Chronic Kidney Disease Class Presentation

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Therapy class: CKD and Nephrotic Syndrome

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Chronic Kidney Disease Class Presentation

  1. 1. Objectives• Epidemiology & etiology of CKD and nephrotic syndrome• Kidney functions• Impaired kidneys, related to CKD and nephrotic syndrome, and the nutritional implications• Understanding of treatments for CKD and nephrotic syndrome• MNT for both• Current nutrition-related research1/4/2012 Lauren Richardson, RD Eligible 2
  2. 2. 1/4/2012 Lauren Richardson, RD Eligible 3
  3. 3. Epidemiology & Etiology1• Over 20 million in US• Women : Men• White : Black : Mexican• DM & HTN – CVD, Obesity, Cholesterol, Genetics, Age – Kidney Damage • Infections, Drugs, Toxins1/4/2012 Lauren Richardson, RD Eligible 4
  4. 4. Renal Function, Homeostasis2• pH/Fluid/Electrolytes/Bp• Excretion of waste via urine• Enzyme production• Hormone production1/4/2012 Lauren Richardson, RD Eligible 5
  5. 5. Homeostasis2• HOW IS IT REGULATED? –BP • ADH: urine output, fluid balance • Renin Angiotensin System • Na2+: Exchanged for K+ –pH • Reabsorption of HCO3- • Secretion of H+1/4/2012 Lauren Richardson, RD Eligible 6
  6. 6. Waste Excretion2• Uric acid• Creatinine• Urea• Drugs/Toxins1/4/2012 Lauren Richardson, RD Eligible 7
  7. 7. Enzymes & Hormones2• RENIN• 1,25-dihydroxycholecalciferol• Erythropoietin1/4/2012 Lauren Richardson, RD Eligible 8
  8. 8. Checking for Functional Status2• Microalbuminuria• GFR• Creatinine Clearance• Tubular Function Tests1/4/2012 Lauren Richardson, RD Eligible 9
  9. 9. GFR2• Not influenced by hydration status• Characterizes stage of CKD1/4/2012 Lauren Richardson, RD Eligible 10
  10. 10. Q: What are the sx of poor kidney function?Q: When will they begin to appear?
  11. 11. Impaired Kidney Function Results In…2• Edema, Hyperkalemia, Metabolic Acidosis, HTN• Uremia, Azotemia, Oliguria• Bone & Mineral Disorders, Hyperphosphatemia• Anemia1/4/2012 Lauren Richardson, RD Eligible 12
  12. 12. Impaired Kidney Function Results In…2• Fluid/Electrolytes/pH/BP – Edema, Hyperkalemia, Metabolic Acidosis (PEW), HTN• Waste Excretion – Uremia (PEW), Azotemia, Oliguria• Hormone Production – (Active Vit. D) Bone & Mineral Disorders, Hyperphosphatemia – (Erythropoietin) Anemia1/4/2012 Lauren Richardson, RD Eligible 13
  13. 13. SHPT: Secondary Hyperparathyroidism2• NORMAL – PTH: • Reabsorb Ca2+ • Excrete P • Activate D3• DAMAGED – High P • PTH released, cannot excrete P • PTH constantly triggered • Parathyroid cells undergo hyperplasia1/4/2012 Lauren Richardson, RD Eligible 14
  14. 14. 1/4/2012 Lauren Richardson, RD Eligible 15
  15. 15. CKD: Chronic Kidney Disease2• “…syndrome of progressive and loss of the , , and functions of the kidney, secondary to kidney damage; progresses slowly over time…”1/4/2012 Lauren Richardson, RD Eligible 16
  16. 16. Measuring Disease Progression2• Slow, progressive degeneration of kidney function• How do we measure kidney function?? – GFR!1/4/2012 Lauren Richardson, RD Eligible 17
  17. 17. Measuring Disease Progression2 1 Normal or increased GFR w/ kidney damage 2 Mildly decreased GFR w/ kidney damage 3 30-59 GFR 4 15-29 GFR 5 (ESRD) Inadequate GF; Dialysis or replacement req’d.1/4/2012 Lauren Richardson, RD Eligible 18
  18. 18. Disease Treatment2• DELAY PROGRESSION – Treat causes; co-existing conditions• Dialysis – Hemodialysis (HD) – Peritoneal Dialysis (PD) – Continuous renal replacement therapy (CRRT)• Transplant1/4/2012 Lauren Richardson, RD Eligible 19
  19. 19. Dialysis2• Dialyzer• Dialysate• Filtration – Osmosis, Ultrafiltration, Diffusion• Does not replace endocrine or metabolic functions1/4/2012 Lauren Richardson, RD Eligible 20
  20. 20. HD: Hemodialysis2• Permanent Access Site• Radial artery and cephalic vein• Dialysate• 3x wk; 4 h each1/4/2012 Lauren Richardson, RD Eligible 21
  21. 21. PD: Peritoneal Dialysis2• CCPD• CAPD• Catheter access• Dextrose dialysates Prince,ES. Uremic Frost. http://www.uremicfrost.com/2009_03_01_archive.html. Accessed February 20, 2011.1/4/2012 Lauren Richardson, RD Eligible 22
  22. 22. CRRT2,3• [Continuous Renal Replacement Therapy]• For acute care – Hemodynamically unstable – Volume is gradually exchanged• Intolerant of HD or PD• Temporary1/4/2012 Lauren Richardson, RD EligibleInfo. http://crrtinfo.blogspot.com/. Accessed CRRT 23 February 20, 2011.
