CKD MNT Module 5: The Transition from Chronic Kidney Disease to Kidney Failure
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Transcript of CKD MNT Module 5: The Transition from Chronic Kidney Disease to Kidney Failure
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Module 5: The Transition from Chronic Kidney Disease (CKD)
to Kidney Failure
The Diet Changes as CKD Develops and Progresses to Kidney Failure.
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1. Use biochemical data to assess and monitor CKD
2. Recommend diet changes for CKD
3. Identify the four treatment options for kidney failure
4. Differentiate between the diet requirements for hemodialysis, peritoneal dialysis, and kidney transplantation
Participants will be able to:
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Maria is a 41-year-old woman who was diagnosed with type 2 diabetes at age 30; she has a history of gestational diabetes at age 27.
She lives with her husband and 13-year-old son.
Maria works full time as teacher’s aide.
Putting it all together
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Referred for medical nutrition therapy
Type 2 diabetes
Dyslipidemia
- Reference 12/06Weight (kg) - 80
BP - 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 -
Creatinine 0.8–1.3 -
eGFR > 60 -
Na 135–145 -
K 3.5–5.0 -
CO2 21–32 -
Phos 2.7–4.6 -
Ca (Corrected) 8.5–10.2 -
Alb 3.4–5.0 -
Urine Dipstick - -
UACR < 30 -
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- Reference 12/06
Weight (kg) - 80
BP - 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 -
Creatinine 0.8–1.3 -
eGFR > 60 -
Na 135–145 -
K 3.5–5.0 -
CO2 21–32 -
Phos 2.7–4.6 -
Ca (Corrected) 8.5–10.2 -
Alb 3.4–5.0 -
Urine Dipstick - -
UACR < 30 -
Initial impression (ABCs for diabetes)
A1C and blood glucose HIGH
Blood pressure OK
Cholesterol (LDL) HIGH
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- Reference 12/06
Weight (kg) - 80
BP - 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 20 H
Creatinine 0.8–1.3 1.1
eGFR > 60 56
Na 135–145 -
K 3.5–5.0 -
CO2 21–32 -
Phos 2.7–4.6 -
Ca (Corrected) 8.5–10.2 -
Alb 3.4–5.0 -
Urine Dipstick - >300
UACR < 30 -
Now assess kidney function and kidney damage
Check kidney function
‒ eGFR 56
Check kidney damage
‒ UACR not available, dipstick > 300
Request UACR
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- Reference 12/06
Weight (kg) - 80
BP - 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 20 H
Creatinine 0.8–1.3 1.1
eGFR > 60 56
Na 135–145 135
K 3.5–5.0 4.2
CO2 21–32 23.9
Phos 2.7–4.6 2.9
Ca (Corrected) 8.5–10.2 8.0 L (9.36)
Alb 3.4–5.0 2.7 L
Urine Dipstick - >300
UACR < 30 7,443
Briefly review for any other abnormal parametersBUN slightly above reference range
Creatinine slightly elevated, reflected in lower eGFR
Potassium, CO2, and phosphorus within reference ranges
Hypoalbuminemia
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UACR results are very HIGH 7,443
- Reference 12/06
Weight (kg) - 80
BP - 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 20 H
Creatinine 0.8–1.3 1.1
eGFR > 60 56
Na 135–145 135
K 3.5–5.0 4.2
CO2 21–32 23.9
Phos 2.7–4.6 2.9
Ca (Corrected) 8.5–10.2 8.0 L (9.36)
Alb 3.4–5.0 2.7 L
Urine Dipstick - >300
UACR < 30 7,443
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Reference 12/06
Weight (kg) 80
BP 120/67
Glucose 70–100 305 H
A1C < 7.0 10.1
LDL < 100 146
BUN 7–18 20 H
Creatinine 0.8–1.3 1.1
eGFR > 60 56
Na 135–145 135
K 3.5–5.0 4.2
CO2 21–32 23.9
Phos 2.7–4.6 2.9
Ca (Corrected) 8.5–10.2 8.0 L (9.36)
Alb 3.4–5.0 2.7 L
Urine Dipstick >300
UACR < 30 7,443
If we just look at the ABCs, we miss the CKD
UACR results are very HIGH 7,443
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Food and beverage intake
Breakfast: 1 cup (c.) oatmeal, ½ c. whole milk, 2 eggs fried in 1 teaspoon (t.) butter, 2 slices wheat toast, 2 t. butter, 16 ounces coffee OR yogurt. Skips lunch. Supper: fast food; 2 pieces fried chicken, biscuit, coleslaw; or large burger, fries. Doesn’t add salt.
Diet experience Diet controlled gestational diabetes, did “everything they told me.” Nutrition instruction when first diagnosed with type 2 diabetes. Buys fruit and vegetables, son gets them first.
Medications 70/30 insulin 40 units twice a day (BID), 850 milligrams (mg) metformin BID, 10 mg lisinopril daily, 20 mg simvastatin daily. Takes evening medications when she remembers, maybe twice a week. May take 70/30 insulin at bedtime instead of before supper.
Physical activity No planned exercise. Walks a lot at summer weekend flea market.
