Renal Nutrition in ESRD - Part 2

Question 1

What is CKD-MBD?

Answer 1

Chronic Kidney Disease Mineral Bone Disease

Question 2

What is CKD-MBD characterized by?

Answer 2

• Abnormal levels of Ca, Phos, PTH and active Vit D
• Abnormal bone morphology
• Calcification of blood vessels and other soft tissues

Question 3

What is renal osteodystrophy

Answer 3

• Abnormal bone morphology

- Calcification of the joints

Question 4

What is metastic calcification?

Answer 4

The calcification of blood vessels and other soft tissues

Question 5

Prevalence of renal osteodystrophy (RO)?

Answer 5

0More than 50% of patients with CKD by the time GFR <50 ml/min

Question 6

What is the leading cause of RO?

Answer 6

-Hyperphosphatemia

Question 7

What is metastic calcification?

Answer 7

The deposition of calcium crystals in soft tissues

Question 8

Why does phosphate influence the crystallization of calcium?

Answer 8

PO4 will bind to Calcium, forming an insoluble precipitate, therefore high levels of PO4 can lead to metastic calcification and RO

Question 9

What is calciphylaxis?

Answer 9

When blood vessels are calcified, and can develop severe ulcers and amputations

Question 10

How must phosphate be controlled?

Answer 10

Almost always in excess in blood

• Diet
• Phosphate binders
• Dialysis

Question 11

How much phos does dialysis remove/session?

Answer 11

800 mg

Question 12

What is the phosphorus recommendation per day?

Answer 12

800-1200 mg day, which is very difficult to achieve with high protein requirements

Question 13

What is organic phosphate? How much is typically absorbed?

Answer 13

From whole foods

50-60%

Question 14

What is inorganic phosphate? How much is typically absorbed?

Answer 14

From food additives
100% absorbed
We will be focused on reducing phosphorus from food additives first

Question 15

Discus the risk:benefit of lowering phosphate

Answer 15

• Lowering phosphate by decreasing protein intake may lead to increased death risk in HD patients
• Controlling phosphorus while maintaining high dietary protein intake may be associated with the best survival in HD patients

Question 16

Organic plant protein phosphorus absorption and examples?

Answer 16

• Nuts, seeds, chocolate, beans

- 20-40&

Question 17

Organic animal protein phosphorus absorption and examples?

Answer 17

• Fish, meat, chicken, eggs, milk and dairy

- 60-60%

Question 18

What are the two types of phos binders?

Answer 18

Calcium and non-calcium based

Question 19

Calcium based phos binders?

Answer 19

• Calcium carbonate

- Tums

Question 20

Regular 500 mg phos binder =

Answer 20

200 mg elemental calcium

Question 21

Extra strength 750 mg phos binder =

Answer 21

300 mg elemental calcium

Question 22

Ultra 1000 mg phos binder =

Answer 22

400 mg elemental calcium

Question 23

Key concept with phos binders?

Answer 23

MUST be taken with food

Question 24

What is a non-calcium, non-metal, 800 mg phos binder which will lower LDL?

Answer 24

-Renagel

Question 25

What is a non-calcium 800 mg phos binder which will lower LDL and may improve bicarbonate levels? Which population may this be recommended for?

Answer 25

- Renvela | - Pre-dialysis to correct bicarbonate levels

Question 26

What is a non-calcium, chewable phos binder which may risk lanthanum accumulation?

Answer 26

Fosrenol

Question 27

How can we nutritionally intervene with phos binders?

Answer 27

- Suggest crushing and mixing up into liquids - Ensure that they are taken with their meals, and prescribed customized to their usual-intake (i.e. 3 vs 5 meals per day)

Question 28

Provide some practical steps to control serum phosphate levels

Answer 28

- Limit dietary phos while meeting protein needs - Titrate binder dosage to meal and snack - Evaluate actual P intake to plan the initial and subsequent phos binder doses

Question 29

What is contraindicated for constipation intervention in ESRD?

Answer 29

-We cannot suggest increasing fibres, fluids or exercise

Question 30

What may be attributed to constipation?

Answer 30

Phos binders

Question 31

How can we attenuate and pre-emptively address constipation in PD?

Answer 31

-Will immediately have stool softeners and laxatives, even if there is normal BM

Question 32

Why is preventing constipation crucial in PD?

Answer 32

Constipation can cause increased pressure in the peritoneum, which can (1) displace the catheter and (2) increase risk of bacterial translocation and infection of the perioneal membrane

Question 33

Which commonly used laxatives are contraindicated?

Answer 33

- Milk of magnesia - Magnolax - Citro-mag - Fleet Phospho-soa

Question 34

Examples of stool softners?

Answer 34

- Docusate sodium - Docusate calcium - Laculose

Question 35

Examples of bulking agents?

Answer 35

- Unifibre - Benefibre - -> Not used very foten

Question 36

Which bulking agents are contraindicated?

Answer 36

Metamucil and Prodiem