UCSF Kidney Transplant Symposium 2012

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1 UCSF Kidney Transplant Symposium 2012 Nutrition Fitness in Kidney Transplant Mary Ellen DiPaola, RD, CDE UCSF Outpatient Dietitian

2 Goal of Nutrition Fitness for Transplant Nutritional guidance of pre- & post- transplant patient Towards best nutritional shape To enhance outcomes Positive Nutritional status Optimum Weight Well managed Co-morbidity Delay of kidney Replace therapy Long term kidney Health

3 Outline of Nutrition Fitness Medical Nutrition Therapy (MNT) Assessment Intervention Monitoring & Evaluation Academy of Nutrition & Dietetics Evidence-based Library Guidelines

4 ADA Chronic Kidney Disease Evidence Based Nutrition Practice Guideline Executive Summary of Recommendations Academy of Nutrition & Dietetics (Formally American Dietetic Association) 2010 ADA Evidence Analysis Library

5 Evidence- Based Dietetics Practice Systematic review of scientific evidence For food & nutrition practice decisions By integrating Best available evidence Professional expertise Clients values To improve outcomes ADA Scope of Dietetics Practice Framework: Approved by ADA House of Delegates

6 Evidence Based Library (EBL) Ratings & Statements Rate review of evidence quality Strong Fair Weak Consensus Insufficient Recommendations statement Conditional Imperative

7 EBL Guideline Focus Chronic Kidney Disease Medical Nutrition Therapy (MNT) Adults Chronic Kidney Disease (CKD) Stage 1-5 Not on dialysis Post kidney transplant Strong Imperative

8 Chronic Kidney Disease Medical Nutrition Therapy 2010 ADA Evidence Analysis Library

9 EBL Guideline Focus Medical Nutrition Therapy Prevents & Treats Protein-energy malnutrition Mineral & electrolyte disorders Minimizes impact of comorbidities on progression of CKD Diabetes Obesity Hypertension Disorders of Lipid metabolism Strong Imperative

10 EBL Guidelines: Initiation of MNT Referral for MNT per federal & state guidelines Initiated at diagnosis of CKD To maintain adequate nutritional status Prevent disease progression Delay renal replacement therapy (RRT) At least 12 months prior to anticipated RRT Dialysis Transplant Strong Imperative

11 MNT: Delaying need for RRT MNT May Be Cost Effective May slow CKD progression May help manage CKD complications CKD & ESRD are increasing Burden of RRT is significant to individual & society MNT to aid management Too few patients receive nutritional intervention prior to RRT

12 Medical Nutrition Therapy (MNT) Purpose in Post-Transplant Achieve/maintain healthy weight Manage chronic disease risk factors BG, lipids, BP, bone health Minimize medication side effects Increase appetite & weight Increase serum lipids & glucose Increase blood pressure & fluid retention Potential stomach ulcers & bone disease

13 Nutrition Interventions & Practices Considered Evaluation Nutrition Assessment Management & Treatment Medical Nutrition Therapy Coordinate Nutrition Care & Monitor Progress Improve Outcomes

14 Chronic Kidney Disease Nutrition Outcomes 2008 ADA Evidence Analysis Library

15 Major outcomes considered Pre-Transplant Nutritional status Weight Muscle & fat stores Serum albumin Glomerular filtration rates (GFRs) Blood pressure levels Progression of kidney disease Serum phosphorus levels Blood glucose levels Bone health status

16 Major Outcomes Considered Post-Transplant Nutritional Status Weight status Co morbidities BG Lipids Blood pressure Bone health Medication side affects Healthy kidney

17

18 Chronic Kidney Disease Nutrition Assessment/Evaluation 2010 ADA Evidence Analysis Library

19 Nutritional Status Pre-Transplant Proper Nutrition Assessment prior to surgery Avoid Malnutrition Impaired wound healing Higher rates of infection Identify signs of macro- or -micronutrient depletion Supplementation recommendations Assess laboratory values related to CKD Appropriate diet restrictions in accordance

