+ Understanding Kidney Disease and Renal Dialysis Brooke Grussing Concordia College

+

Understanding Kidney Disease and Renal Dialysis Brooke Grussing

Concordia College

+Learning Objectives

Acquire a better understanding of the stages of Chronic Kidney Disease (CKD) and its risk factors

Become informed about the progression of kidney disease into End Stage Renal Disease (ESRD)

Learn about the Medical Nutrition Therapy (MNT) for the two main types of dialysis; hemodialysis and peritoneal dialysis

Gain knowledge about a realistic ethical issue renal patients may face and current research on avoiding protein-energy malnutrition in this population

+Risk Factors of Developing CKD

26 million American adults have CKD and many others are at risk of developing it

Those with the greatest risk: Diabetics Individuals with hypertension People with family members who had or have had CKD (genetics) Seniors

Ethnic populations African Americans Hispanics Pacific Islanders Native Americans

(National Kidney Foundation website)

+Importance of the Kidneys

Remove waste products and excess fluid from the body

Regulates the body's salt, potassium, and acid content

Produce hormones for other organs in the body

Produce active form of vitamin D

Control production of RBCs(National Kidney Foundation, 2012)

+Renal Disease Pathology: Chronic Kidney Disease (CKD)

“Syndrome of progressive and irreversible loss of the excretory, endocrine, and metabolic functions of the kidney secondary to kidney disease”

Kidney function is based on glomerular filtration rate (GFR) GFR measures the rate at which substances are cleared

from the plasma by the glomeruli

Risk factors mentioned previously are the main causes

(Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

+

(National Kidney Foundation, 2012)

+Medical Nutrition Therapy for CKD

Nutrition Care Process Screening and Referral Nutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

+Screening and Referral

MNT used to prevent and treat protein-energy malnutrition, mineral, and electrolyte disorders

MNT minimizes the risk of obtaining other comorbidities due to the progression of CKD

Referral for MNT from an RD should be made at diagnosis of CKD Made 12 months prior to renal replacement therapy (RRT)

(Academy of Nutrition and Dietetics EAL, 2012)

+Nutrition Assessment

RD should assess the food and nutrition related history of the patient Food and nutrient intake Medication Knowledge, beliefs, or attitudes Behavior Factors affecting access to food and food and nutrition-related

supplies

Biochemical and physical


+Nutrition Diagnosis

Many diagnoses may be present due to the complexity of CKD Examples include:

Inadequate energy intake, oral/food and beverage intake Excessive fluid intake, protein intake, mineral intake (K, P, or Na) Malnutrition Altered GI function or nutrition-related labs Food-medication reaction Involuntary weight loss/gain Food and nutrition-related recommendations Undesirable food choices Impaired ability to prepare food/meals Poor nutrition quality of life Limited access to food


+Nutrition Intervention: CKD Stages 1-4

(Taken from: http://andevidencelibrary.com/template.cfm?template=guide_summary&key=2510&highlight=chronic%20kidney%20disease&home=1)

+Nutrition Intervention, continued Other intakes to consider with renal patients

Energy Calcium Vitamin C and D Iron supplement Folic acid

Also remember to monitor fluid intake

All recommended values can be found on The Academy’s EAL site


+Nutrition Monitoring and Evaluation

RD must monitor and evaluate the biochemical parameters and evaluate how well the patient is adjusting

Monitor every one to three months More frequently if the RD sees this to be necessary

My clinical experience Patients came in every other day for dialysis RD kept a chart of their lab values Discussed how to improve them each visit


+End Stage Renal Disease (ESRD) Also referred to as CKD Stage 5

Kidney function has declined to 10-15% of normal

GFR is <15 mL/min/1.73 m2

Patient requires renal replacement therapy

Progression into ESRD: Harmful waste buildup in blood Rise in blood pressure Excess fluid retained


+Treatment: Renal Dialysis Lifetime commitment for CKD Stage 5 patients

Renal replacement procedure put in place to remove excess and toxic by-products of metabolism from the blood Replaces the filtering function of healthy kidneys

Must show symptoms in order to initiate dialysis treatment Pericarditis Uncontrollable fluid overload Pulmonary edema Uncontrollable and repeater hyperkalemia Coma Lethargy

