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MNT in Renal Disorders
 

MNT in Renal Disorders

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  • “scerosis”= scarring. Once microalbuminuia is detectable, inexorable progression of nephropathy occurs. 20-30% of TYPE 1 or 2 DM will develop evidence of nephropathy; much smaller % go on to EDRD. Hyperglycemia increases filtration 2 nd to osmotic load and toxic high B.G.; increase GFR with enlargement of kidneys. Incipitent “AT Risk; then within 5 years, 20% develop nephropathy on standard care; 50% do not progress. 10% of those with proteinuria, have nephrotic range. Good candidates for early intervention by reducing intraglomerular pressure through enhanced glycemic control, BP, normalized pro. intake. Microalbuminuria=30-300 mg/day. TYPE 1 DM: Without specific interventions, 80% will progress to overt nephropathy or clinical albuminuria (>300mg./d) with HTN then 77% of these go on to ESRD in 20 year. TYPE 2 DM: 20-40% wit h microalbuminuria to on to overt nephropathy Then 20% by 20 years progress to ESRD. Albuminuria is a marker of high morbidity/mortality from cardiovascular disease; >300 mg./day albumin in urine
  • Diabetes Control and Complications Trial: Tight B.S. control with decrease risk of progression of kidney disease. Meds: ACE (ace inhibitors) or ARB (angiotensin receptor blockers) may increase K+. Diuretics- decrease. If wt. loss hinders glycemic control; back off. Na+ restrict 2400 mg. with HTN, 3000 mg. without. Lipids: sat fat <200 mg.
  • Malnutrition: insulin deficiency increases gluconeogenesis a. Metabolic acidosis needs correction for + N-bal. Low protein, will need to liberalize fats and CHO. 0.8 more common. Insulin deficiency results in increased rates or protein degradation and EAA oxidation. Nephrotic syndrome; damage to glomeruli losses of large amounts of pro. in urine . Most frequent with dm, glomerulonephritis or amyloidosis.
  • Infed, Ferrelicit
  • Indicate P.D. process in packet

MNT in Renal Disorders MNT in Renal Disorders Presentation Transcript

  • Medical Nutrition Therapy for Renal Disorders
  • Functions of the Kidney
    • Excretory
    • Acid-base balance
    • Endocrine
    • Fluid and electrolyte balance
  • Excretory Functions
    • Removal of excess fluid and waste products
    • 180 L of filtrate pass through the kidneys each day  producing 1-2 L of urine
    • Wastes excreted from the body in urine include urea (byproduct of protein metabolism); excess vitamins and minerals; metabolites of some drugs and poisons
  • Acid-Base Functions
    • Acid-base balance is maintained through a buffer system, which maintains blood at pH of 7.4
    • Bicarbonate carries hydrogen ions to the kidneys where they are removed from extracellular fluid in the tubules, returned to the bloodstream as needed
    • Phosphate buffers intracellular fluid
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • Acid-Base Balance Functions
    • When fluid volume is low, anti-diuretic hormone (ADH) or vasopressin is released from the anterior pituitary; increases absorption of water in the collecting duct
    • When extracellular volume (ECV) decreases, the renin-angiotensin-aldosterone system is activated  excretes less sodium chloride
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • Endocrine Functions
    • 1,25-dihydroxy-vitamin D3 or calcitriol is produced in the kidney; enhances calcium absorption
    • Activation of Vitamin D and excretion of excess phosphate maintain healthy bones
    • Erythropoietin: acts on the bone marrow to increase production of red blood cells
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004 Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • The Nephron
  • The Most Common Kidney Diseases
    • Diabetic Nephropathy damage to the nephrons in the kidneys from unused sugar in the blood, usually due to Diabetes.
    • H igh Blood Pressure can damage the small blood vessels in the kidneys.  The damaged vessels cannot filter poison from the blood as they are supposed to.
    • Polycystic Kidney Disease (PKD) is a hereditary kidney disease in which many cysts grow in the kidneys.  These cysts may lead to kidney failure.
  • The Most Common Kidney Diseases
    • A cute Renal Failure - Sudden kidney failure caused by blood loss, drugs or poisons.  If the kidneys are not seriously damaged, acute renal failure may be reversed.
    • Chronic Renal Failure - Gradual loss of kidney function is called Chronic Renal Failure or Chronic Renal Disease.
    • End-Stage Renal Disease - The condition of total or nearly total and permanent kidney failure. 