Height & weight Height 63”, weight 176 pounds (lb.) (80 kilograms [kg]), Body Mass Index (BMI) 31.2. Previous weight 81 kg (in July)
Biochemical data A1C 10.1, LDL 146, eGFR 56, albumin 2.7, dipstick protein > 300, UACR 7,443
Physical findings Poor dentition, states not a problem for her.
Referred for Medical Nutrition Therapy: Uncontrolled type 2 diabetes, dyslipidemiaAssessment (December 2006)
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Personal history
41 years old, lives with husband and 13-year-old son in a condo.
Patient/family history
Diabetes (DM): mother, father, paternal grandfather. Mother on hemodialysis.
Grandfather with left foot amputation due to DM. Not planning pregnancy, using birth control. Denies polyuria, polydipsia, fatigue, or blurred vision. Checks fasting glucose about once a week, “usually 150 to 180.” Notes nocturnal lows when takes 70/30 insulin at bedtime. Denies mid-day lows. Refuses to change type of insulin, prefers only 2 shots/day.
Social history Teacher’s aide; hard to come for appointments unless summer or school break. Husband not working now; son doing great in school. His evening activities make meal time and medication use erratic.
Assessment continued (December 2006)
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http://www.nal.usda.gov/fnic/foodcomp/search/
ALL of the nutrient analyses are from the USDA nutrient analyses
library website:
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* Used current weight of 80 kg to estimate protein needs (0.8 g/kg), used 23 kcal/kg for obesity
Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg)
K (mg)
1 c. oatmeal (regular) 166 5.94 28.08 3.56 9 180 164
½ c. whole milk, vitamin D 74 3.84 5.86 3.96 52 102 161
2 eggs (large, fried) 180 12.5 0.76 13.65 190 198 140
3 t. butter 102 0.12 0.01 11.52 101 3 3
2 slices wheat toast (2 oz.) 177 7.35 31.62 2.42 346 107 126
16 oz. brewed coffee 9 0.57 0 0.09 9 14 232
½ c. fast-food coleslaw 138 0.87 14.95 8.25 180 19 134
1 fried chicken breast & leg- Removes breading
18570
33.9910.52
0.220.04
5.463.06
596210
31689
38609
1 biscuit (no butter) 185 3.77 22.11 9.07 548 305 60
21 oz. diet cola 10 0.53 0.15 1.41 39 44 39
TOTALS (% cal) 1,296 80 g (24.7%)
103.78 g (32.0%)
62.45 g (43.3%)
2,280 1,377 1,554
Recommended intake or DRI (% cal)
1,840 64 g*(20 %)
230 g(50 %)
61 g(< 30 %)
1,500 700 4,700
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Inappropriate intake of fats (LDL 146, diet history)
Inconsistent carbohydrate intake (skips meals)
Food-medication interaction − Alterations in biochemical tests (not taking evening
meds. consistently: LDL 146, A1C 10.1)
Overweight/obesity (BMI 31.2)
Undesirable food choices (LDL 146, A1C 10.1)
Physical inactivity (no planned exercise)
Limited access to food (limited variety)
Where do you start?
Reference: International Dietetics & Nutrition Terminology, 2011
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3. Inappropriate intake of fats (LDL 146, diet hx)
2. Inconsistent carbohydrate intake (skips meals)
1. Food-medication interaction − Alterations in biochemical tests (not taking evening meds
consistently: LDL 146, A1C 10.1)
Overweight (BMI 31.2)Undesirable food choices (LDL 146, A1C 10.1)Physical inactivity (no planned exercise)Nutrition-related knowledge deficit Limited access to food (limited variety)
Prioritizing NCP diagnoses (12/06)
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Nutrition-related medication management− Review medications, particularly insulin timing.
− Take 70/30 insulin before breakfast and supper, not at bedtime.
Recommended modifications− Have consistent carbohydrate intake and do not skip
meals.
− Reduce saturated fat intake (1% milk, fast foods).
PLAN: Take medications as prescribed.
Intervention (12/06)
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Taking evening meds more regularly now− Still not 100%, but improved
− Not taking 70/30 insulin at bedtime any longer
Eating school lunch; eats vegetables & fruit
Family accepting 2% milk
Still working on reducing fast foods, but it’s hard
Follow-up phone call shows some changes made (2/07)
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Multiple missed appointments Needs new medication prescriptions
- Reference
12/06 12/07
Weight (kg) - 80 79.2
BP - 130/67 131/74
Glucose 70–100 305 H 75
A1C < 7.0 10.1 11.3
LDL < 100 146 111
BUN 7–18 20 H 13
Creatinine 0.8–1.3 1.1 1.1
eGFR > 60 56 54
Na 135–145 135 141
K 3.5–5.0 4.2 3.7
CO2 21–32 23.9 22.2
Phos 2.7–4.6 2.9 3.7
Ca (Corrected) 8.5–10.2 8.0 L (9.36) 7.9 L (9.82)
Alb 3.4–5.0 2.7 L 2.6 L
Urine dipstick >300 -
UACR < 30 7,443 7,986
Blood PressureOK
A1CHIGH
Cholesterol LDLHIGH
eGFR Stable
Hypoalbuminuria
UACR Still Very HIGH
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High levels of urine albumin are associated with kidney
damage and more rapid progression
of kidney disease.
