Chapter 12 The Aging Kidney and Renal Disease

dialysis treatment is a decision involving the care team and the client/client’s family, and conversations about treatment need to be done well before it is needed.

HEMODIALYSIS

Up to 50% of those requiring hemodialysis are mal- nourished. Inadequate dialysis and dialysis access problems may affect oral intake, since poor dialysis results in uremic symptoms. Although protein require- ments may be slightly reduced in older adult clients, the combination of amino acids lost during dialysis, catabolic events of dialysis, and acidosis increases the protein requirement for those on dialysis (11). Those on hemodialysis (HD) are at risk for devel- oping hyperkalemia (potassium levels greater than 6 mg/dL), but hypokalemia (potassium levels less than 3.5 mg/dL) can also be dangerous and can lead to cardiac arrest. High-potassium foods must be limited in the diet to control serum potassium levels. As with all interventions, the client must be involved in determin- ing the best way to modify the diet to control serum potassium. Examples of high- potassium foods include bananas, oranges, melons, potatoes, prunes, and tomatoes. A sodium restriction of approximately 2 to 3 g per day is recommended for those on HD. The most diffi- cult restriction for most on dialysis is the fluid restric- tion. Large interdialytic weight gains of more than 5% of the client’s edema-free body weight cannot be removed in a 3- to 4-hour dialysis session. Excessive fluid gains result in pulmonary edema, peripheral edema, congestive heart failure, cramping, and low blood pressure, often leading to nausea, headache, and vomiting during dialysis and often for hours after dial- ysis. Fluid restrictions are determined by urine output plus 1,000 mL, or typically 1,000 to 1,500 mL/d (7,8).

PERITONEAL DIALYSIS

Clients with peritoneal dialysis (PD) are also at risk for malnutrition. The diet is usually less restrictive with the diet prescription based on blood chemistries. Clients with PD generally do not require potassium or fluid restriction. They do, however, require a higher protein intake because of the excessive loss of amino acids in the dialysate. Clients on PD often complain of early satiety because the dialysate limits the amount they can eat. Often these clients are unable to achieve an albumin level above 3.5 mg/dL and require small, frequent meals and modular protein powders or enteral supplements (7,8).

PD clients who have diabetes may require an adjustment in their energy requirement or in their hyperglycemic agent or insulin because of the higher concentration of glucose in the dialysate solution. A

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typical client with PD can absorb 300 to 600 kcal/d from the dialysate (7,8).

Another nutrition concern of PD clients is hyper- lipidemia, especially elevated triglycerides. This is also related to the glucose load from the dialysate. A dietary restriction limiting fats and simple sugars may be bene- ficial for these clients. A lipid-lowering agent may also be prescribed (17).

PD clients are also at risk for malnutrition, renal osteodystrophy, and anemia, as previously discussed. Treatment may need to be implemented for each of these conditions. See Table 12.2 (see page 175) for recommendations.

NUTRITION CONSIDERATIONS

FOR TRANSPLANT CLIENTS When an older adult receives a successful kidney trans- plant, dietary modifications are still necessary. Transplant candidates with diabetes need to monitor sodium intake, avoid excessive weight gain, monitor fat intake, and control carbohydrate intake (18). Table 12.2 provides nutrient recommendations for the trans- plant population.

SUMMARY

Whether an older adult has early kidney disease or requires HD or PD, special nutrition problems can be evident. In the older adult, the diet often needs to be liberalized because of poor appetite, decreased intake, and weight loss. Use of polypharmacy and drug nutri- ent interactions can also be factors leading to malnutri- tion in an older adult. Medications should be reviewed frequently for drug-nutrient interactions. It is essential that RDNs have frequent communication with the dial- ysis center regarding laboratory values, oral intake, client progress on the diet, medications, and weight changes to ensure optimal care for the older adult with kidney disease.

REFERENCES 1. US Renal Data System. USRDS 2013 Annual Data Report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013.

2. Stevens LA, Coresh J, Levey AS. CKD in the elderly— old questions and new challenges: World Kidney Day 2008. Am J Kidney Dis. 2008;51:353-357.

3. Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipi- ents (SRTR). OPTN/SRTR 2012 Annual Data Report. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administra- tion; 2014. http://srtr.transplant.hrsa.gov/annual_ reports/2012/Default.aspx. Accessed December 29, 2015