Quiz 4 Weeks 9-12 15% Flashcards
1
Q
What is cardiovascular disease?
A
- an umbrella term for a group of disorders that involve the heart and blood vessels
- coronary artery disease (most common)
- hypertension
- ischemic heart disease (limited blood flow to the heart, over time some of the blood vessels are diseased or narrow)
- peripheral vascular disease
- heart failure
2
Q
What is the cardiovascular system?
A
- consists of blood, blood vessels, and the heart
- when the heart pumps, it moves blood through the blood vessels
- blood transports oxygen and nutrients to tissue cells and carries away metabolic wastes (CO2)
3
Q
What are the 2 major types of blood vessels?
A
- Arteries: carry oxygenated blood away from the heart to the tissues
- Veins: carry deoxygenated blood from tissues back to the heart
4
Q
What are the 2 main circuits of the cardiovascular system?
A
- Arteries and veins from closed pathways/circuits within the body
1. Pulmonary circulation: heart pumps deoxygenated blood to the lungs where it picks up oxygen and gives off CO2. Oxygenated blood returns to the heart which then pumps it into the systemic circulation
2. Systemic circulation: the heart pumps oxygenated blood into the aorta which branches into arteries that enter tissues and organs. Blood delivers O2 and picks up CO2. The deoxygenated blood enters veins and drains into the inferior vena cava and superior vena cava: two large veins that drain deoxygenated blood back into the heart
5
Q
How many Canadian adults live with heart disease?
A
- 1 in 12
- 2.4 million Canadians
- every hour 12 Canadian adults are diagnosed
- more common in ages 20+
- heart disease affects men and women equally but differently: men at a younger age, women older age
- there has been a decline in heart disease: reduced sodium intake, trans fat in products, medical advancements
6
Q
What is the role of the cardiovascular system?
A
- regulates blood flow to tissues
- delivers oxygenated blood and nutrients to all organs, tissues and vessels.
When there is reduced blood flow, there is reduced oxygen to the periphery (parts of the nervous system outside the brain and spinal cord) and organs.
When the heart is damaged, it tries to work in overdrive to make sure a sufficient amount of blood is injected into the body to help sustain its needs (esp energy needs). Over time as the muscle weakens, blood flow reduces to the body into tissues and organs = detrimental side effects - Retrieves waste products.
As blood is brought into your tissues and organs helps retrieve and eliminate CO2 through kidneys, urination, and breath
- Blood helps: regulate body temp transport hormones very important in the maintenance of fluid volume regulates pH & gas exchange
7
Q
What happens when there’s a dysfunction in your vessels or heart?
A
The fibres in the septum stretch and elongate = cardiomyopathies and enlarged heart. An enlarged heart doesn’t function as efficiently
8
Q
How does blood flow through the heart?
A
- inferior vena cava: returns blood back to the right side of the heart, from trunk and legs
- superior vena cava: returns blood from the head and upper limbs. Deoxygenated blood comes in (pulmonary system) and is pushed out through the pulmonary arteries to the left and right lung. Here it picks up O2 and flows back in through the right pulmonary veins
- blood comes into the left pulmonary veins into the left atrium where blood moves through into the right atrium (this is where the heart muscle works very hard to eject blood through to the systemic circulation (lower body) through the aorta (three branches) = where blood gets to your tissues and gives all the O2 away and picks up CO2 to be brought back and circulated again
- valves are like little doors and prevent backflow of blood through the system = a closed system, blood should be moving in one direction
- when there is a dysfunction in the valves, blood can move backward = regurgitation, which causes dysfunction in the heart over time
- coronary arteries come out of the aorta that goes into your neck = where we can diagnose coronary artery disease (build-up of plaque in the coronary arteries)
- electrical conductance of the heart: specific nodes and sinus nodes = messenger system of the heart muscle and tell the heart to relax and beat = sequential movement of the heart/rhythm
Dysfunction with these nodes can cause irregularities in heartbeat and rhythm = further heart disease
9
Q
What are two big players in heart disease?
A
- coronary artery disease (CAD)
2. hypertension
10
Q
What is coronary artery disease (CAD)?
A
- caused by atherosclerosis (progressive thickening of plaque on the blood vessels)
- healthy lumen of an artery is very pinkish and smooth, as plaque builds up
First step: fatty streak, can be removed but if you have a genetic predisposition, poor dietary habits, or comorbidities then you will see plaque progress to,
Second step: fibrous plaque: can start to see plaque build up on several different organs and even on the heart
Third step: advanced plaque = complete occlusion Thrombus = heart attack, stroke - comorbidities can affect blood vessels: there are a lot of channels that help with constriction and relaxation, therefore when the vessel is diseased, the vessels don’t relax and explain as they should = rigid/constricted state and is where plaque loves to build-up
11
Q
What are some risk factors of Atherosclerosis?
