Diseases of the Renal System

KNH 413

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 Preferred access site – AVF, AVG Typical regimen

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

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: .6-.75 g/kg Energy: 30-35 kcal/kg

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

CKD - Stages 3 & 4 Outcome measures

Clinical Biochemical Anthropometrics

Clinical signs and symptoms

Behavioral Meal planning, meeting nutrient needs, awareness of food/drug

interactions, exercise

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

©  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

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

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

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

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

CKD - Stage 5 Nutrition Intervention

Fluid and Sodium PD – based on ultrafiltration; 2 -2.5 kg fluid/day Fluid 2 L

Sodium 2-4 g

Fluid overload: shortness of breath, htn., CHF, edema

CKD - Stage 5 Nutrition Intervention

Phosphorus Hyperphospatemia - GFR 20-30 mL/min Dietary phosphorus restriction: 800-1000 mg/day, < 17 mg/kg

body IBW 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 include B12, folic acid, vitamin C Avoid high doses of vitamins A & C May need vitamin K if on antibiotics

CKD - Stage 5 Nutrition Intervention

Mineral supplementation Avoid Mg-containing phosphate binders, antacids, and

supplements Iron Zinc