CKD Stage 5
Outline•   Stage 5 CKD•   Hemodialysis•   Peritoneal Dialysis•   MNT•   Patient Assessment•   Complications•   Questions?
Etiology of CKD•   Most common causes:     • Diabetes (39% of patients)     • Hypertension (28%)     • Glomerulonephritis ...
Pathophysiology of CKD Kidney injury Destruction of nephrons  Renal function and GFR Adaptation causes nephron size ...
Stage 5 CKD: End Stage RenalDisease• Kidney function inadequate to sustain  life (50-66% of normal function lost)• GFR < 1...
Risk Factors•   Proteinuria•   Ethnicity•   Gender•   Smoking•   Heavy consumption of non-narcotic    analgesics, particul...
United States ESRD Incidence                  32000                  31000Number of Cases                  30000          ...
United States ESRD Prevalence                  610000                                                      605376Number of...
Indications to begin dialysis• Diabetics: Creatinine clearance is < 15  mL/min• Non-diabetics: serum creatinine reaches 6 ...
Additional Indications       Symptoms    •    Pericarditis    •    Uncontrollable fluid overload    •    Pulmonary edema ...
Main Goals of Dialysis Remove                Maintain   Fluid                 Fluid   Waste Products        Electrol...
Dialysis Health Care Team•   Patient•   Dialysis Nurse•   Dialysis Technician•   Nephrologist•   Nephrology Social Worker•...
Therapeutic Modalities•   Hemodialysis    • In center dialysis    • Home hemodialysis    • In center nocturnal dialysis•  ...
Hemodialysis• Waste products filtered from blood by a  semipermeable membrane and removed  by the dialysis fluid, or dialy...
Access• Arteriovenous Fistula• Arteriovenous Graft• Central Venous Catheter
Arteriovenous Fistula      Venous Needle                                    • Radial artery toArterial Needle             ...
Arteriovenous Graft             Artery           • Used when veins are   Vein              Graft                          ...
Central Venous Catheter   Blood to   dialysis   Blood from dialysis   machine    machine
Hemodialysis
Dialysate•   Highly purified water•   Sodium•   Potassium•   Calcium•   Magnesium•   Chloride•   Bicarbonate•   Dextrose
Mechanisms of transport• Diffusion• Ultrafiltration (convection)        • Hydrostatic ultrafiltration          • Transmemb...
Peritoneal Dialysis      Infusion                Drain                  Dialysis                  Solution                ...
Peritoneal Dialysis• Peritonealcavity: reservoir for dialysate• Peritoneum: semipermeablemembrane  across which excess bod...
Peritoneal DialysisContinuous             Automated PDAmbulatory PD•   2.0-2.5 L dwells   •   3-10 dwells nightly•   4-8 h...
PD Transport• Diffusion  • Uremic solutes and potassium    • Peritoneal capillary ➔ dialysis solution  • Glucose, lactate,...
Calculation of Glucose Absorbed inPeritoneal Dialysis Patients•   60% of daily dialysate glucose load is    absorbedglucos...
MNT Objectives in Dialysis• Maintain protein and kcal balance• Prevent dehydration or fluid overload• Maintain normal pota...
Renal MNTTreatment          Pre-Stage 5 CKD   Hemodialysis       Peritoneal                                               ...
Renal MNTTreatment     Hemodialysis           Peritoneal DialysisFat           25-35% of total kcal   25-35% of total kcal...
Adjusted Edema- Free BodyWeight Calculating protein and energy  requirements for underweight and obese  patients aBWef =...
Phosphorus Binders•   Calcium acetate (Phos-Lo)•   Calcium carbonate (Tums, Calci-Chew)•   Calcium citrate (Citracal 950)•...
Calcium   Low serum calcium due to     Alterations in vitamin D metabolism     Decreased absorption of calcium from gut...
CKD Response to LowSerum Calcium and/or HighPhosphorus in CKD Stage 5                         Calcitriol                 ...
Vitamin & Mineral Supplements  10-50 mg vitamin B    60-100 mg vitamin C  1.5 mg thiamin        6μg – 1 mg vitamin B12  1....
Patient Recommendations Foods to enjoy   Fresh meat, fish and poultry   Enriched bread, pasta and rice   Allowed veget...
ProteinFoods to Enjoy      Food to Limit • Fish              • Processed meats • Seafood           • Cheese • Beef        ...
CaloriesFoods to Enjoy:        Foods to Limit: • Candy                • Candy with • Cake                   chocolate, nut...
PhosphorusLimit or avoid:• Dairy products• Dried Beans• Nuts and Seeds• Protein Foods: Enhanced  meats, liver, organ meats...
PotassiumFruits to Enjoy:     Vegetables to Enjoy • Apples             • Asparagus • Blackberries       • Bean Sprouts • B...