A
- accumulation of plaque
- production of less nitric oxide
- oxidized LDL cholesterol is taken up my macrophages
- formation of foam cells and fatty streaks
Comorbidities:
- smoking
- obesity
- hypertension
- elevated LDL cholesterol: not being moved and utilized by the body = builds up within your arteries
Atherosclerosis can happen in any vessel within the body
Coronary artery disease = accumulation of plaque buildup within the coronary artery (main artery), which distributes the main source of oxygenated blood to your entire body
- genes
- high saturated fat/cholesterol diet
- elevated serum triglycerides
- inactivty
- diabetes
- stress
- decreased HDL: important to have a normal range of HDL because it helps remove LDL so it doesn’t stick/transports LDL, reduces the risk of CVD, helps with the integrity of the blood vessel - maintains health and flexibility
- ageing
- hyperhomocysteinemia
- endothelial dysfunction
Lots of dietary factors can be intervened
12
Q
What are some clinical findings of atherosclerosis?
A
- elevated serum total cholesterol
- elevated LDL cholesterol
- elevated serum triglycerides
- elevated c-reactive protein
- low HDL
Remember that atherosclerosis is hard to diagnose if these blood values are not elevated and even if they are elevated we can’t say for sure that the person has it unless done with ultrasounds or tools looking for plaque
13
Q
What are non-modifiable risk factors of atherosclerosis?
A
- genetics/ family history
- increasing age
- sex (males more)
- race
14
Q
What are modifiable risk factors of atherosclerosis?
A
- type 1 diabetes (can reduce your risk if you have controlled T1D)
- high blood pressure
- high LDL
- low HDL
- high blood pressure
- uncontrolled hypertension = significant risk because of the vessels surrounding the heart, mico vessels = very serious that needs to be controlled
- dyslipidemia (unhealthy levels of fats in the blood) found from a lipid profile
- obesity
- physical inactivity
- smoking
- unhealthy diet
15
Q
Why are lipoproteins important?
A
- lipids are transported via lipoproteins, which are composed of a lipid interior and protein shell
- important to see how much LDL and HDL is in each type of lipoprotein - cholesterol, triglyceride, phospholipid, apolipoproteins = want VDLD and LDL to be lower and HDL higher
- different types of lipids can have densities of different lipoproteins within each one
16
Q
What are some lipid profile targets for dyslipidemia?
A
- dyslipidemia = elevated total or LDL levels
- we want an LDL-C consistently < 2.0 mmol/L
- or >50% reduction of LDL-C when treatment is begun
- alternative target variables are non-HDL-C <2.6 mmol/L
- > 50% reduction in LDL-C for patients with LDL-C >5.0 mmol/L and have begun treatment = decreases the risk of CVD events and mortality
17
Q
What are some diagnostic tests for atherosclerosis?
A
- blood and urine tests are most commonly done to see if the patient is at risk for atherosclerosis
- Doppler ultrasound is used often, one of the best tools
- ECG/EKG
- angiography: going through one of the leg or arm arteries, put a catheters through the heart to access if there’s plaque buildup
- heart MRI
18
Q
What is the nutrition therapy for atherosclerosis and CAD?
A
- focus on dietary patterns, ex. prescribing the Mediterranean diet and individualizing the diet for the patient: low in saturated and trans, high in unsaturated fat, high starch and fibre, evidence that it lowers the risk of CVDs
- portfolio diet
- DASH diet
- dietary patterns high in nuts, legumes, olive oil, F&Vs, total fibre, - low glycemic load/index
- vegetarian
19
Q
What are the differences in dietary fats?
A
- there’s 9 cals for every gram of fat no matter the type but the quality of the fat is what is important
Monounsaturated fat (MUFAs)
- positive health effect with CVD
- reduced mortality
- reduced CAD risk
- reduced stroke risk
- increased vascular function
- does the opposite of trans and saturated fats
- sources: olive oil, canola, peanut, sunflower, and soybean oil, avocado, peanut butter, almond butter, nuts and seeds, low G.I, whole grains
Polyunsaturated fat (PUFAs): omega 3 & 6 FAs
- mixed PUFA sources = sources with a combination of omega 3 & 6, ex. fatty fish (salmon, mackerel), eggs, flaxseeds, walnuts, soybeans, tofu,
- omega 6 (linoleic acid) sources: sunflower oil, safflower oil, corn oil, soybean oil, nuts and seeds, grains
- omega 3 (linolenic acid, EPA/DHA) sources: flaxseed oil, walnut oil, canola, nuts and seeds, fatty fish, fortified foods
- omega 6 gets a bad wrap since there’s a higher consumption (soybean and corn oil heavily used) when compared to omega 3
- talk to your patients about where they are getting their sources from, how much, and council accordingly
Saturated Fats
- decreasing intake can help reduce the risk of CVD
- research is a bit mixed right now, some people say saturated fats should not be completely eliminated from the diet
- sources: cheese, coconut oil, red meat, chicken with skin, butter, high-fat milk, palm oil, palm kernel oil
- recommend: leaner meats, cooking chicken without the skin, lower-fat dairy products, mindful of your consumption with oils
Trans Fats
- detrimental to the entire vascular system when eating a high trans-fat diet = plaque build-up & fatty streaks, leads to CVD
- increases LDL-C and blood lipids
- decreases HDL
- sources: chips, fries, hydrogenated oils, baked goods, icing, coffee whiteners, vegetable shortening, hard margarine
- trans fats come from hydrogenation of polyunsaturated FAs by taking vegetable oils or fats that are liquid at room temp and go through a chemical process to become solid at room temp
- WHO recommends <1% total energy should come from trans fat in the diet
- educate your patients about which food sources has trans fats and the effects it has on their body
20
Q
What are the recommendations for saturated fat?
