1. Diseases of the Renal System
KNH 413

2. CKD - Renal Replacement Therapy
Hemodialysis (HD) or Peritoneal Dialysis (PD)
Type based on underlying kidney disease and co-morbid factors
Both require selective, permeable membrane
Allows passage of water and small molecules
Both HD and PD exclude large molecules such as protein

3. CKD - Renal Replacement Therapy
Hemodialysis (HD)
Membrane is manmade dialyzer
Preferred access site – AVF, AVG
Typical regimen
Dialyzer is the artificial kidney
AVF-Arteriovenous Fistula
AVG-Arteriovenous Graft
Typical regimen is 3 days per week for 4 hours of treatment

4. CKD - Renal Replacement Therapy
Peritoneal dialysis (PD)
Lining of patient’s peritoneal wall is the selective membrane
Types
CAPD
CCPD
Access via catheter into peritoneal cavity
Dwell time and number of exchanges
Types of Peritoneal Dialysis-
CAPD-continuous ambulatory
CCPD-Continuous cycling

5. Chronic Kidney Disease picture of peritoneal dialysis

6. CKD - Stages 1 & 2 Nutrition Therapy
Focus on co-morbid conditions: diabetes, hypertension, hyperlipidemia, progression of CVD
K/DOQI guidelines for GFR ≤ 20
SGA every 1–3 mo.
Dietary interviews and food intake
Protein: g/kg
Energy: kcal/kg
K/DOQI-Kidney Disease Outcome Quality Initiative Guidelines
Subjective Global Assessment of Kidney Disease - nutrition assessment

7. CKD - Stages 3 & 4 Nutrition Therapy See ADA guidelines
Nutrition assessment recommendations
Nutrient recommendations
Protein, energy, sodium, potassium, phosphorus, calcium, vitamins, minerals, fluid may need adjustment
Emphasize usual foods
The guidelines for a nutrition assessment includes protein, calories, sodium, potassium, phosphorus, calcium, vitamins, minerals, and fluid

8. This is a 2000kcal and 2100 kcal renal plan which includes a protein, phosphorus, potassium, and sodium

9. CKD - Stages 3 & 4 Outcome measures Clinical Behavioral Biochemical
Anthropometrics
Clinical signs and symptoms
Behavioral
Meal planning, meeting nutrient needs, awareness of food/drug interactions, exercise
Clinical assessment includes biochemical, anthropometrics, and clinical signs and symptoms

10. Biochemical data levels to monitor- albumin, BUN, Creatinine, potassium, phosphorus, calcium, cholesterol, triglycerides, hemoglobin, hematocrit, ferritin, and transferrin

11. CKD - Stage 5 Nutrition Assessment
On dialysis – measures not different
Dietary intake
Biochemical: serum albumin
Goals: meet nutritional requirements, prevent malnutrition, minimize uremia, minimize complications
Maintain blood pressure, fluid status
The measure of nutrition status does not change for a person on dialysis---a dietary intake/recall is used to assess nutrient intake and biochemical markers such as albumin are used to assess the patients nutrition status.

12. The lab data- important to measure the lab values using serial measurements to determine changes in nutrition status

13. The percent body weight will change from dialysis session to dialysis session. That is why it is important to look at that measurement in 4 month increments to establish true changes in weight. Subjective Global Assessment is a good measure of changes in eating patterns that may account for changes in lab values over a long period of time. DEXA can measure changes in bone mineral status. Bicarbonate can assess pH status.
© 2007 Thomson - Wadsworth

14. CKD - Stage 5 Nutrition Intervention
HD – high in protein, control intake of potassium, phosphorus, fluids and sodium
PD – more liberalized; higher in pro., sodium, potassium and fluid, limit phosphorus
nutrients to monitor
HD vs. PD—HD has more strict guidelines for the patient whereas PD is much more liberal regarding nutrients. HD may need to address modifications in fat, cholesterol, and triglycerides if warranted