  • Kidney Diseases
    • Glomerular diseases
      • Nephrotic syndrome
      • Nephritic syndrome—tubular or interstitial
    • Tubular defects
      • Acute renal failure (ARF)
    • Other
      • End-stage renal disease (ESRD)
      • Kidney stones
  • Nephrotic Syndrome
    • Alterations of the glomerular basement membrane allows persistent loss of large amounts of protein in the urine
    • Associated with diabetes, glomerulonephritis, amyloidosis, lupus
    • High risk for cardiovascular disease
    • Hypercoagulability
    • Abnormal bone metabolism
  • Nephrotic Syndrome
    • Albuminuria: more than 3 g/day urinary albumin losses, with proportionally lesser amounts for children
    • Hypoalbuminemia
    • Hypertension
    • Hyperlipidemia
    • Edema
  • Medical Mgt of Nephrotic Syndrome
    • Corticosteroids
    • Immunosuppressants
    • ACE inhibitors/angiotensin receptor blockers to reduce protein losses, control blood pressure and fluid balance
    • Coenzyme A reductase inhibitors to control hyperlipidemia
  • MNT in Nephrotic Syndrome
    • Protein 0.8 to 1 g/kg IBW 80% HBV
    • Sodium based on fluid status
    • Potassium and other minerals (calcium, phosphorus) monitored and individualized
    • Fluid unrestricted
    • Diet therapy probably not effective for hyperlipidemia; may require medication
    Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  • Nephritic syndrome
    • Acute glomerulonephritis (inflammation of the glomerulus
    • Sudden onset, often after streptococcus infections
    • Symptoms include hematuria, hypertension
    • Usually resolve on their own or advance to nephrotic syndrome or ESRD
  • Nephritic syndrome: Nutritional Management
    • Diet to treat underlying disease
    • Restrict diet if necessary to control symptoms
    • Protein restricted in uremia
    • Sodium restriction in hypertension
    • Potassium restriction in hyperkalemia
  • Acute Renal Failure
    • Rapid, often reversible deterioration of renal function
    • GFR declines over hours to days
    • Most commonly occurs during hospitalization (5% of hospitalized pts; 30% of ICU pts)
    • Associated with major in-hospital morbidity and mortality (7 to 80%)
    Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  • Causes of Acute Renal Failure
    • Pre-renal: caused by intravascular volume depletion, decreased cardiac output
    • Post-renal: benign prostatic hypertrophy, prostate cancer, cervical cancer, colorectal cancer, neurogenic bladder, urethral strictures
    • Intrinsic or parenchymal ARF: vascular disease, interstitial nephritis, glomerular disease, acute tubular necrosis
    Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  • Causes of Acute Renal Failure
    • Ischemic Injury (50% of all incidence) d/t loss of blood supply to the kidneys secondary to surgical complications, thrombosis, hypotension, hypovolemia
    • Nephrotoxic injury: medications, contrast medium, chemotherapy, poisons (35%)
    • Multiorgan system failure, particularly liver failure
    • Sepsis, especially bacterial
    • Obstructive uropathy (trauma during surgery, urolithiasis, enlarged prostate)
    • Acute glomerular nephritis
  • Acute Tubular Necrosis
    • Most common cause of ARF
    • Ischemia: due to major surgery, hypotension, cardiogenic, septic, or hypovolemic shock
    • Nephrotoxicity: drugs, chemotherapeutic agents, organic solvents, heavy metals, cocaine
  • Acute Tubular Necrosis
    • Initiating phase
    • Period between onset and established renal failure
    • Usually reversible by treating the underlying disorder or removing offending agent
    • Time frame: hours or days
    Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  • Acute Tubular Necrosis
    • Maintenance Phase
    • Epithelial cell injury
    • Urine output is at its lowest; complications associated with uremia, fluid overload, electrolyte imbalance (decreased sodium, increased potassium levels)
    • Time frame: 10-16 days in oliguric patients; 5-8 days in nonoliguric patients
  • Acute Tubular Necrosis
    • Recovery Phase
    • Tubule cell regeneration and gradual return of GFR
    • BUN and creatinine return to near normal
    • May be complicated by marked diuresis, dehydration and fluid and electrolyte imbalance (increased sodium, decreased potassium)
    • Time frame: days to months
  • Renal Replacement Therapies in ARF
    • Recommended for patients with pronounced azotemia, electrolyte imbalance, fluid overload, severe acidosis
    • Used in 85% of patients with oliguric ARF and 30% of nonoliguric
    • Purpose is to correct imbalances as well as provide sufficient renal support to other organs
  • Renal Replacement Therapies in ARF
    • Hemodialysis: standard treatment if patient is hemodynamically stable
      • However, risk of hypotension and wide swings in body weight in unstable patients
    • Continuous hemofiltration (CAVH, CVVH) provides slow, continuous filtration across a membrane, driven by arterial pressure (CAVH) or pump (CVVH)
  • Renal Replacement Therapies in ARF
    • Continuous hemodialysis (CAVHD, CVVHD) uses an ultrafiltrate fluid similar to plasma
      • Clearance occurs through diffusion from high concentration (blood) to low concentration
    • Peritoneal dialysis: less often used in the US; not as effective when large volume or solute clearances needed.
