Nutrition in case of renal insufficiency
The diet in case of renal insufficiency should prevent an excess of potassium ( hyperkalaemia ) and phosphorus ( hyperphosphataemia ) as well as overhydration . In addition, it must ensure a sufficient supply of protein and energy . Patients with renal insufficiency in the stage before the start of renal replacement therapy are hardly restricted in their drinking behavior. With the start of dialysis treatment , the patient's nutritional plan changes fundamentally. In addition to the now mostly restricted drinking quantity, the intake of protein must also be greatly increased. Malnutrition is a major problem; around 20 to 50 percent of predialytic patients are protein and energy deficient, and around 70 percent of patients who require dialysis. The problem is even more acute in diabetics who require dialysis than in non-diabetics. Diet recommendations depend on the type of renal replacement therapy chosen . The peritoneal dialysis allows the patient through daily detox a little more flexibility in eating plan than hemodialysis .
Diet before starting renal replacement therapy
The nutritional recommendations before starting renal replacement therapy depend on the patient's underlying disease, the remaining kidney performance and the laboratory parameters. The aim of the diet is to prevent an excessive increase in urinary substances in the blood. A diet that is not too high in protein is essential for this, as the nitrogen in the ingested protein is converted into urea . The European Dialysis & Transplant Nurses Association (EDTNA) and the European Renal Care Association (ERCA) recommend an energy intake of 147 kJ (35 kcal) per kg body weight and day and a protein intake of 0.6–1.0 g / kg in the predialysis stage Body weight and day. This corresponds to the same amount for the daily protein intake as for the normal population (the DGE recommends 0.8 g / kg body weight). Compared to animal protein, vegetable protein contributes to an improvement in the existing acidification due to its lower proportion of sulfur-containing amino acids and should therefore be preferred. The ingested protein should have the highest possible biological value . The recommended reduction in phosphate to 600–1000 mg can also be easily achieved with a low-protein diet , provided the patient refrains from artificially added phosphates in foods such as cola drinks or instant products.
Strongly protein-reduced diet forms such as the Sweden diet or the potato-egg diet (both up to 0.4 g protein / kg body weight / day) are often poorly tolerated by those affected for reasons of taste. A substitution of essential amino acids in the form of tablets or granules is essential for these diet forms. In addition, the strictly protein-reduced diets exacerbate the problem of malnutrition , so that these diets are not recommended.
The amount you can drink is usually not yet restricted in the predialysis stage. It is recommended to drink two to three liters of fluids a day to promote the excretion of urinary substances. If the diuresis is already limited, the amount to drink is calculated using the formula residual excretion in 24 hours + 500 ml . If there is a tendency to high blood pressure and edema , a reduction in the daily salt intake is recommended.
Shortly before the start of renal replacement therapy, nutrient uptake is usually greatly reduced, as the onset of uremia increases gastrointestinal complaints such as nausea, vomiting and loss of appetite.
Kidney Replacement Therapy Diet
aims
After starting kidney replacement therapy, greater attention must be paid to diet and drinking behavior. The diet recommendation is intended to help those affected maintain quality of life and prevent or minimize acute complications and long-term consequences of dialysis. Proper nutrition should avoid the sometimes life-threatening hyperkalaemia , prevent overhydration in the patient with subsequent respiratory and blood pressure problems and, in the long term, avoid bone diseases caused by excessive phosphate intake ( hyperphosphataemia ). Furthermore, malnutrition should be prevented by adequate calorie intake and optimal protein intake.
Drinking amount
When dialysis therapy is started, a “dry weight” (including target weight, final weight or final weight) is set for each patient, which can be adjusted up or down if necessary. The patient should ideally achieve this weight after each dialysis treatment. The dry weight is subtracted from the current weight before dialysis; the difference corresponds to the water withdrawal during dialysis.
The amount of drinking is determined individually for each patient and depends on the remaining excretion per day. It is calculated from the remaining excretion of one day + 500 ml. If a patient has no more excretion at all, the daily fluid intake should not exceed half a liter. The main purpose of reducing the amount of drinking is to avoid overwatering. A disciplined drinking behavior also makes dialysis treatment gentler and better tolerated. Excessive dehydration can lead to a drop in blood pressure and muscle cramps. The remaining excretion should be checked by the patient at regular intervals (approximately every three months) and the amount drunk if necessary.
