Dialysis
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This is a presentation that I created for my Medical Nutrition Therapy course during graduate school.
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Dialysis
- 1. CKD Stage 5
- 2. Outline • Stage 5 CKD • Hemodialysis • Peritoneal Dialysis • MNT • Patient Assessment • Complications • Questions?
- 3. Etiology of CKD • Most common causes: • Diabetes (39% of patients) • Hypertension (28%) • Glomerulonephritis (13%) • Hereditary cystic and congenital renal disease (4%) • Interstitial nephritis and phyelonephritis (4%) • Neoplasm/tumor (2%)
- 4. Pathophysiology of CKD Kidney injury Destruction of nephrons Renal function and GFR Adaptation causes nephron size and glomerular pressure Increased glomerular pressure causes loss of nephrons
- 5. Stage 5 CKD: End Stage Renal Disease • Kidney function inadequate to sustain life (50-66% of normal function lost) • GFR < 15 mL/min/1.73m2 (or dialysis) • Requires renal replacement therapy • Renal Transplant • Dialysis 5
- 6. Risk Factors • Proteinuria • Ethnicity • Gender • Smoking • Heavy consumption of non-narcotic analgesics, particularly phenacetin 6
- 7. United States ESRD Incidence 32000 31000 Number of Cases 30000 29000 28000 2009 27000 2010 26000 2011 25000 24000 Q1 Q2 Q3 Q4 Quarter United States Renal Data System
- 8. United States ESRD Prevalence 610000 605376 Number of Cases 600000 598409 590000 592367 586445 580000 578637 570000 571414 560000 550000 Quarter
- 9. Indications to begin dialysis • Diabetics: Creatinine clearance is < 15 mL/min • Non-diabetics: serum creatinine reaches 6 mg/dL
- 10. Additional Indications Symptoms • Pericarditis • Uncontrollable fluid overload • Pulmonary edema • Uncontrollable and repeated hyperkalemia • Coma • Lethargy • Less Severe Symptoms • Azotemia • Nausea • Vomiting
- 11. Main Goals of Dialysis Remove Maintain Fluid Fluid Waste Products Electrolyte ○ Urea Acid-base balance ○ Creatinine ○ Potassium ○ Phosphorous ○ Sodium
- 12. Dialysis Health Care Team • Patient • Dialysis Nurse • Dialysis Technician • Nephrologist • Nephrology Social Worker • Renal Dietitian
- 13. Therapeutic Modalities • Hemodialysis • In center dialysis • Home hemodialysis • In center nocturnal dialysis • Peritoneal Dialysis • Continuous ambulatory peritoneal dialysis • Continuous cycling peritoneal dialysis
- 14. Hemodialysis • Waste products filtered from blood by a semipermeable membrane and removed by the dialysis fluid, or dialysate. • In-center: 4 hours, 3 days a week • Home: may be daily • Nocturnal In-center: 6-8 hours, 3 nights/week
- 15. Access • Arteriovenous Fistula • Arteriovenous Graft • Central Venous Catheter
- 16. Arteriovenous Fistula Venous Needle • Radial artery to Arterial Needle cephalic vein Vein • 4-6 weeks to become fully functional AV Fistula Artery • Subclavian route can be used temporarily
- 17. Arteriovenous Graft Artery • Used when veins are Vein Graft not adequate Connection • Polytetrafluroethylene Graft (teflon) tube • Needles placed in graft Venous Needle Arterial Needle
- 18. Central Venous Catheter Blood to dialysis Blood from dialysis machine machine
- 19. Hemodialysis
- 20. Dialysate • Highly purified water • Sodium • Potassium • Calcium • Magnesium • Chloride • Bicarbonate • Dextrose
- 21. Mechanisms of transport • Diffusion • Ultrafiltration (convection) • Hydrostatic ultrafiltration • Transmembrane pressure (blood- dialysate) • Ultrafiltration coefficient (KUF): water permeability • Osmosis
- 22. Peritoneal Dialysis Infusion Drain Dialysis Solution Peritoneum Abdominal Cavity Catheter
