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Stephanie Ruel
Sodexo/St. Joseph’s Medical Center
MNT for the CKD Patient Complicated by a Pressure
Ulcer
Controversy of recommendations
Studies: Inconclusive or inadequate
Abstract
Anatomy and PhysiologyEtiology and pathologyMedical managementMedical Nutrition TherapyThe PatientConclusionFuture studiesRecommendations
Introduction
Chronic Kidney Disease
FunctionsMetabolic waste removalElectrolyte balanceFluid balanceBlood pressure controlpH regulationPlasma volume and osmolalityGlucose homeostasisHormone secretion (erythropoietin)Carnitine synthesis
Anatomy & Physiology of the Kidneys
Anatomy
Anatomy
Afferent arterioleGlomerulusBowmans’s capsuleProximal tubuleEfferent arteriolePeritubular
capillariesRenal vein
Proximal tubule
Glomerulus: Selective permeability
UltrafiltrateSelective resportion and excretion
Physiology: Electrolyte Balance
Tubule Efferent arteriole
= fluid homeostasis
Physiology: Electrolyte Balance
Electrolytes
Two main systems:VasopressinRenin-angiotensin aldosterone
system (RAAS)
Physiology: Fluid Balance
↑Blood osmolality or ↓blood pressure
HypothalamusPituitary gland
Kidney ↑blood pressure ↓blood osmolality
Vasopressin
Vasopressin
↓blood pressureAngiotensinogen
KidneyAngiotensin I
Angiotensin II
Adrenal Aldosterone
↑blood pressure
Renin-Angiotensin Aldosterone System
Renin
Lungs
RAAS
Etiology & Pathology
Diabetes Hypertension Family historyEthnicityAutoimmune diseaseInfectionSevere dehydrationAcute renal failure (ARF)
Etiology & Pathology
44%
of new CKD diagnoses caused by diabetes
Diabetic Nephropathy
Diabetic NephropathyGlomerular Anatomy
mesangium
↑blood glucose afferent arteriole dilationaltered hemodynamic regulation↑blood flow to glomerulus
Hypertrophy damage to podocytes Hyperfiltration and mesangial cellsHyperperfusion
altered permeabilityof glomerulus= PROTEINURIA
Hyperglycemia
Inflammatory mediatorsProinflammatory cytokines
Oxidative stressInflammation
FibrosisGlomerulosclerosis
Kimmelstiel-Wilson lesions
Proteinuria
DefinitionHypertension:
Systolic >140mm Hgor
Diastolic >90mm HgPrehypertension:
121/81mm Hg – 139/89mm HgNormal blood pressure:
<120/80mm Hg
Hypertension
Cause and effectBlood vessel remodelingInflammationOxidative stressArteriosclerosis
Hypertension
Endothelial lesions in blood vessels caused by buildup of hyaline
Decreased action of smooth muscle cells
Inhibited autoregulationIschemic tubulointerstitial injury
Hyaline Arteriosclerosis
Studies – Impact of protein restriction and blood pressure control on progression of CKD:
Modification of Diet in Renal Disease (MDRD) study
Northern Italian Cooperative Study Group
Multiple studies with smaller sample size; data from mid-1980’s to mid-1990’s
INCONCLUSIVE, INSIGNIFICANT
Dietary Protein
Medical Management
Irreversible loss of kidney function with decreased glomerular filtration rate (GFR) and/or evidence of kidney damage that persists >3 months, progressive in nature.
Diagnosis
Stage
eGFR (mL/min/1.73m2)
Description
1 >90 Kidney damage with normal or increased GFR
2 60-89 Kidney damage with mildly decreased GFR
3 30-59 Moderately decreased GFR
4 15-29 Severely decreased GFR
5 <15 or dialysis Kidney failure
Item Normal ValueIn CKD, may
be:
Potassium 3.5-5.3meq/L Elevated
Phosphorus 3.4-5.9mg/dL Elevated
Blood urea nitrogen (BUN)
9-20mg/dL Elevated
Creatinine 0.5-1.3mg/dL Elevated
Albumin 3.5-5g/dL Decreased
Sodium 135-150meq/L Elevated
Urine protein Negative Positive
Blood pressure <120/80mm Hg Elevated
Laboratory Values
Hypertension: 80-85% Angiotensin Receptor Blockers (ARBs)
Angiotensin Converting Enzyme (ACE) Inhibitors
Diuretics
Antihypertensive Therapy
Albuminuria >300mg and all diabetic CKD (without hypertension)ARBsACE Inhibitors
Albuminuria <30mg and BP >140/90mm HgTarget BP <140/90mm Hg
Albuminuria >30mg, BP >130/80mm HgTarget BP <130/80mm Hg
Blood Pressure Control/RAAS
Highest risk category for development of cardiovascular disease (CVD)
CVD as cause of death before end-stage renal disease (ESRD) and dialysis
Statins
Improving Cardiovascular Health
Target HbA1C ~7.0%Hypoglycemia risk
Medication and lifestyle modification
Glycemic Control
Metabolic Bone DiseaseParathyroid hormone (PTH)CalciumPhosphorus
PotassiumMetabolic acidosisAnemia
Overview of Additional Complications
Smoking cessationPhysical activity
Weight managementFunctional capacity
Non-pharmacological Interventions
AllopurinolAvosentanMesenchymal stem cells
New Medication and Treatment
GFR <10ml/min/1.73m2
