Nutritional Management of

Chronic Kidney Disease (CKD)

and Diabetes

Dani Renouf, RD, MSc

Renal Resource Dietitian
St. Paul’s Hospital
May 25, 2017

1
Overview

 Burden of Disease: CKD and

Diabetes
 Diabetic Nephropathy
 Approaches for Nutrition Care
 Questions

2
Burden of Disease: Diabetes and
CKD1,2

 Worldwide, 200 Million have CKD

 Diabetes is the leading cause of
kidney disease
 50% of persons with diabetes
demonstrate signs of kidney
damage in lifetime

3
Stages of Kidney Disease

RD

KCC

4
http://choosingdialysis.org/YourKidneyHealth/ChronicKidneyDisease.aspx
 Diabetic Nephropathy

 Hyper-filtration
 Persistent Albuminuria
 Peripheral Edema
 GFR Decline
 Hypertension
 Increased Risk for CVD/Cardiac
Events

https://www.slideshare.net/ahmadtanweer/diabetic-nephropathy-tanweer-1
5
Risk Factors for Diabetic
Nephropathy
Most Risk
Factors Are
Modifiable Male Hyperglycemia
Gender

Preventative Obesity
Healthcare
Models need Duration Inflammation
to be Hypertension
supported

Smoking Dyslipidemia

6
 Nutritional Care Areas3

RD Support

Glycemic Control
Blood Pressure Control

Patient-Centered
Care
Physical
RD Support Activity
RD Support

Heart Healthy
Fats Management of Lipids

7
Patient’s Experience

8
Approaches for Nutrition Care
 CKD and Diabetes are progressive
and chronic diseases
 Relationship with food and dietitian
needs to be sustainable in order to
slow progression
 Food Champion, not Food Police
 Limit contraindications and focus on
“what to eat”
 STREAMLINED APPROACH TO
NUTRITION

9
Nutrition Care
 What CAN patients
eat? Support
 What FITS into their
life?
 What SUCCESSES
have they had
already?
 What are their
GOALS?
Collaboration
 What is most Active Listening
EFFICIENT?
Nutrition Care Areas

 Glycemic Control
 Sodium Reduction
 Protein Recommendations
 Potassium Control
 Phosphate Control
 Weight Management/Physical
Activity

11
Glycemic Control

12
 Evidence for Glycemic Control2
 DCCT/EDIC Studies show HbA1C of 7.0%
prevented nephropathy, but during follow
up period, effects of reduction persisted
with 8.0%
 ADVANCE/ACCORD/VADT studies showed
no significant benefit on GFR with more
intensive glycemic control (HbA1C<7.0%)
 Risk of hypoglycemia plays a major role in
setting targets
 HbA1C may be underestimated in anemia

13
Hypoglycemia Considerations2,3
 Risks are higher in our patients
 Consider insulin metabolism as GFR
declines (increased half life)
 Impaired gluconeogenesis with reduced
kidney mass
 Consider extension of HbA1C above 7.0%
with co-morbidities
 Explore lifestyle interventions as
contributing factors:
 Erratic eating pattern
 Decreased appetite
 Increased exercise

14
Dietary Management of Diabetes

 RD visit every 3 months recommended

(telehealth)2
 General meal patterns/timing/portions
rather than carbohydrate counting
 Hydration
 Higher fibre diet – whole
grains/fruits/vegetables
 Blood glucose monitoring (scattered)
 Physical activity, not weight loss

15
 The Healthy Plate

https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ 16
Teaching Tools

http://www.bcre nalagency.ca/resource -gallery/Documents/Diabetes%20and%20Kidney%20Basics%20final_0.pdf

17
 Sodium Reduction

https://www.cdc.gov/salt/food.htm 18
 Evidence for Blood Pressure Control7

 RCT cross-over trial

 Low sodium diet (less than 2,000 mg per day),
washout, crossover
 Significant reductions in urinary sodium (-57.3
mEq/24 h; 95% CI, -81.8 to -32.9), weight (-2.3
kg; 95% CI, -3.2 to -1.5), and 24-hour systolic BP
(-10.8 mmHg; 95% CI, -17.0 to -4.6) were also
observed (all P<0.01).
 Motivational Interviewing by RD

19
Salt Reduction = Label Reading

20
Streamlining Food Lists

21
 Salt Reduction = Food Selection
While Dining Out
 Dressings on the Side
 Limit Soups, Dips,
Appetizers
 Ask the restaurant
staff to “Not Salt
Food” or offer lower
salt options (call
ahead)

https://www.kidney.org/sites/default/files/docs/diningout.pdf
22
Salt Reduction = Meal Preparation

23
Protein Recommendations

24
 Protein Guidelines4

http://www2.kidney.org/professionals/KDOQI/guideline_diabetes/guide5.htm 25
Protein: A Juggling Act

Obesity

Prednisone
Co-Morbidities

Muscle
Rate Individual mass loss
of Progression Protein (Acidosis)

Needs

26
Protein Energy Wasting5

27
Protein Calculations
 Protein distribution/amounts based on
preservation of muscle mass
 (0.8-1.3g/kg) – include vegetarian
proteins to help reduce metabolic
acidosis
 Use adjusted body weight calculations:
 Obesity
 Edema

 Underweight

28
Protein Education
 Potassium Control

Additives?
Was it REALLY the banana?

