Niken Dharmawati Cahyaningsih,S.Kep.Ns
Diet plays as a vital role in dialysis patients’ rehabilitative care. A well-balanced diet is necessary for them to stay fit as their kidneys are no longer functioning at its full capacity. To strive towards well being dialysis patients, they would need to consume the right kind and amount of food on a daily basis, take their medication correctly as prescribed by the doctor, comply with the haemodialysis treatment, for instance, not “miss” any dialysis session.
Dialysis patients require a much higher intake of protein than the common person. To achieve good dialysis outcome, dialysis patients need to strictly control their diet so as to help control the waste products and fluids accumulated between dialysis treatments. It is essential for dialysis patients to have the right amount intake of protein, calories, fluids, vitamins and minerals each day. A good diet for a dialysis patient is adequate in protein, adequate in calories, low in potassium, low in sodium, and low in phosphorus, controlled in fluids.
During dialysis, some amount of proteins is lost and therefore patients require a higher protein intake. Low protein and calorie intake often leads to protein energy malnutrition. Malnutrition on dialysis patient is often associated with increased of morbidity and mortality and decreased quality of life. There are many contributing factors, including inadequate dialysis, nutrient losses during dialysis, dietary restrictions, medications and socioeconomic factors.
Malnutrition has been found in 44% of pre dialysis patient, 30% of haemodialysis patient, and 40% of peritoneal dialysis patients. (Ahmed, 1999). Malnutrition has a significant influence on survival. Nutritional status is a strong predictor of patient outcome, including mortality, as well as quality of life.
Nutritional management of chronic kidney disease (CKD) is an integral component of the medical care of both progressive and end stage kidney disease. Diet therapy is potential to slow the progression of chronic kidney disease, compensate for impaired renal function and/or limitations of treatment modalities, has a major role in the management of the co-morbid conditions and is a mainstay of therapy for malnutrition. Protein intake must meet nutritional needs and compensate for any losses. Excessive enhances production of nitrogenous toxins while inadequate intake protein promotes protein malnutrition. It is the role of the dialysis nurse to identify patients at risk from malnutrition and do a nursing intervention about their condition and make appropriate referral to the dietician.
Nutritional assessment of dialysis patient
Timely and thorough assessment of nutritional status is crucial to diagnosis and treatment or prevention of malnutrition in CKD patients. A perfect diagnosis must be made on multiple factors. There is no single test that stands alone for diagnosis. Nurses can work with the patient care team to ensure timely assessment and diagnosis of malnutrition. Nurses see patient frequently and can assess changes in appetite, weight loss or gain, decrease muscle mass and decrease strength and endurance. Nurses need to communicate these finding to other members of the healthcare team (Greene & Hoffart, 2001).
Nursing assessment of nutritional status
Signs & Symptoms
Assess for anorexia, nausea, vomiting, dysphagia, ability to buy/get food, dieting and exercise, depression, diabetes mellitus, thyroid disorders, ability to chew, dentures, medical or cultural religious reasons for not eating
Decreased muscle mass
Thin/ bony appearance
Assess back of hands, shoulders, and thighs for atrophy (most evident there); may notice that BP cuff fits looser
Decreased strength & endurance
Grade muscle strength 0-5
0 = no muscle contraction
1 = contraction barely noticeable
2 = active movement without gravity
3 = active movement against gravity
4= active movement against some resistance
5 = active movement against resistance without fatigue
Fatigue, weakness, cold intolerance, flaky dermatitis, ankle swelling
Eliminate work, stress, grief and causes of fatigue
From Bickley & Szilagyi (2002)
No one test can adequate asses nutritional status. K/DOQI guidelines recommend using blood panels for nutritional testing, which may include serum albumin, serum prealbumin, BUN, serum creatinine, and total cholesterol.’
Serum albumin is the best predictor of morbidity and mortality (Ahmed, 1999; Greene & Hoffart, 2001). Survival is predicted best if the level is greater than 3.5 g/dL. Normal values of serum albumin vary based on the method of assessment. Serum albumin levels should be interpreted cautiously an in relation to the entire clinical picture because falsely low result can occur related to infection or inflammation, decreased protein synthesis related to liver disease, peritoneal dialysis or urinary losses, overhydration, and acidemia (Greene & Hoffart, 2001).