Symptoms:Electrolyte abnormalitiesAcid-base disturbanceUncontrolled BP and fluid balanceUremiaCognitive impairmentDecline in nutritional status
Dialysis
Renal Replacement Therapy
Treatment of choiceEarlier decision:
GFR <20ml/min/1.73m2
Irreversible progression for 6-12 months
Impact:Reduction of dietary restrictionsDelays or eliminates need for
dialysisMedications to prevent rejection =
↓immunity
Renal Transplant
Pressure Ulcers
Functions:Conduct sensory data to the brain via nerve
endings located in the skinProtect the bodyRegulate body temperatureSynthesize vitamin DStore energy and water
Anatomy & Physiology of the Integumentary System
Etiology & Pathology
Injury to the skin and/or underlying tissue as a result of pressure, friction, shear, or ischemiaRisk factors:ImmobilityPoor perfusion of blood supplyMoistureAnemiaAgeNutrition status
Development of Pressure Ulcers
10-18%
Inflammasomes in kertinocytesActivation of inflammatory cytokines
Danger signals and wound healing
Youth vs. Aging
Inflammasome Activity
Stage Description
ISkin intact but with non-blanchable redness for >1 hour after relief of pressure
IIBlister or other break in the dermis with partial thickness loss of dermis
III
Full thickness tissue loss. Subcutaneous fat may be visible, destruction extends into muscle; undermining or tunneling may occur
IV
Full thickness skin loss with involvement of bone, tendon, or joint; often includes undermining and tunneling
UnstageableFull thickness tissue loss in which base of ulcer is covered by slough and/or eschar in the wound bed
Suspected Deep Tissue
Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying tissue from pressure and/or shear
Stages of Pressure Ulcers
A: Stage IB: Stage IIC: Stage IIID: Stage IV
Stages of Pressure Ulcers
Medical Management
Risk assessment (Braden Scale score)Proper positioning and rotationSupport surfacesPain managementInfection managementWound cleansingDebridementDressingsBiophysical agents
Prevention & Care
Medical Nutrition Therapy(MNT)
AssessmentDiagnosisInterventionMonitoringEvaluation
Nutrition Care Process
MultidisciplinaryAnthropometricsMedical and social historiesMedicationsAnalysis of laboratory values
Assessment
Diet and diet historyNutrition statusComorbid conditionsLab values of BUN, potassium,
phosphorus, albumin, urinalysisAssess for education needs
Nutrition Assessment for CKD
Nutrient Dietary Recommendation
Energy 23-35kcal/kg/dayProtein (without
DN)0.6-0.8g/kg body weight
Protein (presence of DN)
0.8-0.9g/kg body weight
Sodium <2.4g/day
Potassium(stages 3-4)
<2.4g/day
Phosphorus 800-1000mg/day
Calcium(stages 3-4)
2g/day
Vitamin DSupplementation if 25-hydroxyvitamin D
<30ng/ml
IronSupplementation if:
Serum ferritin <100ng/ml andTransferrin saturation <20%
Fluid Varies with medical status
Nutrition Prescription for CKD
MNT for Hypertension and DiabetesDiabetes: glycemic control through consistent-carbohydrate diabetes meal planning
Hypertension:
Dietary protein restriction did not significantly slow progression
Dietary restrictions and nutrition status
BP control was more effective in reducing proteinuria than modifications in dietary protein intake
The Role of Dietary Protein
Comprehension of and adherence to dietary recommendations
Maintenance of ideal body weightBlood glucose controlBlood pressure controlNormalization/improvement of
nutrition-related laboratory values
Monitoring & Evaluation
Dietary intake as related to needsStaging of pressure ulcer and changes
in stage/healingUsefulness of laboratory valuesUnintentional weight changesMobility assessmentAssess for education needsAdditional risk factors/comorbid
conditions
Nutrition Assessment for Pressure Ulcers
Based on limited, small studies and expert opinion:
Nutrition Prescription for Pressure Ulcers
Nutrient Recommendation
Energy30-35kcal/kg IBW (up to 40kcal/kg for repletion)
Protein 1.25-2g/kg
ZincIf deficiency is suspected,
220mg ZnSO4 bid for <3 weeks
Arginine/Glutamine
Inconclusive support, but may be supplemented if not
contraindicated
Fluid30-35mL/kg, minimum 1500mL
unless contraindicated
Necessity of protein in tissue-building
Ability of body to utilize protein in wound-healing
Nitrogen loss in wound exudateAttaining a positive nitrogen balanceProtein as energy in catabolism
The Role of Dietary Protein
Achievement of ideal body weight/weight maintenance
BMIEvidence of wound healingAdequate nutrient intakeAdequate hydrationComprehension/knowledge of
nutrition recommendations
Monitoring & Evaluation
The Patient
88 year old Caucasian femaleAdmitted for altered mental status and
dehydrationPMH: CKD stage 3-4, HTN, diverticular