In addition to the fluid intake through drinks, dialysis patients also need to include soups, stews and sauces in their fluid balance. Even “solid” foods sometimes contain a lot of water, for example tomatoes, cucumbers, yoghurt and watermelon have a high water content. In the case of wine, beer, cola, milk, buttermilk and cocoa, attention must be paid to the potassium or phosphate content of the drinks. The so-called sports drinks or "isodrinks" are usually not suitable for dialysis patients due to the added minerals , but otherwise there is no restriction in the selection of drinks. If you have problems keeping to the drinking quantity, it can be helpful to keep a drinking log, on which each day it is noted when and how much was drunk.
In the case of severe overhydration, pulmonary edema can occur. The resulting more or less severe shortness of breath may require emergency dialysis. With peritoneal dialysis , this complication rarely occurs due to daily dialysis.
Sucking a lemon wedge or slowly sucking an ice cube helps against the often excruciating thirst. Many patients also resort to sugar-free candy or chewing gum. Avoiding very salty or very sweet foods helps to avoid strong thirst.
potassium
The potassium is one of the electrolyte and makes for a normal person 0.25% of body mass that corresponds to about 170 g. Too high a potassium level in the blood ( hyperkalaemia ) is an acute, potentially life-threatening complication of renal insufficiency, so a reduced intake of foods containing potassium is essential. The intake should not exceed 1500–2000 mg / day, but depends individually on the residual kidney function. Foods high in potassium should be avoided, including bananas, legumes , broccoli, dried potato products such as potato chips and instant mashed potatoes and nuts. In order to reduce the potassium contained in the vegetables, it is advisable to cut the vegetables (e.g. potatoes) as small as possible before cooking and to cook them in plenty of water. The increased surface area means that more potassium is lost during the cooking process. The boiling water should no longer be used as it contains the boiled potassium. Canned fruits and vegetables (without juice) are preferable to fresh fruits and raw vegetables. Only a small portion of fresh fruit, vegetables or salad should be consumed per day.
If life-threatening hyperkalemia occurs due to a diet error, dialysis must be performed as soon as possible. If hyperkalaemia occurs frequently, the dialysis time can be extended in order to better reduce the potassium level. Hyperkalemia manifests itself as sensory disturbances (especially in the legs or tongue), a slowed pulse and muscle paralysis.
Those affected should completely forego the consumption of carambola (star fruit), which relatively often leads to symptoms of poisoning with hiccups, vomiting, impaired consciousness, muscle weakness, numbness of the extremities, paresis and seizures in patients with kidney failure . Patients who are dialyzed immediately recover without any consequences. Patients who are not dialyzed often die.
| Food | Potassium content / 100 g |
|---|---|
| tomato | 242 mg |
| paprika | 177 mg |
| Potatoes (cooked) | 333 mg |
| Potato Chips | 1000 mg |
| Apple | 144 mg |
| banana | 393 mg |
| blueberries | 73 mg |
phosphate
Healthy, adult humans have around 0.7 kg of phosphate in their body, which corresponds to around one percent of body mass. 70–80% of the phosphate is found together with calcium in bones and teeth. The restriction of phosphate intake in connection with the intake of phosphate binders is intended to avoid renal osteodystrophy and the calcification of tissue and soft tissues, which among other things cause bone and joint pain, increased bone fragility and muscle atrophy . The aim is to prevent the resulting severe reduction in quality of life. The phosphate level in the blood of dialysis patients should be between 3.5 and 5.5 mg / dl (1.13 to 1.78 mmol / l).
Phosphate can only be removed by dialysis to a very limited extent. With peritoneal dialysis it is an average of 300 mg / day, with hemodialysis about 240 mg are removed three times a week, which is significantly less. A purely dietary phosphate reduction is very difficult. So-called phosphate binders should therefore be taken with every meal containing phosphates. These bind the phosphate from food to a large extent and are excreted with the stool. The amount of phosphate binders to be taken depends on the preparation and the estimated phosphate content of the meal. Ideally, the patient controls the intake of phosphate binding agents completely independently; a fixed intake plan is only drawn up for patients who are unable to do so for various reasons. The phosphate binders must be taken before or during the meal, the tablets do not work after the meal. Calcium and aluminum salts, sevelamer and lanthanum carbonate are currently used as phosphate binders .