20 Nutrition Assessment/Evaluation Medical & Health History Comorbidities Medications, supplements, herbs/botanicals Food & Nutrition-related Intake Diet history Factors affecting food access Lifestyle Habits Behavior & attitude Knowledge & belief Adherence to lifestyle recommendations Readiness to change

21 Nutrition Assessment/Evaluation Biochemical Parameters Kidney function Glycemic control Dyslipidemia Anemia Protein-energy malnutrition Bone & mineral disorders Electrolyte disorders Inflammation Anthropometric Measures BMI & Weight history Physical History Energy levels & activity

22

23 Weight Loss Advisory Increasing proportion of overweight & obesity Excessive somatic stores often mask nutritional deficiencies Later stage CKD may have increased mortality risk Caution with weight loss goals BMI >35 Benefit more from increased exercise Burn fat Preserve LBM Assess parameter beyond weight status Lean body mass Visceral protein status Micronutrient status

24 EBL Guideline: Clinical Judgment in Assessing Body Weight (BW) Absence of standard reference norms for BW in CKD Nutrition needs for Protein & Energy Base estimations of body weight (BW) on: Actual measured weight History of weight changes (both long-term & recent) Serial weight measurements, monitored longitudinally Adjustments for suspected impact of: Edema, ascites, polycystic organs Consensus Imperative

25 Case example I 42 yo male HTN since 20s DM- insulin no A1c no SMBG GFR = 21 Dyslipidemia # BMI=34.92 muscular, does not appear overweight Construction work + regular strength training, 3-4x/wk Albumin 2.6 Diet: Less red meat and salt as per MD advise Diet hx: Excess total/saturated fat, sodium, total carbohydrates, Inadequate protein d/t intentional reduction for CKD

26 Chronic Kidney Disease Nutrition Intervention = Medical Nutrition Therapy (MNT) 2008 ADA Evidence Analysis Library

27 MNT Nutrition Care Macro- & micro-nutrient needs Protein & Energy Phosphorus, sodium, calcium, vitamin D Supplementation Management of co-morbidities Hypertension, diabetes, anemia, lipids

28 MNT Nutrition Care Post-Transplant Promote wound healing Reduce infection Combat adverse effects of post-transplant medications Macro- & micro-nutrients needs Management of co-morbidities Hypertension, diabetes, anemia, lipids

29 MNT Nutrition Care Post-Transplant Minimize unwanted side effects of medication Possible increases: Appetite Lipids Blood pressure Stomach ulcers Weight gain Blood sugars Fluid retention Osteoporosis

30 MNT Nutrition Care Pre & Post-Transplant Enhance Outcomes Physical activity interventions Behavioral interventions Self-management education Coordination of care

31 MNT Nutrition Care Post-Transplant Achieve healthy body weight Increased appetite > Increased intake Exercise as soon as permitted Micro nutrient monitoring Serum phosphorus declines Supplementation may be required to increase Enhance optimal bone density Calcium & vitamin D supplementation

32 MNT Nutrition Care Post-Transplant Manage Potential Co-Morbidities Maintain acceptable blood sugar levels Control BG to aid healing process Control carbohydrates portions Aim for desired blood lipid & blood pressure levels Heart healthy eating: DASH diet Plant based/high fiber Lean/low fat fats, low sodium

33 Nutrition & Heart Health Increase Whole Plant Foods Fiber Plant Protein Vitamins & Minerals Healthy Fats Monounsaturated Omega-3s Decrease Animal Foods Saturated fats Cholesterol Processed Foods Trans Fats Sodium Portion Sizes

34 A Healthy Plate for Balanced Nutrition

35 USDA 2011 MyPlate

36 Case example II 59 yo male Asian- decent HTN DM2 Insulin, OHA HA1c=8.1, SMBG 1-2x/day CKD Stage 4 GRF=20 Dyslipidemia 68, 180# BMI=27.4 General walking, energy fair Diet: No salt, no sugar No RD MNT Diet hx: Excess total carbohydrate (rice, fruit), excess sodium, excess saturated fat (meats), >RDA protein

