1. + Understanding Kidney Disease and Renal Dialysis Brooke Grussing Concordia College

2. + Learning Objectives Acquire a better understanding of the stages of Chronic Kidney Disease (CKD) and its risk factors Become informed about the progression of kidney disease into End Stage Renal Disease (ESRD) Learn about the Medical Nutrition Therapy (MNT) for the two main types of dialysis; hemodialysis and peritoneal dialysis Gain knowledge about a realistic ethical issue renal patients may face and current research on avoiding protein-energy malnutrition in this population

3. + Risk Factors of Developing CKD 26 million American adults have CKD and many others are at risk of developing it Those with the greatest risk: Diabetics Individuals with hypertension People with family members who had or have had CKD (genetics) Seniors Ethnic populations African Americans Hispanics Pacific Islanders Native Americans (National Kidney Foundation website)

4. + Importance of the Kidneys Remove waste products and excess fluid from the body Regulates the body's salt, potassium, and acid content Produce hormones for other organs in the body Produce active form of vitamin D Control production of RBCs (National Kidney Foundation, 2012)

5. + Renal Disease Pathology: Chronic Kidney Disease (CKD) Syndrome of progressive and irreversible loss of the excretory, endocrine, and metabolic functions of the kidney secondary to kidney disease Kidney function is based on glomerular filtration rate (GFR) GFR measures the rate at which substances are cleared from the plasma by the glomeruli Risk factors mentioned previously are the main causes (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

6. + (National Kidney Foundation, 2012)

7. + Medical Nutrition Therapy for CKD Nutrition Care Process Screening and Referral Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

8. + Screening and Referral MNT used to prevent and treat protein-energy malnutrition, mineral, and electrolyte disorders MNT minimizes the risk of obtaining other comorbidities due to the progression of CKD Referral for MNT from an RD should be made at diagnosis of CKD Made 12 months prior to renal replacement therapy (RRT) (Academy of Nutrition and Dietetics EAL, 2012)

9. + Nutrition Assessment RD should assess the food and nutrition related history of the patient Food and nutrient intake Medication Knowledge, beliefs, or attitudes Behavior Factors affecting access to food and food and nutrition-related supplies Biochemical and physical (Academy of Nutrition and Dietetics EAL, 2012)

10. + Nutrition Diagnosis Many diagnoses may be present due to the complexity of CKD Examples include: Inadequate energy intake, oral/food and beverage intake Excessive fluid intake, protein intake, mineral intake (K, P, or Na) Malnutrition Altered GI function or nutrition-related labs Food-medication reaction Involuntary weight loss/gain Food and nutrition-related recommendations Undesirable food choices Impaired ability to prepare food/meals Poor nutrition quality of life Limited access to food (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

11. + Nutrition Intervention: CKD Stages 1-4 (Taken from: http://andevidencelibrary.com/template.cfm?template=guide_summary&key=2510& highlight=chronic%20kidney%20disease&home=1)

12. + Nutrition Intervention, continued Other intakes to consider with renal patients Energy Calcium Vitamin C and D Iron supplement Folic acid Also remember to monitor fluid intake All recommended values can be found on The Academys EAL site (Academy of Nutrition and Dietetics EAL, 2012)

13. + Nutrition Monitoring and Evaluation RD must monitor and evaluate the biochemical parameters and evaluate how well the patient is adjusting Monitor every one to three months More frequently if the RD sees this to be necessary My clinical experience Patients came in every other day for dialysis RD kept a chart of their lab values Discussed how to improve them each visit (Academy of Nutrition and Dietetics EAL, 2012)

14. + End Stage Renal Disease (ESRD) Also referred to as CKD Stage 5 Kidney function has declined to 10-15% of normal GFR is <15 mL/min/1.73 m 2 Patient requires renal replacement therapy Progression into ESRD: Harmful waste buildup in blood Rise in blood pressure Excess fluid retained (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

15. + Treatment: Renal Dialysis Lifetime commitment for CKD Stage 5 patients Renal replacement procedure put in place to remove excess and toxic by-products of metabolism from the blood Replaces the filtering function of healthy kidneys Must show symptoms in order to initiate dialysis treatment Pericarditis Uncontrollable fluid overload Pulmonary edema Uncontrollable and repeater hyperkalemia Coma Lethargy Less severe symptoms Azotemia Nausea and vomiting (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

