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Diseases of the Renal System
KNH 413
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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
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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
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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
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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: g/kg Energy: kcal/kg
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CKD - Stages 3 & 4 Nutrition Therapy See ADA guidelines
Nutrition assessment recommendations Nutrient recommendations Emphasize usual foods
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CKD - Stages 3 & 4 Outcome measures Clinical Behavioral
Meal planning, meeting nutrient needs, awareness of food/drug interactions, exercise
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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
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© 2007 Thomson - Wadsworth
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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
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CKD - Stage 5 Nutrition Intervention
Protein g/kg (HD), at least 50% HBV PD same except during peritonitis – increase protein Losses increase % and may remain elevated
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CKD - Stage 5 Nutrition Intervention Energy to prevent catabolism PD
Caloric load 24-27 kcal/kg/day average intake
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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
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CKD - Stage 5 Nutrition Intervention Fat
HD typically have normal LDL, HDL, TG PD higher TC, LDL, TG Recommend TLC diet guidelines for both
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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
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CKD - Stage 5 Nutrition Intervention Fluid and Sodium
PD – based on ultrafiltration Fluid 2 L Sodium 2-4 g Fluid overload
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CKD - Stage 5 Nutrition Intervention Phosphorus Hyperphospatemia
Dietary phosphorus restriction Phosphate binders; calcium salts Limit calcium intake
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© 2007 Thomson - Wadsworth
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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
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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
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CKD - Stage 5 Nutrition Intervention Mineral supplementation
Avoid Mg-containing phosphate binders, antacids, and supplements Iron Zinc
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