NUTRITION CONSIDERATIONS FOR PATIENTS WITH DIABETIC NEPHROPATHY

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1 NUTRITION CONSIDERATIONS FOR PATIENTS WITH DIABETIC NEPHROPATHY Becca Wallschlaeger, MS RDN CD Transplant Nutritionist University of Wisconsin Transplant Program Fall 2017

2 OBJECTIVES Recognize kidney disease is a growing epidemic, much like diabetes, and obesity Understand relationship between diabetes and kidney function Identify nutrition changes for people living with diabetes and advanced kidney disease Discuss Nutrition Interventions to preserve kidney function and prolong need for dialysis/transplant Understand kidney replacement options and the nutrition implications of each Next steps: how do we reduce the prevalance?

3 OVERVIEW Background Anatomy and Physiology of Renal Organ System Diabetic Kidney Disease Nutrition Implications and Changes in Advanced Kidney Disease Kidney Replacement Options Nutrition and Diabetes in Kidney Replacement

4 KIDNEY DISEASE FACTS More than 30 million (or more than 10%) US adults are estimated to have CKD and most are undiagnosed In the US, diabetes and hypertension are the leading causes of kidney failure, accounting for 72% or about ¾ of new cases The number of kidney failure cases in the US population has more than tripled since % with advanced kidney disease are not aware of having CKD 96% with CKD are not aware of having CKD Centers for Disease Control and Prevention, CKD Initiative, 2017

5 KIDNEY DISEASE FACTS CONT. Risk factors for developing CKD Diabetes Hypertension Both DM and HTN Heart disease Obesity Family history Centers for Disease Control and Prevention, CKD Initiative, 2017

6 KIDNEY DISEASE FACTS CONT.

7 DETECTION OF CKD IN DIABETICS Centers for Disease Control and Prevention, 2015

8 DIAGNOSIS COMMUNICATION Centers for Disease Control and Prevention, CKD Initiative, 2015

9 OBESITY--DEFINED Obesity Class I: BMI >/= kg/m2 Class II: BMI >/= kg/m2 Class III: BMI >/= 40 kg/m2 Extreme Obesity Morbid Obesity Severe Obesity Underweight: BMI < 18.5 kg/m2 Normal: BMI kg/m2 Overweight: BMI kg/m2 Limitations to Using BMI Does not reflect body composition Does not tell us where weight is located (i.e. central vs peripheral)

10 OBESITY CONTRIBUTORS Caloric Intake High carbohydrate intake Refined sugar intake (soda now linked as #1 cause ) Activity Level Genetics Medications Diseases Hypothyroidism Insulin resistance PCOS Cushing s

11 OBESITY AND DIABETES TRENDS

12 OBESITY AND DIABETES TRENDS

13 OBESITY AND DIABETES TRENDS

14 PREVENTING & MANAGING CKD Control Risk Factors Hypertension Diabetes Test for kidney disease in high risk patients NKF KDOQI Guideline 1: Patients with DM should be screened annually for DKD Manage CKD Healthy lifestyle Medication compliance Avoid kidney injuries Infections OTCs (ibuprofen, naproxen) Certain Antibiotics Dyes used for imaging tests Centers for Disease Control and Prevention, CKD Initiative, 2017

15 PUBLIC HEALTH EFFORTS

16 HEALTHY PEOPLE 2020 DM & CKD Goal: Reduce the disease burden of DM and improve the quality of life for all people who have, or are at risk for, DM 16 Objectives Goal: Reduce new cases of CKD and its complications, disability, death, and economic costs Nearly 25% of the Medicare budget is used to treat people with CKD and ESRD. 14 Objectives Office of Disease Prevention and Health Promotion, Healthy People 2020, 2017

17 HEALTHY PEOPLE 2020 OBESITY Nutrition and Weight Status Increase proportion of adults who are healthy weight Reduce proportion of adults who are obese Reduce proportion of children 2-19 who are obese Food Insecurity/Healthier Food Access Food and Nutrient Consumption Increase total vegetables in diets of those >/= 2 years Health Care and Worksite Settings Increase proportion of PCPs regularly measuring BMI Increase proportion of PCPs offering counseling/education related to weight Increase proportion of worksites that offer nutrition or weight management classes or counseling Office of Disease Prevention and Health Promotion, Healthy People 2020, 2017