15. Here is a list of nutrient needs for HD patients and PD patients

16. Additional nutrient needs for HD and PD patients.

17. CKD - Stage 5 Nutrition Intervention
Protein g/kg (HD), at least 50% HBV
PD same except during peritonitis
Nutrition intervention for patients with stage 5 CKD—half of all protein must be of high biological value and must provide 1.2 grams/kg
PD patients with complications such as peritonitis will need increased protein---losses increase % and may remain elevated even after the peritonitis resoves

18. CKD - Stage 5 Nutrition Intervention
Energy to prevent catabolism; needs slightly higher
PD - account for kcal in dialysate
Caloric load
24-27 kcal/kg/day average intake
Energy needs are slightly higher and need to be individualized for each patient.
PD – you need to account for the kcal in the dialysate
Caloric load can be as high as 27kcal/kg

19. CKD - Stage 5 Nutrition Intervention
Adjusted Edema-Free Body Weight should be used to calculate body weight for calculating protein and kcal
For those < 95% or > 115% median standard weight NHANESII
For maintenance in HD and PD pts.
Obtained postdialysis for HD pts., and after drainage for PD patients
It is important to obtain postdialysis weight which is the patients actual weight or dry weight.

20. CKD - Stage 5 Nutrition Intervention
Fat - increased risk for CAD and stroke
HD typically have normal LDL, HDL, TG
PD higher TC, LDL, TG
Recommend TLC diet guidelines for both
Recommendation for HD and PD patients is the Therapeutic Lifestyle Change—lipds should be monitored

21. HD patients are at increased risk for CAD and stroke.

22. CKD - Stage 5 Nutrition Intervention
Fluid and Sodium highly individualized based on residual urine output and dialysis modality
Interdialytic weight gain (HD) should not exceed 5% of body weight
2 gram sodium diet
Not more than 1 L fluid daily
If urine output > 1 L/day sodium and fluid can be liberalized to 2-4 g and 2 L
Interdialytic weight gain should be no greater than 5% body weight which is equivalent to no more than 1 liter of fluid per week. Sodium restriction can be liberalized along with fluids if urine output is greater than 1 liter

23. CKD - Stage 5 Nutrition Intervention Fluid and Sodium
PD – based on ultrafiltration; kg fluid/day
Fluid 2 L
Sodium 2-4 g
Fluid overload: shortness of breath, htn., CHF, edema
PD is more liberal with fluids kg fluid/d
Concerns would arise if patient exhibited signs of fluid overload such as SOB, HTN, CHF, or edema

24. There are several nutrition interventions/instructions that can help the CKD patient

25. CKD - Stage 5 Nutrition Intervention Phosphorus
Hyperphospatemia - GFR mL/min
Dietary phosphorus restriction: mg/day, < 17 mg/kg body IBW
Phosphate binders; calcium salts
Limit calcium intake
Phosphorus is another nutrient to monitor closely---it should be restricted to no more than mg/d or 17 mg/kg of IBW

26. Binders are used to prevent phosphorus intoxication
© 2007 Thomson - Wadsworth

27. CKD - Stage 5 Nutrition Intervention
Calcium requirements higher in CKD
Restrict foods high in calcium
Take supplements on empty stomach
Limit to 2000 mg/day from all sources
Calcium must be monitored closely. Needs are higher, but must be taken in supplemental form

28. CKD - Stage 5 Nutrition Intervention Vitamin Supplementation
Water-soluble vitamins
Daily requirements
“Renal” vitamins include B12, folic acid, vitamin C
Avoid high doses of vitamins A & C
May need vitamin K if on antibiotics
Specific renal vitamins must be taken to meet nutritional needs of the dialysis patient

29. The specific levels are listed for the dialysis patient on this chart

30. CKD - Stage 5 Nutrition Intervention Mineral supplementation
Avoid Mg-containing phosphate binders, antacids, and supplements
Iron
Zinc
There are specific minerals to avoid—magnesium
Need to monitor iron status and zinc levels to avoid deficiencies.