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Midterm 2 quick Flashcards

1
Q

Name the indications for bariatric surgery (5)

A

 BMI ≥ 40
OR
 BMI > 35 with significant obesity-related comorbidities (e.g. MetS, OSA, Osteoarthritis, HTN, …)
 Acceptable operative risk (risk of surgery < risk of not undergoing surgery)
 Failure of non-surgical weight loss attempts
 Well-informed, compliant, and motivated patient (need to understand lifestyle habits still have to change despite the surgery being done)

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2
Q

Name the contraindications to bariatric surgery (6)

A
  • Active pregnancy
  • Cirrhosis
  • Active substance abuse
  • Uncontrolled psychiatric illness
  • Pulmonary hypertension
  • Severe cardiac and respiratory disease
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3
Q

Name 2 possible problematics of adjustable gastric bands (AGBs)

A

Can lead to band erosion and damage the tissue of the stomach.
Band can also leak which requires more surgeries to fix.

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4
Q

Name the 3 mechanisms of weight loss in bariatric surgeries.

A
  1. Gastric restriction (reduced PO intake)
  2. Malabsorption (length of common limb)
  3. Gut hormones
    a) decreased Ghrelin (parietal cells of stomach)
    b) Increased leptin
    c) PYY involved in DM resolvement
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5
Q

Name 5 possible EARLY (< 30 days) complications of bariatric surgeries.

A
  • Anastomotic leak
  • stricture
  • Obstruction
  • Bleeding
  • Infection
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6
Q

Name possible LATE (> 30 days) complications of bariatric surgeries.

A

Ulcer, stricture, obstruction, hernia, nutrition deficiencies, dumping syndrome, weight regain or weight loss failure, psychological complications, malnutrition, gastric reflux

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7
Q

Bariatric surgeries: Nutrition guidelines preop?

A

Very low-calorie diet (VLCD) 2 weeks prior to surgery (can be more depending on the BMI and where the patient carries the weight)
o 800-900 calories
o Low Carb (< 100g/d), high protein, moderate fat
o Shakes, milk products etc.
o Induces ketosis

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8
Q

Bariatric surgeries: Nutrition guidelines postop?

A

Texture progression and portion progression

Texture progression: Clear fluids (1-3 days) –> full fluids/puree (5 weeks) –> solids
Otherwise, vomiting ++

Portion progression: After surgery, stomach is swollen and inflamed. 1/2 cup –> 1 cup later
To reduce vomiting

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9
Q

Name 4 reasons why nutritional deficiencies are common in bariatric surgeries.

A

Reduced dietary intake

Removal of fundus (fewer parietal cells)
=Reduced gastric acidity (hydrochloric acid helps in the digestion of protein, calcium and iron) and Reduced intrinsic factor (IF)

Bypassed intestines (malabsorption)

Tolerance issues (more vomiting, more dysphagia (temporary)…) Beef and eggs usually difficult after surgery

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10
Q

What are the 5 nutrients to watch for deficiencies in RYGB?

A 
Calcium (Less acid + absorbed in duodenum)
Iron (less acid + absorbed un duodenum)
VD 
Folate 
Vitamin B12 (IF in stomach)
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11
Q

What are the 8 nutrients to watch for deficiencies in BPD-DS?

A 
Calcium
Iron
ADEK (usually absorbed in the jejunum and beginning of ileum which are bypassed)
Folate
B12
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12
Q

Name the thiamin supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

12 mg/d for each.

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13
Q

Name the B12 supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

Same for all:
Oral: 350-500 mcg/d
IM: 1000 mcg/mo

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14
Q

Name the Folate supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

Same for all:
400-800 mcg/d
Women of childbearing age: 800-1000 mcg/d

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15
Q

Name the VD supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

300 IU/d for all until 25OHD WNL

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16
Q

Name the VA supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

sleeve gastrectomy: Standard MVI
RYGB: Standard MVI
BPD-DS: 10,000 IU/d

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17
Q

Name the VE supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

sleeve gastrectomy: Standard MVI
RYGB: Standard MVI
BPD-DS: standard MVI

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18
Q

Name the VK supplement recommendations for sleeve gastrectomy, RYGB and BD-DS.

A

sleeve gastrectomy: Standard MVI
RYGB: Standard MVI
BPD-DS: 300 mcg/d

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19
Q

Name the Iron supplement recommendations for sleeve gastrectomy, RYGB and BPD-DS.