A
<9% total energy to help maintain a healthy LDL cholesterol and reduce the risk of developing CAD or hypertension
21
Q
What happens when you replace saturated fat with unsaturated fats?
A
- you can see a 1% decrease in dietary saturated FAs
- 2% decrease in blood LDL and heart disease risk
22
Q
How to suggest dietary patterns to lower LDL
A
- dietary patterns high in pulses >1 serving/day or >130g/day
- low glycemic index
- DASH diet
- Portfolio
- each patient is different and collaborative
23
Q
What are the differences between soluble and viscous soluble fibre?
A
- soluble fibre: creates a gel inside the body which slows transit time, recommended in diabetes because it slows the spike in insulin
- viscous soluble fibre: creates more of a gel-like consistency ex. oats, barley, flax seeds
the gelling can help bind to fats and cholesterol and helps to excrete cholesterol - we don’t get energy from fibre since it goes right through the body
- insoluble fibre creates roughage, helps move things a lot faster
24
Q
What are plant sterols?
A
- naturally occurring in some food sources
- have a similar structure to cholesterol
- body does not absorb it well
- can lower serum LDL and total cholesterol levels
25
What are recommendations for omega 3 FAs?
- include fatty fish in a meal two or three times a week
- better health benefits if fish is grilled, baked, boiled
- plant sources include flaxseed, flaxseed oil, canola, soybean oil, and nuts
26
Are fish oil (EPA/DHA) supplements recommended?
- for CVD prevention: not recommended because it shows no benefit to preventing CVD
- for CVD management: 800-1000 mg EPA/DHA is recommended for:
patients with CAD
at risk for sudden cardiac death
high triglycerides
27
What is hypertension (HTN)?
- when your blood pressure, the force of your blood pushing against the walls of your blood vessels is consistently too high
- doesn't mean you have dysfunction with your heart
- focuses on the vessels and the force it takes for blood to be pushed through your vessels
- if the blood going through your vessels has some resistance, your heart works harder to get that blood to where it needs to go = increases force and causes pressure on the vessels, over time can lead to plaque build-up and might not dilate and constrict as they should
- over time the heart muscles can become enlarged from working harder to push the blood in the right direction
28
What is systolic and diastolic blood pressure?
- systolic: the force at which blood is pumped out of the heart (out of the left ventricle)
- diastolic: pressure in blood vessels when the heart is at rest (in the vessels, not the heart itself)
- stage 1 hypertension: anything above systolic mm/Hg 130-139 or diastolic 80-89
high blood pressure has to be diagnosed over 3 doctor visits
verbal recommendations to improve blood pressure
high blood pressure on third visit = maybe put on meds
- stage 2 hypertension: 140 or high systolic, 90+ diastolic
put on meds
recommend lifestyle changes
- hypertensive crisis: higher than 180 systolic, 120+ diastolic = high risk for a heart attack
- elevated blood pressure: anything above systolic 120-129 or diastolic 80-89
- normal blood pressure: less than 120/80
29
What are the two pathophysiologies of hypertension?
1. primary/essential: idiopathic (relating to any disease which arises spontaneously where the cause is unknown) but influenced by lifestyle factors and inflammatory response
most individuals fall under this category
2. secondary hypertension: the result of another chronic condition
ex. if the patient has a renal disease they could develop hypertension
30
What are the factors that influence arterial blood pressure?
- Mean arterial blood pressure: pressure in our arteries
- heart rate and stroke volume (amount of blood/volume that's ejected from your left ventricle on each pump of your heart) affect cardiac output
- parasympathetic activity, sympathetic activity and epinephrine, and venous return have an effect on stroke volume and heart rate
- blood volume and respiratory activity affects venous return
- if you have secondary hypertension there are many factors that can influence the parasympathetic/sympathetic systems as well as your blood volume and respiratory activity
- Total peripheral resistance: blood flow offered by all of the systemic vasculatures, excluding the pulmonary vasculature, can be affected by blood viscosity (consistency of blood) and arteriolar radius
- Vasopressin and angiotensin II: blood vessel constrictors, when there's an increase in sympathetic activity, we might see more circulating levels of Vasopressin and angiotensin II = causes more constriction in the arteries, which increase resistance the blood is seeing when going through the arteries
- therefore factors that influence arterial blood pressure can come from components that affect the heart and how the blood vessel functions
31
What are factors that influence blood pressure?
- 90 - 95% of hypertension cases are caused by unknown circumstances
Non-Modifiable risk factors:
- increasing age: your vessels become more used, more prone to comorbidities
- genetics/ family history: a huge determinant of hypertension
Modifiable risk factors:
- high LDL
- low HDL
- alcohol
- diabetes
- obesity
- physical inactivity
- smoking
- unhealthy diet
32
What is a comprehensive treatment of HTN?
- want to focus on physical activity and dietary intake, reducing sodium intake
- most individuals are on two or more meds
- dietary approach: DASH, sodium restriction, potassium intake
33
What are drug therapies for HTN?
