organ needs adequate fluids to function well! • Dehydration is harmful to kidneys and Chronic Kidney Disease • Drinking adequate fluids is one of the most important things you can do for your kidneys and your whole body!

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What Counts as Fluid? • Water • Juice • Milk • Coffee and Tea • Soda pop • Anything that melts at room temperature - Jello - Ice - Ice cream, sherbet, popsicles

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Fluid Requirements • Based on your body size • 30 ml per kg of body weight • Most healthy adults need ~ 6-10 cups of fluid per day • 1 cup = 8 ounces • Congestive Heart Failure: 25 ml per kg of body weight • Adjusted body weight used for requirements

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Goal of Diabetes and Healthy Kidneys/CKD • Blood Pressure control • Blood Sugar control: 120-180 with AIC levels 6.5-7.5 • Adequate Fluid intake • Healthy Eating plan

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Nutrition Intervention • People with diabetes and CKD should receive intervention from a specialty-trained registered dietitian that includes individualized management of multiple nutritional aspects • Several studies have documented that frequent patient contact with a registered dietitian accomplishes dietary goals and/or improves clinical outcomes. • Medicare covers MNT for CKD

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Thank you Questions?

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