Dairy? Soups?
Hyperkalemia
 #1: Explore Non-Dietary Causes
 Blood glucose patterns before/after meals
 Recent hospitalization/surgery (blood loss)

 Factors affecting hydration

 Bicarbonate therapy (acidosis)

 Medication changes

 #2: Explore Dietary Causes

 Meal Pattern/Portions/Spacing
 Processed Foods

 Salt Substitutes

 Beverages – Wine, Coffee, Juice, Milk, Pop

 Protein portions/meal timing/spacing

 Fruits and Vegetables

31
Lipid Management2,6

 Statin + Ezetimibine therapy

 Reduction of saturated fats,
processed foods
 Inclusion of monounsaturated and
polyunsaturated fats (nuts, canola,
olive, salmon)
 Physical activity

32
 Phosphate Control

 Organic (from food) has 40-60%

absorption versus Inorganic (from
additives) which has >90%
absorption
 Start education when patient has
pattern of levels greater than 1.4
mg/dL
 Dietary intervention prior to starting
binders preferred
33
Phosphate
Teaching

34
Counseling for Weight Loss

 Avoid statements to patient such

“lose weight”
 Losing weight usually is
synonymous with losing muscle
mass in CKD 4-5
 Sarcopenia results in poorer
outcomes in CKD9
 Focus should be on physical activity
goal setting based on functional
ability9 35
 Physical Activity in CKD

 NHANES III showed that CKD

groups who were physically active
had lower rates of mortality when
compared to inactive CKD groups
(HR 0.44)10

Like Child’s Play!

36
Suggestions for Physical Activity
 Walking (Nordic Walking)
 Swimming
 Cycling
 Chair Exercises (NHS)11
 Strength Training

37
Nordic Walking at St. Paul’s Hospital

Anyone interested is welcome to join!

 Meeting In The Middle

Fruits and Veg Physical

Activity

High Fibre

Vegetarian
Healthy Eating,
Simplified Heart
Low Sodium Healthy
Fats

39
A Positive Experience for Patients
 Food Champions
 “What-to-Eat” Philosophy
 Streamlined Approach
 Fewer Rules, Lists, and Records

40
Questions

41
 References
1. McFarlane, P. et.al. Canadian Diabetes Association Clinical Practice Guidelines. Canadian
Journal of Diabetes. 2013; 37: S129-S136.
2. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012
Update. American Journal of Kidney Disease. 2012; 60(5):850-886.
3. 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. April 2015.
4. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice
Recommendations for Diabetes and Chronic Kidney Disease. 2007.
http://www2.kidney.org/professionals/KDOQI/guideline_diabetes/guide5.htm
5. Carrero, JJ et.al. Etiology of the Protein-Energy Wasting Syndrome from Chronic Kidney Disease:
A Consensus Statement From the International Society of Renal Nutrition and Metabolism
(ISRNM). 2013; 23(2): 77-90.
6. Halverstadt, A. et.al. Endurance exercise training raises high-density lipoprotein cholesterol and
lowers small low-density lipoprotein and very low-density lipoprotein independent of body fat
phenotypes in older men and women. Metabolism Clinical and Experimetal. 2007; 56(4): 444-450.
7. Saran, R. et.al. A Randomized Crossover Trial of Dietary Sodium Restriction in Stage 3–4 CKD.
Clinical Journal of the American Society of Nephrology. 2017; 12(3); 399-407.\
8. Bump, M. Organic Phosphorus Versus Inorganic Phosphorus; Empowering Adult Kidney Patients
with Nutrition Education. Journal of Renal Nutrition. 2016; 26(5): e31-e33.
http://www.jrnjournal.org/article/S1051-2276(16)30044-9/pdf
9. Roshanravan, B. et.al. Exercise and CKD: Skeletal Muscle Dysfunction and Practical Application
of Exercise to Prevent and Treat Physical Impairments in CKD. American Journal of Kidney
Disease. 2017;
10. Beddhu, S. et.al. Physical Activity and Mortality in Chronic Kidney Disease (NHANES III). Clinical
Journal of the American Society of Nephrology. 2009; 4: 1901-1906.
11. National Health Service. Exercises for Older People.
https://www.nhs.uk/Tools/Documents/NHS_ExercisesForOlderPeople.pdf

42