kidney 2 Flashcards
Antihypertensive Agents
- ACE-Inhibitors, -Adrenergic blockers, Angiotensin II Receptor Blockers
- Can increase serum K levels
- Ca Channel Blockers
Diuretics
-K sparing or K losing, depending on type
Lipid Lowering Agents (people with chronic kidney desease are more at risk for coronary heart disease
e.g. Statins, Fibrates
Phosphorus Binders
–IF SERUM [PHOSPHATE] ELEVATED.
-Take with meals to bind phosphate and prevent its absorption from the GIT. —Aluminum Based -Amphojel & Basaljel —Calcium Based -Oscal & Tums —Non-Aluminum, Non-Calcium (NANC) Based -Renagel & Fosrenol
Vitamin D Analogues (often later stages)
e. g. Calcitriol
- as 1,25 dihydroxycholecalciferol since kidney cannot efficiently hydroxylate 25-OH cholecalciferol at the 1-postion.
Sodium polystyrene sulfonate
-a cation-exchange resin to bind K.
IF SERUM K IS HIGH.
Diuretics
- Potassium sparing (e.g. spironolactone/Aldactone)
- Potassium wasting (e.g. furosemide/Lasix)
Anemia Management SIGNIFICANT PROBLME IN CHRONIC KIDNEY DISEASE
-Causes:
treatment
a) erythropoietin production erythrocyte production = major cause
b) (later) blood losses associated with dialysis and laboratory tests may contribute.
c) dietary factors – poor intake-may contribute.
Treatment: —Human recombinant erythropoietin Eprex or Aransep —Adequate nutritional support for the increased erythrocyte production Iron B12 Folate
NUTRITIONAL CARE Nutritional recommendations vary for: • acute renal disease • chronic kidney disease -Stages 1-4 -Stage 5- renal replacement therapy -hemodialysis -peritoneal dialysis -renal transplantation Hemodialysis Renal transplantation
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-Objectives of nutritional care:
- Maintain optimum nutritional status.
- Minimize metabolic disorders & related symptoms:
i) reduce intake of substances that the kidney can no longer excrete well
ii) provide replacements for compounds lost in quantities. - Retard progression of disease: help people with overweight or obesity
Individualize guidelines for each patient throughout care. Based on blood work and history
Protein-energy malnutrition is a very common problem in those with advanced chronic kidney or in those undergoing dialysis.
There are many causes:
• Poor food intake due to:
o Anorexia caused by uremia (don’t feel like eating)
o Altered taste
o Unpalatable prescribed diets
• Catabolic response to the illness and chronic inflammation
• Dialysis causes loss of some nutrients and promotes protein catabolism
• Endocrine disorders of uremia (high wate products in the blood) (e.g. resistance to insulin and IGF [insulin-like growth factor])
• Accumulation of uremic toxins
Nutritional Care: Stages 1-4
= the stage prior to dialysis, transplantation.
Protein
HOW MUCH? CONSULT TABLES
Note the difference between Stage 3&4. – look at tables. Prn – as required
-With progression through stages 1 through 4, endproducts of protein metabolism are not being eliminated normally in the urine (uremia).
- Consider all sources of these endproducts:
1) Exogenous protein intake: with dietary protein
2) Endogenous protein breakdown.
-Factors that muscle catabolism uremia:
• inadequate energy intake
• inadequate protein intake
• unbalanced protein
-How do we deal with these metabolic alterations from a nutritional point of view?-Recommendations intended to:
- Aim: Do not provide excess protein to prevent accumulation of endproducts + maintain N balance.
- i.e. match the dietary protein to the workload capability of the kidneys.
- Note small increase in protein requirement in earlier stages related to issues described above for protein-energy malnutrition.
• prevent symptoms associated with uremia nausea, vomiting, fatigue.
• delay progression of kidney disease.
[evidence from Modification of Diet in Renal Disease (MDRD Study) and others].
Know the g/kg… on tables
Energy
HOW MUCH? CONSULT THE TABLES. BUT, assessment of individual energy requirement required- stays the same in each stage
WHY THE DIFFERENCE BY AGE?
How to assess whether you are meeting protein and energy needs:
BMR goes down
-protein recommendations assume energy needs are met by nonprotein sources.
-important to meet energy requirements and minimize endogenous protein catabolism to supply energy.
a) accumulation of protein breakdown products
e.g. serum [urea] –but note it is nonspecific, being affected by:
• renal function serum [urea]
• protein intake serum [urea]
• inadequate energy intake serum [urea]
b) nutritional assessment tests of protein and energy status
-biochemical and anthropometric assessment
-Appropriateness of level of protein intake is continually assessed and adjusted as required.
Biochemical and anthropometric assessment
Biochemical: would serum [albumin] be useful? Its going to go down so wont tell as much about nutritional status as we would like
Example of anthropometric measurement?
Fluid
HOW MUCH? NOTE CHANGE BETWEEN STAGES 1/2 AND 3/4. WHY?
½ stage: stay well hydrate
3- stay hydrated but restrict as needed
4- stay hydrated but restrict as needed
If dietary Na diminishes, thirst often decreases appropriately.
- IF DIETARY Na DIMINISHES, THIRST OFTEN DECREASES APPROPRIATELY.
- BUT, as urine output declines, may come a time when fluid has to be restricted to equal fluid loss. E. g. Volume of urine output for previous day + ~1000 ml to compensate for nonurinary losses.
Phosphorus and Calcium
HOW MUCH? NOTE CHANGE BETWEEN STAGES 1/2 AND 3/4.
½ calcium: DRI, phosphorus: unrestricted
3/4: calcium: avoid/treat symptomatic hypocalcemie ; <2000mg (diet + supplements) phosphorus: 800-1000mg ideal up to 1200mg if PO4 normal and nutritional status warrants (decrease protein)
Note all sources of Ca being considered.
Why the increase in recommended protein intake, compared with stages 1-4? for 5
1) Dialysis assists with getting rid of metabolic endproducts.
2) Some extra protein losses:
- Some loss into the dialysate during each session (further increases with peritonitis(increase protein loss) in peritoneal dialysis).
- Accelerated protein catabolism due to dialysis.
What other recommendations change at Stage 5? CONSULT TABLES
LET’S THINK ABOUT WHY
Stage 5: 1.2g/kg for HD, 1.2-1.3G/Kg (PD); 50% HBV
Energy stays the same
Soium: same
Potassium: restriction is typical on HD, but of PD more liberal as more is loss
Phosphorus: 800-1000 is ideal, however, increased protein requirement will make restriction more challenging
Vit/min: same
Fluids: 1-1.5L on HD; more liberal on peritoneal dialysis
Some Transplant-Related Problems with Nutritional Implications
- Carbohydrate intolerance
- Increased protein catabolism during early posttransplant period
- Hypertension
- Increased drug-nutrient interactions
- Obesity
- Hyperlipidemia
- Hyperkalemia
- Calcium and Phosphorus Concerns
