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MNT in Renal Disorders


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MNT in Renal Disorders

  1. 1. Medical Nutrition Therapy for Renal Disorders
  2. 2. Functions of the Kidney <ul><li>Excretory </li></ul><ul><li>Acid-base balance </li></ul><ul><li>Endocrine </li></ul><ul><li>Fluid and electrolyte balance </li></ul>
  3. 3. Excretory Functions <ul><li>Removal of excess fluid and waste products </li></ul><ul><li>180 L of filtrate pass through the kidneys each day  producing 1-2 L of urine </li></ul><ul><li>Wastes excreted from the body in urine include urea (byproduct of protein metabolism); excess vitamins and minerals; metabolites of some drugs and poisons </li></ul>
  4. 4. Acid-Base Functions <ul><li>Acid-base balance is maintained through a buffer system, which maintains blood at pH of 7.4 </li></ul><ul><li>Bicarbonate carries hydrogen ions to the kidneys where they are removed from extracellular fluid in the tubules, returned to the bloodstream as needed </li></ul><ul><li>Phosphate buffers intracellular fluid </li></ul>Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  5. 5. Acid-Base Balance Functions <ul><li>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 </li></ul><ul><li>When extracellular volume (ECV) decreases, the renin-angiotensin-aldosterone system is activated  excretes less sodium chloride </li></ul>Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  6. 6. Endocrine Functions <ul><li>1,25-dihydroxy-vitamin D3 or calcitriol is produced in the kidney; enhances calcium absorption </li></ul><ul><li>Activation of Vitamin D and excretion of excess phosphate maintain healthy bones </li></ul><ul><li>Erythropoietin: acts on the bone marrow to increase production of red blood cells </li></ul>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
  7. 7. The Nephron
  8. 8. The Most Common Kidney Diseases <ul><li>Diabetic Nephropathy damage to the nephrons in the kidneys from unused sugar in the blood, usually due to Diabetes. </li></ul><ul><li>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. </li></ul><ul><li>Polycystic Kidney Disease (PKD) is a hereditary kidney disease in which many cysts grow in the kidneys.  These cysts may lead to kidney failure. </li></ul>
  9. 9. The Most Common Kidney Diseases <ul><li>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. </li></ul><ul><li>Chronic Renal Failure - Gradual loss of kidney function is called Chronic Renal Failure or Chronic Renal Disease. </li></ul><ul><li>End-Stage Renal Disease - The condition of total or nearly total and permanent kidney failure.  </li></ul>
  10. 10. Kidney Diseases <ul><li>Glomerular diseases </li></ul><ul><ul><li>Nephrotic syndrome </li></ul></ul><ul><ul><li>Nephritic syndrome—tubular or interstitial </li></ul></ul><ul><li>Tubular defects </li></ul><ul><ul><li>Acute renal failure (ARF) </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>End-stage renal disease (ESRD) </li></ul></ul><ul><ul><li>Kidney stones </li></ul></ul>
  11. 11. Nephrotic Syndrome <ul><li>Alterations of the glomerular basement membrane allows persistent loss of large amounts of protein in the urine </li></ul><ul><li>Associated with diabetes, glomerulonephritis, amyloidosis, lupus </li></ul><ul><li>High risk for cardiovascular disease </li></ul><ul><li>Hypercoagulability </li></ul><ul><li>Abnormal bone metabolism </li></ul>
  12. 12. Nephrotic Syndrome <ul><li>Albuminuria: more than 3 g/day urinary albumin losses, with proportionally lesser amounts for children </li></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Hypertension </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Edema </li></ul>
  13. 13. Medical Mgt of Nephrotic Syndrome <ul><li>Corticosteroids </li></ul><ul><li>Immunosuppressants </li></ul><ul><li>ACE inhibitors/angiotensin receptor blockers to reduce protein losses, control blood pressure and fluid balance </li></ul><ul><li>Coenzyme A reductase inhibitors to control hyperlipidemia </li></ul>
  14. 14. MNT in Nephrotic Syndrome <ul><li>Protein 0.8 to 1 g/kg IBW 80% HBV </li></ul><ul><li>Sodium based on fluid status </li></ul><ul><li>Potassium and other minerals (calcium, phosphorus) monitored and individualized </li></ul><ul><li>Fluid unrestricted </li></ul><ul><li>Diet therapy probably not effective for hyperlipidemia; may require medication </li></ul>Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  15. 15. Nephritic syndrome <ul><li>Acute glomerulonephritis (inflammation of the glomerulus </li></ul><ul><li>Sudden onset, often after streptococcus infections </li></ul><ul><li>Symptoms include hematuria, hypertension </li></ul><ul><li>Usually resolve on their own or advance to nephrotic syndrome or ESRD </li></ul>