  • CAVH
  • MNT for Adult ARF
    • Energy: BEE X 1.2-1.3 or 25-35 kcal/kg
    • Protein: .8-1.2 g/kg noncatabolic, without dialysis; 1.2-1.5 g/kg catabolic and/or initiation of dialysis
    • Fluid: 24 hour urine output + 500 ml (750-1500 ml)
    • Sodium: 2.0-3.0 grams
    • Potassium: 2.0-3.0 grams
    • Phosphorus: 8-15 mg/kg; may need binders; needs may increase with dialysis, return of kidney function, anabolism
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • Nitrogen Balance in ARF
    • Standard nitrogen balance studies require a creatinine clearance of more than 50 mL/min/1.73m2
    • In ARF, urea nitrogen appearance (UNA) is a better method of determining nitrogen balance
    • UNA = UUN + change in the urea nitrogen pool
  • Calculation of Urea Nitrogen Appearance (UNA)
    • UNA (g) = UUN + [BUN2 – BUN1) x .6 x BW1] + [(BW2-BW1) x BUN2]
    • Net protein breakdown = UNA x 6.25
    • UUN = urinary urea nitrogen (g/24hr)
    • BUN1 = initial collection of blood urea nitrogen, postdialysis (g/L)
    • BUN2 = final collection of blood urea nitrogen, predialysis (g/L)
    • BW1 = postdialysis wt (kg)
    • BW2 = predialysis wt (kg)
  • Chronic Kidney Disease
  • Causes of Chronic Kidney Disease 10 Other 2 Tumors 3 Renal cystic disease 4 Interstitial disease 13 Glomerulonephritis 27 Hypertension 40 Diabetes Incidence (%) Cause
  • Progression to End-Stage Renal Disease (ESRD)
    • First Decline in glomerular filtration rate (GFR)
    • Second Adaptations in renal function, i.e., increase in GFR
    • Third Adaptations improve renal function in short term
    • Fourth Long term loss of nephron units.
    • Fifth Slow, progressive decline in renal function
    • Sixth Eventually this decline leads to renal insufficiency, i.e., ESRD
  • Stages of Chronic Kidney Disease National Kidney Foundation K/DOQI Clinical Practice Guidelines on CKD. Am J Kidney Dis 2002;39(suppl 1):46. Replacement, if uremia present <15 or dialysis 5. Kidney failure Prepare for kidney replacement tx 15-29 4. Severe decrease in GFR Evaluating, treating complications 30-59 3. Moderate decrease in GFR Estimating progression 60-89 2. Mild decrease in GFR Tx comorbid conditions. Slow progression. CVD risk reduction >90 1. Kidney damage with normal or increased GFR Screening; CKD risk reduction CKD risk factors At increased risk Action GFR Stage
  • ESRD: Medical Management
    • Dialysis
    • Immunosuppressant drugs
    • Kidney transplant
    • Psychological support
  • Uremia, a Clinical Syndrome— Signs and Symptoms
    • Malaise
    • Weakness
    • Nausea and vomiting
    • Muscle cramps
    • Itching
    • Metallic taste (mouth)
    • Neurologic impairment
  • Stages of CKD Nutrient Recommendations Fedje and Karalis. Nutrition mgt in early stages of CKD. Clin Guide Nutr Care Kidney Dis, ADA, 2004 <2000 mg/day <2000 mg/day 1.2-1.5 1.2-1.5 1.2-1.5 Calcium g/day 800-1000 mg/day No restriction Unless high 1-4 g to NAS 30-35 kcal/kg 0.6-0.75 5 800-1000 mg/day No restriction Unless high 1-4 g to NAS 30-35 kcal/kg .6 4 800-1000 mg/day No restriction Unless high 1-4 g to NAS Based on energy expenditure .75 3 Monitor and restrict if nec No restriction Unless high 1-4 g to NAS Based on energy expenditure .75 2 Monitor and restrict if nec No restriction Unless high 1-4 g to NAS Based on energy expenditure .75 1 Phos K+ Na+ g/day Kcal Pro g/kg