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Maria has significant albuminuria; her kidney function declined rapidly
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As eGFR declined, blood pressure was harder to control
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Maria needed less insulin to control her blood glucose levels
December 2007 Discontinue metformin
Increase 70/30 insulin to 45 units BID (from 40 units)
July 2008 Decrease 70/30 insulin to
35 units BID
November 2008 Decrease 70/30 insulin to
30 units BID
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Maria’s serum phosphorus increased;phosphorus binder added 11/08
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Vitamin D may lower iPTH
Reference: *IOM, 2011
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Vitamin D increased phosphorus absorption
Reference: *IOM, 2011
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Complex interactions between vitamin D and iPTH affect P and Ca
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Correcting calcium for hypoalbuminemia is worthwhile when assessing calcium levels
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Maria’s bicarbonate level decreased, medication was added, and
dietary protein was restricted
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Maria’s potassium increased when her eGFR was quite low
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Maria developed anemia
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Iron supplement improved anemia
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Individualize− Small steps− Realistic changes
Emphasize self-management − What is their priority?− What can they live with?
Prioritize changes based on laboratory data
Where do you start?
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Let’s work through the meals
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A high fiber breakfast may be good for many people
Reference: Adapted from Nutrition Care Manual type 2 diabetes meal planhttp://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf
Food Kcal Pro (g)
Carb (g)
Fat (g)
Na (mg)
P (mg)
K (mg)
½ banana, medium 53 0.64 13.48 0.19 1 13 211
½ c. bran flakes 64 1.89 16.16 0.44 147 102 124
1 c. skim milk 83 8.26 12.15 0.2 103 247 382
1 slice whole wheat toast
76 4.07 12.79 1.02 146 76 82
1 tbsp. peanut butter (reduced Na)
94 3.84 3.49 7.98 32 51 120
TOTALS 301 18.7 58.07 9.83 429 489 919
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If potassium is high, choose blueberries instead of banana on the cereal
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May need to recommend different cold cereal to lower Na, P, or K in CKD
Phosphorus in plant foods not completely absorbed
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Some instant hot cereals may be higher in Na
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What is on the cereal may add Na, P, and K in CKD
(use ½ cup milk as place to start)
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Yeast bread contributes 7% of sodium in U.S. diet
Bread: Frequent consumption of lower sodium foods adds to daily totals
Reference: Dietary Guidelines for Americans, 2010
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Egg whites are lower in Na, K, and P than egg substitutes
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Breakfast beverage may make a difference in P or K
Phosphorus from food additives is 90–100% absorbed
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Breakfast choices at a glance
* Read labels to compare brands
Food Sodium Phosphorus Potassium
Hot cereal Regular < instant
Corn, rice, wheat < oat
Corn, rice, wheat < oat
Cold cereal Refined < bran*
Refined < branUnfortified <fortified*
Refined < bran
Milk (1/2 cup)
Protein-fortified has more
Protein-fortified has more
Protein-fortified has more
Nondairy Rice < soy * Rice < soy < cow’s Check label for phos
Rice < soy < cow’s
Bread Wheat < rye * Wheat < corn White < whole wheat
Egg Egg white < egg sub.
Egg white < egg sub. Egg white < egg sub.
Fruit - - Lower K fruits if needed
Hot beverage - - Instant < brewed
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A vegetarian lunch may be good for the heart
Reference: Adapted from Nutrition Care Manual type 2 diabetes vegetarian meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type%202%20Diabetes%20Nutrition%20Therapy%20for%20Vegetarians.pdf
Food Kcal Pro (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg)
1 c. green leaf lettuce 5 0.49 1.03 0.05 10 10 70
1/3 c. tomato chopped 11 0.52 2.31 0.12 3 14 141
1 tbsp. reduced fat Italian salad dressing
11 0.07 0.69 0.96 161 2 13
1 c. reduced sodium vegetable soup
83 2.78 15.33 1.14 491 58 549
1 garden burger, frozen 124 10.99 9.99 4.41 398 144 233
1 mixed grain bun 113 4.13 19.18 2.58 197 52 69
1 c. soymilk, added Ca, unsweetened
80 6.95 4.23 3.91 90 78 292
TOTALS 427 25.93 52.76 13.17 1,350 358 1,367
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Salad greens differ in K content
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Vinegar/oil or low-sodium salad dressing aids 1,500 mg Na budget
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Salt added to cooking may still mean less sodium than canned.Eat small portions of beans and peas when serum potassium is high.
Canned beans may be a little lower in K, but still very high in Na
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Read ingredient list for KCl in lower sodium canned soups
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CKD patients should limit sodium to 1,500 mg per day.
Salad dressing packets tend to be large.
Smaller, single items are still high in sodium.
Double meat means more Na, P, and K.