- Diuretics: Hydrochlorothiazide (HCTZ) & Indapamide (soft diuretic): problem with hypertension is there is an increased blood volume because of the amount of blood that needs to be forced through for adequate delivery to organs and tissues. Therefore diuretic drugs decrease the blood volume within the arteries by urinary excretion through the kidneys, water, and sodium reabsorption
Food interaction: want to avoid natural black licorice and grapefruit because it affects the mechanisms of the meds
- Vasodilators: Angiotensin-converting enzyme (ACE) inhibitors - Enalapril, Perindopril.
Food interaction: can cause dry cough, hyperkalemia (potassium level in your blood is higher than normal)
- Angiotensin receptor blocker - Candesartan, eprosartan, irbesartan, valsartan, losartan. A sympathetic nervous system feedback loop that helps with blood volume. Interferes with one of the points of the feedback system
Food interaction: Avoid natural licorice and grapefruit, salt substitutes (use potassium salt, which can increase your blood potassium and cause hyperkalemia)
- Calcium channel blockers: Amlodipine (Norvasc), Diltiazem, Verapamil.
Food interaction: can cause nausea, heartburn. Avoid licorice, limit caffeine, avoid/limit alcohol
34
What is the DASH study?
- randomized control trial
- looked at three groups of diet
- the DASH diet + sodium reduction is the best way to reduce blood pressure
- DASH = low in saturated fat, cholesterol, total sat, and sodium
35
What 3 foods contribute most to high sodium intakes?
1. bakery products 20%: Canadians eat a lot of bread
2. mixed dishes: frozen and non-frozen 19%
3. processed meats 11%
36
Which 2 groups are the biggest sodium consumers?
1. kids: based on what their caregivers are feeding them
| 2. males: consume more than women
37
What are tips to reduce sodium intake?
- use herbs and spices instead
- homemade baked goods
- make own sauces
- low sodium sauces
- watch out for takeout soups: look at menus online before ordering food to see sodium amounts
- ask for sauce on the side when eating out
- choose fresh, frozen or canned
- use fresh poultry, fish, and lean meat, rather than canned, smoked or processed
- rinse canned foods such as tuna and canned beans to remove sodium
38
What has changed in the new nutrition labels in Canada?
- made calories & serving size bigger to read
- added new percent daily value for sugars because there are a high intake of sugars and to be mindful of added sugar
- nutrients at the bottom changed: vit A and C are not shown because we get enough in our diet. Calcium and iron stayed and potassium was added for heart health/blood pressure
- percent daily value for sodium, a footnote at the bottom helps them avoid 15% or more of sodium in a product
39
What are some HTN dietary recommendations regarding potassium?
- patients who are taking certain meds (renin-angiotensin) that inhibit the excretion of potassium can be at an increased
risk of hyperkalemia (high potassium levels, serum potassium concentration above 3.5-5 mmol/L)
- if the patient has chronic kidney disease plus taking meds or uncontrolled blood sugars = rise in potassium
- recommended to consume at least 3000 mg potassium per day, the target of achieving adequate intake level of 4700 mg UNLESS patient is at risk for hyperkalemia
- focus on fresh fruits and vegetables and whole grains = good way to increase potassium if needed, because potassium helps decrease blood pressure
40
What are some dietary sources of potassium?
excellent sources:
- potato, small baked
- Lima beans, boiled
- dried apricots
- bananas
- avocados
- legumes
- dark leafy vegetables
A lot of these foods are part of the DASH diet
41
How much alcohol can one consume when managing hypertension?
- Men: no more than 2 drinks
- Women: no more than 1 drink
- alcohol has an effect on your blood vessels, which affects blood pressure
42
[Case study] during a grocery store tour what would you advise in the produce aisle?
- eat the rainbow, different colours = different nutrients
- aim to eat min 1 green and 1 orange veg per day
- fibrous plants can help reduce cholesterol (brussels sprouts, broccoli, kale)
- aim for 1/2 plate and half of your cart of veggies
43
[Case study] during a grocery store tour what would you advise in the cheese aisle?
- the harder the cheese the saltier it is
- soft/fresh cheeses have lower sodium
- milk fat is at the front of a cheese label, look for milk fat <30%, depends on the patient and can reduce to 20%
- aim for <8% daily value of sodium
- mozzarella, swiss, bocconcini, and brie have less sodium
- the only difference in light cheeses is there's more skim milk rather than whole milk = less fat and reduced saturated fat, but sodium remains the same
44
[Case study] during a grocery store tour what would you advise in the cooking sauce and marinades aisle?
- recommend sauces that are less than 15% sodium per serving
45
What are some facts about the kidney?
- adult kidney weighs about 142 grams or 5 ounces = size of a fist or a small cellphone
- kidneys have a higher blood flow compared to the brain and liver
- there are 2 million nephrons in your body with healthy kidneys, about 8km (5 miles) long
- make sure to hydrate, the most common cause of kidney stones is not drinking enough water/liquids. The largest kidney stone was the size of a coconut, weighed 1.1 kg (2.5 lbs)
- the kidneys pump around 1,515 Ls (400 gallons) of blood every day
46
What is the physiological functioning of the kidney?