37 Case example III 59 yo male Asian- decent HTN DM2 Insulin, OHA HA1c=6.8, SMBG 4-6x/day CKD Stage 4 GRF=20 Dyslipidemia # BMI= 22.5 Recent 6# loss since diet change Regular gym work-out: 30+min. CV, 5x/wk + walking Diet: Renal diet for diabetes - RD MNT Diet hx: Moderate carbohydrate, low fat, inadequate protein

38 ADA Chronic Kidney Disease Evidence Based Nutrition Practice Guideline Executive Summary of Recommendations Academy of Nutrition & Dietetics 2010 ADA Evidence Analysis Library

39 Protein & Energy Intake Needs Individualized nutrient diet restriction Stage of CKD & post-transplant Patient compliance expectancy Assess on individual basis Special considerations to catabolic conditions Infection Gastrointestinal symptoms Diarrhea or vomiting Comorbidities Ulcerative colitis, HIV infection

40 Protein & Energy Intake Biochemical indices Pre-albumin, albumin Anthropometric changes Weight change BMI Physical activity (if possible) Benefits in optimizing nutritional status Energy needs may increase

41 CKD/Pre-Transplant Protein Intake Diet prescription Adjusted body weight if BMI >30 Pre-dialysis no catabolic condition RDA protein gm/kg Diabetes Nephropathy.8-.9 gm/kg/day Prevent hypoalbuminemia Improve microalbuminuria Strong Conditional Fair Conditional

42 Post-Transplant Protein & Energy Intake Short term High Protein gm/kg (as high as 2.0 mg) Adequate energy for protein sparing kcal/kg Long term RDA Protein gm/kg Energy to prevent signs of malnutrition kcal/kg Individualized Consensus Conditional Fair Imperative

43 Energy Intake Individualized based on: Metabolic stressors Weight status & goals Age Gender Level of physical activity Fair Imperative

44 Micronutrient Intake Sodium <2.4 gm Potassium <2 gm Phosphorus gm Fair/Imperative Fair/ Conditional Strong/Conditional Elevated serum levels or parathyroid hormone High Post-transplant Consensus/Conditional Calcium gm Consensus/Condition Vitamin D IU Consensus/Conditional

45 CKD Nutrition Prescription: Pre & Post Transplant Protein Energy Calcium Vit D Sodium Potassium Phosphorus Pre-dialysis No catabolic condition.6-.8 gm 35 kcal gm < 2gm IU < 2.4 gm < 2 gm Serum increase gm Serum increase Pre-dialysis DM nephropathy Dialysis for anabolism Post transplant Short term Post tx Long term.8-.9 gm kcal 1.2 gm 35 kcal < 2 gm 1-3 gm gm gm kcal kcal 1.5 gm <2.4 gm " High Serum reduction <2-3gm Monitor Monitor

46 Chronic Kidney Disease Nutrition Outcomes 2008 ADA Evidence Analysis Library

47 Goal of Nutrition Fitness for Transplant Nutritional guidance of pre- & post- transplant patient Towards best nutritional shape To enhance outcomes Positive Nutritional status Optimum Weight Well managed Co-morbidity Delay of kidney Replace therapy Long term kidney Health

48

49 For additional information: ADA Evidence Analysis Library ADA Evidence Analysis Library

50 Citation Evidence-based Nutrition Practice Guideline on Chronic Kidney Disease published at and copyrighted by the American Dietetic Association; accessed on July ADA Evidence Analysis Library

51 Nutrition Fitness in Kidney Transplant Thank you. Questions?

52 UCSF Kidney Transplant Symposium 2012 Nutrition Fitness in Kidney Transplant Mary Ellen DiPaola, RD, CDE

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