  23. 23. Transplant2,4,5• Major histocompatibility complex – Human leukocyte antigens (HLA)• Immunosupressants Drug Interactions Cyclosporine GI effects; “oral candida, gum hyperplasia, pancreatitis, hepatotoxicity, nephrotoxicity, hyperkalemia” Corticosteroids GI upset; Hemorrhage; “pancreatitis; osteoporosis; poor wound healing; fluid retention” Imuran GI upset; “pancreatitis; muscle wasting” Prograf GI upset; “Albuminuria, proteinuria, hematuria, hypomagnesemia, hyperglycemia, nephrotoxicity, appetite loss”; distorted K levels1/4/2012 Lauren Richardson, RD Eligible 24
  24. 24. NUTRITION THERAPY: NCP1/4/2012 Lauren Richardson, RD Eligible 25
  25. 25. A: Assessment2• Dietary: Patterns, Fears, Intolerances, Restrictions, Appetite (changes?)• Physical Exam: Muscle wasting, edema• Anthro’s: Baseline weight• Changes in bowel movements/urine output• Social circumstances; Accessibility; Food Insecurity; Barriers to learning• Labs, Medications, Comorbid Conditions1/4/2012 Lauren Richardson, RD Eligible 26
  26. 26. A: (LABS)2LOWERED INCREASED• Albumin* • BUN*• BUN* • Calcium*• Calcium • Cl*• C-rp• Glucose* • Glucose• H&H • H&H*• K • K*• PAB • Phos• Phos • Protein*• Protein• Na* • Na*1/4/2012 Lauren Richardson, RD Eligible 27
  27. 27. A: (Medications)5 PURPOSE DRUG CLASS INTERACTION Control BP ACE Inhibitors Na subs; K; some GI effects Angiotensin II Receptor Licorice; (*Losartan: gf-related Blockers citrus); some GI effects; K; H&H Diuretics K; Mg; Cl; glucose; some GI effects (diarrhea esp.) Beta-blockers Licorice; some GI effects (diarrhea esp.); Reduction in insulin Calcium channel blockers Licorice; Contains sorbitol; May need to calcium intake Direct renin inhibitors Avoid HF meals; some GI effects (esp. GERD); K Treat anemia rhEPO May need fol, B12, Fe suppl.; BP Iron suppl. Ferrous salts (IV or Oral) Food abs; Take w/ C or MFP; Take antacids separately; Anorexia; severe GI effects Electrolyte Imbalances Binders (phosphate) Some GI effects; PO4; PTH Fluid Buildup Diuretics ““1/4/2012 Lauren Richardson, RD Eligible 28
  28. 28. D: Diagnosis2NI NB• Inadequate energy intake OR oral • Food and nutrition-related food/beverage knowledge deficit• Malnutrition • Disordered Eating Pattern• Excessive […] intake – Fluid • Limited Adherence to nutrition- – Protein related recommendations – Mineral • Undesirable food choicesNC • Impaired ability to prepare• Altered GI function food/meals• Altered nutrition-related lab • Poor nutrition quality of life values • Limited access to food• Food-RX interaction• Involuntary weight (loss or gain)1/4/2012 Lauren Richardson, RD Eligible 29
  29. 29. I: Intervention21&2 3&4• Meet Needs • Meet Needs• Focus: Comorbidities • Focus: Prevent malnutrition – Adequate energy – Diabetes – Balance protein needs/intake – HTN w/ renal decline and LBM – Hyperlipidemia preservation – Deficiencies• Drug Interactions? • Drug Interactions?• Assess @ 1-3 mo. Intervals • Manage comorbidities• Food Record • Food Record• Diet education (sources, • Diet education (sources, handouts) handouts)1/4/2012 Lauren Richardson, RD Eligible 30
  30. 30. I: Intervention25 (ESRD)• Meet needs• Prevent malnutrition• Manage complications and comorbidities• Bp and fluid status• Diet Education (sources, handouts)• Drug-Nutrient Interactions1/4/2012 Lauren Richardson, RD Eligible 31
  31. 31. I: Stages 1-4 MNT2 CKD (non-dialysis) requirementsEnergy 35 (<60y) 30-35 (>60 y)Protein 0.6-0.75g/kgFluid Not typically restrictedNa Varies. (0-3g)K Not typically restrictedP 800-1000mg/d OR 10-12mg/g PROCa Maintenance, otherwise WNLVit/Min B-complex + Vit C; Maintain Vit D; Individualize Fe, Zn1/4/2012 Lauren Richardson, RD Eligible 32