  16. 16. Nephritic syndrome: Nutritional Management <ul><li>Diet to treat underlying disease </li></ul><ul><li>Restrict diet if necessary to control symptoms </li></ul><ul><li>Protein restricted in uremia </li></ul><ul><li>Sodium restriction in hypertension </li></ul><ul><li>Potassium restriction in hyperkalemia </li></ul>
  17. 17. Acute Renal Failure <ul><li>Rapid, often reversible deterioration of renal function </li></ul><ul><li>GFR declines over hours to days </li></ul><ul><li>Most commonly occurs during hospitalization (5% of hospitalized pts; 30% of ICU pts) </li></ul><ul><li>Associated with major in-hospital morbidity and mortality (7 to 80%) </li></ul>Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  18. 18. Causes of Acute Renal Failure <ul><li>Pre-renal: caused by intravascular volume depletion, decreased cardiac output </li></ul><ul><li>Post-renal: benign prostatic hypertrophy, prostate cancer, cervical cancer, colorectal cancer, neurogenic bladder, urethral strictures </li></ul><ul><li>Intrinsic or parenchymal ARF: vascular disease, interstitial nephritis, glomerular disease, acute tubular necrosis </li></ul>Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  19. 19. Causes of Acute Renal Failure <ul><li>Ischemic Injury (50% of all incidence) d/t loss of blood supply to the kidneys secondary to surgical complications, thrombosis, hypotension, hypovolemia </li></ul><ul><li>Nephrotoxic injury: medications, contrast medium, chemotherapy, poisons (35%) </li></ul><ul><li>Multiorgan system failure, particularly liver failure </li></ul><ul><li>Sepsis, especially bacterial </li></ul><ul><li>Obstructive uropathy (trauma during surgery, urolithiasis, enlarged prostate) </li></ul><ul><li>Acute glomerular nephritis </li></ul>
  20. 20. Acute Tubular Necrosis <ul><li>Most common cause of ARF </li></ul><ul><li>Ischemia: due to major surgery, hypotension, cardiogenic, septic, or hypovolemic shock </li></ul><ul><li>Nephrotoxicity: drugs, chemotherapeutic agents, organic solvents, heavy metals, cocaine </li></ul>
  21. 21. Acute Tubular Necrosis <ul><li>Initiating phase </li></ul><ul><li>Period between onset and established renal failure </li></ul><ul><li>Usually reversible by treating the underlying disorder or removing offending agent </li></ul><ul><li>Time frame: hours or days </li></ul>Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
  22. 22. Acute Tubular Necrosis <ul><li>Maintenance Phase </li></ul><ul><li>Epithelial cell injury </li></ul><ul><li>Urine output is at its lowest; complications associated with uremia, fluid overload, electrolyte imbalance (decreased sodium, increased potassium levels) </li></ul><ul><li>Time frame: 10-16 days in oliguric patients; 5-8 days in nonoliguric patients </li></ul>
  23. 23. Acute Tubular Necrosis <ul><li>Recovery Phase </li></ul><ul><li>Tubule cell regeneration and gradual return of GFR </li></ul><ul><li>BUN and creatinine return to near normal </li></ul><ul><li>May be complicated by marked diuresis, dehydration and fluid and electrolyte imbalance (increased sodium, decreased potassium) </li></ul><ul><li>Time frame: days to months </li></ul>
  24. 24. Renal Replacement Therapies in ARF <ul><li>Recommended for patients with pronounced azotemia, electrolyte imbalance, fluid overload, severe acidosis </li></ul><ul><li>Used in 85% of patients with oliguric ARF and 30% of nonoliguric </li></ul><ul><li>Purpose is to correct imbalances as well as provide sufficient renal support to other organs </li></ul>
  25. 25. Renal Replacement Therapies in ARF <ul><li>Hemodialysis: standard treatment if patient is hemodynamically stable </li></ul><ul><ul><li>However, risk of hypotension and wide swings in body weight in unstable patients </li></ul></ul><ul><li>Continuous hemofiltration (CAVH, CVVH) provides slow, continuous filtration across a membrane, driven by arterial pressure (CAVH) or pump (CVVH) </li></ul>
  26. 26. Renal Replacement Therapies in ARF <ul><li>Continuous hemodialysis (CAVHD, CVVHD) uses an ultrafiltrate fluid similar to plasma </li></ul><ul><ul><li>Clearance occurs through diffusion from high concentration (blood) to low concentration </li></ul></ul><ul><li>Peritoneal dialysis: less often used in the US; not as effective when large volume or solute clearances needed. </li></ul>
  27. 27. CAVH