- the kidneys lie in the lower abdominal cavity, on its rear wall
- adhering to the surface of each kidney are two layers of fat to help cushion them, they have to be well protected
- the kidneys are located at the rear wall of the abdominal cavity just above the waistline and are protected by the ribcage. They are considered retroperitoneal = they lie behind the peritoneum (the tissue that lines your abdominal wall and covers most of the organs in your abdomen)
- the renal artery connects the kidneys to the aorta, while the renal vein connects the kidneys to the inferior vena cava
- the adrenal glands lie superior to the kidneys
47
What is a nephron?
- the most important part of the kidney
- each of your kidneys is made up of about a million filtering units = nephrons
- each nephron has a glomerulus to filter your blood and a tubule that returns needed substances to your blood and pulls out additional wastes
- Loop of Henle: long U-shaped portion of the tubule that conducts urine within each nephron of the kidney. The principal function = recovery of water and sodium chloride from urine
Loop diuretics decrease the reabsorption of sodium and chloride ions in the thick ascending link of the look of Henle
48
What are the 5 stages of kidney decline?
Stage 1: normal function
Stage 2: mild loss of function
Stage 3: moderate loss of function
Stage 4: severe loss of function
Stage 5: kidney failure
49
What is chronic renal failure (CRF)?
- an irreversible disease of not only glomerular and tubular function but also endocrine renal function
- doctors and nephrologists can quickly pick up signs and symptoms of CRF in early-stage kidney decline
50
What is the incidence of chronic kidney disease (CKD)?
- approx 10 cases per 100,000 people
- in industrialized nations alone tens of thousands of people are dependent on dialysis because of the widespread contributory causes of chronic kidney failure in these countries
51
What is the most common cause of CKD?
- diabetic nephropathy is 30 to 40% of cases
- approx 20% live with hypertensive nephropathy
- glomerulonephritis is responsible for almost 15% of cases and primarily affects younger people
- polycystic kidney disease and tubulointerstitial nephritis are each responsible for approx 10% of cases
- congenital obstructive urinary flow disorders, chronic recurrent nephrolithiasis, or amyloidosis can permanently damage the kidneys and lead to CKD
52
What is acute kidney disease?
- sudden and temporary loss of kidney function
- can develop rapidly over several hours or days
- occurs in those who are critically ill or already in the hospital, or alcohol and drug abuse
53
What are some examples of problems that can cause direct damage to your kidneys?
- blood clots in or around the kidneys
- diseases that affect the kidneys, glomerulonephritis or lupus
- certain meds, chemotherapy drugs, some antibiotics, contract dyes during CT scans, MRI scans and other imaging tests
- alcohol or drug abuse
- some blood or blood vessel disorders
54
What is compartment syndrome?
- when the pressure within a compartment increases, restricting the blood flow to the area and potentially damaging the muscles and nearby nerves
- usually occurs in legs, feet, arms, or hands
- when the body does not move for a long period, the blood pools in the area of most pressure, at the hospital, have to open up that part of the body to let the pressure/swelling out
- acute
55
What is the pathophysiology is kidney disease?
- patients with stages 1-3 of CKD = generally asymptomatic, electrolytes are okay
- stages 4 to 5 you can clinically see something is wrong:
Generalized edema: swelling, check for pitting edema in the shins
Pulmonary crackles: shortness of breath because there's fluid around the heart and lungs
Anemia: erythropoietin is decreased (a hormone that produces red blood cells in the bones)
Weight loss: too much urea, your body cannot metabolize protein properly
Hyperkalemia: because of the retention of potassium in the body, kidneys cannot secrete potassium in the urine = life-threatening arrhythmias
Hyperphosphatemia: damaged kidneys fail to excrete phosphate
Hypocalcemia: secondary to low vit d3 lvls. early stages of CKD = low levels of calcitriol are due to hyperphosphatemia (negative feedback loop)
Secondary and tertiary hyperparathyroidism
56
What are the complications of uremia?
- uremia is a toxin that accumilates in the blood and takes a long time to get out = life threatening issue:
- Ecchymosis, bleed of the GI track
- Pericardial friction rub, chest pain, headaches, confusion
- Sodium balance: sodium retention and volume overload is treated with sodium restriction diuretics
- Potassium excretion: hyperkalemia (high potassium levels) treated with dietary restriction and avoiding NSAIDs (Non-steroidal anti-inflammatory drugs)
- Acid excretion: metabolic acidosis (serious electrolyte disorder) is treated with sodium bicarbonate (baking soda) in tablets or powder
- Calcium/phosphate balance: when phosphate and PTH (parathyroid hormone) increase and serum calcium and calcitriol (the active form of Vit D) decreases because your kidney can't activate it anymore
- Erythropoiesis (a process that produces red blood cells/erythrocytes). Anemia is treated with iron supplements: stages 3 and below are not counselled about increasing iron because it can't be processed anymore, IV iron is given
57
How is CKD treated?
- Cardiovascular disease (CVD) is the leading cause of death in patients with CKD
- treating hyperlipidemia (blood has too many lipids/fats): recommending sing fish oils and olive oil, get cholesterol down eating soluble fibres
- tight blood pressure control: reducing damage due to the end-organ effects of hypertension on the kidney and heart. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARBs) slow down the progression of proteinuria (increased levels of protein in the urine) in patients with diabetic CKD
- diabetes management: right glucose management slows the progression of vascular and heart disease
- on hemodialysis (used to clean the blood), we want blood sugars to be below 10, but not lower than 4
- Diet: most patients, esp stages 3 and 4, are not eating enough protein, protein affects the renal hemodynamics, there could be pressure inside the glomerulus bowl, but we don't give many protein restrictions
- have to control hyperphosphatemia (serum phosphate concentration >1.46 mmol/L
58
How can I tell if I have kidney disease?