  • Treatments: CKD, HD, CAPD
  • MNT for CKD, HD, PD
    • CKD Hemodialysis CAPD or CCPD
    • Protein 0.6-1.0 1.1-1.4 1.2-1.5
    • g/kg/day
    • Energy 30-35 30-35 30-35
    • (kcal/kg IBW)
    • Phosphorus 8-12 indiv < 17 indiv < 17 indiv
    • (mg/kg IBW)
    • Sodium 1000-3000 2000-3000 2000-4000
    • (mg/d)
    • Potassium Individualized ~ 40 Individualized
    • (mg/kg IBW)
    • Fluid Unrestricted 500-750 + Individualized
    • (ml/d) urine output
    • (1000 if anuric)
    • Calcium Individualized Individualized Individualized
    • (mg/d) based on serum level ~1000 mg/day ~1000 mg/day
    • Use adjusted IBW if obese
    National Renal Diet Professional Guide 2 nd edition, ADA 2002
  • Nutrition Assessment and Monitoring in the CKD Pt
  • Anthropometric Measurements
    • % usual body weight (%UBW)
    • % standard body weight (%SBW)
    • Height
    • Skeletal frame size
    • BMI
    • Skinfold thickness
    • Mid-arm muscle area, circumference, or diameter
  • Body Weight Assessment in CKD
    • Use dry weight or edema-free body weight
      • In HD: post-dialysis weight
      • In PD: weight after drainage of dialysate with peritoneum empty
    • In obese or very underweight people, use adjusted edema-free body weight
    • Adjusted EFBW=
    • BWef + [SBW*-BWef x .25]
    • *Use NHANES II data for standard body weight (SBW)
    National Kidney Foundation. K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2000;35(suppl);S27-S86.
  • Blood Urea Nitrogen (BUN)
    • Measure of the nitrogenous waste products of protein
    • High BUN in CKD may reflect high protein intake, GI bleeding or inadequate dialysis, increased catabolism due to infection, surgery, poor nutrition
    • Decreased BUN may mean protein anabolism, overhydration, protein loss, low dietary protein
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • Creatinine (nl 0.5-1.4 mg/dL)
    • Nitrogenous waste product of muscle metabolism
    • Produced proportionate to muscle mass
    • Unrelated to dietary protein intake (DPI)
    • Sensitive marker of renal function: the higher the serum creatinine, the greater the loss of renal function; may reflect inadequate dialysis or muscle catabolism
    • A decrease in creatinine over time may reflect loss of lean body mass
    Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  • Causes of Hyperkalemia (  K+) Goal 3.5-5.5 mEq/L
    • >6 mEq/L – abnormal, potentially dangerous
    • Renal failure (kidney is primary filter)
    • Excessive nutritional intake
    • Chronic constipation
    • Infection
    • GI bleeding
    • Insulin deficiency (high BG)
    • Metabolic acidosis
    • Drug interactions
    • Catabolism of malnutrition or cell damage caused by injury or surgery
    • Decreased urinary output
    • Chewing tobacco
  • Causes of Hypokalemia ( ↓ K+)
    • Vomiting, diarrhea
    • Diuresis
    • Potassium binder
    • K+ too low in dialysate
    • Urine output >1000 mL/day or serum NL, do not need to restrict K+
  • Phosphorus (normal 3.5-5.5 mg/dL)
    • As renal function decreases, phos accumulates in the blood
    •  phos triggers release of PTH that releases calcium from bone
    • Phos binders prevent phosphorus from being absorbed in the gut; form insoluble compound so phos is excreted in stool
    • Phos clearance poor in HD and CAPD
    • ↓ phos may mean excess phos binder or poor p.o.