  28. 28. MNT for Adult ARF <ul><li>Energy: BEE X 1.2-1.3 or 25-35 kcal/kg </li></ul><ul><li>Protein: .8-1.2 g/kg noncatabolic, without dialysis; 1.2-1.5 g/kg catabolic and/or initiation of dialysis </li></ul><ul><li>Fluid: 24 hour urine output + 500 ml (750-1500 ml) </li></ul><ul><li>Sodium: 2.0-3.0 grams </li></ul><ul><li>Potassium: 2.0-3.0 grams </li></ul><ul><li>Phosphorus: 8-15 mg/kg; may need binders; needs may increase with dialysis, return of kidney function, anabolism </li></ul>Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  29. 29. Nitrogen Balance in ARF <ul><li>Standard nitrogen balance studies require a creatinine clearance of more than 50 mL/min/1.73m2 </li></ul><ul><li>In ARF, urea nitrogen appearance (UNA) is a better method of determining nitrogen balance </li></ul><ul><li>UNA = UUN + change in the urea nitrogen pool </li></ul>
  30. 30. Calculation of Urea Nitrogen Appearance (UNA) <ul><li>UNA (g) = UUN + [BUN2 – BUN1) x .6 x BW1] + [(BW2-BW1) x BUN2] </li></ul><ul><li>Net protein breakdown = UNA x 6.25 </li></ul><ul><li>UUN = urinary urea nitrogen (g/24hr) </li></ul><ul><li>BUN1 = initial collection of blood urea nitrogen, postdialysis (g/L) </li></ul><ul><li>BUN2 = final collection of blood urea nitrogen, predialysis (g/L) </li></ul><ul><li>BW1 = postdialysis wt (kg) </li></ul><ul><li>BW2 = predialysis wt (kg) </li></ul>
  31. 31. Chronic Kidney Disease
  32. 32. Causes of Chronic Kidney Disease 10 Other 2 Tumors 3 Renal cystic disease 4 Interstitial disease 13 Glomerulonephritis 27 Hypertension 40 Diabetes Incidence (%) Cause
  33. 33. Progression to End-Stage Renal Disease (ESRD) <ul><li>First Decline in glomerular filtration rate (GFR) </li></ul><ul><li>Second Adaptations in renal function, i.e., increase in GFR </li></ul><ul><li>Third Adaptations improve renal function in short term </li></ul><ul><li>Fourth Long term loss of nephron units. </li></ul><ul><li>Fifth Slow, progressive decline in renal function </li></ul><ul><li>Sixth Eventually this decline leads to renal insufficiency, i.e., ESRD </li></ul>
  34. 34. 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
  35. 35. ESRD: Medical Management <ul><li>Dialysis </li></ul><ul><li>Immunosuppressant drugs </li></ul><ul><li>Kidney transplant </li></ul><ul><li>Psychological support </li></ul>
  36. 36. Uremia, a Clinical Syndrome— Signs and Symptoms <ul><li>Malaise </li></ul><ul><li>Weakness </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Muscle cramps </li></ul><ul><li>Itching </li></ul><ul><li>Metallic taste (mouth) </li></ul><ul><li>Neurologic impairment </li></ul>
  37. 37. 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
  38. 38. Treatments: CKD, HD, CAPD
  39. 39. MNT for CKD, HD, PD <ul><li>CKD Hemodialysis CAPD or CCPD </li></ul><ul><li>Protein 0.6-1.0 1.1-1.4 1.2-1.5 </li></ul><ul><li>g/kg/day </li></ul><ul><li>Energy 30-35 30-35 30-35 </li></ul><ul><li>(kcal/kg IBW) </li></ul><ul><li>Phosphorus 8-12 indiv < 17 indiv < 17 indiv </li></ul><ul><li>(mg/kg IBW) </li></ul><ul><li>Sodium 1000-3000 2000-3000 2000-4000 </li></ul><ul><li>(mg/d) </li></ul><ul><li>Potassium Individualized ~ 40 Individualized </li></ul><ul><li>(mg/kg IBW) </li></ul><ul><li>Fluid Unrestricted 500-750 + Individualized </li></ul><ul><li>(ml/d) urine output </li></ul><ul><li>(1000 if anuric) </li></ul><ul><li>Calcium Individualized Individualized Individualized </li></ul><ul><li>(mg/d) based on serum level ~1000 mg/day ~1000 mg/day </li></ul><ul><li>Use adjusted IBW if obese </li></ul>National Renal Diet Professional Guide 2 nd edition, ADA 2002
  40. 40. Nutrition Assessment and Monitoring in the CKD Pt
  41. 41. Anthropometric Measurements <ul><li>% usual body weight (%UBW) </li></ul><ul><li>% standard body weight (%SBW) </li></ul><ul><li>Height </li></ul><ul><li>Skeletal frame size </li></ul><ul><li>BMI </li></ul><ul><li>Skinfold thickness </li></ul><ul><li>Mid-arm muscle area, circumference, or diameter </li></ul>
  42. 42. Body Weight Assessment in CKD <ul><li>Use dry weight or edema-free body weight </li></ul><ul><ul><li>In HD: post-dialysis weight </li></ul></ul><ul><ul><li>In PD: weight after drainage of dialysate with peritoneum empty </li></ul></ul><ul><li>In obese or very underweight people, use adjusted edema-free body weight </li></ul><ul><li>Adjusted EFBW= </li></ul><ul><li>BWef + [SBW*-BWef x .25] </li></ul><ul><li>*Use NHANES II data for standard body weight (SBW) </li></ul>National Kidney Foundation. K/DOQI clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2000;35(suppl);S27-S86.
