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Diseases of the Renal System
KNH 406
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
CKD - Renal Replacement Therapy
Hemodialysis (HD)
Membrane is manmade dialyzer – “artificial kidney”
Preferred access site – AVF, AVG
Typical regimen
3 days/week for 4 hrs/treatment
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
Range of dextrose concentrations
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
More frequent if GFR ≤ 15
Protein: .6-.75 g/kg
Energy: 30-35 kcal/kg
CKD - Stages 3 & 4
Nutrition Therapy
See ADA guidelines
Nutrition assessment recommendations
Nutrient recommendations
Emphasize usual foods
CKD - Stages 3 & 4
Outcome measures
Clinical
Behavioral
Meal planning, meeting nutrient needs, awareness of food/drug
interactions, exercise
© 2007 Thomson - Wadsworth
CKD - Stage 5
Nutrition Assessment
On dialysis – measures not different
Goals: meet nutritional requirements, prevent malnutrition,
minimize uremia, minimize complications
Maintain blood pressure, fluid status
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
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
CKD - Stage 5
Nutrition Intervention
Protein - 1.2 g/kg (HD), at least 50% HBV
PD same except during peritonitis – increase protein
Losses increase 50-100% and may remain elevated
CKD - Stage 5
Nutrition Intervention
Energy to prevent catabolism
PD
Caloric load
24-27 kcal/kg/day average intake
CKD - Stage 5
Nutrition Intervention
Adjusted Edema-Free Body Weight
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
CKD - Stage 5
Nutrition Intervention
Fat
HD typically have normal LDL, HDL, TG
PD higher TC, LDL, TG
Recommend TLC diet guidelines for both
© 2007 Thomson - Wadsworth
CKD - Stage 5
Nutrition Intervention
Fluid and Sodium highly individualized
Interdialytic weight gain (HD)
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
CKD - Stage 5
Nutrition Intervention
Fluid and Sodium
PD – based on ultrafiltration
Fluid 2 L
Sodium 2-4 g
Fluid overload
© 2007 Thomson - Wadsworth
CKD - Stage 5
Nutrition Intervention
Phosphorus
Hyperphospatemia
Dietary phosphorus restriction
Phosphate binders; calcium salts
Limit calcium intake
© 2007 Thomson - Wadsworth
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
CKD - Stage 5
Nutrition Intervention
Vitamin Supplementation
Water-soluble vitamins
Daily requirements
“Renal” vitamins
Avoid high doses of vitamins A & C
May need vitamin K if on antibiotics
© 2007 Thomson - Wadsworth
CKD - Stage 5
Nutrition Intervention
Mineral supplementation
Avoid Mg-containing phosphate binders, antacids, and
supplements
Iron
Zinc