  32. 32. I: 5 MNT2 Hemodialysis RequirementsEnergy 35 (<60y) 30-35 (>60 y)Protein > 1.2Fluid Output + 1000ml (*wt. gain)Na 2gK 2-3g (adjust to lab values)P 800-1000mg/d OR 10-12mg/g PROCa <2.0 g + binder loadVit/Min C (60-100mg); B6 (2mg); Folate (1-5mg); B12 (3µg/d); Vit E (15IU/d); Zn (15mg/d); Individualize vit D and Fe1/4/2012 Lauren Richardson, RD Eligible 33
  33. 33. I: 5 MNT2 Peritoneal Dialysis RequirementsEnergy 35 (<60y) 30-35 (>60 y)Protein > 1.2-1.3Fluid Maintain fluid balanceNa 2g; Monitor fluidsK 3-4g (adjust to lab values)P 800-1000mg/d OR 10-12mg/g PROCa <2.0 g + binder loadVit/Min C (60-100mg); B6 (2mg); Folate (1-5mg); B12 (3µg/d); B1 (1.5-2mg/d); Vit E (15IU/d); Zn (15mg/d); Individualize vit D and Fe1/4/2012 Lauren Richardson, RD Eligible 34
  34. 34. I: MNT2 Transplant Requirements Acute ChronicEnergy 30-35 Weight maintenanceProtein 1.3-1.5 1.0Fluid Unrestricted UnrestrictedNa 2-4g/d 2-4mg/dK 2-4g/d UnrestrictedP 1200-1500mg/d 1200-1500mg/dCa 1200-1500mg/d 1200-1500mg/d1/4/2012 Lauren Richardson, RD Eligible 35
  35. 35. I: Intervention• Enteral Nutrition – Non-dialysis • Low-protein formula (Suplena, 45g/L) – Dialysis • High-protein formula (Nepro, 81g/L) – Dialysis with less energy • Glucerna 1.5 (82.5g/L)1/4/2012 Lauren Richardson, RD Eligible 36
  36. 36. I: Intervention6• Enteral/Parenteral Recommendations (ESPEN) – NON-DIALYSIS – Uremic syndrome, GI Upset  PEW – Metabolic Acidosis  Protein catabolism • PN not usually needed – If so, low protein1/4/2012 Lauren Richardson, RD Eligible 37
  37. 37. I: Intervention6• Enteral/Parenteral Recommendations (ESPEN) – HD • PEW – Typically low oral intake at beginning of HD • Increases energy expenditure • Nitrogen balance is negative on HD days • 25 g loss of glucose into dialysate • Loss of water-solubles – Thiamin esp. – Vit E for those at high risk of CVD • PN indicated for severely malnourished – BMI <20, 10% wt. loss in 6 mo., Albumin <35, PAB <300 – Consider intradialytic parenteral nutrition (IDPN)1/4/2012 – Central accessLauren Richardson, RD Eligible (concentration) 38
  38. 38. I: Intervention6• Enteral/Parenteral Recommendations (ESPEN) – PD (CAPD) • Usually less severe uremia in PD than HD • Glucose uptake of 100-200g/d – Gaining weight? • Intraperitoneal parenteral nutrition (IPPN) – Reserved for severely malnourished • Central route if acute, IPPN if non-acute1/4/2012 Lauren Richardson, RD Eligible 39
  39. 39. M,E: Monitor & Evaluate• Labs – Protein, Hydration, GFR• Intake – Spec. restricted nutrient intake – Quantity• Status – Treatments, GI problems• Medications – Changes• Weight – Body Composition – Input/Output –1/4/2012 PEW Lauren Richardson, RD Eligible 40
  40. 40. Specific MNT Guidelines2• At risk for increased risk of CVD• Secondary Hyperparathyroidism (SHPT)• Anemia, Microcytic1/4/2012 Lauren Richardson, RD Eligible 41
  41. 41. Research Topics• Vitamin D Supplementation7• Bicarbonate Supplementation8• Gastric Bypass Surgery in the pt requiring transplant91/4/2012 Lauren Richardson, RD Eligible 42
  42. 42. 1/4/2012 Lauren Richardson, RD Eligible 43
  43. 43. Nephrotic Syndrome: “Glomerular Disease”2• Membrane changes – Problematic filtration• Epidemiology & Etiology – 2 in 10,000 – Children : Adults – Males : Females – DM, Membranous Nephropathy, Genetics, FSGS1/4/2012 Lauren Richardson, RD Eligible 44
  44. 44. Nephrotic Syndrome: How?21/4/2012 Lauren Richardson, RD Eligible 45
  45. 45. Nephrotic Syndrome: S & S2• Proteinuria – Kwashiorkor or PEM1/4/2012 Lauren Richardson, RD Eligible 46
  46. 46. Nephrotic Syndrome: S & S2• Hyperlipidemia• Hypoalbuminemia• Extravascular  Vascular Shift• Edema – Anasarca – Mobile• Frothy urine• Oliguria1/4/2012 Lauren Richardson, RD Eligible 47
