Lecture 9 Flashcards
(54 cards)
1
Q
How many Canadians have kidney disease?
A
10%
2
Q
What its the leading cause of kidney disease?
A
Diabetes 38%
3
Q
How much blood is filtered a day and how much filtrate is produced?
A
1600l/day filtered
180l/day of ultra filtrate
4
Q
What is the functional unit of a kidney?
A
Nephrons
5
Q
What are the main functions of a kidney?
A
• Maintenance of homeostasis through control of fluid, pH, electrolyte balance, and blood pressure
• Excretion of metabolic end products and foreign substances
- Elimination of drugs/toxins
• Production of enzymes and hormones
-Production of active form of Vit D
-Erythropoietin (EPO)
– Stimulates bone marrow to produce RBCs
6
Q
What are the markers for renal function ?
A
- Urinalysis
- Microalbuminuria
- Often one of the first signs of renal insufficiency
- Glomerular Filtration Rate (GFR)
- Standard marker to show how much kidney function one has
- Normal GFR is greater than 90 mL/min/1.73m2 BSA
• Blood urea nitrogen (BUN)
• Measures the amount of urea nitrogen, a protein waste product, in the
blood; increases with decreased kidney function
- Creatinine (Crt) and Crt Clearance
- Compares creatinine in the blood to that in the urine to determine the amount of blood plasma cleared of creatinine; serum Crt increases with decreased kidney function
7
Q
What happens as GFR decreases?
A
Serum Crt and BUN increase
8
Q
What are the S&S of advanced kidney impairment?
A
- Hypertension
- Edema
- Metabolic acidosis
- Uremia: symptoms resulting from disordered biochemical process of chronic kidney disease progresses
- Hyperkalemia
- Microcytic anemia and iron deficiency
- Azotemia: build up of nitrogenous waste products in the blood
- Secondary hyperparathyroidism: ↑ PTH that stimulate bone turnover
- Renal osteodystrophy: bone disease r/t CKD d/t over- or under of PH
9
Q
What are the S&S of Uremia?
A
BUN and Crt ↑ significantly v• Extreme fatigue • Weakness • Nausea and vomiting • Muscle cramps • Pruritis (itching) • Metallic taste (mouth) • Neurologic impairment • Anorexia • Weight loss • Increased thirst
- start to see these when GFR is decreasing
10
Q
What is CKD?
A
Chronic Kidney Disease
Progressive decline in kidneys’ ability to excrete waste products, maintain fluid & electrolyte balance, and produce hormones
• Irreversible
11
Q
What are the causes and risk factors for CKD?
A
- Age
- Ethnicity: People of Indigenous, Asian, South Asian, Pacific Island, African/Caribbean and Hispanic decent
- Family history
- Diabetes: 35% dialysis starts
- Hypertension
- Glomerulonephritis
- Polycystic kidney disease
- Overuse of OTC pain medications
12
Q
What are the treatment options for end-stage CKD?
A
Dialysis
• Removal of excessive and toxic by-products of metabolism from the blood
- Dialysates
- Fluid used by the dialysis procedure to remove metabolic by- products, wastes and toxins
• Major types of renal replacement therapy
- Hemodialysis (HD) and peritoneal dialysis (PD)
13
Q
How does dialysis clean the blood?
A
Achieved through diffusion, ultrafiltration, and osmosis
14
Q
What is the most common treatment for end stage CKD?
A
Hemodialysis (most common)
Peritoneal dialysis
Kidney transplant
15
Q
What condition is common in patients on dialysis?
A
Malnutrition :Protein energy wasting
16
Q
What are the factors leading to protein energy wasting in CKD?
A
Inadequate food intake due to physiological and psychological factors
Inadequate food intake due to social barriers
Systemic inflammation (persistent uremic inflammation)
Increased energy expenditure and protein loss
Endocrine disorders associated with uremia
Loss of blood
Metabolic acidosis
17
Q
What are examples of Inadequate food intake due to physiological and psychological factors?
A
- Nausea and vomiting
- Diabetic retinopathy resulting in impaired vision • Taste alterations
- Fatigue
- Anorexia caused by uremia
- Emotional distress
- Unpalatable diet
- Concurrent medications resulting in anorexia
18
Q
What are examples of Inadequate food intake due to social barriers?
A
- Limited income
- Inability to prepare foods and meals
- Living and eating alone
- Depression
- Lack of motivation
- Lack of family support
- Missed meals due to travel and/or treatments
19
Q
What are examples of Systemic inflammation (persistent uremic inflammation)?
A
- Dialysis
- Fluid status/volume overload
- G l bacterial overgrowth
- Failed kidney transplant
20
Q
What are examples of Increased energy expenditure and protein loss?