Some items have PHOS additives.
http://www.case.edu/med/ccrhd/phosfoods/
Fast foods and CKD
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Some fast-food salad dressings are large servings and high in sodium
Salad has 81 mg P, 356 mg K
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Size and what’s on the fast food cheeseburger adds up
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Even a small fast-food bean burrito has about 1/3 of the daily Na
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If you’re having pizza, thin crust is a better choice
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Nut butter is convenient; watch portion size if serum P or K is high
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Possible changes for lunch: IndividualizeFood Sodium Phosphorus PotassiumSalad dressing
Oil/vinegar, low-Na type < regular dressing;Homemade < fast food, restaurant
Non-milk based < milk based
Read label for KCl in low-Na type
Salad Raw < pickled vegetable;No-added-salt canned < regular canned vegetables
Cheese, meat, beans, nuts, seeds add more
Potato or bean salad, meat, seeds, nuts add more; use lower K vegetables
Soup Homemade < canned, dried, instant, or restaurant
Non-dairy based < dairy based
Bean, pea, vegetable soup have more; read label for KCl in low-Na type
Sandwich Restaurant, fast food, deli meats, cheese are high
Double meat and/or cheese add more
Meat, cheese, bean, nut butter add more
TIPS:•Salad dressing on the side: dip fork in dressing, then into salad•Leftovers from food prepared from scratch •Smaller servings of protein in sandwiches and burritos •Fast foods, restaurant meals only once every other week (SODIUM)
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A healthy evening meal usually includes a variety of foods
Reference: Adapted from Nutrition Care Manual type 2 diabetes meal plan http://nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf
Foods Kcal PRO (g) Carb (g) Fat (g) Na (mg) P (mg) K (mg)
3 oz. baked chicken, rotisserie
111 21.8 0 2.62 256 192 222
1 small baked potato 73 1.53 16.81 .08 4 39 305
½ c. green beans, frozen 22 1.10 3.87 .23 2 23 132
1 tbsp. margarine-like spread w yogurt (40% fat)
46 .28 .28 4.9 88 5 9
1 ½ c. spinach/feta/ grapefruit salad
87 2.1 8.5 5.7 78 37.5 292
1 c. skim milk 83 8.26 12.15 .20 103 247 382
1 medium peach 58 1.36 14.31 0.38 0 30 285
TOTALS 480 36.43 55.92 14.1 451 573.5 1,627
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Source and preparation of chicken can increase Na, P, and K
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Potato preparation affects K (Boiling helps remove some K)
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020406080
100120140160180200
Raw Boiled Canned Microwaved Frozen,microwaved
Frozen,boiled
K
Boiling removes more K from green beans
½ cup serving
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Type of spread may add some sodium, saturated or trans fat
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Type of rice can increase P or K, still a better choice than potato if K is high
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Amount and processing of spinach makes a difference in K content
NAS = No Added Salt
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Check ingredient list of processed cheese for additives
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Size and processing of a peach makes a difference in K intake
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Beverage choice can make a difference in Na, P, or K; read ingredient list
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Prepare foods from scratch.
Read ingredient list to identify food additives.
Use ingredients with fewer food additives.
Use less salt than the recipe lists.
Use liquid vegetable oil instead of butter, margarine, lard, or shortening in cooking.
Use less meat, poultry, or fish in soup or stew.
If K is high, use rice not potatoes.
Possible changes for supper: Individualize
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So many changes to make, so many things to consider…
Where do you start?
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Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf
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Reference: http://nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf
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Reference: http://nkdep.nih.gov/
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Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf
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Reference: http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf
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Reference: http://nkdep.nih.gov/resources/nkdep-kidney-test-results-508.pdf
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Reference: http://nkdep.nih.gov/resources/nkdep-ckd-amt-guide-508.pdf
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RENAL REPLACEMENT THERAPY (RRT)
OptionsDiet Considerations
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Kidneys cannot maintain homeostasis.
Kidney failure is associated with fluid, electrolyte, and hormonal imbalances and metabolic abnormalities.
End-stage renal disease (ESRD) means patient is on dialysis or has a kidney transplant.
Kidney failure is an eGFR < 15
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Patients with kidney failure will have the same complications
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eGFR < 30
Medicare B − Individual pays 20%, deductible applies
Qualified providers: physicians, physician assistants, nurse practitioners, and clinical nurse specialists
Up to six sessions covered
Kidney disease education is a Medicare benefit
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The topics include many of the ones you already know about
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Consistent messages are better.
Providers should be teaching the same thing.
Education may help patients to be successful in their self-management efforts.
An informed patient is better prepared
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Discuss options early with patients with progressive CKD, give them time to prepare.
Patients diagnosed with kidney “failure” or loss of kidney function may experience grief, fear, or depression.
Include family members if possible.
The “diet” will change; and changes depend on the chosen option.
Discuss treatment options early
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Reference: http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtreatment.pdf
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Renal replacement therapy (RRT)1. Hemodialysis
• In-center or home, three times a week or more frequently
2. Peritoneal dialysis• Daily, at home
3. Kidney transplantation
No RRT4. Conservative management
• Active medical management
Four options for treating kidney failure
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Concentration gradient − Flows from high to low
Area through which diffusion takes place− Large surface area of the membrane
Size of molecules− Protein-bound substances not usually dialyzed
Dialysis involves diffusion of substances across a semipermeable membrane
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In-center hemodialysis− Most common type
http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/hemodialysis.pdf
Home hemodialysis− Individual has more control
− Need assistance
http://kidney.niddk.nih.gov/kudiseases/pubs/pdf/homehemodialysis.pdf
Hemodialysis occurs in two settings
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Hemodialysis
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Removal is based on size.
Protein-bound substances are not usually removed.
Amino acids are removed.
Glucose is removed.
Water-soluble vitamins are removed to some degree.
