Renal Disease Part 3

Question 1

nutrition assessment for renal disease included…

Current _______, ______ of CKD, _______ of CKD, ________ plan, ________

PMHx, ____________

Medications=> food-drug interactions

Anthropometric assessment; _____

Nutrition-focused physical examination

Biochemical assessment

Answer 1

diagnosis
cause
stage
treatment
urine output

comorbid conditions

EDW

Question 2

Diet Interview:
Changes in ______
GI c/o; _________
Dietary restrictions – ___________&___________
Nutrition ___________

Answer 2

appetite
altered taste
comprehension & adherence
supplements

Question 3

Diet recall:

assessment of intake of _____, ______,
_______, _______, ________, ________,
______, _______, ________

Ability to ________________________

Answer 3

kcal, protein
Na, K+, Phos, Ca,
fluid, vitamins & minerals

shop and prepare meals

Question 4

Note: need to consider _____________ for patients in ESRD on dialysis.

Answer 4

“acceptable” ranges

Question 5

K+: ______ mEq/L
Higher level=> __________, __________

Answer 5

3.5 – 5.5

excessive intake
food-drug interactions

Question 6

Phos: ________ mg/dL

Higher level=> _____________, ______________

Answer 6

3.0 – 6.0

not taking Phos binders
excessive dietary intake

Question 7

BUN: __________ mg/dL

Higher level=> _____, ______, _____, _______, _______

Lower level=> ______, _______, ______

Answer 7

50-100

inadequate dialysis, excessive protein intake, GIB, hypercatabolism, dehydration

low protein intake, hypervolemia, liver failure

Question 8

Serum albumin

Not a good indicator of _______
Serum level is affected by many factors

Good predictor of ______________in CKD

________ is lost in dialysis
Goal for CKD patient: >_____ g/dL
If low=>___________

Answer 8

nutrition status
morbidity & mortality
Protein
4.0
increase intake of protein-rich foods

Question 9

Goals of MNT for CKD

Maintain or improve __________
Reduce the accumulation of __________=> minimize _________ symptoms

Slow _________ of renal disease
Control ____
Minimize _________ imbalances
Prevent _____________
Provide a healthy and palatable diet

Answer 9

nutritional status
metabolic byproducts
uremic

progression
HTN
fluid & electrolyte
renal osteodystrophy

Question 10

Nutritional Requirements Individualized based on:

_____ of CKD and treatment _____
Nutritional status

Use the______ of energy & protein ranges for patients with malnutrition
Comorbidities

Answer 10

Stage
modality

upper end

Question 11

Energy

Higher kcal to spare _______ and prevent _______
______ kcal/kg body weight
Weight to use is based on clinician judgement (EDW, IBW, current wt, or ABW)

Note: if on PD, consider ________
Dextrose can be absorbed from the dialysate and contribute up to ______ kcal/day

Answer 11

protein
catabolism
25-35

kcal from dialysate
400-800

Question 12

Calculating Calories Absorbed from PD Dialysate

Add the _______ from all exchanges in a day
Multiply by:
CAPD: ____% absorption
APD: ____% absorption
Multiply by ____ kcal/ gram

Answer 12

grams of dextrose

60
40

3.4

Question 13

Calories Absorbed from PD Dialysate - CAPD (calculate)

PD Prescription:
2 exchanges of 2L 1.5% dextrose
2 exchange of 2L 4.25% dextrose

Answer 13

4000 ml X 0.015= 60 grams
4000 ml X 0.0425= 170 grams
Total: 230 g of dextrose

230 g X 60% absorption=138 g CHO
138 g X 3.4 kcal/g= 469 kcal from CHO from PD dialysate

Question 14

Protein

Eating too much can contribute to ______
Eating too little contributes to _______________

Answer 14

uremia
muscle wasting and malnutrition

Question 15

Protein Recommendations

CKD, Stage 3-5 non-dialysis, who are metabolically stable:
_________ g/kg body wt

