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Food For Thought - Newsletter Archives
Protein Intake and Chronic Kidney Disease (CKD) in the Elderly Resident


Can there be too much protein?

It has long been recognized that adequate protein intake is needed throughout the life cycle and a necessary nutrient in tissue building and repair. For residents in long-term care facilities, adequate protein intake is a key component in a positive nitrogen balance that allows for healing of a variety of skin issues—including pressure ulcers, stasis or diabetic ulcers, skin tears, surgical incision sites and bone fractures. Providing adequate nutrients to residents to support the healing process is a key function of the facility nursing and food service departments. CMS looks closely to see that facilities are providing timely/ adequate nutrition for any needed healing to each resident.

The National Kidney Foundation (NKF) estimates 1 in 9 adults in the U.S. have some level of kidney function impairment. As kidney function declines with age and frequently further decreased with the various diseases and conditions that we see with the aging (i.e., diabetes, hypertension, frequent UTI’s, proteinuria, among others), we can expect those residents over the age of 70 years in LTC facilities to have a much higher incidence of renal insufficiency than the “1 in 9” estimate.
Functions of the kidneys include the elimination of waste products (including urea from the metabolism of protein) from the blood and maintaining a balance between fluids and electrolytes. If the kidneys are not functioning at normal levels, blood urea nitrogen (BUN) levels will be elevated as urea remains in the blood. As well as being an indicator of hydration, BUN and creatinine levels can help identify patients who have impairment in kidney function for the clinician to take appropriate action to address their needs.

The NKF has established five (5) stages of CKD to help diagnose and treat renal impairment. Glomerular filtration rate (GFR) is usually accepted as the best overall index of kidney function in health and disease; and, can be estimated with the Cockcroft-Gault equation, using the patient’s age, sex, and serum creatinine levels. A resident with an eGFR of < 60 indicates a mild to moderate renal insufficiency. GFR of 15 or less indicates severe renal insufficiency and is the usual level when dialysis or other treatment is initiated.
Research has shown that the progression of renal disease in individuals with mild to moderate renal insufficiency can be halted or delayed with diet and medication. In CKD with GFR’s of 15-59, the NKF recommends 0.6 to 0.8g of protein per kg body weight per day, with at least 60% of high biological value in addition to treating the disease state of HTN or uncontrolled blood sugar levels in diabetes, etc.

Blood urea nitrogen levels can be elevated for a wide variety of causes including the side effects of diuretic, cardiac glycoside therapy and antibiotics; infections; sepsis; shock; CHF and fluid restrictions; as well as an impairment in renal function with azotemia (BUN > 50), in addition to dehydration which is frequently the most often considered problem associated with an elevated BUN. With the geriatric patient that has mild to moderate renal insufficiency as indicated by the GFR, a diet very high in protein can put additional stress on renal function and further elevate BUN and creatinine levels due to excess urea nitrogen levels due to the body’s inability to filter out and excrete high levels of ingested protein. When the protein in the diet (85 grams minimum with 58 gms HBV protein in the General diets per Ill. Regs.) is combined with supplemental items such as shakes, 2 cal per cc supplements (that provide an additional 20 gms protein per 8 oz.), super cereal and other fortified products often used, protein powders, supplemental drinks containing primarily Arginine and Glutamine amino acids, as well as other liquid high protein products, its possible that a patient that has some level of renal insufficiency receives well over 2 or 3 grams protein per kg weight—well over the level recommended to help prevent further deterioration of kidney function.

In evaluating lab values in patients and providing adequate nutrients to meet their nutritional needs—including needs for anabolism and wound healing, as well as evaluating hydration status, it may be beneficial to consider that ingesting a very high protein diet can be “Too Much” for an elderly patient whose GFR is between 15 and 59 (mL/min/1.73m ). While the residents’ actual intake of the diet and supplements needs to be considered, a more moderate approach to protein supplementation may be more appropriate for these residents.
 
 
Food For Thought - Newsletter Archives

Previous Newsletter Articles

  • September 2008
    Protein Intake and Chronic Kidney Disease (CKD) in the Elderly Resident

    Can there be too much protein?

    It has long been recognized that adequate protein intake is needed throughout the life cycle and a necessary nutrient in tissue building and repair. For residents in…
    Read more...
  • August 2009
    Procedure for Holding Food Safely during Meal ServiceAll potentially hazardous foods, especially those items that are cooked and held for service, need to be maintained in order to prevent the growth of bacteria.  It is important to remember that microorganisms can grow at temperatures between 41oF and 135oF, so to…
    Read more...
  • December 2009
    The holidays can be a time of excitement for all of us when we are surrounded by family and friends. Along with great company, the holidays are synonymous with our favorite foods. Below are some tips to avoid increasing your waistline while still enjoying all of your favorite foods!Stay hydrated:…
    Read more...
  • January 2010
    We don’t work in a facility, we work in their home. Phrases like “culture change” and “resident centered living” have been popping up in meetings, newsletter, and research regarding how we manage long term care facilities. What do all of these words mean and why all of this change now? …
    Read more...
  • December 2008
    Making Your Facility Feel Like ‘Home’

    Food is an important part of our everyday lives. It’s not just about nutrition and hydration. Food is about psychological, ethnic, cultural and religious issues. Food is about socialization. Because of this, facilities that don’t have a good dining program, that…
    Read more...
  • September 2009
    Identifying the Need for Feeding AssistanceResidents in long-term care are encouraged to maintain their independence and feed themselves whenever possible.  There are, however, many reasons why a resident may require feeding assistance.  Depending on the severity of the symptoms, from physical problems such as being unable to hold the fork,…
    Read more...
  • October 2008
    Is snacking beneficial to older Americans?


    As we age it has been shown that there is a reduction in energy intakes. The decreased intake is most likely due to physiological, psychological, economic and social factors. Altered taste and flavor sensations are what can account for the…
    Read more...
  • October 2008
    A Calibrated Thermometer is an Essential Tool in Food Service


    The regular and consistent use of a calibrated probe thermometer in any food service is an indispensable tool. It helps any food service protect their customers from foodborne illnesses which are a major health concern to…
    Read more...
  • April 2009
    Proper Feeding TechniquesLong-term care residents should be encouraged to maintain their independence and feed themselves whenever possible. However, there are many reasons why a patient may require feeding assistance.  Physical problems (for example, being unable to hold a fork, tremors that prevent getting spoon to mouth, etc) or cognitive problems…
    Read more...
  • September 2008
    Prepare for the Baby Boomer Generation!

    A new group of health care consumers has begun to utilize the services of long term care. These are the Baby Boomers who total approximately 78 million, born between 1946 and 1964. These men and women, some of whom have reached…
    Read more...
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