PotassiumFruits to Limit/Avoid:   Vegetables to • Bananas                  Limit/Avoid: • Cantaloupe             • Articho...
SodiumInstead of:                  Try this: • Canned vegetables          • Fresh or frozen                               ...
Helpful Fluid Tips•   Each morning, measure fluid allowance    in water and store in container•   Every time you drink flu...
Nutrition Assessment• Diet Recall• Food Diary• Food Frequency Questionnaire
NutritionalIndicators, Target, andFrequencyIndicator                     Target                       FrequencySerum Album...
NutritionalIndicators, Target, andFrequencyIndicator                     Target                  Frequency% Usual Dry Weig...
Behavioral Outcomes Meal planning Meeting nutrient needs Awareness of potential food/drug  interactions Exercise
Comorbid Conditions andComplications Malnutrition Cardiovascular disease Secondary Hyperparathyroidism     Osteitisfib...
For Further Reading•   Daugirdas JT, Blake PG, Ing    TS.“Handbook of Dialysis Fourth    Edition" Lippincott Williams    &...
Questions?
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Dialysis

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This is a presentation that I created for my Medical Nutrition Therapy course during graduate school.

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  • number of new cases per population in a given time period
  • a measure of the total number of cases of disease in a population rather than the rate of occurrence of new cases
  • Dialysis

    1. 1. CKD Stage 5
    2. 2. Outline• Stage 5 CKD• Hemodialysis• Peritoneal Dialysis• MNT• Patient Assessment• Complications• Questions?
    3. 3. Etiology of CKD• Most common causes: • Diabetes (39% of patients) • Hypertension (28%) • Glomerulonephritis (13%) • Hereditary cystic and congenital renal disease (4%) • Interstitial nephritis and phyelonephritis (4%) • Neoplasm/tumor (2%)
    4. 4. Pathophysiology of CKD Kidney injury Destruction of nephrons  Renal function and GFR Adaptation causes nephron size and glomerular pressure Increased glomerular pressure causes loss of nephrons
    5. 5. Stage 5 CKD: End Stage RenalDisease• Kidney function inadequate to sustain life (50-66% of normal function lost)• GFR < 15 mL/min/1.73m2 (or dialysis)• Requires renal replacement therapy • Renal Transplant • Dialysis 5
    6. 6. Risk Factors• Proteinuria• Ethnicity• Gender• Smoking• Heavy consumption of non-narcotic analgesics, particularly phenacetin 6
    7. 7. United States ESRD Incidence 32000 31000Number of Cases 30000 29000 28000 2009 27000 2010 26000 2011 25000 24000 Q1 Q2 Q3 Q4 Quarter United States Renal Data System
    8. 8. United States ESRD Prevalence 610000 605376Number of Cases 600000 598409 590000 592367 586445 580000 578637 570000 571414 560000 550000 Quarter
    9. 9. Indications to begin dialysis• Diabetics: Creatinine clearance is < 15 mL/min• Non-diabetics: serum creatinine reaches 6 mg/dL
    10. 10. Additional Indications Symptoms • Pericarditis • Uncontrollable fluid overload • Pulmonary edema • Uncontrollable and repeated hyperkalemia • Coma • Lethargy• Less Severe Symptoms • Azotemia • Nausea • Vomiting
    11. 11. Main Goals of Dialysis Remove  Maintain  Fluid  Fluid  Waste Products  Electrolyte ○ Urea  Acid-base balance ○ Creatinine ○ Potassium ○ Phosphorous ○ Sodium
    12. 12. Dialysis Health Care Team• Patient• Dialysis Nurse• Dialysis Technician• Nephrologist• Nephrology Social Worker• Renal Dietitian
    13. 13. Therapeutic Modalities• Hemodialysis • In center dialysis • Home hemodialysis • In center nocturnal dialysis• Peritoneal Dialysis • Continuous ambulatory peritoneal dialysis • Continuous cycling peritoneal dialysis
    14. 14. Hemodialysis• Waste products filtered from blood by a semipermeable membrane and removed by the dialysis fluid, or dialysate.• In-center: 4 hours, 3 days a week• Home: may be daily• Nocturnal In-center: 6-8 hours, 3 nights/week
    15. 15. Access• Arteriovenous Fistula• Arteriovenous Graft• Central Venous Catheter