Less severe symptoms Azotemia Nausea and vomiting


+Treatment: Renal Dialysis, continued

Waste products and excess fluids are removed from the body by: Diffusion, ultrafiltration, and osmosis

During removal: Fluid and electrolyte balance must be maintained Done by passing blood across the semipermeable membrane

Exposed to dialysate Dialysates: have varying ion and mineral compositions to aid

in the process, but do not come into contact with the blood


+Types of Renal Dialysis

Two types of dialysis Hemodialysis (HD) Peritoneal Dialysis (PD)

Both methods require a selective, semipermeable membrane to allow passage of material

Continuous Renal Repair Therapies (CRRT) Used for acute care during ARF or as temporary treatment

until patient begins HD or PD

Kidney Transplantation (Alternative to dialysis)


+Hemodialysis (HD) Selective membrane is a man-made dialyzer

Sometimes referred to as an artificial kidney

Must have procedure to allow for continuous access to the circulatory system Arteriovenous fistula (AVF) Arteriovenous graft (AVG)

Explanation of the process

Typically occurs 3 times/week for ~4 hours/session Most done at a dialysis center Other alternatives:

Daily home hemodialysis (DHHD): 5-7 days/week, 2-3 hours/session

Nocturnal home hemodialysis (NHHD): 3-6 days/week, during sleep


+

+MNT for HDNutrient Hemodialysis (HD)

Protein (50% from HBV)

1.2 g/kg/d

Energy 35 kcal/kg/d <60 yr of age, 30-35 older than 60

CHO and Fat After calculation of PRO, assess patient needs—calculate percentages accordingly

Fluid ≥ 1 L fluid output = 2 L fluid needed. < 1 L fluid output = 1-1.5 L fluid needed. Anuria = 1 L fluid needed

K and P Check levels of K and P; modify diet accordingly

Na Limit Na intake unless there are large losses in dialysate, vomiting, or diarrhea. Restrict to 2-4 g

Vitamins Water soluble vitamins to replace dialysate losses. Folic acid, vitamin B6, vitamin C, and vitamin B12

Minerals Monitor serum labs. Individualize Ca

Omega-3 FA Fish oil—may help reduce prostaglandin synthesis and improve hematocrit levels(Stump-Escott, S., 2012)

+Peritoneal Dialysis (PD) Patient’s peritoneal wall serves as the selective membrane

Access to patient’s blood supply is via a catheter Dialysate introduced into the peritoneum through catheter

Explanation of process

Two types of PD Continuous Ambulatory Peritoneal Dialysis (CAPD)

No machine required Dwell time of 4-6 hours, followed by draining of used dialysate

and replacement of fresh solution (~30-40 minutes) Most patients change the fluid 4 or more times/day and also

sleep with it Continuous Cycling Peritoneal Dialysis (CCPD)

Requires a cycler Machine that fills and empties the abdomen 3-5 times/week

with a dwell time that lasts the entire day


+

+MNT for PDNutrient Peritoneal Dialysis (PD)

Protein 1.2-1.3 g/kg/d (1.5 g/kg for peritonitis)

Energy 35 kcals/kg/d for <60 years and 30-35 for 60 or older

CHO and Fat

Must be individualized due to dialysate (adding 300-450 kcals of glucose). Limit simple sugars and SFA

Fluid Less common; 1-3 L/d suggested. Should be determined by state of hydration. No more than 1 kg gained/day

K and P Same as HD

Na Intake should be liberal, depending on hydration, BP, losses in dialysate, vomiting, and diarrhea

Vitamins Water-soluble, especially vitamin B6 and folic acid

Minerals Same as HD

Omega-3 FA

Same as HD(Stump-Escott, S., 2012)

+National Renal Diet (Patient on Dialysis)Food List Protein

(g/serv)Calories

(kcal/serv)

Sodium(mg/serv)

Potassium

(mg/serv)

Phosphurs

(mg/serv)