Foods with a high phosphate content should only be consumed in small quantities or replaced with other products of the same quality. For cheese, for example, the following rule of thumb applies: the harder the cheese, the more phosphate it contains. The exception to this is processed cheese , which contains a lot of phosphate due to the melting salts it contains. In addition, phosphate is very often found as an additive in lemonades, baking powder , condensed milk and sausage products. Buying sausage without added phosphate is recommended, as is baking with tartar baking powder, which contains significantly less phosphate than normal baking powder.
Some food additives are also problematic, such as orthophosphoric acid (E 338), sodium, potassium and calcium phosphates ( E 339 , E 340 and E 341 ), sodium, potassium and calcium diphosphates ( E 450 a), triphosphates (E 450 b ) and tetrasodium diphosphate (E 450 c).
In Germany, the costs for phosphate binders, which are actually available without a prescription, are covered by health insurance companies for dialysis patients.
| Food | Phosphate content / 25 g |
|---|---|
| Processed cheese | 600 mg |
| Edam 30% fat i. Tr. | 140 mg |
| Brie | 75 mg |
| ham | 40 mg |
| cod | 45 mg |
| Nuts (on average) | 165 mg |
| chocolate | 60 mg |
protein
The adequate intake of protein is important after the start of the dialysis treatment and represents the second major change in diet. The patient who should eat low-protein in the predialysis stage should now eat more protein again in order to prevent malnutrition. Protein and amino acids are lost during dialysis and have to be replaced by food. A daily protein intake of 1.2 g / kg body weight is recommended for hemodialysis patients, 1.4 g / kg body weight for peritoneal dialysis. Since protein-rich foods always contain phosphate, care should be taken to ensure that the foods have a low phosphorus-protein ratio (mg phosphorus / g protein) so that they can take in as much protein as possible with low phosphate at the same time. For example, Harz cheese , beef, pork and mutton have a favorable phosphorus-protein quotient (a value below 16 is ideal) .
Table salt
Table salt ( sodium chloride ) is a combination of sodium and chlorine . The sodium binds water in the body and, together with the chloride, holds it back in the tissue. Dialysis patients should generally eat a low-sodium diet, as a low-salt diet is not only good for the high blood pressure that often exists , but can also have a positive effect on weight gain between two dialyses. The salty the food, the greater the feeling of thirst . A salt intake of 5–6 g / day is recommended, which corresponds to 2–3 g sodium. Dialysis patients should therefore avoid heavily salted foods, such as cured meat, salted and smoked fish, pretzel sticks, lye pastries , ready-to-use soups and sauces. Seasonings such as stock cubes, soy sauce and herbal salt are also unsuitable . Salt substitutes should also be avoided, as these “diet salts” consist of potassium chloride , which has a negative effect on the potassium balance. The recommended amount of table salt is already contained in daily food as hidden salt, so that additional salting is not necessary.
With peritoneal dialysis, salt restriction is not necessary; enough sodium is lost through daily dialysis, so that a low-salt diet could lead to hyponatremia .
Vitamins
The water-soluble vitamins B and C are lost in the body during dialysis treatment and must therefore be substituted. Because of the problematic potassium balance, a sufficient supply of vitamins is hardly possible through food alone. If necessary, the attending physician will prescribe vitamin tablets that are specially tailored to the needs of dialysis patients. The costs for this are covered by the health insurance companies in Germany.
The fat-soluble vitamins A , D , E and K are stored in the body and do not need to be replaced. Because of the possible serious side effects, the administration of vitamin A is even contraindicated in dialysis patients . Vitamin D is prescribed by doctors to treat secondary hyperparathyroidism , a regulatory disorder of the parathyroid glands , which is common in dialysis patients . Dialysis patients are not advised to take over-the-counter multi-vitamin supplements.
Peritoneal Dialysis Diet
Patients who have opted for so-called peritoneal dialysis are not so closely tied to the guidelines in terms of the amount they drink, table salt, potassium and phosphate. Due to the daily change of bags and the constant detoxification, the urinary substances in the body do not increase as much as in hemodialysis patients who have a 48- to 72-hour interval between detoxification. This reduces the feeling of thirst and hyperkalemia is very rare. With peritoneal dialysis, however, the body loses 5–15 g protein / day and 2–4 g amino acids / day. In the case of peritonitis , the protein loss can increase by 50–100% and thus lead to disorders of the amino acid metabolism and to osteopathy .
