Diseases of the Renal System KNH 413 34 – CHI April 2nd www.nufs.sjsu.edu/renaldial/index.html

CKD - Renal Replacement Therapy Hemodialysis (HD) or Peritoneal Dialysis (PD) Type based on underlying kidney disease and co-morbid factors Both require selective, permeable membrane Allows passage of water and small molecules

CKD - Renal Replacement Therapy Hemodialysis (HD) Membrane is manmade dialyzer – “artificial kidney” Preferred access site – AVF, AVG Typical regimen 3 days/week for 4 hrs/treatment

CKD - Renal Replacement Therapy Peritoneal dialysis (PD) Lining of patient’s peritoneal wall is the selective membrane Types CAPD CCPD Access via catheter into peritoneal cavity Range of dextrose concentrations

CKD - Stages 1 & 2 Nutrition Therapy Focus on co-morbid conditions: diabetes, hypertension, hyperlipidemia, progression of CVD K/DOQI guidelines for GFR ≤ 20 SGA every 1–3 mo. Dietary interviews and food intake More frequent if GFR ≤ 15 Protein: .6-.75 g/kg Energy: 30-35 kcal/kg

CKD - Stages 3 & 4 Nutrition Therapy See ADA guidelines Nutrition assessment recommendations Nutrient recommendations Emphasize usual foods

CKD - Stages 3 & 4 Outcome measures Clinical Behavioral Meal planning, meeting nutrient needs, awareness of food/drug interactions, exercise

CKD - Stage 5 Nutrition Assessment On dialysis – measures not different Goals: meet nutritional requirements, prevent malnutrition, minimize uremia, minimize complications Maintain blood pressure, fluid status

© 2007 Thomson - Wadsworth

CKD - Stage 5 Nutrition Intervention HD – high in protein, control intake of potassium, phosphorus, fluids and sodium PD – more liberalized; higher in pro., sodium, potassium and fluid, limit phosphorus nutrients to monitor

CKD - Stage 5 Nutrition Intervention Protein - 1.2 g/kg (HD), at least 50% HBV PD same except during peritonitis – increase protein Losses increase 50-100% and may remain elevated

CKD - Stage 5 Nutrition Intervention Energy to prevent catabolism PD Caloric load 24-27 kcal/kg/day average intake

CKD - Stage 5 Nutrition Intervention Adjusted Edema-Free Body Weight For those < 95% or > 115% median standard weight NHANESII For maintenance in HD and PD pts. Obtained postdialysis for HD pts., and after drainage for PD patients

CKD - Stage 5 Nutrition Intervention Fat HD typically have normal LDL, HDL, TG PD higher TC, LDL, TG Recommend TLC diet guidelines for both

CKD - Stage 5 Nutrition Intervention Fluid and Sodium highly individualized Interdialytic weight gain (HD) 2 gram sodium diet Not more than 1 L fluid daily If urine output > 1 L/day sodium and fluid can be liberalized to 2-4 g and 2 L

CKD - Stage 5 Nutrition Intervention Fluid and Sodium PD – based on ultrafiltration Fluid 2 L Sodium 2-4 g Fluid overload

CKD - Stage 5 Nutrition Intervention Phosphorus Hyperphospatemia Dietary phosphorus restriction Phosphate binders; calcium salts Limit calcium intake

© 2007 Thomson - Wadsworth

CKD - Stage 5 Nutrition Intervention Calcium requirements higher in CKD Restrict foods high in calcium Take supplements on empty stomach Limit to 2000 mg/day from all sources

CKD - Stage 5 Nutrition Intervention Vitamin Supplementation Water-soluble vitamins Daily requirements “Renal” vitamins Avoid high doses of vitamins A & C May need vitamin K if on antibiotics

CKD - Stage 5 Nutrition Intervention Mineral supplementation Avoid Mg-containing phosphate binders, antacids, and supplements Iron Zinc