NUTRITIONAL MANAGEMENT OF ESRD TREATED WITH MAINTENANCE HEMODIALYSIS

Objectives: Describe the importance of nutritional intervention for Hemodialysis patients Identify components of nutritional assessment Explain nutritional requirements for hemodialysis patients

IMPORTANCE OF RENAL DIET Renal diet minimizes the amount of wastes A good meal plan choices can: Minimize build-up of waste products & fluid between treatments Improve nutritional and functional status Conserve muscle mass

NUTRITIONAL ASSESSMENT Anthropometric measurements: Height, and weight; BMI Weight changes Intradialytic weight gain Triceps skin folds, and midarm muscle circumference

Diet history: Appetite change Preferred foods Time schedule and pattern of eating Food allergies and intolerance Acute or chronic GI concerns Swallowing and chewing problems Psychological factors contributing to food intake; stress, anxiety or depression Religious and cultural restriction Supplement intake & medication Nutritional knowledge

Food records; 24 hour recall, 3 days food record, food frequency questionnaire

Laboratory findings: Serum albumin and blood glucose Serum sodium, potassium, phosphorous, calcium Lipid profile; cholesterol, HDL, LDL, Triglycerides Hemoglobin level Iron and ferritin stores Hemoglobin A1C Parathyroid hormone (PTH) Urea clearance (URR)

GOALS OF NUTRITIONAL MANAGEMENT Provide an attractive and palatable diet Control edema and serum electrolytes Prevent nutritional deficiencies Prevent renal osteodystrophy Prevent cardiovascular complications

Maintenance of adequate protein intake: 1.2-1.5grams protein per kg per day; average 80gm Necessary to make & repair cells, builds muscle and keeps the immune system working Important for growth & maintenance of body tissue. Choose high biological protein food such as meat, fish, chicken, cheese, eggs and dairy products Oral supplement or intradialytic parenteral nutrition (IDPN) for protein should be given for severe protein energy malnutrition.

Calorie intake: Sufficient calorie intake is required to prevent protein catabolism and malnutrition. 30-35 calories per kg per day

Present in carbohydrates, fats and protein Inadequate caloric intake cause muscle wasting and malnutrition

Manage Hypertension and Sodium restriction: Reduce salt intake; 2-3gm/day Reduce dietary salt and alcohol intake, and stop smoking Use a little salt in meal preparation and avoid adding salt after preparation Use spices and herbs to add flavor to food. Fresh garlic, anion, ginger, vinegar, ground pepper, lemon and lime juice can be used to make food taste better. High sodium intake may increase thirst and tend to drink more water. Avoid meals prepared using monosodium glutamate; take-away outlets and ready-to eat- meals sold in supermarkets. Limit convenience foods and cook more. Avoid salted, canned, packaged convenience foods, smoked or cured fish or meat, food canned in brine, and soy sauce Avoid salt substitute or Lo-salt; they contain large amount of potassium Prepare meals using fresh ingredients Read food labels and check for additives such as MSG or salt substitutes.

Potassium restriction: Potassium helps your muscles and heart work properly. Too much or too little potassium in the blood can be dangerous. With hemodialysis patients need to limit high-potassium foods. Large amounts of potassium are found in: - certain fruits and vegetables (like bananas, melons, oranges, potatoes, sweet potatoes, tomatoes, nuts and some juices) - milk and yogurt - dried beans and peas - most salt substitutes - protein-rich foods such as meat, poultry, pork and fish. - Decrease potassium in vegetable by soaking them in large amount of water to leaches out the potassium (ANNA, 1995)

Calcium and phosphate: Decrease phosphate intake and increase calcium intake. Eating foods high in phosphorus will raise blood phosphorus level, and dialysis cannot remove all of this phosphorus. When phosphorus builds up in the blood, calcium is pulled from the bones. Over time, the bones will become weak and break easily.

A high level of phosphorus in blood may also cause calcium phosphorus crystals to build up in your joints, muscles, skin, blood vessels and heart. These deposits contribute to calcification; o Peri-articular calcification cause tendonitis and bone pain o Cardiovascular calcification damages to the heart and other organs, poor blood circulation and skin ulcers. Symptoms of high phosphorus include itching, red eyes, joint pain. High phosphorus diet includes; Dairy products beans, nuts and seeds, processed meats, chocolate, pancakes, waffles, biscuits, cakes, sardines, yogurt, pudding, custard, peanut butter, beans and peas. Beer, bran products, organ meats and whole grain products are also high phosphorus foods. Note: phosphorus is found in almost all foods. Calcium is a mineral that is important for building strong bones. However, foods that are good sources of calcium are also high in phosphorus. The best ways to prevent loss of calcium from your bones are to follow a diet that limits high-phosphorus foods and to take phosphate binders Prescribe phosphate binder; e.g. calcium carbonate Supplement calcium; give after 1 hour after meal to promote absorption.

Manage anemia and iron intake: Anemia can impact on general nutritional status by causing general lethargy, taste change and poor appetite. Anemia also involved in pathogenesis of left ventricular hypertrophy and increase risk of cardiovascular diseases. It is important to ensure adequate intake of iron, B12, folic acid. However, iron rich food such as red meat and pulses are high protein and phosphate content. Vitamin B6 and C also have important roles in erythropoiesis. Potassium lowering diet may result in a decrease of iron, folate and vitamin C. Oral and parental iron supplementation.

Eating and hemodialysis: Eating immediately before and after hemodialysis increase incidence of hypotension and associated problem because blood is shunted from skeletal muscles to the viseral organs to aid digestion. Foods binges predialysis or during dialysis are not advised; sodium and potassium from food eaten shortly before dialysis will not be in bloodstream, thus it cannot be removed through hemodialysis leading to hypernetremia and hyperkalemia postdialysis.

Maintain fluid balance: Urine output + 1000ml Maintain interdialytic weight gain under 1.5 kg or within 2-5% Fluid overload causes edema, shortness of breath, high BP and congestive heart failure. Low sodium and blood sugar control is recommended to control thirst. Avoid chewing lots of ices and super-sized beverages. Practice small glasses at meals and medication. Keep mouth and lips wet by rinsing with cold water of chilled mouthwash.