19 BACKGROUND SUMMARY CKD rates are rising Diabetes and hypertension are main causes Obesity rates are rising Diabetes and hypertension are linked to obesity There are public health efforts to: Reduce obesity rates Reduce diabetes rates Improve diabetes management Reduce CKD rates Improve screening of high risk populations

20 RENAL PHYSIOLOGY Filters Blood Makes Urine Drug metabolism Removes Toxins Regulates Homeostasis Acid/base Electrolytes Fluids Blood Pressure Control Makes Erythropoietin Vitamin D Metabolism Much, much, more

21 RENAL ANATOMY

22 STAGES OF CKD National Kidney Foundation, KDOQI Guidelines

23 DIABETIC KIDNEY DISEASE Hyperglycemia Filtration rate Leaking (glomerular capillaries) Loss of protein Microalbuminuria (early stages) Macroalbuminuria (nearing ESRD) Loss of filtering Waste build up Dialysis/Transplant Wikipedia.org

24 GLUCOSE CONTROL AND MICROALBUMINURIA KDOQI Guideline 2 Intensive treatment of hyperglycemia prevents elevated albuminuria or delays its progression Recommend: HbA1c of ~ 7% to prevent or delay progression of microvascular complications of diabetes (Diabetes Control and Complications Trial) Recommend: Not treating to HbA1c <7% in patients at risk of hypoglycemia ADVANCE Trial

25 DIABETES CONTROL AND COMPLICATIONS TRIAL (DCCT) DM1

26 ADVANCE TRIAL DM2 11,140 participants Randomly assigned Intensive glucose-lowering strategy Standard glucose control Measures ESRD Risk Microalbuminuria Macroalbuminuria Results: HbA1c level was 6.5% in intensive group, and 7.3% in standard group Significant reduction in ESRD risk by 65%, microalbuminuria in intensive group Significant reduction in microalbuminuria by 9% Significant reduction in macroalbuminuria by 30%

27 DIABETIC CHANGES IN CKD Insulin metabolism Glomerulus Peritubular Capillaries Impaired renal function=impaired insulin metabolism Prolonged half-life of circulating insulin Wikipedia.org

28 DIABETES MANAGEMENT Consistent meal times; avoid skipping meals Reduce sugar and sweets Consistent meal composition My Plate Include a lean protein source at meals and snacks Choose high-fiber foods Eat less fat Be physically active Moderate weight loss (5-10%) Compliance with medications and glucose monitoring

30 DASH DIET 1,500-2,300 mg sodium/day Grains: 6-8 servings/day whole grains or sweet potatoes Vegetables: 4-5 servings/day Fruit: 4-5 servings/day Dairy: 2-3 servings/day (Low- or Non-Fat) Lean Protein: < 6 oz/day Nuts, Seeds, Beans: 4-5 servings/week Fats & Oils: 2-3 servings/day (unsaturated) Sweets: < 5/week

31 KDOQI GUIDELINES: PROTEIN GFR < 50 ml/min per 1.73 m gram protein/kg/day (IBW if BMI > 30 kg/m 2 ) Ensure adequate caloric intake to prevent malnutrition GFR < 20 ml/min per 1.73 m gram protein/kg/day (IBW if BMI > 30 kg/m 2 ) Keto acid analogs Vitamin/Mineral supplementation Diabetic Nephropathy gram protein/kg/day (IBW if BMI > 30 kg/m 2 ) Prevent hypoalbuminemia Dialysis 1.2 gram protein/kg/day (IBW if BMI > 30 kg/m 2 )