  • Calcium (8.4-9.5 mg/dL)
    • Most abundant mineral in human body
    • Nearly half of calcium is bound to albumin; if serum calcium is low, evaluate albumin level; can correct for low albumin
    • Calcium-Phosphorus Product: multiply serum calcium x serum phos: if >55-75, calcification can occur
    • <2000 mg/day elemental calcium from diet + binders stage 3-4
    • High ca+: calcification, nausea, vomiting, muscle twitching may mean too much Ca+ from meds or diet
  • Serum Sodium (nl 133-145 mEq/L)
    • Not a reliable indicator of sodium intake in CKD
    • Fluid retention due to decreased urine production can dilute an elevated level
    • Serum levels must be evaluated in conjunction with fluid status
  • Lipids
    • Cardiovascular disease is the most common cause of death in people with CKD
    • Kidney disease is considered the equivalent of a risk factor, like diabetes
    • HD: often have normal LDL, TC, ↑ triglycerides, ↓ HDL
    • PD: have ↑ LDL/TC + ↑ TG
    • Renal Tx: ↑ LDL/TC/TG, normal HDL, often due to medications
  • Cholesterol in CKD
    • High
        • High risk TC 200-300 mg/dl (non-fasting)
        • LDL goal < 100 mg/dl
    • Low
        • <150 -180, evaluate for pro-energy malnutrition
        • Increased mortality
  • Hematological Indicators
    • Hemoglobin: ↓ due to lack of erythropoetin, produced by the kidney; pts receive synthetic EPO tx (Epogen)
    • May have anemia of chronic disease
    • Ferritin: may be indicator of iron overload; ↑ ferritin may mean EPO resistance
  • Glomerular Filtration Rate (GFR)
    • Best index of kidney function
    • Used to establish stage of CKD
    • GFR is the amount of filtrate formed per minute based on total surface area available for filtration (number of functioning glomeruli)
    • Can be determined using injected isotope (inulin) measurement in urine
    • Can be calculated from serum creatinine using standard equations
  •  
  • Cockroft-Gault Equation to Calculate GFR
    • MICROMOL: [ (140-age) x weight x 1.23 x (0.85 if female)]/ Creat[micromol/l]
    • MG: [(140-age) x wt/kg x .85 if female]/(72*serum creatinine mg/dL)
    http://renux.dmed.ed.ac.uk/EdREN/Handbookbits/HDBKgfrest.html
  • Interdialytic Weight Gain
    • Pts on dialysis gain several kg of fluid between HD treatments
    • If pts gain >5%, may reflect excessive fluid intake, leading to hypertension, edema, ascites, pleural effusion
    • Fluid gains of <2% reflect minimal fluid and food intake, may be losing body mass
  • Measures of Dialysis Adequacy
    • Urea Reduction Rate (URR)
    • Refers to change in urea concentration between pre and post-dialysis blood tests
    • Statistically significant predictor of mortality
    • CMS goal is >65%
    • Kt/V
    • The fractional clearance of urea as a function of its distribution volume
    • Goal is 1.2 or more
  • Monitoring Nutrition Status in CKD with GFR<12mL/min/1.73m2 Fedje and Karalis. Nutrition mgt in early stages of CKD. Clin Guide Nutr Care Kidney Dis, ADA, 2004 Every 3-4 months nPNA or dietary interviews and diaries Every 1-3 months Edema-free actual body weight, % std wt, SGA Every 3 months Serum albumin levels Frequency Recommended measure
  •  
  • Pre-ESRD (DM)
    • Primary Prevention
      • Glycemic control (DCCT)
        • Aim for Euglycemia
        • Watch for low B.S.
      • B.P. control
        • 130/80
        • Na+ restrict
          • Base on comorbidities (~2-3 g.)
          • Medications may increase or decrease K+; monitor
        • Wt. loss (gradual)/exercise
      • Meds: ACE inhibitors and ARB’s
  • Pre-ESRD
    • Secondary Prevention (overt nephropathy; GFR ~ 25)
      • Protein normalization
      • 0.6 g/kg - RDA 0.8 g/kg ( minimum for DM)
      • Delay need for dialysis, control uremic symptoms, reduce acidosis
    • Stage 4 CKD: monitor labs, may need to limit K+, Phos., Ca++, Mg++
  • MNT in Patients on Hemodialysis
  • Hemodialysis
    • Removes concentrated molecules and excess fluid from pts blood through diffusion and ultrafiltration
    • Three parts of the system are the dialyzer (artificial kidney), the dialysis machine, and the dialysate
    • Requires vascular access, usually through an AV (arteriovenous) fistula
  • AV (arteriovenous) Fistula
  • ESRD: Nutritional Management
    • Prevent deficiencies
    • Control edema and serum electrolytes
    • Prevent renal osteodystrophy
    • Provide an attractive and palatable diet
  • MNT in HD: Protein
    • 10-12 g free amino acids lost per treatment during dialysis
    • Greater amino acid losses with glucose-free dialysate and high flux dialyzers