The protein intake should be 1.4 g / kg body weight per day; here too, attention should be paid to the most favorable possible phosphorus-protein ratio.
The use of dialysis solutions containing glucose sometimes causes problems . The higher the glucose content of the solution, the higher the patient's glucose exposure. The uptake of glucose via dialysis can lead to significant weight gain while at the same time suppressing the feeling of hunger. This can result in protein malnutrition because the patient is no longer eating enough.
Dialysis and diabetes
Due to the restricted or absent kidney function, the breakdown of a high glucose level in diabetics via glucosuria is not possible. The blood sugar level can therefore rise very quickly and fall sharply again as a result of the therapy. The patient is, however, well protected against hypoglycaemia during dialysis by the glucose-containing dialysate . Gastroparesis causes problems, as the stomach empties slowly, which can lead to fluctuations in blood sugar and potassium problems and which contribute to malnutrition through nausea, bloating and vomiting. The coordination between the dialysis and the diabetes diet is difficult, compromises often have to be made and priorities have to be set. In the case of insulin-dependent diabetics who have opted for peritoneal dialysis, an adjustment of the insulin dose is often necessary because of the glucose-containing dialysis solution.
Artificial nutrition
If artificial nutrition is necessary due to an additional illness, acute malnutrition or a massively deteriorated general condition , there is a tube diet specially developed for dialysis patients. A diet via a PEG should not exceed a fluid volume of more than 1.5 liters per day, so that an energy-rich food with a physiological calorific value of 6.3 kJ / ml (1.5 kcal / ml) is recommended to provide energy - and sufficient nutritional requirements of the patient. In severely malnourished but clearly conscious patients, tube feeding is hardly accepted, but attempts should be made to consume this type of sip feed during dialysis treatment. Regular, additional intake of a sip of food with 16.6 g protein and almost 2100 kJ (500 kcal) leads to a significant improvement in laboratory values after six months.
In pediatric nephrology, artificial feeding is often the only way to provide adequate nutritional therapy.
The parenteral nutrition difficult due to limited potential hydration difficult and needs in highly concentrated form through a central venous done.
Nutritional advice
Due to the complex topic and the amount of information, it is necessary to provide nutritional advice at regular intervals and to answer questions on the topic. Nutritional advice and training should be tailored to the patient and his or her circumstances as individually as possible. It is most promising to first go through the recommendations one by one and, if necessary, to practice using training material (picture cards, other illustrative material). The connections should then be discussed with the patient over a longer period of time so that the patient can acquire the necessary basic knowledge. In principle, it makes sense to include the patient's partner in the nutritional advice, especially if the partner is the one who cooks most of the time.
literature
- Huberta Eder, Henning Schott: Better nutrition for dialysis patients . 6th edition Kirchheim, Mainz 2010, ISBN 3-87409-497-9 .
- Hans-Herbert Echterhoff, Sabine Echterhoff: Everything is allowed ... Nutritional atlas for dialysis patients . 5th edition Nephron-Verlag, Bielefeld 2001, ISBN 3-930603-84-5 .
- Hans Konrad Biesalski, Stephan C. Bischoff, Christoph Puchstein (eds.): Nutritional medicine: According to the new nutritional medicine curriculum of the German Medical Association . Thieme-Verlag, Stuttgart 2010, ISBN 978-3-13-100294-5 ( limited preview in the Google book search).
