Mar 31, 2020
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Protein Intake and Chronic Kidney Disease (CKD) in the Elderly Resident

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.

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.