Prealbumin (transthyretin) is more responsive than albumin because it has a shorter half life (2 days) and more sensitive to acute changes in nutrition (K/DOQI, 2006). The normal value for prealbumin is 16-35 mg/dL. Level less than 15 mg/dL indicate risk for malnutrition.
Predialysis BUN less than 60 mg/dL and creatinine less than 10 mg/dL in CKD patient may indicate poor nutritional status (Greene & Hoffart, 2001). When assessing BUN and creatinine, residual kidney function and the dialysis prescription require consideration because urea nitrogen and creatinine are excreted by the kidneys and are typically elevated in CKD.
Serum total cholesterol less than 150 mg/dL suggests malnutrition (Ahmed, 1999). Low cholesterol may indicate chronic inadequate protein intake or protein catabolism because cholesterol cannot be synthesized where there are inadequate protein stores.
1. Subjective Global Assessment (SGA)
The SGA is an inexpensive, easy, and reproducible way to assess nutritional status. It correlates with serum albumin levels in the nutrition assessment and relates to anthropometry. Patient history, physical examination, and protein-calorie status are subjectively scored. The scores from each section are summed to obtain the final score, which indicates the patient’s nutritional status. Higher scores indicate a better nutritional status (K/DOQI, 2006). This is generally part of a thorough nutrition assessment completed by a renal dietician.
Anthropometric data are used to estimate tissue mass of bone, muscle and fat (Ahmed, 1999). K/DOQI guidelines (2006) for using anthropometric data include the measurement of percent of usual body weight, body mass index (BMI), skin fold thickness, estimated percent body fat, and mid-arm muscle mass. An unintentional loss of normal body weight of more than 10% is indicative of malnutrition. The percent of body fat is assessed using skin fold thickness of the nondominant, non-access arm at the triceps. Mid-arm muscle area circumference can be used to determine body muscle mass
3. Diet interviews and food diaries
Diet records (diaries) with or without interviews and food recalls examine the food intake over relatively short intervals of time. They are most commonly used tools to assess directly the intake of protein and energy and other nutrients in patients undergoing maintenance dialysis. CKD patient especially those on dialysis, are often anorexic. Decrease intake can lead to malnutrition. Three-day food diaries followed by interviews can provide data to calculate actual protein, calorie, and nutrient intake (K/DOQI, 2006).
Psychosocial factors can also influence nutrition. This necessitates performance of a thorough psychosocial assessment, including culture, socioeconomics, and education, on all patient. Culture can affect the food that patients are willing to eat or foods that they choose to eat that are not part of their diet prescription. Economic may also dictate which foods patients eat. One studied the effect of socioeconomic status on quality of life and found them to be directly proportionate. Poor quality of life, social relations, and emotions may lead to depression or anxiety, which can also alter pattern possibly leading to anorexia (Halsted, 2001). Also lack of education may preclude a patient’s ability to understand his or her diet.
Renal insufficiency / predialysis patients
Nutrition needs to be optimizes as early as possible in the progression of CKD. Patients who are malnourished before the initiation of dialysis have a high risk of continued malnutrition after dialysis is initiated. As CKD progress, the number of functioning nephrons decreases, leading to decreased metabolite clearance and increase uremic toxin level. Uraemia causes loss of appetite, decrease intestinal motility, gastritis and ulcers. The primary intervention when treating malnutrition is correction or prevention of uraemia.
Some medication used by dialysis patient can cause anorexia. Other medications commonly use in CKD can cause nausea and vomiting that, if severe, can lead to anorexia and malnutrition. K/DOQI guidelines recommend a protein intake of 0.6 g/kg/day, which is low. At least 50% of protein needs to be of high biological value. Careful monitoring of the patient’s nutritional status will help avoid malnutrition (K/DOQI, 2006)
The daily energy intake (DEI) needs to be 35 kcal/kg/day for those under 60 years old and 30-35 kcal/kg/day for those over 60 years old (K/DOQI, 2006).