Concentration gradients move substances across the semipermeable
membrane for removal
Reference: Descombes et al. Artif Organs 2000; 24(10):773–778.
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More dietary protein is needed to replace losses.
Specific renal vitamin may be used.− Consider taking vitamin after treatment to avoid
removal during treatment.
Nutrient losses during dialysis need to be replaced
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Maintain homeostasis Adequate dialysis
− Type and size of the dialyzer− Blood flow rate− Dialysate composition (similar to normal levels)
Sodium, potassium, calcium, bicarbonate
− Time Individual patient factors
The hemodialysis prescription is individualized
Reference: Locatelli et al. Nephrol Dial Transplant 2004; 19(4):785–796.
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Levels build up between treatments; examples of these substances are:− Fluid
− Nitrogen
− Sodium
− Potassium
− Phosphorus (only to some degree)
− Hydrogen (acid)
Hemodialysis removes some substances that accumulate between treatments
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A normal kidney works “24/7.”
Damaged kidneys (in CKD) still work nonstop but at a reduced level.
An artificial kidney works only during dialysis treatments.
Dialysis replaces only a fraction of normal kidney function
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Arteriovenous (AV) fistula
Graft
Temporary access
Permanent access, usually placed in non-dominant arm
Protect blood vessels in both arms− Avoid venipuncture and IV catheter placement above
the wrist
A vascular access is needed for hemodialysis
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Provides permanent access
Surgically connects artery to a vein− Vein grows larger due to increased
blood flow.
− Needles are inserted to access the bloodstream.
Takes time to mature− Few weeks to months
Less likely to clot
An AV fistula is the preferred access
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An AV graft will work for hemodialysis
Synthetic tube connects artery and vein.
Graft takes less time to mature.
Graft is more likely to become infected or clot.
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Emergency dialysis
Less than optimal blood flow
No needles
Permanent access surgery needed later
The only option when patient is not prepared and needs dialysis
A “temporary access” is just temporary
Catheter for temporary access
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Treatment is three times per week.
Dialysis treatment lasts 3–4 hours.
In-center hemodialysis is scheduled
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Conventional home hemodialysis− Three times per week
− Most common type of home hemodialysis
Daily home hemodialysis− 2–3 hours, 5–6 days per week
Nocturnal hemodialysis− 6–8 hours, 3 or more days per week
− Dialyze more frequently
Home hemodialysis requires training and support
Reference: http://www.homedialysis.org/
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In-center hemodialysis: Pros and cons
PROS
Social setting
Facilities are found nationwide.
Staff does the work.− Placing/removing needle
− Monitoring the treatment
− Maintaining the equipment
CONS
Requires strictest diet− Substances and fluid build up
between treatments.
Have to follow set schedule
Must travel to the unit
May take more medication
May feel fatigued
Some nutrients are removed during treatment
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Home hemodialysis: Pros and cons
PROS
Diet is less restrictive with more frequent treatments
Can schedule around work
No travel to the unit is needed
Newer machines are small
Fewer ups and downs occur
CONS
Must have a partner
May be stressful for partner
Need space for treatment: machine, supplies, access to water and drainage, electricity
Have to insert needles
Need time off from work for initial training
Training not offered everywhere
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Protein: > 1.2 g/kg (some loss during treatment) Calories: 30–35 kcal/kg
− > 60 years old: 30 kcal/kg
Sodium: 1,000–3,000 mg
Potassium: 2,000–3,000 mg Phosphorus: 800–1,000 mg phosphorus
− Need binders
Fluid restriction: urine output + 1,000 mL (cc)− 240 cc/cup
Nutrition prescription: In-center hemodialysis
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Increased frequency of treatment means fewer restrictions.
Fewer phosphate binders may be needed. Adequate protein is still needed.
Nutrition prescription: Home hemodialysis
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Reference: http://kidney.niddk.nih.gov/KUDiseases/pubs/peritoneal/index.aspx
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Continuous ambulatory (CAPD).
Continuous cycler-assisted (CCPD).
PD uses the peritoneal membrane as the filter.
PD still requires surgery for catheter placement.
Some people experience body-image concerns.
PD is a continuous therapy.
Peritoneal dialysis (PD) options
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Dextrose is the most common osmotic agent used in the dialysate.
Osmotic gradient helps move water into the peritoneal cavity.
Clearance affected by: Concentration gradient Size Permeability of the peritoneal
membrane
The peritoneal membrane is the semipermeable “filter” in peritoneal
dialysis
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The peritoneal dialysis exchange
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Dialysis solution with dextrose flows into the abdominal cavity.
The solution remains for a prescribed time period, also known as the dwell time.
Substances and fluid pass from the capillaries in the peritoneum into the solution.
Dextrose enters the blood; and substances and fluid enter the solution.
The solution is drained at the end of the dwell.
What is an “exchange”?
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Dextrose solutions are used as osmotic agent.− 1.25%, 2.5%, 4.25% concentrations
Exchanges are 2–3 liters in volume.
Dwell time and number of exchanges vary.