    • 1.2 g protein/kg standard body weight (SBW) with 50% high biological value (meat, poultry, fish, eggs, soy, dairy)
    • Most HD patients take in less than 1 g/day
    NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in Byham-Gray, p. 45-46
  • MNT in HD: Energy
    • Adults <60 years: 35 kcal/kg SBW
    • Adults > 60 or obese: 30-35 kcals/kg body weight
    • Actual intakes of HD patients in studies are lower than that (mean 23 kcals/kg in HEMO study)
    NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in Byham-Gray, p. 46
  • MNT in HD: Lipids
    • HD patients at risk for lipid disorders
    • Recommended fat intake<30% of calories and saturated fat<10%; cholesterol <300 mg/day
    • Optimum fiber intake 20-25 g/day
    • These restrictions are difficult to achieve along with other restrictions of HD diet
  • MNT in HD: sodium and fluid
    • ≥ 1 L fluid output: 2-4 g Na and 2 L fluid
    • ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid
    • Anuria: 2 g Na and 1 L fluid
    • Restrict Na+ if ↑ interdialytic wt gain, CHF, edema, HTN, low serum sodium
  • MNT in HD: Potassium
    • Potassium needs related to urinary output
    • Most patients on HD can tolerate 2.5 g of K+
    • Stricter diet may be indicated for pts w/ insulin deficiency, metabolic acidosis, treated with beta blockers or aldosterone antagonists, hypercatabolic
    • Individuals: 40 mg/kg edema-free IBW or SBW
  • MNT in HD: Phosphorus
    • Maintain s. phos 3.5-5.5 mg/dL
    • Usually ok until GFR ↓ to 20-30 mL/min
    • Dialysis removes 500-1000 mg/treatment
    • Use phosphorus binders with meals: absorb 50% of dietary phosphorus
    • Dietary intake: 800 to 1000 mg/day or <17 mg/kg IBW or SBW
    • Identify high protein, low phos food sources
  • MNT in HD: Calcium
    • High from excess Ca++ type binders, vitamin D analogs, Ca++ fortification
    • Goal 8.4-9.5 mg/dl
    • Always use corrected Ca++ (adjusted Ca++)
        • [ (4-alb.) x 0.8] + Ca++]
    • CaXPhos product: goal <55
  • Phosphate Binders (Taken with meals to prevent phos absorption) TUMS, Os-Cal, calci-Chew, Calci-Mix Calcium carbonate Alucap, Amphogel Aluminum hydrozide Aluminum carbonate Renagel Sevelamer hydrochloride MagneBind Mg/Ca++ carbonate PhosLo Calcium acetate
  • MNT in HD: Vitamins
    • H2O soluble vitamins
    • Dialyzable – take after H.D.
    • B vitamins and vitamin C in renal vitamin
      • ↑ Vit. C -> ↑ oxalate -> calcification of soft tissues and stones
    • Individualize need for:
      • Fe++ (IV most common), Vitamin D, Ca++, Zinc.
  • MNT in HD: Vitamin D
    • Vitamin D is activated in the kidney to calcitriol, or vitamin D3
    • As D3 levels fall, calcium absorption ↓ and phos excretion ↓
    • Vitamin D3 therapy helps prevent renal bone disease but may cause hypercalcemia
    • Renal pts should use calcitriol supplements under the supervision of a physician
  • Hemodialysis
    • Typical diet order
      • 2000 calorie, 80 g protein, 2 g Na+, 3 g K+, low phosphorus, 1500 cc fluid restriction
  • Skeletal Effects of Chronic Renal Failure
    • Hyperphosphatemia
    • Hypocalcemia
    • Hyperparathyroidism
    • Low bone mass and density
    • Osteitis fibrosa cystica—hyperplastic demineralized bone
  • Monitor Patient Status
    • 1. BP >140/90
    • 2. Edema
    • 3. Weight changes
    • 4. Urine output
    • 5. Urine analysis:
      • Albumin
      • Protein
  • Monitor Patient Status (cont)
    • 6. Kidney function
    • Creatinine clearance
    • Glomerular filtration rate (GFR)
    • 7. Blood values
    • BUN 10 to 20 mg/dl (<100 mg/dl)
    • Creatinine 0.7 to 1.5 mg/dl (10-15 mg/dl)
    • Potassium 3.5 to 5.5 mEq/L
    • Phosphorus 3.0 to 4.5 mg/dl
    • Albumin 3.5-5.5 g/dl
    • Calcium 9-11 mg/dl
  • Peritoneal Dialysis
  • CAPD (continuous ambulatory peritoneal dialysis)
    • Most patients do 4-5 exchanges per day
    • A specific volume of dialysate (1500-3000 ml) is infused into the peritoneal cavity via a catheter
    • The dialysate dwells for 4 hours as excess fluid and toxins diffuse through peritoneal membrane
    • Dialysate and wastes are drained from the body and the process repeated.
    • Dialysate is present in the body 24 hours per day
    • APD (automated peritoneal dialysis therapy) speeds the process
  • Peritoneal Dialysis (home dialysis)
    • Blood cleansed by passive movement from capillaries to dialysate (diffusion)
    • Ultra-filtration (UF): fluid removed by osmosis due to high osmolality of dextrose in dialysate
    • Better control of labs, fluid balance and B.P.
    • Advantages for those with heart failure, access problems. Diet liberal, independence.