Individual evidence
- ↑ Gerd Breuch, Willi Servos: Dialyse für Einsteiger , Urban & Fischer Verlag, 2006, ISBN 3-437-27790-1 , p. 39
- ↑ a b Irmgard Landthaler: Dialysis and nutrition in dialysis for care professions , Ed. Hans E. Franz, Thieme-Verlag, 2nd edition 1996, ISBN 3-13-781402-2 ; P. 285
- ^ A b Rainer Nowak, Rainer Birk, Thomas Weinreich: Dialysis and nephrology for nursing professions , Springer-Verlag, Berlin, 2nd edition 2003, ISBN 3-540-42811-9 ; P. 287
- ↑ Reinhold Kluthe, Herbert Quirin: Varied diet for kidney patients , Trias-Verlag, 1998, ISBN 3-89373-424-4 ; P. 20
- ↑ a b c dialyse.de: Guideline enteral nutrition in nephrology ( Memento of the original from October 15, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , accessed October 28, 2009
- ↑ Gerd Beuch, Willi Servos: Dialysis for beginners , Urban & Fischer-Verlag, 2006, ISBN 3-437-27790-1 ; P. 169/170
- ↑ a b c d Irmgard Landthaler: Dialysis and nutrition in dialysis for care professions , Ed. Hans E. Franz, Thieme-Verlag, 2nd edition 1996, ISBN 3-13-781402-2 ; P. 293
- ↑ Example of a drinking quantity log on ernaehrung-lueneburg.de ( Memento from May 15, 2012 in the Internet Archive ) (pdf; 74 kB), accessed on November 20, 2012
- ^ A b Rainer Nowak, Rainer Birk: Dialysis and Nephrology for Nursing Professions ; Springer-Verlag, 1999; ISBN 3-540-61923-2 ; P. 390
- ^ Gerd Breuch: Specialist care nephrology and dialysis ; Urban & Fischer Verlag, 2002, ISBN 3-437-26252-1 ; P. 198
- ↑ MM Neto et al .: Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome . In: Nephrol. Dial. Transplant . Volume 18, Number 1, 2003; Pp. 120-125, PMID 12480969
- ↑ Database at dialyse.de ( Memento of the original from December 27, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , accessed March 2, 2009
- ^ Rainer Nowak, Rainer Birk: Dialysis and Nephrology for Nursing Professions ; Springer-Verlag, 1999, ISBN 3-540-61923-2 ; P. 392
- ↑ Guideline of the Kidney Disease Outcome Quality Initiative on dialyse.de ( Memento of the original from December 27, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. , accessed October 28, 2009
- ↑ a b c Irmgard Landthaler: Dialysis and nutrition in dialysis for care professions , Ed. Hans E. Franz, Thieme-Verlag, 2nd edition 1996, ISBN 3-13-781402-2 ; P. 290
- ^ Günter Schönweiß: Dialysis primer 2 ; Abakiss-Verlag, 1996, ISBN 3-931916-01-4 ; P. 472
- ↑ a b Reimbursement of costs for non-prescription drugs by the health insurance companies on the homepage of the social association VdK Germany , accessed on November 20, 2012
- ↑ Phosphate-containing foods on ernaehrung.de , accessed on March 2, 2009
- ^ Gerd Breuch: Specialist care nephrology and dialysis ; Urban & Fischer Verlag, 2002, ISBN 3-437-26252-1 ; P. 339
- ↑ Sabine Echterhoff: When detoxification fails , p. 4, accessed on November 20, 2012 (pdf; 99 kB)
- ^ A b Heinrich Kasper, Monika Wild, Walter Burghardt: Nutritional medicine and dietetics ; Urban & Fischer Verlag, 2004, ISBN 3-437-42011-9 ; P. 357
- ↑ Irmgard Landthaler: dialysis and nutrition in dialysis for nursing professions , ed Hans E. Franz, Thieme-Verlag, 2nd edition 1996.. ISBN 3-13-781402-2 ; P. 292
- ^ Walter H. Hörl, Christoph Wanner (eds.): Dialysis procedures in clinic and practice: Technology and clinic , Thieme-Verlag, 2003, ISBN 3-13-497706-0 ; P. 92
- ↑ Christa Tast, Petra Knödler, Thomas Mettang: Peritonealdialyse Volume 1 ; Pabst Science Publishers, 2nd ed. 2002, ISBN 3-933151-52-X ; P. 78/79
- ^ Gerd Breuch: Specialist care nephrology and dialysis ; Urban & Fischer Verlag, 2002, ISBN 3-437-26251-3 ; P. 349
- ↑ Irmgard Landthaler: dialysis and nutrition in dialysis for nursing professions , ed Hans E. Franz, Thieme-Verlag, 2nd edition 1996.. ISBN 3-13-781402-2 ; P. 297
- ^ A b Gerd Breuch: Specialist care of nephrology and dialysis ; Urban & Fischer Verlag, 2002, ISBN 3-437-26251-3 ; P. 348