- early kidney disease usually doesn't have any symptoms. Testing it is the only way to know how well your kidneys are working.
- Get checked if you have: diabetes, high blood pressure, heart disease, family history = get tested every year
59
What is the lab evaluation of kidney function?
- GFR (glomerular filtration rate) results show whether your kidneys are filtering at a normal level. Measure of your creatinine (substrate your kidneys filtrates daily), age, race, and gender to see how well your kidneys are working
- 0-15 GFR = kidney failure
- 15-60 = kidney disease
- 60-123 = normal
- a healthy kidney does not let albumin pass into the urine, therefore a damaged kidney will let some albumin (proteins) pass into the urine, see a lot in diabetes from excess sugar going through
60
What are the acid-base buffering systems of the body?
- the body has a very large buffer capacity
- doctors are always looking at the bicarbonate level
- Buffer: a solution containing substances that have the ability to minimize charges in pH when the acid or base is added to it
- there are 3 buffering systems:
1. the lungs assist in maintaining a constant blood pH by removing CO2, breathing it out
2. while the kidney excretes acid in the form of H2P04 and NH4 (ammonia) and alkaline in the form of HCO3 (bicarbonate)
3. the most important role = bone buffers, only in metabolic acidosis and not respiratory acidosis. The carbonate and the phosphate salts in the bone act as a long term supply of suffering, especially during prolonged metabolic acidosis
61
What are inorganic hydroxyapatite crystals?
- the matrix is composed of organic (collagen and other proteins in ground substance) and inorganic hydroxyapatite crystals. This allows minimizing the disturbance of metabolic acidosis (serious electrolyte disorder)
- inorganic hydroxyapatite crystals makeup two thirds of the total bone volume but are extremely small and have a huge total surface area
- kidneys remove h+ ions and other components of the pH buffers that build up in excess
- acidosis that results from failure of the kidneys to perform this excretory function = metabolic acidosis
- the bones take over some of the components of getting rid of and balancing the acidosis when the kidneys are failing
62
What can cause chronic kidney disease?
- damage to the kidneys can happen suddenly in some cases due to traumatic events such as an injury or a viral infection
- CKD is a condition that results in a loss of kidney function over time. The two most common causes of CKD = 1. diabetes, 2. high blood pressure which accounts for two-thirds of all cases.
- Diabetes affects blood sugar levels and over time damages many organs including the kidneys
- high blood pressure increases the force of blood against the walls of the blood vessels = more damage
- some ethnic groups are at increased risk: African America, Hispanic, and Native Americans are considered to be at more risk due to higher levels of diabetes, high blood pressure, and obesity
- family history increases the risk of CKD
- overuse of pain meds: ibuprofen
- excessive intake of alcohol or drug abuse
63
What is acute chronic kidney failure?
- preventable
- found in El Salvador and Nicaragua, sugar cane workers who work long hours in extreme heat
- disorder called CKDnT: Chronic Kidney Disease nephropathy tubulointerstitial which is not related to traditional causes such as hypertension and diabetes
- affects young male agricultural workers
- CKDnT = tubulointerstitial nephropathy with low-grade proteinuria (increased levels of protein in the urine), which has a long subclinical period that tends to progress to end-stage renal disease in a short time
- the workers are dehydrated and eat sugar during work because it is easily available and they don't get to go to the washroom as much as they should = type 2 diabetes and quick onset of chronic kidney failure
64
After the kidney fails, what are three treatments?
1. peritoneal dialysis (PD)
- patient's peritoneum (the tissue that lines your abdominal wall and covers most of the organs in your abdomen) is used as the dialysis membrane
- this natural organ filters the toxins and excretes waste from the body
- the peritoneum has two layers that come together to form a pocket called the peritoneal cavity
- fluid is instilled into the peritoneal cavity using a peritoneal catheter (implanted by the surgeon into the abdominal wall). It's important to know the BMI of the patient because if the surface area of the person is too large the PD catheter will not work. Over 40 BMI is very tricky and body composition is important in terms of where the actual obesity is
- the dialysis fluid is instilled into the cavity by either gravity (CAPD) or a machine called a cycler (CCPD) (more common because it can be connected at night)
- the fluid is left in for several hours, during that time, waste materials and excess fluids pass through the membrane and are then drained from the cavity via the peritoneal catheter
- no needles involved in PD
- CONS: requires home supplies and storage space, the risk for infection, and requires dialyzing daily
Complications: peritonitis and encapsulating peritonitis
- PROS: can use it anywhere
- almost everyone can use this but need dexterity and memory to be trained how to use it and is better to have someone around to help
2. hemodialysis (HD): in-center HD, home HD, and nocturnal HD (while you're sleeping)
- medical treatment where an artificial filter outside the body is used to clean the blood
- an access is needed to remove blood from the body to the machine which is attached to the artificial filter
- two needles are needed for HD. One is to remove the blood through access to the machine for filtering. Another needle is needed to return the filtered blood back to the body
- can be done through the arm with a central venous line or around the chest area
- government is trying to regulate that it's 30% home HD and PD and 70% in-center HD
- HD is more expensive than PD
- PROS: home HD = indepdence and conveinence. Flexible scheduling compared to in-center HD, travelling is possible
- CONS: treatments are done during the day, frequent needles, need a partner/support person
- permanent access such as fistula or graft (material that the needle can penetrate to get into. Not the natural vein, superficial vein and artery, but messy to remove) is required
- greater risk for clots and infections
- can cause steal syndrome: fistula steals blood from the distal part of the hand because it can decrease the amount of blood flow to the hand, making it painful, cold, and pale
3. palliative care
- no dialysis/ conservative treatment to keep patient comfortable
- treatment may be HD or PD and is given as necessary
- part of the end of life therapy
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How many pills do HD patients approx take?