    • Disadvantages:, anorexia, a.a. losses in dialysate, peritionitis -> catabolism, anorexia, long- term wasting, high B.S., wt. gain, lack of socialization
  • PERITONEAL DIALYSIS
    • Dialysis solutions
      • Pt. chooses depending on fluid status 1.5%, 2.5% or 4.25% glucose
    • CAPD
      • ~4 – 2L. Exchanges/day
      • Dwells ~6 hours (dialysis) and drain
      • ~60% glucose absorbed (3.7 kcal/g)
    • CCPD
      • ~10 L exchanged throughout night
      • 40% glucose absorbed 2 nd to rapid exchanges
  • MNT for PD: Energy
    • Energy: 35 kcals/kg/day SBW or adjusted body weight for pts<60 years; 30 kcals/kg for those >60
    • Calories provided in the dialysate should be included in total intake (may absorb as much as 1/3 of daily energy needs)
  • PERITONEAL DIALYSIS SAMPLE GLUCOSE ABSORPTION g glucose per liter x volume = total g of glucose Example: one – 2 L. exchange of 1.5% solution = 30 g glucose Total g of glucose x absorption rate (~60%) = g glucose absorbed Example: 30 g glucose x 60% = 18 g glucose absorbed g glucose absorbed x kcal per g glucose (3.7)= calories absorbed Example: 18 x 3.7=66.6 calories/2 L. exchange Patient does 4 exchanges/d 67 x 4 = 268 calories/d from diaysate
  • MNT for PD: Protein
    • PD patients lose 5-15 grams of protein a day, primarily as albumin
    • Goal 1.2-1.3 g/kg SBW or ABW/day
  • MNT for PD: Sodium
    • PD clears sodium very well, so sodium can be fairly liberal
    • However, high salt diets increase thirst and may make adherence to fluid limits more difficult
    • General recommendation is 2-4 grams sodium
  • MNT for PD
    • Potassium : is easily cleared by PD; some patients may need K+ supplementation
    • Calcium : limit to 2000 mg elemental calcium
      • Generally pts get ~1500 mg from calcium-based phosphate binders
      • Serum calcium should be maintained in low normal range (8.4-9.5 mg/dl)
  • MNT for PD
    • Phosphorus: limited to 800-1000 mg/day which is difficult with high protein diet
      • Use phosphate binders
    • Fluid: can be adjusted by varying the dextrose concentrations of the dialysate
      • May need to be restricted if pts cannot achieve fluid balance without frequent hypertonic exchanges
  • PD: weight gain, hypertriglyceridemia, hyperglycemia
    • Increase exercise as allowed by MD
    • Limit sodium and fluid to minimize hypertonic exchanges
    • Use solutions with alternate hypertonic agents such as Icodextrin
    • Modify energy intake to facilitate wt loss
    • Modify intake of sugars and fats, especially saturated fats
  • PD: Protein Losses, Malnutrition
    • Patient education regarding protein goals and ways to meet them
    • Suggest pt eat protein foods first and limit fluids at mealtime
    • Frequent smaller portions of protein and easy to eat proteins such as egg white, cottage cheese, etc
    • Education on sterile technique to avoid peritonitis
  • RENAL EXCHANGES FOR MEAL PLANNING 0 100 0 0 0 0 0 Beverages: Coffee (1c.) tea (1 bag) wine (4 oz.) beer (12 oz.) 5 20 15 0 0 15 60 Calorie Boosters 5 0 150 11 0 0 100 Fat (1TB.) 15 150 5 0 0.5 15 60 Fruit 20 150 15 0 1 5 25 Vegetable 35 35 80 1 2 15 80 Starch 65 100 25 4 7 0 65 Meat 110 185 80 5 4 6 85 Milk ( ½ c.) PO4 mg. K+ mg. Na mg. FAT g. PRO g. CHO g. Kcal Food Groups
  • Protein Foods (65 kcals, 7 grams protein, 25 mg Na, 100 mg K+, 65 mg phos)
    • Meat 1 ounce
    • Egg 1
    • Fish 1 ounce
    • Shellfish 1 ounce
    • Poultry 1 ounce
    • Egg substitutes ¼ c
    • Bacon 4 slices
    • Cheese 1 oz
    • Milk 1 cup
    • Nut butters 2 T
    • Tofu ¼ cup
    • Cottage cheese ¼ cup
    • Lunchmeat 1 oz
  • Milk Servings (2% milk) 85 kcals, 6 g CHO, 4 g pro, 5 g fat, 80 mg Na+, 185 mg K+, 110 mg Phos
    • ½ cup milk