32 VEGETARIAN DIET In patients with CKD, higher proportion of plant sources (>50%) has been associated with better outcomes (Am J Kidney Dis, 2016) 70% protein from plants has shown to reduce creatinine and microalbuminuria and prevent bone bone breakdown (Am J Nephrol, 2016) Protein breakdown increases acid production, kidneys regenerate bicarbonate Constipation increases uremic toxins Plant-based proteins higher in fiber, less fermentable Study of 40 patients demonstrated lower ratio of fiber:protein was associated with higher levels of uremic products in blood (Nutr Metab Cardiovasc Dis, 2015) Higher fiber, Less absorption of uremic toxins in gut, less altering of microbiome studies in the works. Modification of Diet in Renal Disease (MDRD) showed minimal deceleration with low-protein diet (1994)

33 RESTRICTING DIETARY PROTEIN 321 enrolled patients; Provided with KDOQI guidelines Followed every 3 months by RD Diet records with analysis Adherence defined % of diet prescription Motivation additionally self-measured by patient Excellent, very good, fair, poor 4 groups DM adhered DM did not adhered Non-DM adhered Non-DM did not adhered

34 RESTRICTING DIETARY PROTEIN, CONT. Results: Adherence: 49.2% (25% DM 23% non-dm) Significant improvement in fasting glucose in group 1 Creatinine levels decreased significantly in adherent groups E-GFR increased significantly year-to-year in adherent groups with albumin in normal range (>3.8 mg/dl) No protein-energy wasting found Limitation: did not evaluate blood pressure or proteinuria

35 Kidneykorner.com

36 SODIUM & FLUIDS Sodium Based upon blood pressure and fluid balance Stages 1-5 < 2.4 gram/day Dialysis < 2.0 gram/day Fluids No restrictions Stages 1-3 Stage 4: output ml HD: L, depending on output and ID gains PD: 1-3 L/day

37 EFFECTS OF LOWERING PROTEIN & SODIUM N Engl J Med, 2017.

38 ADVANCED KIDNEY DISEASE Stage 4 or egfr ml/min/1.73m 2 Quality vs quantity clearance Symptoms Fluid build up Loss of appetite Changes in sleep Changes in concentration Monitoring Urine Blood

39 RENAL DIET KDOQI guidelines Academy of Nutrition and Dietetics Position Typical Concerns Sodium Potassium Phosphorus Calcium Vitamin D Protein Fluids

40 COMMON MEDICATIONS AND SUPPLEMENTS IN CKD AND ESRD No herbal supplements!!! Statins? Phosphate Binders Calcium-Based Iron-Based Aluminum-Based Aluminum-Free Magnesium-Based B-12/Folic Acid MCV > 100 ng/ml Serum levels < normal Vitamin D Serum 25-hydroxy < 30 ng/ml (75 nmol/l) ergocalciferol or cholecalciferol ipth > 600 pg/ml Calcitriol Iron Serum ferritin < 100 ng/ml TSAT < 20%

41 KDOQI GUIDELINES: POTASSIUM (K) No restrictions until K is > 5.5 mg/dl < 2.4 gram/day if hyperkalemic Restrict K intake to 3-4 g/day CKD Restrict K intake to 2-3 g/day ESRD Misc: multivitamins, sports drinks, salt alternatives, diuretics/blood pressure medications Common Sources Dairy Nuts Produce Dried fruits Processed foods

42 KDOQI GUIDELINES: PHOSPHORUS Restrict if serum level is > 4.6 mg/dl 800-1,000 mg/day RDA healthy population: mg/day Average intake: mg/day Common sources: Dairy Meats/Eggs Nuts Whole grains Processed foods

43 THE PHOSPHORUS PYRAMID D alessandro et al, BMC Nephrology, 2015

44 PHOSPHATE BINDERS

45 DIALYSIS Kidney replacement therapy Access Types Fistula: artery-vein connection in arm Graft: use of plastic tube to join artery-vein in arm Catheter: plastic tube inserted into large vein in neck Dialysis Modalities Hemodialysis In Center Home Peritoneal Dialysis CAPD Cyclic PD RD Assessment monthly-cms requirement Additional assessments Care Conferences

