MNT FOR END STAGE RENAL FAILURE (ESRD) PATEINT

Doctors usually advise the ESRD patients to watch their diet, this should reduce, that should avoid, this shouldn’t take.  Then, what else is left? What should they eat?

Here, I will list out the recommendation micro and macronutrients needed for ESRD patients.  Of course, I will also provide the list of food choices that ESRD patients are save to consume.  Let’s find out what are they.

First, we need to determine which type of dialysis the patient undergoing.  Basically there are two types of dialysis: hemodialysis and continuous ambulatory peritoneal dialysis (CAPD).  The energy and nutrients requirement for both of these are different.

HEMODIALYSIS

NUTRIENTS	RECOMMENDATION	RATIONALE
Calories	35 kcal/kg body weight (<60 y/o) 30-35 kcal/kg (>60 y/o)	Energy expenditure of the hemodialysis patients are the same as those healthy individuals.  However, the energy intake should be adjusted according to the physical activity.
Protein	50% HBV   1.2 g/kg BW 1.3 g/kg BW (severe malnourish/acute illness)	Intake of less than 1.2 g/kg BW per day might lead to negative nitrogen balance.
Carbohydrate	50-60% of total calories	Less than 50% of energy intake from CHO will cause elevation in proportion of protein and fat. For diabetic patients, complex CHO and dietary fiber are recommended.
Fats	25-35% of total calories <7% total calories of SFA 10% of total calories of PUFA 20% of total calories of MUFA <200 mg/day of cholesterol	Patients are at high risk of CVD.
Sodium	2-3 g/day	High sodium intake will increase thirst in patients.
Fluids	750-1000 ml/day
Potassium	2-3 g/day	Hyperkalemia will cause cardiac arrhythmias.
Phosphate	800-1000 mg/day	Hyperphosphatemia will cause elevation of PTH and results in bone disease.
Calcium	<1500 mg/day	Avoid: Dairy products and soybean products
Iron	200 mg/day	In hemodialysis, blood loss increases through dialysers, therefore, there is a need to take supplementation to maintain adequate iron stores.

SAMPLE OF ONE DAY MENU

MEAL TIME	FOOD	AMOUNT
Breakfast	Plain tosai Yellow dhall gravy Tea/coffee + sugar	1 pcs ½ cup 1 tbsp
Morning tea	Kuih apam gula hangus Tea/coffee + sugar	1 pcs 1 tbsp
Lunch	Cooked rice Fried ikan kembong coated with corn flour Cabbage stir-fried Watermelon	150 g 80 g ½ cup 1 slice
Afternoon snack	Tea +sugar Fried popia	200 ml 2 pieces
Dinner	Fried mee Chinese style + chicken pieces + mustard leaves (cut & soaked) Barley water + sugar Lai	80 g 1 tbsp 1 no

CAPD

NUTRIENTS	RECOMMENDATION	RATIONALE
Calories	35 kcal/kg body weight (<60 y/o) 30-35 kcal/kg (>60 y/o) *Includes calories from dialysate due to glucose absorption.	Approximately 60-70% of dialysate fluid glucose may be absorbed. Small and frequent meals are recommended due to early satiety in patients.
Protein	50% HBV   1.2 g/kg BW 1.3 g/kg BW (severe malnourish/acute illness)	Intake of less than 1.3 g/kg BW per day might lead to negative nitrogen balance.
Carbohydrate	50-60% of total calories	Less than 50% of energy intake from CHO will cause elevation in proportion of protein and fat. For diabetic patients, complex CHO and dietary fiber are recommended.
Fats	25-35% of total calories <7% total calories of SFA 10% of total calories of PUFA 20% of total calories of MUFA <200 mg/day of cholesterol	Patients are at high risk of CVD.
Sodium	2-4 g/day	High sodium intake will increase thirst in patients.
Fluids	Up to 1500 ml/day	Ultrafiltration normally can remove 2-2.5kg fluid per day.
Potassium	3-4  g/day	Hypokalemia may occur due to continuous removal of potassium in dialysate.
Phosphate	800-1000 mg/day	Hyperphosphatemia will cause elevation of PTH and results in bone disease.
Calcium	<2000 mg/day	Avoid: Dairy products and soybean products
Iron	200 mg/day	In hemodialysis, blood loss increases through dialysers, therefore, there is a need to take supplementation to maintain adequate iron stores.