If the individual has DM:
________ g/kg body wt

HD & PD:
________ g/kg body wt

There are specially formulated supplements available for individuals with CKD
e.g., ________, __________

Answer 15

0.55-0.6
0.6 – 0.8
1.0-1.2

Nepro, Novasource Renal

Question 16

Protein Sources

For individuals with CKD, there is inadequate evidence to recommend a particular protein type (plant vs. animal)

Vegetarian protein diets may have possible clinical benefits (e.g., lower absorption of ______)

Also need to consider that some high protein foods are also high in ________________

Answer 16

phosphorus

phosphorus and sodium

Question 17

Fluid Recommendations

Patients cannot get rid of extra fluid if they are not _______
Fluid recommendations depend on ____, _____, ______

Answer 17

making urine
urine output, edema, & mode of treatment

Question 18

CKD, non-dialysis: _____________

HD: ___________
Goal is to prevent fluid gains of ____ kg between HD sessions (interdialytic weight gain)

PD: _____________

Answer 18

typically, no restriction

24-hour urine output + 1000 ml
>2

individualized, maintain balance

Question 19

Assess for Fluid Overload

___________- remember many patients will not be making much, if any, urine

Examine ___________ for edema
Daily _______

____________ when patient breathes

Answer 19

Monitor I/O

ankles & hands
weights

Gurgling noises

Question 20

Fluid
Determine fluid allowance;
educate on restriction (if needed)
Includes everything that is ___________

Beverage options:
* Need to consider ___________ content
______, _______, or _________
______ - limit to ____ cup per day due to high ________ content
_____ & ______

Answer 20

liquid at room temperature

K+, phosphorus, & Na

Water, Low K+ juices, Clear or fruit-flavored carbonated beverages

Milk
½
phosphorus

Coffee & tea

Question 21

Tips to control fluid intake

____ beverages and beverages that are _____ will quench thirst better

Limit ________ foods
Drink from __________
_______ candies
Add _______ to water

Swish mouth with ______ (then spit out)
_______ gum

Answer 21

Cold
less sweet

high sodium
small glasses & cups
Sour hard
lemon juice

cold water
Sugar-free

Question 22

Sodium

Limit sodium to:
reduce ____
improve ______
reduce _____
limit ___________
control_______
CKD, Stage 3-5 or on dialysis: <______ mg/d

Answer 22

BP
volume control
edema
interdialytic weight gain
thirst
2300

Question 23

Sodium Recommendations

Educate on sodium _______, _______, and _________

Assess diet recall/food record for _______

Answer 23

restriction
rationale
foods to avoid/limit

sodium sources

Question 24

Hyperkalemia can cause=> ___________

Answer 24

nausea
muscle weakness
fatigue
paralysis
arrhythmias
heart stoppage

Question 25

Potassium Recommendations

CKD Stage 3-5 or on dialysis: ______________

Lower dietary intake if _________

Note: Per previous 2000 KDOQI guidelines:
CKD without dialysis: _____________
HD: _________ mg/d
PD: _________ mg/d

Answer 25

Adjust dietary potassium intake to maintain serum level WNL

hyperkalemia

unrestricted unless hyperkalemia
2000-3000
3000-4000

Question 26

Potassium: Converting mg to mEq

Divide the ________ of potassium by the _________ of potassium to get milliequivalent’s (mEq)

Example:
2400 mg of K

Answer 26

milligrams
atomic weight (39)

2400/39= 62 mEq K+

Question 27

For those with hyperkalemia:
Assess _______ for sources
Inquire about ___________

Educate on limiting _________ foods and substitute with foods ______________

Consider ______

Answer 27

diet recall/food records
salt substitutes

high potassium foods
lower in potassium

food-drug interactions

Question 28

higher potassium fruit choices
> _____ mg K+ per serving (usually ____ cup)

Examples?