- the average is 19 pills per day
| - 25% of people on dialysis have over 25 medications per day
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What was the Mcintyre et al journal AJKD 2017 about?
- targeted deprescribing in an outpatient HD unit: a quality improvement study to decrease polypharmacy
- developed a deprescribing tool and implemented it in 240 HD patients while monitoring patient safety and satisfaction
- looked at 5 meds:
1. diuretics: get rid of salt in their diets
2. statins: cholesterol, patients have decreased energy, therefore need to make food prep exciting and easy 30 mins
3. quinine: for muscle aches and pains, reducing sodium in the diet, make sure their calcium and magnesium are within normal limits
4. alpha 1 blockers: fish oils, olive oils for heart health
5. proton pump inhibitors: ginger beer contains real ginger and can help with gas, reduce saturated fat in the diet to get off some of these PPIs
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How much salt do Canadians consume?
- 3,400 mg per day
- adequate intake is 1,500 mg/day
- tolerable upper intake is 2,300 mg/day
- the sodium reduction strategy: asking the food industry to voluntarily reduce the amount of sodium in 10 food groups
- 25g = slice of bread, 1 cube of cheese
- 45g 2/3 cup of granola
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What's the difference between salt and sodium?
- salt = sodium chloride
- sodium = dietary sodium
- conversions:
1mmol sodium = 23g sodium
1g sodium = 43.5 mmol sodium
1g salt (sodium chloride) = 390 sodium
1 tsp salt = 6g salt = 2,400 mg sodium = 104 mmol sodium
- patients can have 36-54.5kg (80-120 lbs) of fluid but their like expectancy is compromised
- in one session of HD can remove around 5 to 7 litres of fluid
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How much sodium do we need to survive?
- a 100mg per day, but it all depends on hydration
- water accounts for about one half to two-thirds of an average person's weight
- fat tissue has a lower percentage of water than lean tissue and women tend to have more fat, therefore the percentage of body weight that is water in the average woman is lower (52 to 55%) than in the average man (60%)
- % of body weight that is water is lower in people who are older and obese
- stilt fishers in Sri Lanka = dehydration results in severe kidney damage
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What is potassium?
- a mineral and an electrolyte that the body requires to support key processes
- one of the seven essential macrominerals and plays a role in the function of the kidneys
- having too much or too little can result in complications that affect the kidneys
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What is hyperkalemia?
- high levels of potassium
- hyperkalemia may not produce symptoms for some people
- potassium levels of 6.5-7.0 mmol/L or higher can cause serious symptoms:
muscle weakness
abnormal heart rhythm
muscle paralysis
chest palpitations
- other causes besides CKD include diabetes (when you have high blood sugars, the cell membrane changes and allows potassium to come out, therefore as blood sugar rises so does the potassium) Don’t give patients orange juice because this adds more potassium, trauma, rhabdomyolysis, meds, excessive potassium intake
- seasonal diet changes to watch: summer tomatoes, fall pumpkin pie, winter potatoes and late spring strawberries = people eating too much of these and end up in the ICU due to too much potassium
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What happens with diabetes and hyperkalemia?
- happens when the patient has ketoacidosis
- the primary problem is the movement of potassium out of the cells even though the total body potassium may be reduced
- redistributive hyperkalemia most commonly occurs in uncontrolled hyperglycemia (diabetic ketoacidosis, hyperosmolar hyperglycemic state
- hyperosmolality and insulin deficiency are primarily responsible for the transcellular shift of potassium from the cells into the extracellular fluid, which can be reversed by the administration of fluids and insulin
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What’s important about bones?
- it’s built from scratch from ingredients from your blood
- governed by the glands in your head and it’s constantly breaking down and rebuilding itself over and over for as long as you live
- most new bones start as cartilage which is made out of specialized cells called chondrocytes
- in newly formed bones chondrocytes start dividing and secrete collagen (a protein that forms a cartilage model or framework for the bones) and soon blood vessels work their way into the cartilage and bring little cells called osteoblasts that build bone = ossification
- the matrix of the bone is where they are absorbing calcium and phosphate, with the help of enzymes secreted by osteoblasts from calcium phosphate with crystalizes to make your bone matrix
- two-thirds of your bone matrix is a protein like collagen and the other third is calcium and phosphate
- most of your bone isn't even mineral and the part that is living tissues
- even the hardest parts of your bones are alive
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What are some different types of bone?