- 23. Peritoneal Dialysis • Peritonealcavity: reservoir for dialysate • Peritoneum: semipermeablemembrane across which excess body fluid and solutes are removed • Polyurethane or silicone catheter Peritoneal Capillaries Peritoneal Cavity Fluid Urea Creatinine Potassium Sodium Chloride Lactate Glucose
- 24. Peritoneal Dialysis Continuous Automated PD Ambulatory PD • 2.0-2.5 L dwells • 3-10 dwells nightly • 4-8 hours • Continuous Cycling PD– • 4 times/day 1 dwell during the day • Nocturnal Intermittment PD- dry during day
- 25. PD Transport • Diffusion • Uremic solutes and potassium • Peritoneal capillary ➔ dialysis solution • Glucose, lactate, and calcium • Dialysis solution ➔ peritoneal capillary • Ultrafiltration • Water and associated solutes • Peritoneal capillary ➔ dialysis solution • Absorption • Water and solute • Peritoneal cavity ➔ lymphatic system
- 26. Calculation of Glucose Absorbed in Peritoneal Dialysis Patients • 60% of daily dialysate glucose load is absorbed glucose absorbed (kcal) = (1-D/D0)xi where D/D0 is the fraction of glucose remaining and xi is initial glucose
- 27. MNT Objectives in Dialysis • Maintain protein and kcal balance • Prevent dehydration or fluid overload • Maintain normal potassium and sodium blood levels • Maintain acceptable serum phosphorus and calcium levels
- 28. Renal MNT Treatment Pre-Stage 5 CKD Hemodialysis Peritoneal Dialysis Protein (gm/kg .6-.8 ≥1.2 for stable 1.2-1.3 for stable SBW) patients patients 65% HBV ≥ 50% HBV ≥ 50% HBV Energy 35 30-35 30-35 (kcal/kg/SBW) Phosphorus 800-1000 800-1000 800-1000 (mg/kg SBW) (10-12 mg/gm (10-12 mg/gm (10-12 mg/gm protein) protein) protein) Potassium (mg/d) Typically 2000-3000 3000-4000 unrestricted Sodium (mg/d) 1000-3000 2000-3000 2000-4000 Fluid (ml/d) Typically 750-1000 + 24 hr 2000 unrestricted urine output
- 29. Renal MNT Treatment Hemodialysis Peritoneal Dialysis Fat 25-35% of total kcal 25-35% of total kcal Cholesterol < 200 mg/day < 200 mg/day Fiber 20-30 g/day 20-30 g/day Calcium ≤1500 mg/day from 3000-4000 phosphate binders ≤2000 mg/day total
- 30. Adjusted Edema- Free Body Weight Calculating protein and energy requirements for underweight and obese patients aBWef = Bwef + [{SBW-Bwef} x 0.25] Bwef SBW determined from NHANES II data
- 31. Phosphorus Binders • Calcium acetate (Phos-Lo) • Calcium carbonate (Tums, Calci-Chew) • Calcium citrate (Citracal 950) • Magnesium carbonate (MagneBind 200) • Lanthanum carbonate (Fosrenol) • Sevelamer hydrochloride (Renagel) • Aluminum hydroxide (Amphojel) • Aliminum carbonate (Basaljel)
- 32. Calcium Low serum calcium due to Alterations in vitamin D metabolism Decreased absorption of calcium from gut Elevated phosphorous levels Restriction of high calcium foods Calcium Supplementation Should not exceed 2,000 mg/day Coronary calcification
- 33. CKD Response to Low Serum Calcium and/or High Phosphorus in CKD Stage 5 Calcitriol Secondary Osteitis Serum Ca PTH Bone Calcium- Parathyroid Hyperparathyr Fibrosa Serum PO4 Secretion Turnover PO4 Hyperplasia oidism Cystica Renal Resorption
- 34. Vitamin & Mineral Supplements 10-50 mg vitamin B 60-100 mg vitamin C 1.5 mg thiamin 6μg – 1 mg vitamin B12 1.7 mg riboflavin 800 μg – 5 mg folic acid 20 mg niacin 10 mg pantothenic acid 150 – 300 μg biotin
- 35. Patient Recommendations Foods to enjoy Fresh meat, fish and poultry Enriched bread, pasta and rice Allowed vegetables and fruits Olive oil, butter, or margarine
