View
217
Download
3
Category
Tags:
Preview:
Citation preview
+
Understanding Kidney Disease and Renal Dialysis Brooke Grussing
Concordia College
+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
+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)
+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)
+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)
+
(National Kidney Foundation, 2012)
+Medical Nutrition Therapy for CKD
Nutrition Care Process Screening and Referral Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation
+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)
+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)
+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)
+Nutrition Intervention: CKD Stages 1-4
(Taken from: http://andevidencelibrary.com/template.cfm?template=guide_summary&key=2510&highlight=chronic%20kidney%20disease&home=1)
+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 Academy’s EAL site
(Academy of Nutrition and Dietetics EAL, 2012)
+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)
+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 m2
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)
+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)
+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)
+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)
+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)
+
+MNT for HDNutrient Hemodialysis (HD)
Protein (50% from HBV)
1.2 g/kg/d
Energy 35 kcal/kg/d <60 yr of age, 30-35 older than 60
CHO and Fat After 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 P Check levels of K and P; modify diet accordingly
Na Limit Na intake unless there are large losses in dialysate, vomiting, or diarrhea. Restrict to 2-4 g
Vitamins Water soluble vitamins to replace dialysate losses. Folic acid, vitamin B6, vitamin C, and vitamin B12
Minerals Monitor serum labs. Individualize Ca
Omega-3 FA Fish oil—may help reduce prostaglandin synthesis and improve hematocrit levels(Stump-Escott, S., 2012)
+Peritoneal Dialysis (PD) Patient’s peritoneal wall serves as the selective membrane
Access to patient’s 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)
+
+MNT for PDNutrient Peritoneal Dialysis (PD)
Protein 1.2-1.3 g/kg/d (1.5 g/kg for peritonitis)
Energy 35 kcals/kg/d for <60 years and 30-35 for 60 or older
CHO and Fat
Must be individualized due to dialysate (adding 300-450 kcals of glucose). Limit simple sugars and SFA
Fluid Less common; 1-3 L/d suggested. Should be determined by state of hydration. No more than 1 kg gained/day
K and P Same as HD
Na Intake should be liberal, depending on hydration, BP, losses in dialysate, vomiting, and diarrhea
Vitamins Water-soluble, especially vitamin B6 and folic acid
Minerals Same as HD
Omega-3 FA
Same as HD(Stump-Escott, S., 2012)
+National Renal Diet (Patient on Dialysis)Food List Protein
(g/serv)Calories
(kcal/serv)
Sodium(mg/serv)
Potassium
(mg/serv)
Phosphurs
(mg/serv)
Animal Protein 6-8 50-100 20-150 50-150 50-100
Higher Na, K, or P proteins
6-8 50-100 200-500 250-450 100-300
Fruits/Vegetables
-Low 0-3 10-100 1-50 20-150 0-70
-Medium 0-3 10-100 1-50 150-250 0-70
-High 0-3 10-100 1-50 250-550 0-70
Dairy/P 2-8 100-400 30-300 50-400 100-120
Breads/Cereals 2-3 50-200 0-150 10-100 10-70
Calorie 0-1 100-150 0-100 0-100 0-100
Flavorings 0 0-20 250-300 0-100 0-20
Vegetarian Protein
6-8 70-150 10-200 60-150 80-150(Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)
+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 B6.
Kidney is unable to make it
(Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)
+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 Patient’s kidney is unable to convert vitamin D to its active
form, causing osteodystrophy
(Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)
+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)
+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/m2
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)
+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)
+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)
+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
+
Questions??
Recommended