1. Gastroenterology and Nutrition in Chronic Kidney Disease Clinical Nephrology 5 th edition

2. Contents  Gastrointestinal disease  Gastrointestinal hemorrhage  Clostridium difficile infection  Gastrointestinal-renal syndromes  Drugs and gastrointestinal disease  Nutrition in CKD

3. Important Causes of Common GI Symptoms in Patients with CKD

5. Gastrointestinal Disease  Oral disease  Glossitis : deficiency of iron, vit. B12, folic acid  Halitosis : uremia  Gingival hyperplasia : CCB or cyclosporine  Oral candidiasis : immunosupressive drugs

6. Gastrointestinal Disease  GERD  More frequently in patients with CKD  GI dysmotility or delayed gastric emptying  More prevalent with PD  Esophagitis  Irritant effects of drugs  Slow-release potassium preparations, tetracyclines, iron, aspirin, NSAIDs, bisphosphonates  Avoidance of bedtime snacks, fatty foods, cigarettes, alcohol  Raising the head of the patient’s bed  Proton pump inhibitor

7. Gastrointestinal Disease  Peptic Ulcer Disease  More often multiple  Hemorrhage occurs more often, but pain is less frequent  Gastritis and duodenitis  Increased susceptibility of gastric and duodenal mucosa to damage in CKD  Proton pump inhibitors, H 2 receptor antagonists  Aluminum or bismuth-containing preparations should be avoided

8. Gastrointestinal Disease  Delayed Gastric Emptying and Gastroparesis  Autonomic neuropathy and retained GI peptides  Diabetes and amyloidosis  Results in reduced appetite, early satiety, nausea, vomiting, malnutrition  Dx : scintigraphic measurement of gastric emptying  Endoscopy is important to exclude gastric outlet obstruction  Diabetic control, correction of electrolyte abnormalities, discontinuation of drugs that impair gastric emptying  Prokinetic drug therapy (metoclopramide, domperidone, erythromycin)

9. Gastrointestinal Disease  Constipation  Common in CKD  Drugs, dietary restrictions, low oral fluid intake, electrolyte abnormalities  PD : impaired dialysate drainage, catheter malposition  Risk factor for large bowel perforation  Drugs : calcium-based phosphate binders, sevelamer, oral iron, opioid analgesics  Stool-softening agents, stimulant laxatives, fiber preparations

10. Gastrointestinal Hemorrhage  Important complication of CKD, with increased incidence  Gastritis and duodenitis, angiodysplasia, more rarely, dialysis- related amyloidosis and systemic vasculitis  Uremic hemostatic defects and anticoagulation during HD are also important

11. Gastrointestinal Hemorrhage  Upper GI endoscopy : diagnostic and therapeutic procedure  Resuscitation requires careful monitoring in patients with CKD  Avoiding fluid overload  Monitoring of serum potassium with avoidance of hyperkalemia complicating blood transfusion  Correction of coagulation defects and use of DDAVP or cryoprecipitate  Drugs that increase bleeding risk should be discontinued  HD, when it is required, should be performed without heparin for anticoagulation

12. Clostridium difficile Infection  Major cause of nosocomial diarrheal illness  Patients with CKD are at risk of more frequent or severe infection and have a higher resulting mortality  Dx : identifying C. difficile toxin in diarrheal stools  Drugs that reduce diarrhea or impair gut motility must be avoided because they may precipitate toxic megacolon  Preventive measures  Hand washing with soap  Cleanliness of physical environment  Isolation of affected inpatients with barrier nursing  Antibiotic policies should minimize use of broad-spectrum antibiotics

13. Gastrointestinal – Renal Syndromes

14. Drugs and Gastrointestinal Disease

15. Nutrition in Chronic Kidney Disease  Malnutrition: Protein-Energy Wasting  Prevalence : 10 - 70%  Nutritional losses occur during treatment HD : 8-12g a.a. loss PD : 5-10g  Metabolic acidosis and periods of acute or chronic illnesses induce protein catabolism  Inflammatory state of uremia  Endocrine disorders insulin resistance, increased PTH, vitamin D deficiency

16. Assessment of Nutritional Status

17. Estimation of Intake  Food intake  Should be performed every six months  Diet history, recall, food diaries  Protein catabolic rate (PCR)  Protein equivalent of nitrogen appearance (nPNA)  Approximate dietary protein intake

18. Plasma protein measurements  Albumin  Correlates reasonably well with body protein stores  Late manifestation of malnutrition (long half-life)  Should be measured monthly  Transferrin  Commonly used to assess nutritional status in subjects with normal renal function  Frequently reduced in renal failure independent of malnutrition

19. Plasma protein measurements  Prealbumin  Vary with the state of nutrition in patients with normal renal function  Normally excreted and metabolized by the kidney  Tends to accumulate in renal failure  Serial measurements can be monitored  Short half-life and changes rapidly in response to alterations in nutritional status

22. Nutritional Guidelines