PD prescription is individualized
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CAPD requires 3–4 manual exchanges
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The cycler does 3–5 exchanges during the night in CCPD
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Peritoneal dialysis: Pros and Cons
PROS Better preserves residual renal
function Can do it alone Choice of times Choice of location Easier to travel, no machine No travel to unit Treatments done daily
CONS Need space for supplies which are
delivered monthly Must plan around activities Must do as prescribed to get
adequate treatment Must follow instructions to keep
risk of infection low Need to take supplies when
traveling May have weight gain May be harder to control diabetes
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The diet may not be as strict.
Amino acids lost during the exchanges must be replaced, dietary protein needs are higher.
Absorbed dextrose calories may add weight.
People with diabetes are never really “fasting.”− Glucose levels may be harder to control.
− Insulin may be injected into the dialysate bags.
Peritoneal dialysis and diet
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Protein: 1.2–1.3 g/kg
Calories: 30–35 kcal/kg− Includes calories from dextrose solutions
Sodium: 2,000–4,000 mg
Potassium: 3,000–4,000 mg
Phosphorus: 800–1,000 mg− Still need binders
Fluid restriction–as needed
Nutrition prescription: Peritoneal dialysis
Reference: Shiro-Harvey, 2002
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Dextrose concentrations vary − 1.25%, 2.5%, 4.25%
Bag sizes vary− 2-liter, 2.5-liter, 3-liter
In CAPD, 60–70% is absorbed. The amount is higher due to longer dwell times.
In CCPD, 40–50% is absorbed.
Calories count in dextrose solutions
Reference: McCann, 2009
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Four exchanges of 2-liter bags with 1.5% dextrose= 8 liters of 1.5% dextrose (grams dextrose/liter)
= 120 grams of dextrose
3.4 kcal/gram of dextrose (120 grams of dextrose) x 3.4 = 408 calories
60–70% absorbed
Total of 245–286 calories absorbed/day
Estimate of calories from CAPD
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For more information about peritoneal dialysis dose and adequacy
Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritonealdose.pdf
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Reference: http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant.pdf
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Deceased or living donor kidney is required.− Must be ABO compatible, match for human leukocyte
antigens
The transplant workup takes time; eligibility is strict.
Requires major surgery.
Need to take medications daily, including antirejection medication.
Kidney transplantation is a treatment, not a cure
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A transplanted kidney is placed in the groin area. Native kidneys usually are
not removed.
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Kidney transplant: Pros and cons
PROS A transplanted kidney is a
normal, functioning kidney. Dialysis is not needed. Fewer diet restrictions are
needed. Successful transplant may
mean a longer life. Recipient may have better
quality of life.
CONS The waiting list is long for a
deceased donor. The transplant requires major
surgery. Rejection Antirejection medications
suppress the immune system. Weight gain Diabetes may be harder to
control.
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Transplant is a treatment, not a cure.
May need a sodium restriction.
May need to reduce calories to avoid weight gain.
Medications may increase weight gain.
Nutrition prescription: Transplant
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No non-dialysis way can replace loss of clearance of uremic toxins.
Complications can be treated.
Continue medications.
Provide comfort and palliative care.
Encourage patient to inform family.
Conservative management is active medical management with no RRT
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Discuss the options early to allow time for the patient to adjust and make a decision.
The diet will change with dialysis, more protein is needed to replace the losses.
Hemodialysis has the most restrictive diet.
Peritoneal dialysis calories add up. Transplant requires daily immunosuppressant
medication.
All the options still require medications.
Summary: Treatment options
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She was very upset upon hearing she had CKD.
She is now on the waiting list for a transplant.
Hemodialysis is her second choice.
She has a vascular access in place and will probably need in-center hemodialysis prior to transplant.
Maria wants a kidney transplant
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The transition from CKD to ESRD can be short for someone like Maria
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SUMMARY OF ALL CONTENT
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Identify people with chronic kidney disease.
Assess and monitor estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). − eGFR estimates kidney function.
Persistent levels < 60 are considered CKD.
− UACR > 30 mg/g is considered as kidney damage. Patients with high levels of urine albumin are at greatest
risk of rapid progression to kidney failure.
Identify CKD
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Control blood pressure.− 1,500 mg sodium
Do not replace salt with salt substitutes (KCl).− Medications that affect the renin-angiotensin-aldosterone
system (RAAS) increase risk of hyperkalemia.− Limit dietary potassium when serum level is elevated.
Control diabetes.− A1C is individualized.− Spontaneous improvement in control may mean CKD
progression.− Treat hypoglycemia appropriately.
Use juice low in potassium. Avoid dark colas due to phosphorus content.
Slow progression
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Urine albumin is an indicator of kidney damage.− Medications that affect the RAAS may lower urine
albumin.− Lower sodium, planned weight loss, lower protein
intake, tobacco cessation may help lower albuminuria.
Cardiovascular disease is the leading cause of mortality for people with CKD.− Nontraditional risk factors are important.
Anemia Urine albumin Abnormal mineral metabolism (calcium and phosphorus)
Slow progression (continued)
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Anemia− Inadequate erythropoietin and iron
− Hemoglobin and iron indices
Hyperkalemia− Limit dietary potassium when serum level is elevated.
Hypoalbuminemia− Poor oral intake (spontaneous reduction in protein)
− Inflammation
Complications
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Metabolic acidosis− Maintaining serum CO2 > 22 mEq/L may be beneficial.− Animal protein is a source of metabolic acids.− Acidosis may be treated with supplemental
bicarbonate.