    16. 16. Arteriovenous Fistula Venous Needle • Radial artery toArterial Needle cephalic vein Vein • 4-6 weeks to become fully functional AV Fistula Artery • Subclavian route can be used temporarily
    17. 17. Arteriovenous Graft Artery • Used when veins are Vein Graft not adequate Connection • Polytetrafluroethylene Graft (teflon) tube • Needles placed in graft Venous Needle Arterial Needle
    18. 18. Central Venous Catheter Blood to dialysis Blood from dialysis machine machine
    19. 19. Hemodialysis
    20. 20. Dialysate• Highly purified water• Sodium• Potassium• Calcium• Magnesium• Chloride• Bicarbonate• Dextrose
    21. 21. Mechanisms of transport• Diffusion• Ultrafiltration (convection) • Hydrostatic ultrafiltration • Transmembrane pressure (blood- dialysate) • Ultrafiltration coefficient (KUF): water permeability • Osmosis
    22. 22. Peritoneal Dialysis Infusion Drain Dialysis Solution Peritoneum Abdominal Cavity Catheter
    23. 23. Peritoneal Dialysis• Peritonealcavity: reservoir for dialysate• Peritoneum: semipermeablemembrane across which excess body fluid and solutes are removed• Polyurethane or silicone catheterPeritoneal Capillaries Peritoneal Cavity Fluid UreaCreatinine Potassium  Sodium Chloride Lactate Glucose
    24. 24. Peritoneal DialysisContinuous Automated PDAmbulatory PD• 2.0-2.5 L dwells • 3-10 dwells nightly• 4-8 hours • Continuous Cycling PD–• 4 times/day 1 dwell during the day • Nocturnal Intermittment PD- dry during day
    25. 25. PD Transport• Diffusion • Uremic solutes and potassium • Peritoneal capillary ➔ dialysis solution • Glucose, lactate, and calcium • Dialysis solution ➔ peritoneal capillary• Ultrafiltration • Water and associated solutes • Peritoneal capillary ➔ dialysis solution• Absorption • Water and solute • Peritoneal cavity ➔ lymphatic system
    26. 26. Calculation of Glucose Absorbed inPeritoneal Dialysis Patients• 60% of daily dialysate glucose load is absorbedglucose absorbed (kcal) = (1-D/D0)xi where D/D0 is the fraction of glucose remaining and xi is initial glucose
    27. 27. MNT Objectives in Dialysis• Maintain protein and kcal balance• Prevent dehydration or fluid overload• Maintain normal potassium and sodium blood levels• Maintain acceptable serum phosphorus and calcium levels
    28. 28. Renal MNTTreatment Pre-Stage 5 CKD Hemodialysis Peritoneal DialysisProtein (gm/kg .6-.8 ≥1.2 for stable 1.2-1.3 for stableSBW) patients patients 65% HBV ≥ 50% HBV ≥ 50% HBVEnergy 35 30-35 30-35(kcal/kg/SBW)Phosphorus 800-1000 800-1000 800-1000(mg/kg SBW) (10-12 mg/gm (10-12 mg/gm (10-12 mg/gm protein) protein) protein)Potassium (mg/d) Typically 2000-3000 3000-4000 unrestrictedSodium (mg/d) 1000-3000 2000-3000 2000-4000Fluid (ml/d) Typically 750-1000 + 24 hr 2000 unrestricted urine output
    29. 29. Renal MNTTreatment Hemodialysis Peritoneal DialysisFat 25-35% of total kcal 25-35% of total kcalCholesterol < 200 mg/day < 200 mg/dayFiber 20-30 g/day 20-30 g/dayCalcium ≤1500 mg/day from 3000-4000 phosphate binders ≤2000 mg/day total
    30. 30. Adjusted Edema- Free BodyWeight Calculating protein and energy requirements for underweight and obese patients aBWef = Bwef + [{SBW-Bwef} x 0.25] Bwef SBW determined from NHANES II data
    31. 31. Phosphorus Binders• Calcium acetate (Phos-Lo)• Calcium carbonate (Tums, Calci-Chew)• Calcium citrate (Citracal 950)• Magnesium carbonate (MagneBind 200)• Lanthanum carbonate (Fosrenol)• Sevelamer hydrochloride (Renagel)• Aluminum hydroxide (Amphojel)• Aliminum carbonate (Basaljel)
    32. 32. Calcium Low serum calcium due to  Alterations in vitamin D metabolism  Decreased absorption of calcium from gut  Elevated phosphorous levels  Restriction of high calcium foods Calcium Supplementation  Should not exceed 2,000 mg/day Coronary calcification
    33. 33. CKD Response to LowSerum Calcium and/or HighPhosphorus in CKD Stage 5 Calcitriol Secondary OsteitisSerum Ca PTH Bone Calcium- Parathyroid Hyperparathyr FibrosaSerum PO4 Secretion Turnover PO4 Hyperplasia oidism Cystica Renal Resorption