  43. 43. Blood Urea Nitrogen (BUN) <ul><li>Measure of the nitrogenous waste products of protein </li></ul><ul><li>High BUN in CKD may reflect high protein intake, GI bleeding or inadequate dialysis, increased catabolism due to infection, surgery, poor nutrition </li></ul><ul><li>Decreased BUN may mean protein anabolism, overhydration, protein loss, low dietary protein </li></ul>Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  44. 44. Creatinine (nl 0.5-1.4 mg/dL) <ul><li>Nitrogenous waste product of muscle metabolism </li></ul><ul><li>Produced proportionate to muscle mass </li></ul><ul><li>Unrelated to dietary protein intake (DPI) </li></ul><ul><li>Sensitive marker of renal function: the higher the serum creatinine, the greater the loss of renal function; may reflect inadequate dialysis or muscle catabolism </li></ul><ul><li>A decrease in creatinine over time may reflect loss of lean body mass </li></ul>Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease. ADA, 2004
  45. 45. Causes of Hyperkalemia (  K+) Goal 3.5-5.5 mEq/L <ul><li>>6 mEq/L – abnormal, potentially dangerous </li></ul><ul><li>Renal failure (kidney is primary filter) </li></ul><ul><li>Excessive nutritional intake </li></ul><ul><li>Chronic constipation </li></ul><ul><li>Infection </li></ul><ul><li>GI bleeding </li></ul><ul><li>Insulin deficiency (high BG) </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Drug interactions </li></ul><ul><li>Catabolism of malnutrition or cell damage caused by injury or surgery </li></ul><ul><li>Decreased urinary output </li></ul><ul><li>Chewing tobacco </li></ul>
  46. 46. Causes of Hypokalemia ( ↓ K+) <ul><li>Vomiting, diarrhea </li></ul><ul><li>Diuresis </li></ul><ul><li>Potassium binder </li></ul><ul><li>K+ too low in dialysate </li></ul><ul><li>Urine output >1000 mL/day or serum NL, do not need to restrict K+ </li></ul>
  47. 47. Phosphorus (normal 3.5-5.5 mg/dL) <ul><li>As renal function decreases, phos accumulates in the blood </li></ul><ul><li> phos triggers release of PTH that releases calcium from bone </li></ul><ul><li>Phos binders prevent phosphorus from being absorbed in the gut; form insoluble compound so phos is excreted in stool </li></ul><ul><li>Phos clearance poor in HD and CAPD </li></ul><ul><li>↓ phos may mean excess phos binder or poor p.o. </li></ul>
  48. 48. Calcium (8.4-9.5 mg/dL) <ul><li>Most abundant mineral in human body </li></ul><ul><li>Nearly half of calcium is bound to albumin; if serum calcium is low, evaluate albumin level; can correct for low albumin </li></ul><ul><li>Calcium-Phosphorus Product: multiply serum calcium x serum phos: if >55-75, calcification can occur </li></ul><ul><li><2000 mg/day elemental calcium from diet + binders stage 3-4 </li></ul><ul><li>High ca+: calcification, nausea, vomiting, muscle twitching may mean too much Ca+ from meds or diet </li></ul>
  49. 49. Serum Sodium (nl 133-145 mEq/L) <ul><li>Not a reliable indicator of sodium intake in CKD </li></ul><ul><li>Fluid retention due to decreased urine production can dilute an elevated level </li></ul><ul><li>Serum levels must be evaluated in conjunction with fluid status </li></ul>
  50. 50. Lipids <ul><li>Cardiovascular disease is the most common cause of death in people with CKD </li></ul><ul><li>Kidney disease is considered the equivalent of a risk factor, like diabetes </li></ul><ul><li>HD: often have normal LDL, TC, ↑ triglycerides, ↓ HDL </li></ul><ul><li>PD: have ↑ LDL/TC + ↑ TG </li></ul><ul><li>Renal Tx: ↑ LDL/TC/TG, normal HDL, often due to medications </li></ul>
  51. 51. Cholesterol in CKD <ul><li>High </li></ul><ul><ul><ul><li>High risk TC 200-300 mg/dl (non-fasting) </li></ul></ul></ul><ul><ul><ul><li>LDL goal < 100 mg/dl </li></ul></ul></ul><ul><li>Low </li></ul><ul><ul><ul><li><150 -180, evaluate for pro-energy malnutrition </li></ul></ul></ul><ul><ul><ul><li>Increased mortality </li></ul></ul></ul>
  52. 52. Hematological Indicators <ul><li>Hemoglobin: ↓ due to lack of erythropoetin, produced by the kidney; pts receive synthetic EPO tx (Epogen) </li></ul><ul><li>May have anemia of chronic disease </li></ul><ul><li>Ferritin: may be indicator of iron overload; ↑ ferritin may mean EPO resistance </li></ul>