Bone disease in CKD− Calcium, phosphorus, vitamin D, parathyroid hormone
Use corrected calcium with hypoalbuminemia
− Vitamin D supplementation may increase risk of hypercalcemia and hyperphosphatemia.
Complications (continued)
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Use clinical judgment when assessing body weight for estimating nutrient needs.
Caloric requirements are not higher.
For CKD patients limit to 1,500 mg sodium.
Diet has adequate, not excessive, protein.
Restrict phosphorus if serum level is elevated.
Restrict potassium if serum level is elevated.
Diet changes as CKD progresses
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Foods rich in protein tend to be rich in phosphorus and potassium. Egg whites are an exception.
Refined grains are lower in phosphorus and potassium than whole grains.
Boiling potatoes and tubers immediately removes enough potassium. Leaching, or soaking, in water is not required.
The food groups
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Fresh lean meat, poultry, and fish have K and P.
Use products that are not enhanced with Na.
Dried beans and peas are high in phosphorus and potassium; may need to limit amounts.
Dairy foods are high in sodium, protein, phosphorus, potassium, and fluid (milk).
Use foods without food additives, if possible.− Inorganic phosphorus is more readily absorbed.
The foods
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Cereals and breads may be a source of Na.
Bran and whole grains have more K and P.
Fruits and vegetables vary in K content.− Canned fruit may have lower K. − Use lower sodium canned vegetables, if using canned.
Heart-healthy fats are preferred.
The foods
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Kidney failure is considered as an eGFR < 15. ESRD still means many of the same complications. There are 4 options to choose from:
1. Hemodialysis More protein; restrict Na, P, K, and fluid Fewer restrictions with more frequent home hemodialysis
2. Peritoneal dialysis More protein; usually Na and P restriction
3. Transplant May need to limit sodium Other comorbidities (diabetes, hypertension)
4. Conservative management
The diet changes when the kidneys fail
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This professional development opportunity was created by the National Kidney Disease Education Program (NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD), especially among communities most impacted by the disease, NKDEP works in collaboration with a range of government, nonprofit, and health care organizations to:• raise awareness among people at risk for CKD about the need for testing;• educate people with CKD about how to manage their disease;• provide information, training, and tools to help health care providers better detect
and treat CKD; and• support changes in the laboratory community that yield more accurate, reliable,
and accessible test results.To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional
materials from NIDDK, please visit: http://www.niddk.nih.gov.
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Meet our Presenters Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.
Ms. Kuracina is the lead author of the American Dietetic Association’s CKD Nutrition Management Training Certificate Program and NKDEP’s nutrition resources for managing patients with CKD.Ms. Kuracina has more than 20 years of experience in clinical dietetics with the Indian Health Service (IHS). She is a senior clinical consultant with the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health. She also serves as a diabetes dietitian and coordinator for a diabetes self-management education program at the IHS Albuquerque Indian Health Center in New Mexico, a role in which she routinely counsels patients who have chronic kidney disease (CKD).
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Meet our Presenters Andrew S. Narva, M.D., F.A.C.P.
Dr. Narva is the director of the National Kidney Disease Education Program (NKDEP) at the National Institutes of Health (NIH). Prior to joining NIH in 2006, he served for 15 years as the Chief Clinical Consultant for Nephrology for the Indian Health Service (IHS). Via telemedicine from NIH, he continues to provide care for IHS patients who have chronic kidney disease. A highly recognized nephrologist and public servant, Dr. Narva has served as a member of the Medical Review Board of ESRD Network 15 and as chair of the Minority Outreach Committee of the National Kidney Foundation (NKF). He serves on the NKF Kidney Disease Outcomes Quality Initiative Work Group on Diabetes in Chronic Diabetes and is a member of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 8 Expert Panel.
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American Dietetic Association. International Dietetics & Nutrition Terminology (IDNT) Reference Manual. Standardized Language for the Nutrition Care Process. 3rd ed. Chicago, IL: American Dietetic Association; 2011.
American Dietetic Association. Type 2 diabetes nutrition therapy for vegetarians. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type%202%20Diabetes%20Nutrition%20Therapy%20for%20Vegetarians.pdf. 2010. Accessed June 14, 2011.
American Dietetic Association. Type 2 diabetes nutrition therapy. Nutritioncaremanual.org website. http://www.nutritioncaremanual.org/vault/editor/Docs/Type2DiabetesNutritionTherapy.pdf. 2010. Accessed June 14, 2011.
References
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Case Center for Reducing Health Disparities. Fast food, phosphorus containing food additives, and the renal diet. Case Western Reserve University website. http://www.case.edu/med/ccrhd/phosfoods/. 2009. Accessed August 30, 2011.
Descombes E, Boulat O, Perriard F, Feilay G. Water-soluble vitamin levels in patients undergoing high-flux hemodialysis and receiving long-term oral postdialysis vitamin supplementation. Artificial Organs. 2000;24(10):773–778.
Handelman GJ, Levin NW. Guidelines for vitamin supplements in chronic kidney disease patients: what is the evidence? Journal of Renal Nutrition. 2011;21(1):117–119.
