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Lecture 21

11:709:364 Lecture Notes - Lecture 21: Hemodialysis, Edema, Polyphosphate


Department
Nutritional Sciences
Course Code
11:709:364
Professor
Deena
Lecture
21

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Nutrition Considerations in CKD5
- Energy
- Protein
- Sodium/fluid
- Phosphorus
- Potassium
- Calcium
- Other micronutrients and renal vitamins
Energy Needs in CKD5D
- Energy (kcal/kg)
o Hemodialysis
>60 years: 30-35 kcal
<60 years: 35 kcal
o Peritoneal Dialysis
>60 years: 30-35 kcal*
<60 years: 35 kcal*
*including dialysate
- Individuals greater than 60 years tend to be more sedentary, hense the lower kcal
range
- Individuals involved in vigorous physical activity may require greater energy
intakes
- What body weight to use?
o If patients current weight is within 95% to 115% of standard body weight =
use current body weight
If not, calculate adjusted body weight
Edema free body weight, or estimated dry weight, should be used as
current weight
o How to calculate adjusted body weight
KDOQI:

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Adjusted body weight = estimated dry weight (EDW) +
[(standard BW EDW) x .25]
o Example:
AdjBW = 90 kg + [(66 kg 90 kg) x .25]
AdjBW = 90 kg + [-24 kg x .25]
AdjBW = 84 kg
Traditional (typically results in an adjusted BW closer to the standard
BW)
Adjusted body weight = standard BW + [(EDW Standard
BW) x .25)
o Adj BW = 66 kg + [(90 kg 66 kg) x .25]
o Adj BW = 66 kg + [24 kg x 0.25]
o Adj BW = 72 kg
Protein Needs in CKD5D
- Adjusted BW should be used if EDW is <95% or >115% of standard BW
- HD: Loss of 10-15 g amino acids and protein per HD session
o Needs: 1.2 for stable; 1.2-1.3 for acutely ill or PEW
- PD: around 5-15 g/24 hours
o Needs: 1.2 1.3 g/kg
o Unless a patient has demonstrated adequate protein nutritional status on 1.2
g/kg/day diet, 1.3 g/kg/day should be prescribed
- Many patients will maintain protein balance with lower dietary protein intakes
- Protein intake challenges: additives
o Fresh is best
o Choose minimally processed
o Read labels:
If there is an ingredient list check it for additives
If no ingredient list check the rest of the label to see if there are
added solutions

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Labels with no ingredient list and statements of added solutions are
the least likely to contain additives (although they may still be present
in smaller amounts)
o Plant-based stigma
Historically, plant based proteins have been viewed as high in
potassium AND phosphorus
o Protein supplements
Convenient
Come in many forms shakes, powders, bars, etc
May be specially formulated for renal patients
Sodium and Fluids
- Estimated needs:
o Sodium needs:
HD: <2000 mg/day
PD: 2000; monitor fluid balance
o Fluid needs:
HD: 1000 ml + fluid output
PD: maintain balance
- “advising dialysis patients to restrict fluid intake without restricting sodium intake
is not based on evidence and is a waste of time”
- Sodium intake is one of the primary drivers of thirst
- In healthy individuals, renal sodium excretion plays the primary role in maintaining
sodium balance
o Fecal and integumentary (skin) losses are minimal
- Excess sodium and fluid can contribute to elevated blood pressure, left ventricular
hypertrophy, volume overload, intradialytic hypotension, and death
- The average daily sodium intake for Americans >2 years is more than 3,400 mg/day
- Strategies for reducing sodium intake
o Limit processed foods; fresh is best
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