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![Adjusted Edema- Free Body
Weight
Calculating protein and energy
requirements for underweight and obese
patients
aBWef = Bwef + [{SBW-Bwef} x 0.25] Bwef
SBW determined from NHANES II data](https://image.slidesharecdn.com/dialysislectureformnt-pptx-121023183020-phpapp02/85/Dialysis-30-320.jpg)
Uploaded byRoanna Martin
Dialysis
The document outlines essential information regarding Stage 5 Chronic Kidney Disease (CKD), including its causes, pathophysiology, and treatment options such as hemodialysis and peritoneal dialysis. Key topics include risk factors, dietary recommendations, and nutrient management for patients requiring renal replacement therapy. It also highlights the healthcare team's role and goals of dialysis while emphasizing the importance of monitoring nutritional indicators.
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- 1.
- 2. Outline • Stage 5 CKD • Hemodialysis • Peritoneal Dialysis • MNT • Patient Assessment • Complications • Questions?
- 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. 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. Stage 5 CKD:End Stage Renal Disease • 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. Risk Factors • Proteinuria • Ethnicity • Gender • Smoking • Heavy consumption of non-narcotic analgesics, particularly phenacetin 6
- 7. United States ESRDIncidence 32000 31000 Number of Cases 30000 29000 28000 2009 27000 2010 26000 2011 25000 24000 Q1 Q2 Q3 Q4 Quarter United States Renal Data System
- 8. United States ESRDPrevalence 610000 605376 Number of Cases 600000 598409 590000 592367 586445 580000 578637 570000 571414 560000 550000 Quarter
- 9. Indications to begindialysis • Diabetics: Creatinine clearance is < 15 mL/min • Non-diabetics: serum creatinine reaches 6 mg/dL
- 10. Additional Indications Symptoms • Pericarditis • Uncontrollable fluid overload • Pulmonary edema • Uncontrollable and repeated hyperkalemia • Coma • Lethargy • Less Severe Symptoms • Azotemia • Nausea • Vomiting
- 11. Main Goals ofDialysis Remove Maintain Fluid Fluid Waste Products Electrolyte ○ Urea Acid-base balance ○ Creatinine ○ Potassium ○ Phosphorous ○ Sodium
- 12. Dialysis Health CareTeam • Patient • Dialysis Nurse • Dialysis Technician • Nephrologist • Nephrology Social Worker • Renal Dietitian
- 13. Therapeutic Modalities • Hemodialysis • In center dialysis • Home hemodialysis • In center nocturnal dialysis • Peritoneal Dialysis • Continuous ambulatory peritoneal dialysis • Continuous cycling peritoneal dialysis
- 14. Hemodialysis • Waste productsfiltered 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. Access • Arteriovenous Fistula •Arteriovenous Graft • Central Venous Catheter
- 16. Arteriovenous Fistula Venous Needle • Radial artery to Arterial Needle cephalic vein Vein • 4-6 weeks to become fully functional AV Fistula Artery • Subclavian route can be used temporarily
- 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. Central Venous Catheter Blood to dialysis Blood from dialysis machine machine
- 19.
- 20. Dialysate • Highly purified water • Sodium • Potassium • Calcium • Magnesium • Chloride • Bicarbonate • Dextrose
- 21. Mechanisms of transport •Diffusion • Ultrafiltration (convection) • Hydrostatic ultrafiltration • Transmembrane pressure (blood- dialysate) • Ultrafiltration coefficient (KUF): water permeability • Osmosis
- 22. Peritoneal Dialysis Infusion Drain Dialysis Solution Peritoneum Abdominal Cavity Catheter
- 23. Peritoneal Dialysis • Peritonealcavity:reservoir for dialysate • Peritoneum: semipermeablemembrane across which excess body fluid and solutes are removed • Polyurethane or silicone catheter Peritoneal Capillaries Peritoneal Cavity Fluid Urea Creatinine Potassium Sodium Chloride Lactate Glucose
- 24. Peritoneal Dialysis Continuous Automated PD Ambulatory 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. 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. Calculation of GlucoseAbsorbed in Peritoneal Dialysis Patients • 60% of daily dialysate glucose load is absorbed glucose absorbed (kcal) = (1-D/D0)xi where D/D0 is the fraction of glucose remaining and xi is initial glucose
- 27. MNT Objectives inDialysis • 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. Renal MNT Treatment Pre-Stage 5 CKD Hemodialysis Peritoneal Dialysis Protein (gm/kg .6-.8 ≥1.2 for stable 1.2-1.3 for stable SBW) patients patients 65% HBV ≥ 50% HBV ≥ 50% HBV Energy 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 unrestricted Sodium (mg/d) 1000-3000 2000-3000 2000-4000 Fluid (ml/d) Typically 750-1000 + 24 hr 2000 unrestricted urine output
- 29. Renal MNT Treatment Hemodialysis Peritoneal Dialysis Fat 25-35% of total kcal 25-35% of total kcal Cholesterol < 200 mg/day < 200 mg/day Fiber 20-30 g/day 20-30 g/day Calcium ≤1500 mg/day from 3000-4000 phosphate binders ≤2000 mg/day total
- 30. Adjusted Edema- FreeBody Weight 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. 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. 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. CKD Response toLow Serum Calcium and/or High Phosphorus 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. 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. Patient Recommendations Foodsto enjoy Fresh meat, fish and poultry Enriched bread, pasta and rice Allowed vegetables and fruits Olive oil, butter, or margarine
- 36. Protein Foods 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. Calories Foods 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. Phosphorus Limit 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. Potassium Fruits 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. Potassium Fruits 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. Sodium Instead 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. 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- don't swallow • Chew gum • Have a piece of hard sour candy
- 43. Nutrition Assessment • DietRecall • Food Diary • Food Frequency Questionnaire
- 44. Nutritional Indicators, Target, and Frequency Indicator Target Frequency Serum Albumin ≥ 4.0 mg/dL Monthly Serum Prealbumin >30 mg/dL As needed Serum Cholesterol > 150-180 mg/dL As needed Lipid Profile LDL: < 100 mg/dL As needed HDL: > 150 mg/dL Triglycerides: < 150 mg/dL Serum Creatinine > 10 mg/dL Monthly (pre-dialysis treatment) nPNA (protein equivalent of > 1.0 HD: Monthly total nitrogen appearance PD: Every 4 normalized to body weight) months Nelms et al.
- 45. Nutritional Indicators, Target, and Frequency Indicator Target Frequency % Usual Dry Weight after HD N/A Monthly or post-drain with PD % Standard Body Weight N/A Every 4 months BMI Upper 50th percentile Monthly 23.6 kg/m2 for men 24 kg/m2 for women SGA ≥ 6-7 Biannually 4 item, 7 point scale Anthropometrics and DEXA N/A As needed Serum Bicarbonate ≥ 22 mmol/L Monthly Nelms et al.
- 46. Behavioral Outcomes Mealplanning Meeting nutrient needs Awareness of potential food/drug interactions Exercise
- 47. Comorbid Conditions and Complications Malnutrition Cardiovascular disease Secondary Hyperparathyroidism Osteitisfibrosa Anemia Recombinant human erythropoietin Iron Target levels ○ Hematocrit: 33-36% ○ Hemoglobin: 11-12 g/dL
- 48. For Further Reading • Daugirdas JT, Blake PG, Ing TS.“Handbook of Dialysis Fourth Edition" Lippincott Williams &Wilkins:2006.
- 49.