  53. 53. Glomerular Filtration Rate (GFR) <ul><li>Best index of kidney function </li></ul><ul><li>Used to establish stage of CKD </li></ul><ul><li>GFR is the amount of filtrate formed per minute based on total surface area available for filtration (number of functioning glomeruli) </li></ul><ul><li>Can be determined using injected isotope (inulin) measurement in urine </li></ul><ul><li>Can be calculated from serum creatinine using standard equations </li></ul>
  54. 55. Cockroft-Gault Equation to Calculate GFR <ul><li>MICROMOL: [ (140-age) x weight x 1.23 x (0.85 if female)]/ Creat[micromol/l] </li></ul><ul><li>MG: [(140-age) x wt/kg x .85 if female]/(72*serum creatinine mg/dL) </li></ul>
  55. 56. Interdialytic Weight Gain <ul><li>Pts on dialysis gain several kg of fluid between HD treatments </li></ul><ul><li>If pts gain >5%, may reflect excessive fluid intake, leading to hypertension, edema, ascites, pleural effusion </li></ul><ul><li>Fluid gains of <2% reflect minimal fluid and food intake, may be losing body mass </li></ul>
  56. 57. Measures of Dialysis Adequacy <ul><li>Urea Reduction Rate (URR) </li></ul><ul><li>Refers to change in urea concentration between pre and post-dialysis blood tests </li></ul><ul><li>Statistically significant predictor of mortality </li></ul><ul><li>CMS goal is >65% </li></ul><ul><li>Kt/V </li></ul><ul><li>The fractional clearance of urea as a function of its distribution volume </li></ul><ul><li>Goal is 1.2 or more </li></ul>
  57. 58. 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
  58. 60. Pre-ESRD (DM) <ul><li>Primary Prevention </li></ul><ul><ul><li>Glycemic control (DCCT) </li></ul></ul><ul><ul><ul><li>Aim for Euglycemia </li></ul></ul></ul><ul><ul><ul><li>Watch for low B.S. </li></ul></ul></ul><ul><ul><li>B.P. control </li></ul></ul><ul><ul><ul><li>130/80 </li></ul></ul></ul><ul><ul><ul><li>Na+ restrict </li></ul></ul></ul><ul><ul><ul><ul><li>Base on comorbidities (~2-3 g.) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Medications may increase or decrease K+; monitor </li></ul></ul></ul></ul><ul><ul><ul><li>Wt. loss (gradual)/exercise </li></ul></ul></ul><ul><ul><li>Meds: ACE inhibitors and ARB’s </li></ul></ul>
  59. 61. Pre-ESRD <ul><li>Secondary Prevention (overt nephropathy; GFR ~ 25) </li></ul><ul><ul><li>Protein normalization </li></ul></ul><ul><ul><li>0.6 g/kg - RDA 0.8 g/kg ( minimum for DM) </li></ul></ul><ul><ul><li>Delay need for dialysis, control uremic symptoms, reduce acidosis </li></ul></ul><ul><li>Stage 4 CKD: monitor labs, may need to limit K+, Phos., Ca++, Mg++ </li></ul>
  60. 62. MNT in Patients on Hemodialysis
  61. 63. Hemodialysis <ul><li>Removes concentrated molecules and excess fluid from pts blood through diffusion and ultrafiltration </li></ul><ul><li>Three parts of the system are the dialyzer (artificial kidney), the dialysis machine, and the dialysate </li></ul><ul><li>Requires vascular access, usually through an AV (arteriovenous) fistula </li></ul>
  62. 64. AV (arteriovenous) Fistula
  63. 65. ESRD: Nutritional Management <ul><li>Prevent deficiencies </li></ul><ul><li>Control edema and serum electrolytes </li></ul><ul><li>Prevent renal osteodystrophy </li></ul><ul><li>Provide an attractive and palatable diet </li></ul>
  64. 66. MNT in HD: Protein <ul><li>10-12 g free amino acids lost per treatment during dialysis </li></ul><ul><li>Greater amino acid losses with glucose-free dialysate and high flux dialyzers </li></ul><ul><li>1.2 g protein/kg standard body weight (SBW) with 50% high biological value (meat, poultry, fish, eggs, soy, dairy) </li></ul><ul><li>Most HD patients take in less than 1 g/day </li></ul>NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in Byham-Gray, p. 45-46
  65. 67. MNT in HD: Energy <ul><li>Adults <60 years: 35 kcal/kg SBW </li></ul><ul><li>Adults > 60 or obese: 30-35 kcals/kg body weight </li></ul><ul><li>Actual intakes of HD patients in studies are lower than that (mean 23 kcals/kg in HEMO study) </li></ul>NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in Byham-Gray, p. 46
  66. 68. MNT in HD: Lipids <ul><li>HD patients at risk for lipid disorders </li></ul><ul><li>Recommended fat intake<30% of calories and saturated fat<10%; cholesterol <300 mg/day </li></ul><ul><li>Optimum fiber intake 20-25 g/day </li></ul><ul><li>These restrictions are difficult to achieve along with other restrictions of HD diet </li></ul>
  67. 69. MNT in HD: sodium and fluid <ul><li>≥ 1 L fluid output: 2-4 g Na and 2 L fluid </li></ul><ul><li>≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid </li></ul><ul><li>Anuria: 2 g Na and 1 L fluid </li></ul><ul><li>Restrict Na+ if ↑ interdialytic wt gain, CHF, edema, HTN, low serum sodium </li></ul>