A

Same for all:
18 mg/d from MVI
Menstruating: 45-60 mg elemental total

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20
Q

Name the Calcium supplement recommendations for sleeve gastrectomy, RYGB and BPD-DS.

A

Sleeve gastrectomy: 1200-1500 mg/d
RYGB: 1200-1500 mg/d
BPD-DS: 1800-2400 mg/d

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21
Q

Name the zinc supplement recommendations for sleeve gastrectomy, RYGB and BPD-DS.

A

Sleeve gastrectomy: 11 mg men, 8mg women
RYGB: 11-22 mg men; 8-16 mg women
BPD-DS: 122 mg men; 16 mg women

60 mg BID if hair loss

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22
Q

Name the copper supplement recommendations for sleeve gastrectomy, RYGB and BPD-DS.

A

Sleeve gastrectomy: 1 mg/d
RYGB: 2 mg/d
BPD-DS: 2 mg/d

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23
Q

When is LBM loss post op bariatric sx?

A

3 months post op

May lead to decreased RMR and reduced muscle strength and physical function –> risk of weight regain

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24
Q

What are the protein recommendations for AGB, VGS, RYGB and BPD-DS?

A
  1. 0-1.5 g/kg IBW for 3 first

1. 5-2.0 g/kg IBW for BPD-DS

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25
WHat are the 4 main tolerance issues post bariatric surgery?
``` Dehydration Constipation (reduced PO and fiber intake) Diarrhea (lactose intolerance, dumping syndrome, sugar alcohols...) Food intolerances (dysgeusia, regurgitation and esophageal dysphagia) ```
26
What are the symptoms of the early phase of dumping syndrome?
1-30 min after meal; D/t rapid transit of hyperosmotic food into the jejunum (usually simple sugars) Symptoms: dizziness, nausea, weakness, rapid pulse, diarrhea
27
What to do to avoid dumping syndrome?
- Healthy snacking - Advise glucometer - Avoidance of trigger foods (limit simple CHO) - Label reading (≤ 25g absorbable carb)
28
Name 5 causes for weight regain post-op
Dietary habits o Increased calories: sugar and fat o Grazing: emotional eating o Not delaying fluids (drinking and eating at the same time) • Poorly controlled thyroid • New medications (weight promoting, antidepressants) • Stopped exercising • Surgical reasons? (only in 10% of cases; unlikely…)
29
What can influence serum creatinine levels? (7)
``` Diet Muscle breakdown Lab calibration bias Extra-renal elimination (gut bacteria) Age Antibiotics (inhibit secretion) ```
30
What can a high calcium x phosphorus product result in?
metastatic calcification in soft tissue areas: • Conjunctivae of the eye • Heart, especially aortic valve and blood vessels • Lungs • Extremities
31
Which Vitamin supplementations are needed in kidney disease?
Water-soluble vitamins
32
What needs to be avoided to avoid XS Mg intake?
laxatives, enemas or phosphate binders containing magnesium | Water is also a potential source of excess Mg
33
What are the risk factors for CKD?
* Diabetes * Hypertension * Autoimmune diseases (e.g. lupus) * Systemic infections * Urinary tract infections * Urinary stones or lower urinary tract obstruction * Neoplasia * Family history of chronic kidney disease * History of acute kidney injury * Reduction in kidney mass * Exposure to certain drugs * Low birth weight * Age older than 60 years * Exposure to certain chemical and environmental conditions * Low income/education * Ethnicity (African Americans, Hispanic Americans, Asians, Pacific Islanders, and American Indians are at higher risk for CKD.)
34
What are some of the causes of CKD?
Diabetes, HTN, other renal disease (chronic glomerulonephritis, polycystic kidney disease, interstitial nephritis, obstructive nephropathy)
35
What are the signs and symptoms of CKD?
Increasing fatigue, N/V, anorexia, insomnia, uremic syndrome (Weight loss, weakness, vomiting, loss of appetite, fatigue, nausea, SOB, leg cramps, itching, chest pain, easy bruising, swelling of ankles and legs, bad taste in the mouth, restless legs, forgetfulness, difficulty sleeping, cold intolerance, skin color changes, decreased sexual desire)
36
What are the 4 phases of CKD?