46 HEMODIALYSIS In-Center vs Home 3 days/week vs 5 days/week 3-4 hour sessions Increased variation in fluid shifts Typically more restrictive diet Increased protein needs National Institute of Diabetes and Digestive and Kidney Diseases, 2012

47 PERITONEAL DIALYSIS At home, usually while sleeping (cyclic) or ambulatory Daily 9-10 hour sessions Less variations in fluid retention Dextrose can cause unwanted weight gain Diet usually more liberal than HD Increased infection risk Increased protein needs Changes in appetite

48 EXERCISE RECOMMENDATIONS Minimizes catabolic effects of protein restrictions in CKD #1 cause of death in dialysis and transplant patients is CVD Increased risk of frailty in chronic illness and aging American Heart Association Recommendations 150 min/week cardiovascular 2 days/week strength building

49 TRANSPLANT OPTIONS FOR DIABETICS Pancreas Islet Cell Simultaneous Pancreas Kidney Kidney

50 UW TRANSPLANT WAITING TIMES Kidney

51 Figure 7.1 Percentage of dialysis patients wait-listed and unadjusted kidney transplant rates, Data Source: Reference Tables E4 and E9. Percentage of dialysis patients on the kidney waiting list is for all dialysis patients. Unadjusted transplant rates are for all dialysis patients. Abbreviations: Tx, transplant; pt yrs, patient years Annual Data Report, Vol 2, ESRD, Ch 7

52 NUTRITION ASSESSMENT PRE-TRANSPLANT BMI Goals Pancreas < 30 kg/m2 SPK < 30 kg/m2 Kidney < 35 kg/m2 Weight History Diet Restrictions Biochemical Data Activity level Frailty Assessments Diabetes Management

53 FRAILTY ASSESSMENT Fried, et al Gait Speed : timed 4 meter walk Grip Strength: hand dynamometer Exhaustion: patient questionnaire Physical Activity: Minnesota Leisure Activity Weight change: within past year

54 NUTRITION CONCERNS FOLLOWING TRANSPLANT Hyperglycemia Hypophosphatemia Hyperkalemia GI upset Food Safety Hypertension Dyslipidemia Weight management

55 CONCLUSION Diabetes is the number one cause of kidney disease and can prevent/delay if A1c is kept <7% Kidney disease alters electrolytes causing need for diet change The kidney diet is complicated Referring patients to an RD, during early stages to provide renal diet education, can slow microalbuminuria and improve E-GFR Regular follow up with RD can help improve compliance with renal diet

56 QUESTIONS & DISCUSSION Thank you!

57 REFERENCES 1. Centers for Disease Control and Prevention (CDC). Chronic Kidney Disease Initiative. US Department of Health and Human Services, CDC Prevention, Centers for Disease Control and Prevention (CDC). National Chronic Kidney Disease Fact Sheet. US Department of Health and Human Services, CDC Prevention, United States Renal Data System, 2016 Annual Data Report. National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin. New Engl J Med. 2002;346(6): Perkovic et al. Intensive glucose control improves kidney outcomes in patients with type 2 diabetes. Kidney International; vol. 83: issue 3. March 2013, p Academy of Nutrition and Dietetics. Evidence Analysis Library. Chronic Kidney Disease, Nutrition in Chronic Kidney Disease. NKF KDOQI Guidelines, Steiber, A. DASH-style Diet Effective in Preventing, Delaying CKD Progression. Renal and Urology News. June Centers for Disease Control and Prevention (CKD). Chronic Kidney Disease Surveillance Program. US Department of Health and Human Services, CDC Prevention, Office of Disease Prevention and Health Promotion, Healthy People 2020, Ravera M, et al. Importance of blood pressure control in chronic kidney disease. J Am Soc Nephrol. 2006; 17:S Diabetes Control and Complications Trial Group, Report, 2002.

Chronic Kidney Disease

Chronic Kidney Disease Chronic Kidney Disease (CKD) Guideline (2010) Chronic Kidney Disease CKD: Executive Summary of Recommendations (2010) Executive Summary of Recommendations Below are the major recommendations