Animal Protein 6-8 50-100 20-150 50-150 50-100

Higher Na, K, or P proteins

6-8 50-100 200-500 250-450 100-300

Fruits/Vegetables

-Low 0-3 10-100 1-50 20-150 0-70

-Medium 0-3 10-100 1-50 150-250 0-70

-High 0-3 10-100 1-50 250-550 0-70

Dairy/P 2-8 100-400 30-300 50-400 100-120

Breads/Cereals 2-3 50-200 0-150 10-100 10-70

Calorie 0-1 100-150 0-100 0-100 0-100

Flavorings 0 0-20 250-300 0-100 0-20

Vegetarian Protein

6-8 70-150 10-200 60-150 80-150(Nelms, M., Sucher, K.P., Lacey, K., & Roth, S.L., 2011)

+Common Medications and Their Use/Effects on CKD Patients Phosphate binders

Prevents GI absorption of dietary phosphorus. N/V may result

Angiotensin-converting enzyme (ACE) inhibitor For patients with >200 mg protein/g creatinine in a urine

sample

Antidepressants Depression is common within renal dialysis patients-may be

needed to improve appetite and intake

Carnitine Requires adequate vitamin C, niacin, iron, and vitamin B6.

Kidney is unable to make it


+Common Medications, continued Insulin

Used to control blood glucose levels in diabetic patients

Iron supplements Recombinant human erythropoietin: used to treat anemia

Lipid lowering medications Patient’ with an LDL of ≥ 100 mg/dL should be treated with

diet and statin

Vitamin D Patient’s kidney is unable to convert vitamin D to its active

form, causing osteodystrophy


+Current Research: Amino Acid Oral Supplementation in HD Patients Protein-energy malnutrition is a common concern in HD patients

But, CKD is associated with loss of appetite and reduced food intakes

Branched chain amino acid supplements have been able to increase serum albumin and to improve nutritional status

AA formation has been reported to have beneficial effects on Elderly people Elderly affected by CHF Type 2 diabetics

Reason for this study to be conducted: At this time, no data exist about AA supplementation in patients with CKD

Often, CKD patients are also associated with groups listed above

Supplement includes all of the essential AAs, plus two nonessential (tyrosine and cystine)

(Bolasco, P., Caria, S., Cupisti, A., Secci, R., & Dioguradi, F. 2011)

+Current Research, continued

Study conducted on patients with Serum albumin levels < 3.5 g/dL Normalized protein nitrogen appearance of < 1.1 g/kg/die BMI of >20 kg/m2

Receiving HD for at least 6 months Stable clinical conditions and free from acute inflammation

30 patients selected: 15 (5 male, 10 female, aged 72.7 +/- 10 years, dialysis 42.5 +/-

36.2 months) were randomized to oral AA supplementation Remaining 15 (5 male, 10 female, aged 75.2 +/- 11.2 years,

dialysis for 45.1 +/- 36.2 months) were the control group

Study lasted 3 months, results were obtained


+Current Research: Results of Study Study group showed increase in:

Serum albumin Total protein Hemoglobin

Study group showed decrease in: ERI (erythropoietin resistance index) CRP (C-reactive protein)

Findings indicated also that there was a reduction in inflammation and an improvement of anemia

Conclusion of study: Oral AA supplementation was able to improve albumin and

total protein in hypoalbuminemia HD patients


+Ethical Issue: The Shortage of Kidney Transplants Approximately 18,000 transplants done annually

More than 70,000 individuals are waiting for a donor Limited availability of kidneys for transplantation

Commodification (Are organs a commodity??) “Exchanges in which material goods and economic services are literally

bought and sold”

Racial ethical issues: Human dignity

“Treat persons as ends in themselves, never as means” Altruism (welfare of others)

Treating as a “commercial commodity” would “abolish the moral choice of giving to strangers”

Stance of the authors: There should be an alternative to commodification of kidneys Believe it is unethical to be compensated for donation due to altruism

(Rosen, L., Vining, A., & Weimer, D., 2011)

+Recap of Learning Objectives

This morning, we:

Acquired a better understanding of the stages of Chronic Kidney Disease (CKD) and its risk factors

Became informed about the progression of kidney disease into End Stage Renal Disease (ESRD)

Learned about the Medical Nutrition Therapy (MNT) for the two main types of dialysis; hemodialysis and peritoneal dialysis

Gained knowledge about a realistic ethical issue renal patients may face and current research on avoiding protein-energy malnutrition in this population

+

Questions??

Documents

+ Understanding Kidney Disease and Renal Dialysis Brooke Grussing Concordia College