Answer 28

200
½

1 orange; orange juice
Banana
Avocado
Nectarine
Dried fruit: raisins, dates
Prunes & prune juice
Honeydew melon, cantaloupe

Question 29

Lower Potassium Fruit Choices
<_____ mg K+ per serving

Examples?

Answer 29

200

Apple, applesauce, & apple juice
Grapefruit
Grapes & grape juice
Pineapple & pineapple juice
Pears, peaches
Cherries, blackberries, raspberries, strawberries, blueberries
Fruit cocktail
Cranberries & cranberry juice cocktail

Question 30

High Potassium Vegetable Choices
>______ mg K+ per serving (usually ____ cup)

Examples ?

Answer 30

200
½

Potatoes –white & sweet
Tomatoes, tomato sauce, tomato juice
Spinach and greens
Artichokes
Squash
Zucchini
Beets
Brussel sprouts

Question 31

Lower Potassium Vegetable Choices
<____ mg K+ per serving

Examples ?

Answer 31

200

Peppers
Asparagus
Broccoli, cauliflower
Peas
Green beans
Lettuce
Cucumber
Carrots
Mushrooms

Question 32

Additional High Potassium Foods

Answer 32

Milk, yogurt
Legumes

Question 33

Phosphorous

Hyperphosphatemia=> can contribute to _______& _______

CKD Stage 3-5: __________
______________ if hyperphosphatemia

Note: The 2020 KDOQI guideline ________
Per previous 2000 KDOQI guidelines: limit dietary phosphorus intake to ______ mg/day if hyperphosphatemia

Answer 33

renal osteodystrophy
metastatic calcifications

Adjust dietary phosphorus intake to maintain serum level WNL
Lower dietary intake

did NOT provide specific amount
800-1000

Question 34

Phosphorus Recommendations

Review serum levels

_________ may be prescribed to help control serum phosphorus levels.
- these can be taken ______

• Assess diet recall/food records
• Provide diet education
• Eat more ______ and decrease intake of _______
• _______ for phosphate additives

Answer 34

Phosphate binders
with meals

fresh foods
processed foods
Label reading

Question 35

High Phosphorus Foods
>____ mg/serving

Examples ?

Answer 35

100
Dairy products
Meat & poultry
Dried beans & peas
Seeds, nuts, & nut butters
Bran cereal, oatmeal, granola
Soybeans, soy milk, & tofu

Question 36

Possible deficiencies due to:

Poor ______
Dietary _______
Altered _________
Losses during dialysis =>________ vitamins

Answer 36

appetite
restrictions
metabolism
water-soluble

Question 37

Vitamin Recommendations

Vitamin ____and ___ are usually not supplemented for patients on dialysis due to risk of toxicity

Vitamin____ given as active form __________

If at risk for vitamin ___ deficiency, consider supplementation to meet but not exceed the DRI (___ mg/d for women & ___ mg/d for men)

Answer 37

A & E

D
vitamin D3

C
75
90

Question 38

For patients on ____, renal ______________ supplements may be considered

Examples?

Answer 38

HD

water-soluble vitamin

Nephrocaps
Dialyvite

Question 39

Determining the Diet Prescription

Estimate nutritional needs

Avoid ordering the “Renal Diet” – need to individualize
Include recommended amounts of key nutrients in diet order: _______________

Answer 39

protein
K+
Na
Phos
fluid

Question 40

Education & Counseling

CKD is a chronic illness and a life-changing event
May be a time of severe emotional upheaval and adjustment
Must first assess ___________

Answer 40

readiness to learn

Question 41

Factors that Affect Readiness to Learn

Answer 41

Feelings of disbelief
Depression
Uremia
Health literacy

Question 42

Suggestions for Education Sessions

_________ recommendations and prioritize ________

Nutrition priorities may change from visit to visit
_______ instructions and ____ education

Use diet recall/food records
Involve ___________

Answer 42

individualize
nutrition problems

Simplify
pace

significant other(s)