16. + Treatment: Renal Dialysis, continued Waste products and excess fluids are removed from the body by: Diffusion, ultrafiltration, and osmosis During removal: Fluid and electrolyte balance must be maintained Done by passing blood across the semipermeable membrane Exposed to dialysate Dialysates: have varying ion and mineral compositions to aid in the process, but do not come into contact with the blood (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

17. + Types of Renal Dialysis Two types of dialysis Hemodialysis (HD) Peritoneal Dialysis (PD) Both methods require a selective, semipermeable membrane to allow passage of material Continuous Renal Repair Therapies (CRRT) Used for acute care during ARF or as temporary treatment until patient begins HD or PD Kidney Transplantation (Alternative to dialysis) (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

18. + Hemodialysis (HD) Selective membrane is a man-made dialyzer Sometimes referred to as an artificial kidney Must have procedure to allow for continuous access to the circulatory system Arteriovenous fistula (AVF) Arteriovenous graft (AVG) Explanation of the process Typically occurs 3 times/week for ~4 hours/session Most done at a dialysis center Other alternatives: Daily home hemodialysis (DHHD): 5-7 days/week, 2-3 hours/session Nocturnal home hemodialysis (NHHD): 3-6 days/week, during sleep (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

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20. + MNT for HD NutrientHemodialysis (HD) Protein (50% from HBV) 1.2 g/kg/d Energy35 kcal/kg/d <60 yr of age, 30-35 older than 60 CHO and FatAfter calculation of PRO, assess patient needs calculate percentages accordingly Fluid 1 L fluid output = 2 L fluid needed. < 1 L fluid output = 1-1.5 L fluid needed. Anuria = 1 L fluid needed K and PCheck levels of K and P; modify diet accordingly NaLimit Na intake unless there are large losses in dialysate, vomiting, or diarrhea. Restrict to 2-4 g VitaminsWater soluble vitamins to replace dialysate losses. Folic acid, vitamin B 6, vitamin C, and vitamin B 12 MineralsMonitor serum labs. Individualize Ca Omega-3 FAFish oilmay help reduce prostaglandin synthesis and improve hematocrit levels (Stump-Escott, S., 2012)

21. + Peritoneal Dialysis (PD) Patients peritoneal wall serves as the selective membrane Access to patients blood supply is via a catheter Dialysate introduced into the peritoneum through catheter Explanation of process Two types of PD Continuous Ambulatory Peritoneal Dialysis (CAPD) No machine required Dwell time of 4-6 hours, followed by draining of used dialysate and replacement of fresh solution (~30-40 minutes) Most patients change the fluid 4 or more times/day and also sleep with it Continuous Cycling Peritoneal Dialysis (CCPD) Requires a cycler Machine that fills and empties the abdomen 3-5 times/week with a dwell time that lasts the entire day (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

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23. + MNT for PD NutrientPeritoneal Dialysis (PD) Protein1.2-1.3 g/kg/d (1.5 g/kg for peritonitis) Energy35 kcals/kg/d for <60 years and 30-35 for 60 or older CHO and FatMust be individualized due to dialysate (adding 300-450 kcals of glucose). Limit simple sugars and SFA FluidLess common; 1-3 L/d suggested. Should be determined by state of hydration. No more than 1 kg gained/day K and PSame as HD NaIntake should be liberal, depending on hydration, BP, losses in dialysate, vomiting, and diarrhea VitaminsWater-soluble, especially vitamin B 6 and folic acid MineralsSame as HD Omega-3 FASame as HD (Stump-Escott, S., 2012)

24. + National Renal Diet (Patient on Dialysis) Food ListProtein (g/serv) Calories (kcal/serv) Sodium (mg/serv) Potassium (mg/serv) Phosphurs (mg/serv) Animal Protein6-850-10020-15050-15050-100 Higher Na, K, or P proteins 6-850-100200-500250-450100-300 Fruits/Vegetables -Low0-310-1001-5020-1500-70 -Medium0-310-1001-50150-2500-70 -High0-310-1001-50250-5500-70 Dairy/P2-8100-40030-30050-400100-120 Breads/Cereals2-350-2000-15010-10010-70 Calorie0-1100-1500-100 Flavorings00-20250-3000-1000-20 Vegetarian Protein6-870-15010-20060-15080-150 (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