1. Decreased renal reserve (no accumulation of end products of protein metabolism) 2. Chronic renal insufficiency (waste products begin to accumulate; mild, mod or severe) 3. Frank renal failure (sCr and BUN rise steadily due to drop in GFR) 4. ESRD (--> uremia; < 15% of normal function (DM) or < 10% w/o DM)
37
Name 4 complications of CKD
* Uremic syndrome (high urea and creatinine) * Anemia (decreased erythropoietin) * Fluid imbalances (Na imbalance, edema) * Electrolyte imbalances (high K, acidity, PO4)
38
What are the 2 main goals of a nutrition intervention for CKD predialysis stage?
 Delay the progression of CKD while providing adequate calories to maintain or achieve ideal body weight  Preventing or alleviating the symptoms of uremia and restoring biochemical balance
39
What are the potential explanations for transient albuminuria?
Recent major exercise, UTI, febrile illness, decompensated CHF, menstruation, acute severe elevation in BG, acute severe elevation in BP
40
What are the 3 things important to reduce the progression of diabetic nephropathy?
Optimal glycemic control Optimal BP control ACEi or ARB maybe SGLT2i
41
Name 3 potential secondary causes for anemia in CKD
Residual blood in the dialyzer Inflammation due to infection and co-morbid conditions Hyperparathyroidism
42
What are the possible causes of AKI?
* Sepsis * Critical illness * Circulatory shock * Burns * Trauma * Cardiac surgery * Major noncardiac surgery * Nephrotic drugs * Radiocontrast agents * Poisonous plants and animals
43
Who is more susceptible to AKI?
* Dehydration or volume depletion * Advanced age * Female gender * Black race * CKD * Chronic diseases (heart, lung, liver) * Diabetes mellitus * Cancer * Anemia
44
What are 8 signs and symptoms of AKI?
* Too little urine leaving the body * Swelling in legs, ankles, and around the eyes * Shortness of breath * Confusion * Seizures or coma in severe cases * Chest pain or pressure ``` Fluid retention/overload (urination is reduced) - Swelling in the hands, face, or feet - SOB (worse during activity or when lying down) - Tachycardia and enlarged neck veins Metabolic acidosis - Nausea, vomiting, and loss of appetite - Muscle fatigue - Rapid breathing - Headache - Confusion or lethargy Electrolyte abnormalities (K, Mg, Na) - Muscle cramps - Irregular heartbeat - Neurological problems, (tingling, paralysis, confusion) Anemia - Paleness - Shortness of breath - Fatigue - Irregular heartbeat Symptoms of uremia may develop later as nitrogenous products accumulate ```
45
What happens in the oliguric phase of AKI?
Urine output < 500 mL/d Increased: BUN, Cr, K, P, Mg Decreased: Na, CO2, Ca, Hct, Hgb 8-14 days
46
Name complications of AKI.
* Hematuria * Reduced urine output * Dehydration (may lead to excess thirst, dizziness, weak rapid pulse) * Uremia (may affect the digestive system, brain, heart, lungs, and other parts of the body.) * Side or lower back pain * Hyperkalemia * Hyperphosphatemia * Glucose intolerance * Fluid overload, acidosis, azotemia
47
What are the 3 main goals of nutritional interventions on AKI?
- Minimize uremia and maintain the chemical composition of the body as close as possible to normal - Preserve body protein stores until renal function returns - Maintain fluid, electrolyte, and acid-base homeostasis
48
What are the 2 leading causes of CKD?
Diabetes and renal vascular diseases (incl. HTN)
49
What does the Peritoneal Equilibration Test (PET) measure?
used to assess permeability of the peritoneal membrane (give us % dextrose absorption)
50
What is the sodium requirement for HD? for PD?
HD: 2000 mg/d PD: 2000-3000 mg/d
51
What is the potassium requirement for HD? for PD?
HD: 2340 mg/d PD: 3000-4000 mg/d
52
How much protein is lost in HD? PD?
HD: 10-12 g/treatment PD: 6-9 g/d
53
What are the symptoms of starfruit toxicity in people with CKD?
``` o Persistent hiccups o Vomiting o Muscle weakness o Slight or partial paralysis o Muscle weakness o Slight or partial paralysis o Muscle twitching o Insomnia o Mental confusion o Convulsion o Coma and death ```
54
What factors related to uremia can contribute ti PEW in dialysis patients? Factors related to peritoneal dialysis?