    • ½ cup plain ice cream
    • ½ cup yogurt
  • Starch Servings 80 kcal, 15 g CHO, 2 g pro, 1 g fat, 80 mg Na+, 35 mg K+, 35 mg PO4
    • Bread, white or rye 1 slice
    • Cake 2 in sq or cupcake
    • Plain cake donut 1
    • Cold cereal 1 cup
    • Dinner roll 1 small
    • Macaroni, noodles, rice ½ cup
    • Popcorn, unsalted, 1 cup
  • Vegetable Servings 25 kcal, 5 g CHO, 1 g pro, 15 g Na+, 150 mg K+, 20 mg PO4
    • Asparagus ½ cup
    • Green beans ½ cup
    • Cabbage ½ cup
    • Carrots ½ cup
    • Cauliflower ½ cup
    • Corn ½ cup
  • Fruit Servings ↓ K+ 60 kcals, 15 g CHO, .5 g protein, 150 mg K+, 15 mg phos
    • Apple
    • Apple juice ½ c
    • Applesauce ½ c
    • Apricot nectar ½ c
    • Blackberries ½ c
    • Blueberries ½ c
    • Fruit cocktail ½ c
    • Grapes ½ c
    • Lemon
    • Lime
    • Peach
    • Pear
    • Pineapple
    • Plums (1)
    • Raspberries
    • Watermelon
  • Fruit Servings (High potassium) 60 kcals, 15 g CHO, .5 g protein, >250 mg K+, 15 mg phos
    • Apricots
    • Bananas
    • Dates
    • Honeydew melon
    • Kiwifruit
    • Nectarine
    • Orange
    • Orange Juice
    • Prune juice
    • Prunes (5)
    • Raisins
  • Fat Choice 100 kcals, 11 g fat, 150 mg Na+, 5 mg PO4
    • Margarine/butter 1 T
    • Cream cheese 2 T
    • Mayonnaise 11/2 T
    • Non-dairy topping ½ cup
    • Sour cream ¼ cup
    • Vegetable oil 1 T
    • Tartar sauce 2 T
  • Calorie Boosters 60 kcals, 15 g CHO, 15 mg Na+, 20 mg K+, 5 mg PO4
    • Hard candy 4 pieces
    • Jam or jelly 2 T
    • Jelly beans 15
    • Honey 2 T
    • Sugar brown or white 2 T
    • Marshmallows 5 large
    • Fruit snacks and candies 1 oz
  • Beverages 100 mg K+ (also counts as fluid)
    • Coffee 1 cup
    • Tea 1 bag
    • Wine 4 oz
    • Beer 12 oz
  • Medicare Rules for MNT in Renal Disease
    • As of January, 2002, Medicare covers MNT for pre-dialysis renal disease
    • Includes nutritional, diagnostic, therapy and counseling services
    • Restricted to patients with GFR 15 to 50 mL/min/1.73m2 (stages 3-4-5 not on dialysis)
  • Kidney Transplant
    • 1. Types: related donor or cadaver
    • 2. Posttransplant management:
    • Corticosteroids
    • Cyclosporine
    • 3. Diet while on high-dose steroids:
    • 1.3 to 2 g/kg BW protein
    • 30 to 35 kcal/kg BW energy
    • 80 to 100 mEq Na
    • 4. Diet after steroids:
    • 1 g/kg BW protein
    • Kcal to achieve IBW
    • Individualize Na level
  • Well Mr. Osborne, it may not be kidney stones after all.
  • Kidney Stones
    • 1. Particulate matter crystallizes
    • Ca salts (Ca oxalate or Ca phosphate)
    • Uric acid
    • Cystine
    • Struvite (NH 4 , magnesium and phosphate)
    • 2. Ca salts in stones—Rx: high fluid; evaluate calcium from diet; may need more!
    • 3. Treat metabolic problem; low-oxalate diet may be needed; acid-ash diet is sometimes useful but not proven totally effective
  • Kidney Stones—cont’d
    • 4. Uric acid stones
    • Alter pH of urine to more alkaline
    • Use high-alkaline-ash diet
    • Food list in Krause text
    • 5. Cystine stones (rare)
    • 6. Struvite (infection stones) antibiotics and/or surgery
  • Acid-Ash Diet
    • Increases acidity of urine (contains chloride, phosphorus, and sulfur)
    • Meats, cheese, grains emphasized
    • Fruits and vegetables limited (exceptions are corn, lentils, cranberries, plums, prunes)
  • Alkaline-Ash Diet
    • Increases alkalinity of urine (contains sodium, potassium, calcium, and magnesium)
    • Fruits and vegetables emphasized (exceptions are corn, lentils, cranberries, plums, prunes)
    • Meats and grains limited
  • Summary
    • Renal diseases—delicate balance of nutrients
    • Regular monitoring of lab values, with altered dietary interventions accordingly