  47. 47. • Losses2 – ALBUMIN – Zn, Cu, D, Fe• Risks2 – Atherosclerosis • Low LPL (requires protein) • Overall increase hepatic synthesis: VLDL, IDL, LDL, and HDL • Chicken or the egg?• Future damage2 – Workload is passed off, more nephrons die1/4/2012 Lauren Richardson, RD Eligible 48
  48. 48. Treatment2• Etiological• Medications – Antihypertensives • Decrease proteinuria • Watch K levels • Salt substitutes, HF meals – HMG CoA Reductase Inhibitors • Atherosclerotic risk • G/f related citrus; SJW1/4/2012 Lauren Richardson, RD Eligible 49
  49. 49. Outcomes of Tx2• Resolved/managed• Retained• Resolved/improved• Postponed1/4/2012 Lauren Richardson, RD Eligible 50
  50. 50. A: Assessment2• Physical Exam – Edema, Recent wt. loss, clothes fitting differently – Obvious sign of muscle wasting• Social circumstances; Education level; Barriers to learning; Access and Insecurity• Anthro’s• Labs – BUN, Creatinine, GFR – pH – Lipids – Protein status (albumin, PAB, adj. Ca, Ca/Phos product) • [Calcium + .0704] [34-Serum albumin] = adjusted1/4/2012 Lauren Richardson, RD Eligible 51 • Calcium x Phos
  51. 51. A: Assessment2• Needs – Edema?? – Usual or IBW• 24 Hr Recall/Dietary Record – Protein – Phos – Calcium –K – Na1/4/2012 Lauren Richardson, RD Eligible 52
  52. 52. D: Diagnosis2• Increased nutrient needs• Excessive Na intake1/4/2012 Lauren Richardson, RD Eligible 53
  53. 53. I: Intervention2Nutrient RecommendationsEnergy 35 for normal or overweight; less if obese (include complex carbohydrates and fat composition of <30%, limit cholesterol)Protein .8-1.0 (urine losses??)Fluid MaintenanceNa 1-2g/dayPhos Maintenance (bolus?)Calcium Maintenance1/4/2012 Lauren Richardson, RD Eligible 54
  54. 54. M,E: Monitor & Evaluate• Labs – Protein, Hydration• Intake – Spec. restricted nutrient intake – Quantity• Status – GI problems• Medications – Changes• Weight – Body Composition – Input/Output –1/4/2012 PEW Lauren Richardson, RD Eligible 55
  55. 55. Research10• Protein – Changing the distribution? – (Fuel sources) – When increasing protein, overall energy increases!1/4/2012 Lauren Richardson, RD Eligible 56
  56. 56. References1. National Chronic Kidney Disease Fact Sheet 2010. Center for Disease Control and Prevention. http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm. Updated May 26, 2010. Accessed February 20, 2011.2. Nelms MN, Sucher K, Lacey K, et al. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Wadsworth; 2011.3. National Institutes of Health. www.cc.nih.gov/researchers/training/principles/ppt/susla_2002_crrt.ppt. Accessed February 20, 2011.4. Chronic Kidney Disease. WebMD. http://www.webmd.com/a-to-z-guides/chronic-kidney- disease-medications. Updated September 17, 2009. Accessed February 20, 2011.5. Pronsky, ZM. Food Medication Interactions. 15th ed. Birchrunville, PA: Food-Medication Interactions; 2008.6. Cano NJM, Aparico M, Brunori G, et al. ESPEN guidelines on parenteral nutrition: Adult renal failure. Clin Nutr. 2009;28:401-414.7. Williams S, Malatesta K, Norris K. Vitamin D and chronic kidney disease. Ethn Dis. 2009;19(4 suppl 5):S5-8-11.8. Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM. Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol. 2009;20:2075-2084.9. Majorowicz, RR. Nutrition management of gastric bypass in patients with chronic kidney disease. Nephrol Nurs J. 2010;37(2):171-175.10. Squire JR. Nutrition and the nephrotic syndrome in adults. Am J Clin Nutr. 1956;4:509-1/4/2012 522. Lauren Richardson, RD Eligible 57
  57. 57. 1/4/2012 Lauren Richardson, RD Eligible 58
  58. 58. Any questions?

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