SAMPLE ONE DAY MENU

MEAL TIME	FOOD	AMOUNT
Breakfast	Fried meehoon + fried egg Tea/coffee + sugar	½ cup 1 tbsp
Lunch	Cooked rice Roasted pandan chicken Old cucumber soup Apple	100 g
Afternoon snack	Tea +sugar Kuih lapis	1tbsp 1 pieces
Dinner	Cooked rice Fish, fried in chilli Fried petola + fuchok + su-un Papaya	100 g 1 slice

DIAGNOSIS TEST FOR END STAGE

Diagnosis test for end stage renal failure are:

1. Urine test

2. Blood test

3. Imaginary test

4. Biopsy

5. Estimated Glomerular Filtration Rate 

URINE TEST

It is importance to see if the kidneys are working properly. End stage renal usually contains protein ( albumin) . By collect urine within 24-hour period we can predict amount of urine produced. Low urine output usually happens for end stage renal failure.


BLOOD TEST

Commonly Ordered Blood Tests done is complete blood count; calcium, phosphorus, and parathyroid hormone; and potassium levels. Other than that, Blood Electrolytes test, the concentration of sodium, chloride, calcium, and potassium in the blood will be abnormal. Potassium, in particular, can quickly rise to dangerous levels. Beside other test such as Blood Urea Nitrogen (BUN) and Creatinine also can be done. End stage renal failure may also have excess creatinine and urea level in the blood.


RENAL IMAGING

The use of ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT scan) is importance to take pictures of the kidneys. These pictures will show whether urine flow is blocked or whether there is a change in the size of the kidneys.

KIDNEY BIOPSY

A small piece of kidney may be surgically removed and sent to a laboratory in order to find cause of kidney failure.


ESTIMATED GLOMERULAR FILTRATION RATE

Calculate the GFR based on gender, age, body size, and blood creatinine level can be done to determine which stage the patient are.

End stage patients also can download GFR calculator by download software from softpedia.com.  Or this link

http://www.softpedia.com/get/Windows-Widgets/System-Utilities/GFR-Calculator.shtml

DRUG USED FOR END STAGE RENAL FAILURE

• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers –prescribe to lower the blood pressure hence preserve the kidney. Hypertension decreases the kidney function & cause electrolytes imbalance. This medication not only reduce blood pressure but slow down the loss of kidney function as well

• Statins medication- prescribes to lower the blood cholesterol level. Patient with Kidney failure usually experience high level of LDL cholesterol that lead to heart disease

• Erythropoietin-stimulating agents- medication that used to relive anemia by induce production of RBC which can resolve fatigue and weakness associated with anemia. ESAs mimic the erythropoietin hormone that helps body produce RBC. Usually taken with extra iron intake.

• Diuretic medication-prescribe to relieve swelling or water retention that called edema. Diuretic help maintain the balance fluids in the body by help rid the body of excess fluid. Side effect: dizziness, frequent urination.

• Vitamin D & calcium supplement-To protect the bones from bone disease by prevent the bones from weak and lower risk of fracture. Abnormalities of Vitamin D are common in ESRF due to failure of kidney to convert vitamin D to active form that body can utilize.

• Phosphate binder medication- lower the amount of phosphate in the blood(hyperphosphatemia) is common in ESRD) thus increase the amount of calcium available in the bones. Phosphate binder work by absorbing excess amount of phosphorus from ingested food. Example of phosphate binder is sevelamer.

• Cinacalnet HCL(sensipar)-effective in lowering the elevated parathyroid hormone level. Taken by orally. Give several side effect such nausea, vomiting and transient low blood calcium level.

• Sodium Bicarbonate-prescribe with development of metabolic acidosis. Taken by orally with certain precautions since the medication increase the sodium level.