  68. 70. MNT in HD: Potassium <ul><li>Potassium needs related to urinary output </li></ul><ul><li>Most patients on HD can tolerate 2.5 g of K+ </li></ul><ul><li>Stricter diet may be indicated for pts w/ insulin deficiency, metabolic acidosis, treated with beta blockers or aldosterone antagonists, hypercatabolic </li></ul><ul><li>Individuals: 40 mg/kg edema-free IBW or SBW </li></ul>
  69. 71. MNT in HD: Phosphorus <ul><li>Maintain s. phos 3.5-5.5 mg/dL </li></ul><ul><li>Usually ok until GFR ↓ to 20-30 mL/min </li></ul><ul><li>Dialysis removes 500-1000 mg/treatment </li></ul><ul><li>Use phosphorus binders with meals: absorb 50% of dietary phosphorus </li></ul><ul><li>Dietary intake: 800 to 1000 mg/day or <17 mg/kg IBW or SBW </li></ul><ul><li>Identify high protein, low phos food sources </li></ul>
  70. 72. MNT in HD: Calcium <ul><li>High from excess Ca++ type binders, vitamin D analogs, Ca++ fortification </li></ul><ul><li>Goal 8.4-9.5 mg/dl </li></ul><ul><li>Always use corrected Ca++ (adjusted Ca++) </li></ul><ul><ul><ul><li>[ (4-alb.) x 0.8] + Ca++] </li></ul></ul></ul><ul><li>CaXPhos product: goal <55 </li></ul>
  71. 73. 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
  72. 74. MNT in HD: Vitamins <ul><li>H2O soluble vitamins </li></ul><ul><li>Dialyzable – take after H.D. </li></ul><ul><li>B vitamins and vitamin C in renal vitamin </li></ul><ul><ul><li>↑ Vit. C -> ↑ oxalate -> calcification of soft tissues and stones </li></ul></ul><ul><li>Individualize need for: </li></ul><ul><ul><li>Fe++ (IV most common), Vitamin D, Ca++, Zinc. </li></ul></ul>
  73. 75. MNT in HD: Vitamin D <ul><li>Vitamin D is activated in the kidney to calcitriol, or vitamin D3 </li></ul><ul><li>As D3 levels fall, calcium absorption ↓ and phos excretion ↓ </li></ul><ul><li>Vitamin D3 therapy helps prevent renal bone disease but may cause hypercalcemia </li></ul><ul><li>Renal pts should use calcitriol supplements under the supervision of a physician </li></ul>
  74. 76. Hemodialysis <ul><li>Typical diet order </li></ul><ul><ul><li>2000 calorie, 80 g protein, 2 g Na+, 3 g K+, low phosphorus, 1500 cc fluid restriction </li></ul></ul>
  75. 77. Skeletal Effects of Chronic Renal Failure <ul><li>Hyperphosphatemia </li></ul><ul><li>Hypocalcemia </li></ul><ul><li>Hyperparathyroidism </li></ul><ul><li>Low bone mass and density </li></ul><ul><li>Osteitis fibrosa cystica—hyperplastic demineralized bone </li></ul>
  76. 78. Monitor Patient Status <ul><li>1. BP >140/90 </li></ul><ul><li>2. Edema </li></ul><ul><li>3. Weight changes </li></ul><ul><li>4. Urine output </li></ul><ul><li>5. Urine analysis: </li></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>Protein </li></ul></ul>
  77. 79. Monitor Patient Status (cont) <ul><li>6. Kidney function </li></ul><ul><li>Creatinine clearance </li></ul><ul><li>Glomerular filtration rate (GFR) </li></ul><ul><li>7. Blood values </li></ul><ul><li>BUN 10 to 20 mg/dl (<100 mg/dl) </li></ul><ul><li>Creatinine 0.7 to 1.5 mg/dl (10-15 mg/dl) </li></ul><ul><li>Potassium 3.5 to 5.5 mEq/L </li></ul><ul><li>Phosphorus 3.0 to 4.5 mg/dl </li></ul><ul><li>Albumin 3.5-5.5 g/dl </li></ul><ul><li>Calcium 9-11 mg/dl </li></ul>
  78. 80. Peritoneal Dialysis
  79. 81. CAPD (continuous ambulatory peritoneal dialysis) <ul><li>Most patients do 4-5 exchanges per day </li></ul><ul><li>A specific volume of dialysate (1500-3000 ml) is infused into the peritoneal cavity via a catheter </li></ul><ul><li>The dialysate dwells for 4 hours as excess fluid and toxins diffuse through peritoneal membrane </li></ul><ul><li>Dialysate and wastes are drained from the body and the process repeated. </li></ul><ul><li>Dialysate is present in the body 24 hours per day </li></ul><ul><li>APD (automated peritoneal dialysis therapy) speeds the process </li></ul>
  80. 82. Peritoneal Dialysis (home dialysis) <ul><li>Blood cleansed by passive movement from capillaries to dialysate (diffusion) </li></ul><ul><li>Ultra-filtration (UF): fluid removed by osmosis due to high osmolality of dextrose in dialysate </li></ul><ul><li>Better control of labs, fluid balance and B.P. </li></ul><ul><li>Advantages for those with heart failure, access problems. Diet liberal, independence. </li></ul><ul><li>Disadvantages:, anorexia, a.a. losses in dialysate, peritionitis -> catabolism, anorexia, long- term wasting, high B.S., wt. gain, lack of socialization </li></ul>