- 36. Protein Foods to Enjoy Food to Limit • Fish • Processed meats • Seafood • Cheese • Beef • Buttermilk • Poultry • Canned/frozen • Pork dinners • Other Meats • Canned soup • Eggs • Fast foods • Cottage Cheese • Beans • Peanuts/peanut butter
- 37. Calories Foods to Enjoy: Foods to Limit: • Candy • Candy with • Cake chocolate, nuts or • Pie (with allowed peanut butter fruits) • Cream pies • Donuts • Sweet potato pie • Honey • Pumpkin pie • Syrup • Milkshakes • Vanilla Wafers • Nuts • Toaster Pastry • Potato Chips • Butter • Ice cream
- 38. Phosphorus Limit or avoid: • Dairy products • Dried Beans • Nuts and Seeds • Protein Foods: Enhanced meats, liver, organ meats. • Whole grains and cereals: bran, granola, brown rice, whole grain breads & cereals. • Other: Beer, colas, pizza, cocoa, macaroni
- 39. Potassium Fruits to Enjoy: Vegetables to Enjoy • Apples • Asparagus • Blackberries • Bean Sprouts • Blueberries • Broccoli • Cherries • Cabbage • Grapes • Carrot • Peaches • Celery • Pears • Cucumber • Pineapple • Green Beans • Strawberries (5 • Potatoes(only if med) soaked 2-4 hours)
- 40. Potassium Fruits to Limit/Avoid: Vegetables to • Bananas Limit/Avoid: • Cantaloupe • Artichokes • Dried fruits • Beans • Honeydew • Fresh beets, beet • Mango greens • Chinese cabbage • Nectarine • Pumpkin • Oranges • Sauerkraut • Starfruit • Sweet Potatoes • Orange Juice • Tomato
- 41. Sodium Instead of: Try this: • Canned vegetables • Fresh or frozen vegetables, cooked • Processed meats • Unprocessed meats cooked without salt • Convenience/ready • Buy fresh made foods ingredients, cook with herbs • Fast Foods • Pack sandwiches using fresh, unsalted • Salted snack foods ingredients (chips, pretzels, etc.) • Eat fresh, crisp fruits and
- 42. Helpful Fluid Tips • Each morning, measure fluid allowance in water and store in container • Every time you drink fluid, pour out an equal amount. • Drink only when thirsty • Satisfy thirst- cold/frozen fruit • Rinse mouth frequently- don't swallow • Chew gum • Have a piece of hard sour candy
- 43. Nutrition Assessment • Diet Recall • Food Diary • Food Frequency Questionnaire
- 44. Nutritional Indicators, Target, and Frequency Indicator Target Frequency Serum Albumin ≥ 4.0 mg/dL Monthly Serum Prealbumin >30 mg/dL As needed Serum Cholesterol > 150-180 mg/dL As needed Lipid Profile LDL: < 100 mg/dL As needed HDL: > 150 mg/dL Triglycerides: < 150 mg/dL Serum Creatinine > 10 mg/dL Monthly (pre-dialysis treatment) nPNA (protein equivalent of > 1.0 HD: Monthly total nitrogen appearance PD: Every 4 normalized to body weight) months Nelms et al.
- 45. Nutritional Indicators, Target, and Frequency Indicator Target Frequency % Usual Dry Weight after HD N/A Monthly or post-drain with PD % Standard Body Weight N/A Every 4 months BMI Upper 50th percentile Monthly 23.6 kg/m2 for men 24 kg/m2 for women SGA ≥ 6-7 Biannually 4 item, 7 point scale Anthropometrics and DEXA N/A As needed Serum Bicarbonate ≥ 22 mmol/L Monthly Nelms et al.
- 46. Behavioral Outcomes Meal planning Meeting nutrient needs Awareness of potential food/drug interactions Exercise
- 47. Comorbid Conditions and Complications Malnutrition Cardiovascular disease Secondary Hyperparathyroidism Osteitisfibrosa Anemia Recombinant human erythropoietin Iron Target levels ○ Hematocrit: 33-36% ○ Hemoglobin: 11-12 g/dL
- 48. For Further Reading • Daugirdas JT, Blake PG, Ing TS.“Handbook of Dialysis Fourth Edition" Lippincott Williams &Wilkins:2006.
- 49. Questions?
Notas del editor
- number of new cases per population in a given time period
- a measure of the total number of cases of disease in a population rather than the rate of occurrence of new cases