A
Protein catabolism
• Inflammation
• Dialysis
21
Q
What are examples of endocrine disorders associated with uraemia?
A
- Hyperparathyroidism
- Hyperglucagonemia
- Resistance to the actions of insulin and I G F-1
22
Q
What are examples of loss of blood?
A
- Gl bleeding: peptic ulcer disease, gastritis and abnormal GI vessels
- Frequent blood sampling
- Blood lost in the dialyzer and tubing
23
Q
What can metabolic acidosis result in?
A
Increase protein catabolism
24
Q
What should the nutrition intervention look like with CKD from stages 1-4?
A
- Focus on comorbid conditions: diabetes, hypertension, and hyperlipidemia
- Delay the progression of CVD
- Normalize blood lipids
- Low-protein diet
- Sodium <2000mg/d
- Adequate k/cal to prevent malnutrition; adequate protein to maintain muscle mass and serum protein
- Treat abnormal vitamin and mineral status
25
What should the nutrition intervention look like with CKD from stages 5?
• HD diet
- High in protein; controls for intake of potassium, phosphorus, fluids, and sodium
• PD diet
- More liberalized; higher in protein, sodium, potassium, and fluid
- Restrictions for phosphorus are the same as HD
• Nutrients to monitor
- Protein, kcal, sodium, potassium, phosphorus, calcium, fluids, vitamin/minerals, and fibre
• Protein
- Patients on HD require 1.2 g/k g, at least 50% high biological value (HBV)
• Energy
- Requirements estimated as 30–35 k cal/k g/day
26
What should we know about Phosphorus and stage 5 CKD?
* Hyperphosphatemia becomes evident with GFR 20–30 mL/min
* Dietary phosphorus restriction of 800–1000 mg/day
* Most patients use phosphate binders
27
What are tips to control fluid intake and thirst?
```
• Avoid salty foods
• Swallow pills with soft food
• Use small cup / glass
• Sip fluid slowly
• Brush teeth often
• Rinse mouth without swallowing
• Try using ice
• Freeze some juice / pop in cubes
• Eat frozen fruits
• Moisten mouth with:
• Add lemon juice or sour taste to help quench thirst
25
```
28
When on a Phosphorus restricted diet, what is it found in?
Phosphorus is found naturally in meats, dairy products, chocolate, whole grains, nuts/seeds, egg yolk, fish, poultry, and legumes
29
What are the meats and alternatives and grain products to avoid and?
* Deli meats/processed meats
* Legumes
* Nuts/Seeds
* Processed whole grains (breads and cereals)
30
If you are on a P restricted diet, what can you take along side it?
• CaCO3, TUMsTM, RenagelTM, FosrenolTM act as a magnet to bind phosphorus in the
gut which is then excreted through the GI tract
• Taken with meals & phosphorus containing snacks to prevent dietary phosphorus absorption
31
What % absorption is natural and additive phosphorus?
```
Natural:
-40-60% is absorbed Foods:
• Whole grain bread
• Brown rice
• Meat (chicken, beef,
pork, salmon)
• Milk/dairy products
• Soy beverages
```
```
10-30% absorption:
• Nuts/seeds, peanut
butter
• Chocolate
• Legumes/lentils
```
80-100% is absorbed
• Phosphorus is added to
many processed foods Foods
32
What contains the most about of Phosphorus?
Dairy products
33
When someone is stage 5 CKD, what should their K intake be like?
For patients on HD
• 2–3 g/day
• Target range 3.5–6.0 m mmol/L
• M N T should note that some causes of hyperkalemia may be
unrelated to diet
• Nutrition education on limiting high potassium foods
For patients on PD
• Most will not need a restriction
• Some may require oral potassium supplementation
34
If you need to restrict K, what do you need to avoid?
* Sources: fruits/vegetables, nuts, beans, chocolate, dairy
* Restriction prevents cardiac arrhythmias
* Restriction individualized to ~2000 mg/day
35
What are foods with high K and low K?
• High potassium (> 200 mg/serving): banana, avocado, orange/orange
juice, potato, squash
• Low potassium: apple, pineapple, berries, lettuce, string beans
36
What are the different kind of vitamin and mineral supplementation in stages 5 CKD?
Vitamin supplementation
• Water-soluble vitamins are generally supplemented
• Specialized supplements available with thiamin, riboflavin, folic acid, pyridoxine, vitamin B12, niacin, biotin, pantothenic acid, and vitamin C
• Active form of vitamin D required (e.g. calcitriol)
Mineral supplementation
• Magnesium is not generally supplemented
• Iron and zinc are often supplemented
• IV Fe preferred; can use Fe supplement (eg. Palafer)
37
What are the complications of dialysis?