PD patient must compensate for large amounts of protein and amino acids lost in PD effluent (Ahmed, 1999). The feeling of fullness with fluid in the abdomen may decrease appetite, and an inadequate dialysis prescription can lead to poor nutritional status (Ikizler, 2001). In general, PD patients do not have to follow as strict a diet as HD patients because PD provides an environment for more frequent solute removal.
PD patients require at least 1.2 to 1.3 g/kg/day of protein and 50% needs to be high biologic value protein (K/DOQI, 2006). The DEI for PD patients is 35 kcal/kg/day for those under 60 years old and 30-35 kcal/kg/day for those over 60 years old. Patients need to consume enough calories to prevent protein catabolism (Ahmed, 1999).
Amino acids and peptides are lost with each haemodialysis treatment (Greene & Hoffart, 2001) Haemodialysis patients require approximately 1.2 g/kg/day of protein with 50% or more as high biologic value protein (K/DOQI, 2006). The DEI for HD patients is the same as for PD patients: 35 kcal/kg/day for those under 60 years old and 30-35 kcal/kg/day for those over 60 years old (K/DOQI, 2006). It is important to provide enough calories to prevent protein catabolism. Fluid intake must be carefully monitors in HD patients. Fluid intake needs to be about 1000 ml/day plus urinary output (Greene & Hoffart, 2001). If the patient has no urine output, fluid is limited to 1000 ml/day and sodium is tightly controlled.
Collaborative education of patients and families.
Adequate patient education on nutrition requires a team approach. Patients can also be made aware of all resources, such as dialysis staff, including dieticians, and writing materials. Written instruction should be given as reinforcement to oral explanations and patients should be encouraged to ask questions. It is imperative to assess the literacy level of each patient as well as any other barriers to learning. Education often works best in small sessions so not to overwhelm patients. A good time to counsel patients may be during HD, but not when the patient is not feeling well.
Frequent intervention and counselling increases adherence and improve outcomes. K/DOQI guidelines (2006) recommend updating each patient’s plan of care every 3-4 months and offer counselling at least every 1-2 months.
Patients should be assisted to establish goals that consider their lifestyle, ethnicity and socioeconomics. This is a continually changing process based on patient assessment. Open conversation with patients and their family members should be encouraged.
Appropriate diet prescriptions are crucial to all CKD patients to minimize morbidity and decrease mortality. It is also important to appropriately assess and counsel renal patients to ensure adherence and proper nutrition. Nurses have the important role to assess and identify dialysis patient and discuss with other team.
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Blumenkrantz, J.Michael. (1990). Nutrition. In Handbook of Dialysis 1st ed. Ed by Daugirdas, John T; Todd S. Little, Brown and Company. Boston/Toronto
Catherine Wells. (2003). Optimizing Nutrition in Patients with Chronic Kidney Disease. Nephrology Nursing Journal. Vol 30. No. 6
Elaine P. Murray. (2000). The nurse’s role in feeding patients with renal disease. Proceeding of the nutrition society. http://journals.cambridge.org
Greene, J., & Hoffart, N. (2001). Nutrition on renal failure, dialysis and transplantation. In L. Lancaster (Ed), Core curriculum for nephrology nursing (4th Ed.). Pitman, NJ: American Nephrology Nurses’ Association.
Jordi Goldstein-Fuchs, DSc,RD. (2006). Nutrition and Chronic Kidney Disease. In Contemporary nephrology nursing: Principles and practice (2nd Ed.). American Nephrology Nurses’ Association
K/DOQI. (2006) Clinical Practice Guideline for Nutrition in Chronic renal failure. NKF. http://www.kidney.org/profesional/kdoqi/guidelines_updates/doqi_nut.html
Zadeh KK, Kopple JD. (2004). Malnutrition as a risk factor of morbidity and mortality in patients undergoing maintenance dialysis. In Nutritional management of renal disease. 2nd ed. Ed by Kopple DJ, Massry SG. Lippincot William & Wilkin
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Indonesian Nephrology Nurse Association (PPGII)
MEETING AND SYMPOSIUM 2008