  81. 83. PERITONEAL DIALYSIS <ul><li>Dialysis solutions </li></ul><ul><ul><li>Pt. chooses depending on fluid status 1.5%, 2.5% or 4.25% glucose </li></ul></ul><ul><li>CAPD </li></ul><ul><ul><li>~4 – 2L. Exchanges/day </li></ul></ul><ul><ul><li>Dwells ~6 hours (dialysis) and drain </li></ul></ul><ul><ul><li>~60% glucose absorbed (3.7 kcal/g) </li></ul></ul><ul><li>CCPD </li></ul><ul><ul><li>~10 L exchanged throughout night </li></ul></ul><ul><ul><li>40% glucose absorbed 2 nd to rapid exchanges </li></ul></ul>
  82. 84. MNT for PD: Energy <ul><li>Energy: 35 kcals/kg/day SBW or adjusted body weight for pts<60 years; 30 kcals/kg for those >60 </li></ul><ul><li>Calories provided in the dialysate should be included in total intake (may absorb as much as 1/3 of daily energy needs) </li></ul>
  83. 85. 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
  84. 86. MNT for PD: Protein <ul><li>PD patients lose 5-15 grams of protein a day, primarily as albumin </li></ul><ul><li>Goal 1.2-1.3 g/kg SBW or ABW/day </li></ul>
  85. 87. MNT for PD: Sodium <ul><li>PD clears sodium very well, so sodium can be fairly liberal </li></ul><ul><li>However, high salt diets increase thirst and may make adherence to fluid limits more difficult </li></ul><ul><li>General recommendation is 2-4 grams sodium </li></ul>
  86. 88. MNT for PD <ul><li>Potassium : is easily cleared by PD; some patients may need K+ supplementation </li></ul><ul><li>Calcium : limit to 2000 mg elemental calcium </li></ul><ul><ul><li>Generally pts get ~1500 mg from calcium-based phosphate binders </li></ul></ul><ul><ul><li>Serum calcium should be maintained in low normal range (8.4-9.5 mg/dl) </li></ul></ul>
  87. 89. MNT for PD <ul><li>Phosphorus: limited to 800-1000 mg/day which is difficult with high protein diet </li></ul><ul><ul><li>Use phosphate binders </li></ul></ul><ul><li>Fluid: can be adjusted by varying the dextrose concentrations of the dialysate </li></ul><ul><ul><li>May need to be restricted if pts cannot achieve fluid balance without frequent hypertonic exchanges </li></ul></ul>
  88. 90. PD: weight gain, hypertriglyceridemia, hyperglycemia <ul><li>Increase exercise as allowed by MD </li></ul><ul><li>Limit sodium and fluid to minimize hypertonic exchanges </li></ul><ul><li>Use solutions with alternate hypertonic agents such as Icodextrin </li></ul><ul><li>Modify energy intake to facilitate wt loss </li></ul><ul><li>Modify intake of sugars and fats, especially saturated fats </li></ul>
  89. 91. PD: Protein Losses, Malnutrition <ul><li>Patient education regarding protein goals and ways to meet them </li></ul><ul><li>Suggest pt eat protein foods first and limit fluids at mealtime </li></ul><ul><li>Frequent smaller portions of protein and easy to eat proteins such as egg white, cottage cheese, etc </li></ul><ul><li>Education on sterile technique to avoid peritonitis </li></ul>
  90. 92. 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
  91. 93. Protein Foods (65 kcals, 7 grams protein, 25 mg Na, 100 mg K+, 65 mg phos) <ul><li>Meat 1 ounce </li></ul><ul><li>Egg 1 </li></ul><ul><li>Fish 1 ounce </li></ul><ul><li>Shellfish 1 ounce </li></ul><ul><li>Poultry 1 ounce </li></ul><ul><li>Egg substitutes ¼ c </li></ul><ul><li>Bacon 4 slices </li></ul><ul><li>Cheese 1 oz </li></ul><ul><li>Milk 1 cup </li></ul><ul><li>Nut butters 2 T </li></ul><ul><li>Tofu ¼ cup </li></ul><ul><li>Cottage cheese ¼ cup </li></ul><ul><li>Lunchmeat 1 oz </li></ul>
  92. 94. Milk Servings (2% milk) 85 kcals, 6 g CHO, 4 g pro, 5 g fat, 80 mg Na+, 185 mg K+, 110 mg Phos <ul><li>½ cup milk </li></ul><ul><li>½ cup plain ice cream </li></ul><ul><li>½ cup yogurt </li></ul>
  93. 95. Starch Servings 80 kcal, 15 g CHO, 2 g pro, 1 g fat, 80 mg Na+, 35 mg K+, 35 mg PO4 <ul><li>Bread, white or rye 1 slice </li></ul><ul><li>Cake 2 in sq or cupcake </li></ul><ul><li>Plain cake donut 1 </li></ul><ul><li>Cold cereal 1 cup </li></ul><ul><li>Dinner roll 1 small </li></ul><ul><li>Macaroni, noodles, rice ½ cup </li></ul><ul><li>Popcorn, unsalted, 1 cup </li></ul>
  94. 96. Vegetable Servings 25 kcal, 5 g CHO, 1 g pro, 15 g Na+, 150 mg K+, 20 mg PO4 <ul><li>Asparagus ½ cup </li></ul><ul><li>Green beans ½ cup </li></ul><ul><li>Cabbage ½ cup </li></ul><ul><li>Carrots ½ cup </li></ul><ul><li>Cauliflower ½ cup </li></ul><ul><li>Corn ½ cup </li></ul>