References
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Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, D.C.: National Academies Press; 2010. Institute of Medicine website. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx. Accessed June 14, 2011
Khanna R, Nolph KD. Chapter 4. Principles of peritoneal dialysis. In: Henrich WL, Bennet WM, eds. Atlas of Diseases of the Kidney. Vol. 5. http://www.kidneyatlas.org/book5/adk5-04.ccc.QXD.pdf. 1999. Accessed June 14, 2011.
Locatelli F, Covic A, Chazot C, Leunissen K, Luno J, Yaqoob M. Optimal composition of the dialysate, with emphasis on its influence on blood pressure. Nephrology Dialysis Transplantation. 2004;19(4):785–796.
McCann L, ed. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York: National Kidney Foundation; 2009.
References
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National Kidney and Urologic Disease Information Clearinghouse. Home hemodialysis. February 2008. NIH publication 08–6232. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/homehemodialysis.pdf. Accessed June 14, 2011.
National Kidney and Urologic Disease Information Clearinghouse.
Kidney failure: choosing a treatment that’s right for you. November 2007. NIH publication 08–2412. National Institute of Diabetes and Digestive and Kidney Disease website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/choosingtreatment.pdf. Accessed June 14, 2011.
References
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National Kidney and Urologic Disease Information Clearinghouse. Peritoneal dialysis dose and adequacy. December 2006. NIH publication 07–4578. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritonealdose.pdf. Accessed June 14, 2011.
National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure hemodialysis. December 2006. NIH publication 07–4666. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/hemodialysis.pdf. Accessed June 14, 2011.
References
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National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure peritoneal dialysis. May 2006. NIH publication 06–4688. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/peritoneal.pdf. Accessed June 14, 2011.
National Kidney and Urologic Disease Information Clearinghouse. Treatment methods for kidney failure transplantation. May 2006. NIH publication 06–4687. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/transplant.pdf Accessed June 14, 2011.
References
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National Kidney and Urologic Disease Information Clearinghouse. Vascular access for hemodialysis. February 2008. NIH publication 08–4554. National Institute of Diabetes and Digestive and Kidney Diseases website. http://www.kidney.niddk.nih.gov/kudiseases/pubs/pdf/vascularaccess.pdf. Accessed June 14, 2011.
National Kidney Disease Education Program. Chronic kidney disease (CKD) and diet: assessment, management and treatment. Treating CKD patients who are not on dialysis. An overview guide for dietitians. Revised September 2011. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-ckd-amt-guide-508.pdf. Accessed September 8, 2011.
References
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National Kidney Disease Education Program. Eating right for kidney health tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://www.nkdep.nih.gov/resources/nkdep-factsheet-overallpatient-508.pdf. Accessed June 13, 2011.
National Kidney Disease Education Program. How to read a food label tips for people with chronic kidney disease. June 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/NKDEP_NutritionFactsheets_FoodLabel_508.pdf. Accessed August 30, 2011.
References
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National Kidney Disease Education Program. Phosphorus tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-phosphorus-508.pdf. Accessed August 30, 2011.
National Kidney Disease Education Program. Potassium tips for people with chronic kidney disease (CKD). September 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-potassium-508.pdf. Accessed September 8, 2011.
National Kidney Disease Education Program. Protein tips for people with chronic kidney disease (CKD). April 2010. NIH publication 10–7407. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-protein-508.pdf Accessed August 30, 2011.
References
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National Kidney Disease Education Program. Sodium tips for people with chronic kidney disease (CKD). Revised March 2011. NIH publication 11–7405. National Kidney Disease Education Program website. http://nkdep.nih.gov/resources/nkdep-nutritionfactsheets-sodium-508.pdf. Updated March 2011. Accessed August 30, 2011.
National Kidney Disease Education Program. Your kidney test results.
Revised September 2011. NIH publication 11–7407. National Kidney Disease Education Program website. http://www.nkdep.nih.gov/resources/nkdep-kidney-test-results-508.pdf. Accessed September 8, 2011.
Palmer, BF. Chapter 2. Dialysate composition in hemodialysis and peritoneal dialysis. In: Henrich WL, Bennet WM, eds. Atlas of Disease of the Kidney. Vol. 5. http://www.kidneyatlas.org/book5/adk5-02.ccc.QXD.pdf. 1999. Accessed June 14, 2011.
References
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Renal Practice Group of the American Dietetic Association. National Renal Diet Professional Guide. 2nd ed. Chicago, IL: American Dietetic Association; 2002.
Types of home dialysis. Home dialysis central. Homedialysis.org website. http://www.homedialysis.org/types. 2004. Accessed June 14, 2011.
U.S. Department of Agriculture. Agricultural Research Service. 2010. USDA National Nutrient Database for Standard Reference, Release 23. Search the USDA national nutrient database for standard reference. U.S. Department of Agriculture website. http://www.nal.usda.gov/fnic/foodcomp/search/ Accessed August 30, 2011.
References
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U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, D.C.: U.S. Government Printing Office, December 2010. U.S. Department of Agriculture website. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. Accessed June 14, 2011.
U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Did you know Medicare helps cover kidney disease education? March 2010. CMS product 11456. Centers for Medicare & Medicaid Services website. http://www.medicare.gov/Publications/Pubs/pdf/11456.pdf. Accessed June 12, 2011.
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