```
Long term complications
• Anemia
- Inability of kidney to produce erythropoietin (EPO)
-- Recombinant human erythropoietin (rHuEPO)
-- Monitor iron status using serum ferritin
• Coagulopathy
• Dyslipidemia
• Cardiovascular disease
• Malnutrition
• Weight gain (PD) or weight loss (HD)
• Constipation
• Renal osteodystrophy
```
38
What does monitoring and evaluation of CKD look like?
```
Clinical outcomes include assessment of:
• Biochemical outcomes
• Hematological measures
• Anthropometrics
• Clinical signs and symptoms
```
```
Other considerations should include:
• Maintenance of nutritional status
• Functional status
• Appetite
• Blood pressure control
• Maintenance of appropriate body composition
```
39
What is the medical nutrition therapy post kidney transplant?
• Energy
- 30-35kcal/kg for 4-6 weeks
• Protein
- 1.3-2 g/kg/d for 4-6 weeks
- After 6 weeks 1 g/kg/d
• Sodium: 1500-2000 mg/d
• Potassium: variable
No fluid or phosphorus restrictions
40
What is nephrolithiasis?
• Nephrolithiasis or kidney stones are the result of a crystal formation in the urine
41
How are kidney stones formed?
abnormal crystallization of calcium, oxalate, uric acid, struvite, cysteine, or hydroxyapatite, which are not usually excreted in urine
42
What is the pathophysiology of Nephrolithiasis?
imbalance between solubility and precipitation of mineral salts within urine, resulting in “supersaturation”
43
What are the risk factors for Nephrolithiasis?
* Family history;
* Most common in Caucasians; 20-30 y.o.
* Low urine output**
* Other possible causes: gout, excess Vit D intake, UTIs, urinary tract blockages
44
What are the S&S of Nephrolithiasis?
typically no symptoms until stone moved into ureter
-Blockage of urine flow; pain, pain when urinating & urgency to
urinate; hematuria; N/V
45
How do you diagnose Nephrolithiasis?
Diagnosed with intravenous pyelogram, x-ray, and renal ultrasound; analysis of urine & serum for levels of renal stone compounds (calcium, oxalate, sodium, citrate, magnesium, phosphate, uric acid, urine volume, and pH)
46
How do you treat Nephrolithiasis?
Treatment depends on whether stone can be passed; if not:
- Extracorporeal shock wave lithotripsy (ESWL) (most common)
- Percutaneous nephrolithotomy
- Ureterorenoscopy and extraction
47
What is the nutrition therapy for Nephrolithiasis?
↓ factors associated with stone formation; and prevention of reoccurrence
↑ fluid intake
-Most effective preventative treatment
Salt
-No added salt diet
Calcium
-Adequate calcium intake 1000 to 1200 mg/day
Oxalate
-Oxalate intake restricted to 150-440 umol/day
Urine pH
-Acidic urine ↑ risk of uric acid, oxalate and cysteine stones which is associated
with high intakes of animal proteins and low intakes of vegetables and fruits
48
What its AKI?
Acute Kidney Injury
• Abrupt cessation or decline in GFR; usually reversible
• Failure to maintain fluid, electrolyte and acid-base balance
• Usually resolves
49
How do you diagnose AKI?
* Serum creatinineby > 26 μmol/L in 48 hrs
* Serum creatinineby > 1.5-fold from reference value occurring within the past week
* Urine output < 0.5 mL/kg/hr for >6 consecutive hrs
50
What is the Etiology of AKI?
* Dehydration (severe)
* Fluid losses from GI tract or wounds (ex: burns)
* Exposure to toxins
* Systemic inflammatory conditions (ex: sepsis)
51
How do you treat AKI?
Treat the underlying cause, use continuous renal replacement therapy
52
What is the overall nutrition therapy for AKI?
* Nutrition status can decline in short period of time due to ↑nitrogen losses
* Nutrition requirements are influenced by type of renal replacement, nutritional and metabolic status, and degree of hypercatabolism
* Due to altered metabolism that promotes protein degradation, it may be difficult to improve or maintain nutrition status, even with EN or PN
53
What is the specific nutrition therapy for AKI?
Energy: 30-35 kcal/kg IBW
Protein: restriction of protein is not recommended
Electrolytes: depend on degree of renal function. Monitor serum and urine levels.
Vitamins/Minerals: supplementation if appropriate; monitor serum and urine levels.
Fluid: depends on renal function, fluid status
54
When you do more dialysis what are you able to do more of?
The less dietary restrictions you'll have
| -otherwise you need to be careful of diet and fluid intake