Uremia: Inflammation, inadequate dialysis, anorexia, inadequate nutrient intake, hypercatabolism, Hypercatabolism, chronic acidosis, comorbid conditions PD: Loss of nutrients into dialysate, loss of residual renal function, appetite loss d/t glucose absorption from dialysate, abdominal discomfort d/t dialysate, peritonitis, bioincompatible solution
55
Name the pros and cons of meals during dialysis
``` • PROS Counteracts HD related catabolism Improved nutritional status (Increased protein synthesis, Increased albumin) • CONS Patient related risk (Risk of aspiration, Hypotension) Patient and unit hygiene Infection control Inconvenience to staff ```
56
Why do people on PD get + constipated?
Translocation of bacteria (peritonitis) + the catheter in the peritoneal cavity can get compressed, move (d/t constipation) and that will affect dialysis PD patients are always on stool softeners or laxatives
57
Which laxatives are contraindicated for dialysis patients?
o Milk of magnesia o Magnolax o Citro-Mag o Fleet Phospho-Soda
58
Which 2 stool softeners are used for mild constipation in patients with ESDR?
Docusate sodium and docusate calcium
59
What can lead to malnutrition in renal failure?
Decreased intake (d/t appetite loss, uremia, altered taste...) Increased BMR (if superimposed illnesses) Dialysis (removal of nutrients + dialysis-associated catabolism) Inflammation (due to underlying illness) Endocrine disorders (uremia alters insulin, IGF-1, glucagon and PTH activity) No elimination of metabolites (toxins) ``` Inadequate food intake, systemic inflammation (volume overload, dialysis) Increased E expenditure and protein loss ENdocrine disorders (uremia) Blood loss Metabolic acidosis ```
60
What are the protein needs of patients in the post-transplant acute phase? Chronic phase?
Acute: 1.3-2.0 g/kg Chronic: 0.8-1.0 g/kg
61
What are the Energy needs of patients in the post-transplant acute phase? Chronic phase?
Acute: 30-35 kcal/kg Chronic: Maintain desirable weight
62
What are the potassium needs of patients in the post-transplant acute phase? Chronic phase?
Acute: 2000-4000 mg/d if hyperkalemia Chronic: no restriction unless hyperK.
63
What are the sodium needs of patients in the post-transplant acute phase? Chronic phase?
2000-4000 mg/d for both
64
What are the calcium needs of patients in the post-transplant acute phase? Chronic phase?
1200-1500 mg/d for both
65
What are the possible causes of nephrotic syndrome?
Diabetes Primary glomerular disease Many others... Can also be unknown.
66
Symptoms/complications of nephrotic syndrome
* Proteinuria * Hypoalbuminemia (< 20 g/L, despite increased synthesis) * Edema (particularly around eyes, ankles, feet) and weight gain (d/t water retention) * Sodium retention * Hyperlipidemia * Blood clots in veins and lungs * Peritonitis * Urinary tract infection * Low levels of iron * Hypocalcemia (due to hypoproteinemia and other causes) * SOB * Others: Fatigue, loss of appetite
67
Treatments of nephrotic syndrome?
``` • Diuretics (reduces BP; excretes extra water) • ACE inhibitors • Steroids • Vaccines (flu shot, pneumococcal) • Statins/sequestrants • Coumadin/heparin • Early antibiotic intervention • Diet 3 main ones: BP med, statins, diet ```
68
Explain both occurances of hyperlipidemia in renal diseases.
PD: Often high TG, N LDL and low HDL Nephrotic syndrome: Often high TG, LDL and normal HDL (because of the increased lipid synthesis and decreased metabolism, loss of protein = FFA accumulation = inhibition of LPL = increased VLDL
69
Risk factors for kidney stones?
Male sex, caucasian, FHx, low urine volume, hypercalciuria, hyperuricosuria, hyperoxaluria... Other causes: Gout, excess VD intake, UTIs, UT blockages
70
Pathophysiology of kidney stones?
Imbalance between solubility and precipitation of mineral salts within urine Factors contributing to stone development: o Abnormal urine flow, urine composition, and presence of renal calculi that causes retention of urine o Hydration status (the volume of urine produced) and urine pH

Clin 3 (4 decks)

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