  95. 97. Fruit Servings ↓ K+ 60 kcals, 15 g CHO, .5 g protein, 150 mg K+, 15 mg phos <ul><li>Apple </li></ul><ul><li>Apple juice ½ c </li></ul><ul><li>Applesauce ½ c </li></ul><ul><li>Apricot nectar ½ c </li></ul><ul><li>Blackberries ½ c </li></ul><ul><li>Blueberries ½ c </li></ul><ul><li>Fruit cocktail ½ c </li></ul><ul><li>Grapes ½ c </li></ul><ul><li>Lemon </li></ul><ul><li>Lime </li></ul><ul><li>Peach </li></ul><ul><li>Pear </li></ul><ul><li>Pineapple </li></ul><ul><li>Plums (1) </li></ul><ul><li>Raspberries </li></ul><ul><li>Watermelon </li></ul>
  96. 98. Fruit Servings (High potassium) 60 kcals, 15 g CHO, .5 g protein, >250 mg K+, 15 mg phos <ul><li>Apricots </li></ul><ul><li>Bananas </li></ul><ul><li>Dates </li></ul><ul><li>Honeydew melon </li></ul><ul><li>Kiwifruit </li></ul><ul><li>Nectarine </li></ul><ul><li>Orange </li></ul><ul><li>Orange Juice </li></ul><ul><li>Prune juice </li></ul><ul><li>Prunes (5) </li></ul><ul><li>Raisins </li></ul>
  97. 99. Fat Choice 100 kcals, 11 g fat, 150 mg Na+, 5 mg PO4 <ul><li>Margarine/butter 1 T </li></ul><ul><li>Cream cheese 2 T </li></ul><ul><li>Mayonnaise 11/2 T </li></ul><ul><li>Non-dairy topping ½ cup </li></ul><ul><li>Sour cream ¼ cup </li></ul><ul><li>Vegetable oil 1 T </li></ul><ul><li>Tartar sauce 2 T </li></ul>
  98. 100. Calorie Boosters 60 kcals, 15 g CHO, 15 mg Na+, 20 mg K+, 5 mg PO4 <ul><li>Hard candy 4 pieces </li></ul><ul><li>Jam or jelly 2 T </li></ul><ul><li>Jelly beans 15 </li></ul><ul><li>Honey 2 T </li></ul><ul><li>Sugar brown or white 2 T </li></ul><ul><li>Marshmallows 5 large </li></ul><ul><li>Fruit snacks and candies 1 oz </li></ul>
  99. 101. Beverages 100 mg K+ (also counts as fluid) <ul><li>Coffee 1 cup </li></ul><ul><li>Tea 1 bag </li></ul><ul><li>Wine 4 oz </li></ul><ul><li>Beer 12 oz </li></ul>
  100. 102. Medicare Rules for MNT in Renal Disease <ul><li>As of January, 2002, Medicare covers MNT for pre-dialysis renal disease </li></ul><ul><li>Includes nutritional, diagnostic, therapy and counseling services </li></ul><ul><li>Restricted to patients with GFR 15 to 50 mL/min/1.73m2 (stages 3-4-5 not on dialysis) </li></ul>
  101. 103. Kidney Transplant <ul><li>1. Types: related donor or cadaver </li></ul><ul><li>2. Posttransplant management: </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Cyclosporine </li></ul><ul><li>3. Diet while on high-dose steroids: </li></ul><ul><li>1.3 to 2 g/kg BW protein </li></ul><ul><li>30 to 35 kcal/kg BW energy </li></ul><ul><li>80 to 100 mEq Na </li></ul><ul><li>4. Diet after steroids: </li></ul><ul><li>1 g/kg BW protein </li></ul><ul><li>Kcal to achieve IBW </li></ul><ul><li>Individualize Na level </li></ul>
  102. 104. Well Mr. Osborne, it may not be kidney stones after all.
  103. 105. Kidney Stones <ul><li>1. Particulate matter crystallizes </li></ul><ul><li>Ca salts (Ca oxalate or Ca phosphate) </li></ul><ul><li>Uric acid </li></ul><ul><li>Cystine </li></ul><ul><li>Struvite (NH 4 , magnesium and phosphate) </li></ul><ul><li>2. Ca salts in stones—Rx: high fluid; evaluate calcium from diet; may need more! </li></ul><ul><li>3. Treat metabolic problem; low-oxalate diet may be needed; acid-ash diet is sometimes useful but not proven totally effective </li></ul>
  104. 106. Kidney Stones—cont’d <ul><li>4. Uric acid stones </li></ul><ul><li>Alter pH of urine to more alkaline </li></ul><ul><li>Use high-alkaline-ash diet </li></ul><ul><li>Food list in Krause text </li></ul><ul><li>5. Cystine stones (rare) </li></ul><ul><li>6. Struvite (infection stones) antibiotics and/or surgery </li></ul>
  105. 107. Acid-Ash Diet <ul><li>Increases acidity of urine (contains chloride, phosphorus, and sulfur) </li></ul><ul><li>Meats, cheese, grains emphasized </li></ul><ul><li>Fruits and vegetables limited (exceptions are corn, lentils, cranberries, plums, prunes) </li></ul>
  106. 108. Alkaline-Ash Diet <ul><li>Increases alkalinity of urine (contains sodium, potassium, calcium, and magnesium) </li></ul><ul><li>Fruits and vegetables emphasized (exceptions are corn, lentils, cranberries, plums, prunes) </li></ul><ul><li>Meats and grains limited </li></ul>
  107. 109. Summary <ul><li>Renal diseases—delicate balance of nutrients </li></ul><ul><li>Regular monitoring of lab values, with altered dietary interventions accordingly </li></ul>