    34. 34. Vitamin & Mineral Supplements 10-50 mg vitamin B 60-100 mg vitamin C 1.5 mg thiamin 6μg – 1 mg vitamin B12 1.7 mg riboflavin 800 μg – 5 mg folic acid 20 mg niacin 10 mg pantothenic acid 150 – 300 μg biotin
    35. 35. Patient Recommendations Foods to enjoy Fresh meat, fish and poultry Enriched bread, pasta and rice Allowed vegetables and fruits Olive oil, butter, or margarine
    36. 36. ProteinFoods to Enjoy Food to Limit • Fish • Processed meats • Seafood • Cheese • Beef • Buttermilk • Poultry • Canned/frozen • Pork dinners • Other Meats • Canned soup • Eggs • Fast foods • Cottage Cheese • Beans • Peanuts/peanut butter
    37. 37. CaloriesFoods to Enjoy: Foods to Limit: • Candy • Candy with • Cake chocolate, nuts or • Pie (with allowed peanut butter fruits) • Cream pies • Donuts • Sweet potato pie • Honey • Pumpkin pie • Syrup • Milkshakes • Vanilla Wafers • Nuts • Toaster Pastry • Potato Chips • Butter • Ice cream
    38. 38. PhosphorusLimit or avoid:• Dairy products• Dried Beans• Nuts and Seeds• Protein Foods: Enhanced meats, liver, organ meats.• Whole grains and cereals: bran, granola, brown rice, whole grain breads & cereals.• Other: Beer, colas, pizza, cocoa, macaroni
    39. 39. PotassiumFruits to Enjoy: Vegetables to Enjoy • Apples • Asparagus • Blackberries • Bean Sprouts • Blueberries • Broccoli • Cherries • Cabbage • Grapes • Carrot • Peaches • Celery • Pears • Cucumber • Pineapple • Green Beans • Strawberries (5 • Potatoes(only if med) soaked 2-4 hours)
    40. 40. PotassiumFruits to Limit/Avoid: Vegetables to • Bananas Limit/Avoid: • Cantaloupe • Artichokes • Dried fruits • Beans • Honeydew • Fresh beets, beet • Mango greens • Chinese cabbage • Nectarine • Pumpkin • Oranges • Sauerkraut • Starfruit • Sweet Potatoes • Orange Juice • Tomato
    41. 41. SodiumInstead of: Try this: • Canned vegetables • Fresh or frozen vegetables, cooked • Processed meats • Unprocessed meats cooked without salt • Convenience/ready • Buy fresh made foods ingredients, cook with herbs • Fast Foods • Pack sandwiches using fresh, unsalted • Salted snack foods ingredients (chips, pretzels, etc.) • Eat fresh, crisp fruits and
    42. 42. Helpful Fluid Tips• Each morning, measure fluid allowance in water and store in container• Every time you drink fluid, pour out an equal amount.• Drink only when thirsty• Satisfy thirst- cold/frozen fruit• Rinse mouth frequently- dont swallow• Chew gum• Have a piece of hard sour candy
    43. 43. Nutrition Assessment• Diet Recall• Food Diary• Food Frequency Questionnaire
    44. 44. NutritionalIndicators, Target, andFrequencyIndicator Target FrequencySerum Albumin ≥ 4.0 mg/dL MonthlySerum Prealbumin >30 mg/dL As neededSerum Cholesterol > 150-180 mg/dL As neededLipid Profile LDL: < 100 mg/dL As needed HDL: > 150 mg/dL Triglycerides: < 150 mg/dLSerum Creatinine > 10 mg/dL Monthly(pre-dialysis treatment)nPNA (protein equivalent of > 1.0 HD: Monthlytotal nitrogen appearance PD: Every 4normalized to body weight) months Nelms et al.
    45. 45. NutritionalIndicators, Target, andFrequencyIndicator Target Frequency% Usual Dry Weight after HD N/A Monthlyor post-drain with PD% Standard Body Weight N/A Every 4 monthsBMI Upper 50th percentile Monthly 23.6 kg/m2 for men 24 kg/m2 for womenSGA ≥ 6-7 Biannually4 item, 7 point scaleAnthropometrics and DEXA N/A As neededSerum Bicarbonate ≥ 22 mmol/L Monthly Nelms et al.
    46. 46. Behavioral Outcomes Meal planning Meeting nutrient needs Awareness of potential food/drug interactions Exercise
    47. 47. Comorbid Conditions andComplications Malnutrition Cardiovascular disease Secondary Hyperparathyroidism  Osteitisfibrosa Anemia  Recombinant human erythropoietin  Iron  Target levels ○ Hematocrit: 33-36% ○ Hemoglobin: 11-12 g/dL
    48. 48. For Further Reading• Daugirdas JT, Blake PG, Ing TS.“Handbook of Dialysis Fourth Edition" Lippincott Williams &Wilkins:2006.
    49. 49. Questions?
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