disease, dementiaBraden Scale score: 9 (high risk)Upper and lower coccyx stage III pressure
ulcersPoor oral intake and deteriorating mobility
x 3 months
Patient Summary
170# (140% IBW 99-121# upper end of range)Unable to obtain weight history
Height: 5’2”BMI 31.2kg/m2 Stage I obesityDysphagia evaluation: severe oropharyngeal
dysphagia with purees and thickened liquids; high risk for airway obstructionRecommendation: NPO, aggressive oral
care for secretions
Patient Summary
Basic/Comprehensive Metabolic Panel and GFR Normal 1/13/14 1/8/14
Sodium 135-150mEq/L 140 155H
Potassium
3.5-5.3mEq/L 2.7LL 4.8
Chloride 96-107mEq/L 109H 112H
BUN 9-20mg/dL 50H 114HH
Creatinine
0.5-1.3mg/dL 1.4H 3.1H
Glucose 70-110mg/dL 100 85
Calcium 8.5-10.5mg/dL 8.5 9.3
Albumin 3.5-5g/dL 2.1L 2.9L
eGFR >60ml/min/m2 38L 15L
Laboratory Values
Diagnosis: sepsis of urinary source, acute on chronic renal failure secondary to dehydration, likely aspiration pneumonia
Patient confused and lethargic+bowel sounds, no edemaChest x-ray: bibasilar infiltrates, left
pleural effusion+Urine culture: E.coli+Blood culture: S.capitus
Medical Management
IV fluids for rehydration (D5 ½ NS @100ml/hr)
IV fluids modified for potassium repletion:KCl20mEq/L, D5 ½ NS @50ml/hr
IV antibiotics Zosyn and Vancomycin
Dressing changes for pressure ulcers
Medical Management
Feeding withheld until rehydration and electrolyte balance achieved
Poor venous accessOral secretions, congestion, high
aspiration risk – no nasogastric tube inserted for feeding or medication administration
Care for pressure ulcer poorly documented
Medical Management
High nutritional riskEnergy needs: 30-35kcal/kg adjusted
body weight (BW) = 1800-2100kcal/dayProtein needs: until ARF resolved:
0.8g/kg adjusted BW = 48g/day protein (Once ARF resolved, increase protein to 1.4-1.5g/kg adjusted BW = 85-97g/day protein)
Fluid needs: 1ml/kcal = 1800-2100ml/day
Nutrition Assessment
Inadequate protein-energy intake related to SLP recommendation, poor venous access, no NGT insertion as evidenced by NPO status, no PN/EN support order.
Nutrition Diagnosis
1. Patient will meet >75% energy needs via appropriate route within 3 days.
2. Patient will receive restricted dietary protein until ARF resolved (protein to be increased to promote wound healing once ARF resolved)
Nutrition Goals
1. If patient to remain NPO >3 days, recommend TF via NGT with Suplena goal rate at 42ml/hr continuous; provides 1008ml total volume, 1814kcal, 743ml free H2O, 45g protein. Initiate feed at 20ml/hr increase 10ml/hr q4H to goal.
2. Free H2O autoflush 30ml/hr (total free H2O 1463ml); adjust IVF prn, additional fluids per MD
3. Will follow for updated TF recommendations once ARF resolved
4. Maintain head of bed at least 30-45 degrees during feed, monitor GI signs and symptoms for intolerance and hold feeds if intolerance or residuals >250ml.
Nutrition Interventions
Initiation of TFAdvancement of TF to goal rateTolerance of TFNutrition-related labsWound/skin status
Nutrition Monitoring & Evaluation
Patient received no nutrition support during hospital stay (7 days); patient was made DNR/DNI on last day of admission and discharged into hospice care
Pressure ulcer protocol was poorly documented
Plan of care was poorly communicatedNo attempts were made to place NGT
COMMUNICATION!
Critical Comments
Evidence supporting dietary protein restriction for CKD is stronger than evidence supporting the role of increased dietary protein in wound healing of pressure ulcers
Antihypertensive therapy is more impactful than dietary protein on proteinuria
Non-dietary factors are of greater importance in prevention and treatment of pressure ulcers
Conclusions
Level of dietary protein necessary to preserve lean body mass (positive nitrogen balance)
Temporary increase in dietary protein for wound healing and progression of CKD
Dietary protein increases in a patient with a pressure ulcer and the impact on level of proteinuria
Additional long term study on impact of dietary protein restriction in patients with proteinuria
Additional studies with larger sample size to examine role of dietary protein in wound healing
Future Study
Increased overall energy intake of 30-35kcal/kg
Dietary protein restriction of 0.6-0.8g/kg as a lifestyle
Transient increase of protein to 1.25-2g/kg for up to 8 weeks in presence of a pressure ulcer while monitoring renal function
Liberalization of diet as necessary to achieve recommended energy intake
Consideration of patient’s wishes
Recommendations
References available upon request.