25. + Common Medications and Their Use/Effects on CKD Patients Phosphate binders Prevents GI absorption of dietary phosphorus. N/V may result Angiotensin-converting enzyme (ACE) inhibitor For patients with >200 mg protein/g creatinine in a urine sample Antidepressants Depression is common within renal dialysis patients-may be needed to improve appetite and intake Carnitine Requires adequate vitamin C, niacin, iron, and vitamin B 6. Kidney is unable to make it (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

26. + Common Medications, continued Insulin Used to control blood glucose levels in diabetic patients Iron supplements Recombinant human erythropoietin: used to treat anemia Lipid lowering medications Patient with an LDL of 100 mg/dL should be treated with diet and statin Vitamin D Patients kidney is unable to convert vitamin D to its active form, causing osteodystrophy (Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

27. + Current Research: Amino Acid Oral Supplementation in HD Patients Protein-energy malnutrition is a common concern in HD patients But, CKD is associated with loss of appetite and reduced food intakes Branched chain amino acid supplements have been able to increase serum albumin and to improve nutritional status AA formation has been reported to have beneficial effects on Elderly people Elderly affected by CHF Type 2 diabetics Reason for this study to be conducted: At this time, no data exist about AA supplementation in patients with CKD Often, CKD patients are also associated with groups listed above Supplement includes all of the essential AAs, plus two nonessential (tyrosine and cystine) (Bolasco, P., Caria, S., Cupisti, A., Secci, R., & Dioguradi, F. 2011)

28. + Current Research, continued Study conducted on patients with Serum albumin levels < 3.5 g/dL Normalized protein nitrogen appearance of < 1.1 g/kg/die BMI of >20 kg/m 2 Receiving HD for at least 6 months Stable clinical conditions and free from acute inflammation 30 patients selected: 15 (5 male, 10 female, aged 72.7 +/- 10 years, dialysis 42.5 +/- 36.2 months) were randomized to oral AA supplementation Remaining 15 (5 male, 10 female, aged 75.2 +/- 11.2 years, dialysis for 45.1 +/- 36.2 months) were the control group Study lasted 3 months, results were obtained (Bolasco, P., Caria, S., Cupisti, A., Secci, R., & Dioguradi, F. 2011)

29. + Current Research: Results of Study Study group showed increase in: Serum albumin Total protein Hemoglobin Study group showed decrease in: ERI (erythropoietin resistance index) CRP (C-reactive protein) Findings indicated also that there was a reduction in inflammation and an improvement of anemia Conclusion of study: Oral AA supplementation was able to improve albumin and total protein in hypoalbuminemia HD patients (Bolasco, P., Caria, S., Cupisti, A., Secci, R., & Dioguradi, F. 2011)

30. + Ethical Issue: The Shortage of Kidney Transplants Approximately 18,000 transplants done annually More than 70,000 individuals are waiting for a donor Limited availability of kidneys for transplantation Commodification (Are organs a commodity??) Exchanges in which material goods and economic services are literally bought and sold Racial ethical issues: Human dignity Treat persons as ends in themselves, never as means Altruism (welfare of others) Treating as a commercial commodity would abolish the moral choice of giving to strangers Stance of the authors: There should be an alternative to commodification of kidneys Believe it is unethical to be compensated for donation due to altruism (Rosen, L., Vining, A., & Weimer, D., 2011)

31. + Recap of Learning Objectives This morning, we: Acquired a better understanding of the stages of Chronic Kidney Disease (CKD) and its risk factors Became informed about the progression of kidney disease into End Stage Renal Disease (ESRD) Learned about the Medical Nutrition Therapy (MNT) for the two main types of dialysis; hemodialysis and peritoneal dialysis Gained knowledge about a realistic ethical issue renal patients may face and current research on avoiding protein-energy malnutrition in this population

32. + Questions??