- big flat plates that protect your brain
- tiny stirrups in your ear
- all bones have the same basic structure
- if you cut the bone in half, there are two layers:
1. cortical bone: outer part, hard and dense, makes up 80% of bone’s mass, 25% are channels of blood vessels
2. trabecular bone: middle, spongy, softer and more porous and contains the marrow and fatty tissues in the large bones
- the marrow makes new red blood cells and almost all your different blood cells are called hematopoiesis
- the largest bones house the blood stem cells that produce trillions of blood cells every day
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What happens to your bones over time?
- each year of your adult life about 10% of your skeleton is completely broken down and then rebuilt from scratch = remodelling
- the main players are osteoblasts and osteoclasts (bone breakers, destroys)
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What is bone remodelling?
- regulated by hormones that maintain the levels of calcium in your blood
- the parathyroids are found in your neck right beside big arteries and veins
- when calcium in your blood plasma falls below the levels of homeostasis, the parathyroid triggers osteoclasts to take calcium from your bones and release it back into your blood
- when blood calcium levels are too high the thyroid gland signals osteoblasts to take out the blood and lay it down on the bone collagen through more ossification
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How does negative feedback maintain strict regulation?
- your blood sugars are controlled by a negative feedback mechanism, should be between 4 and 7 mmol/L, if it does below 4 or above 7, your body has a hard time adjusting to regain homeostasis
- your parathyroid glands (PTH) fight to keep calcium where it should be in your bones and not in your blood vessels to make them hard and not calcify
- your thyroid gland plays a minor role
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Simplified overview of bone and mineral metabolism in CKD-BMD (Bone Mineral Disorder)
- when phosphorous goes up because your kidneys are not working, you can't pee out the extra phosphate and is instead absorbed by the small intestine and goes back into your blood
- when your kidneys are impaired, your vit D levels drop (a healthy kidney activates vit D to its active form which is essential for GI calcium absorption
- calcium levels go down because it's not absorbed in as much as it should in the gut
- PTH goes up because negative feedback is going out of control. PTH stimulates cone reabsorption of calcium (adaptive response to low calcium) and release of phosphorus from the bone
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What happens when PTH is elevated?
- PTH excess = increased osteoclastic activity with cone resorption
- cortical and trabecular bone is lost and replaced by loose connective tissue
- in some instances collections of osteoclasts, reactive giant cells in the long bone, and hemorrhagic debris from a distinct mass, termed brown tumours of hyperparathyroidism
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What's the difference between inorganic and organic phosphate?
- inorganic phosphate: fast food, soda, sports drinks, convenience foods, processed cheese, snack bars
- organic phosphate: animal, meat, poultry, fish, dairy, eggs planted based, grains, nuts/seeds, legumes, F&Vs
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What are hidden sources of phosphorus?
- food additives
- pH regulators
- stabilizers
- flavour/colour enhancers
- 50% more food additives from 1990 to 2005
- poor labelling of phosphorus content
- phosphorus in meds
- phosphate >1.4 mmol/L = poison to the bone and vascular systems ex. switch coca-cola (72.2 mg 1.2 cups) for gingerale 0 mg, remove cheese slice 135mg or use cream cheese 15mg/t tbsp, switch Ritz cheese crackers 200 mg with non salted crackers 70mg
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What are phosphate binders?
- medications used to reduce the absorption of dietary phosphate
- used in people with CKF who are less able to excrete phosphate = elevated serum phosphate
- ex. PhosLo, Phoslyra - calcium, acetate 1500 mg/day
- get the phosphate binder in the stomach to bind with Tums after a few bites of food = binds as much phosphate as possible
- Fosrenol - lanthanum carbonate, heavy metal, doesn't linger long in the long bones or the brain
- Renagel - sevelamer HCL, not for patients with GI problems
- Velphoro - sucroferric oxyhydroxide, iron-based, new on the market
- timing of the meds is very important and has to be taken with meals - phosphate binder needs to bind before it gets to the small intestine
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KDIGO nutrition recommendations (Kidney Disease Improving Global Outcomes)
- energy guidelines for CKD predialysis & HD is 30-35 kcals/day
- PD is higher 35-40 kcal/day per ideal weight
- for overweight patients: must calculate the fluid and take into consideration the BMI close to obesity
- protein: CKD predialysis 0.8 -1.0 g/day ideal body weight
HD 1.1-1.3 g/day
PD 1.2-1.3 g/day - PD patients lose protein every day
- BMI is used: anything under 20 = malnourished state, 20-29 = good place for patients
above 30-35 = cautious of reducing to under 30 when calculating energy cals
42-52 not calculating weight at the point, bring it down to a BMI of at least 35
- BMI is factored into the calculation for ideal body weight = basing off of where you want their BMI to be
- proteins and lipids are calculated first, then carbs are calculated
- carbs promote inflammation and infection, so it's important to reduce the amount and have more cals come from protein and fat (mixed fat - olive oil, soybean, fish oil)
- fat for all categories = 30-35 g/day, healthier fats help the liver
- fluids: no restrictions for predialysis unless they are eating a lot of salt
- HD = 1000ml + urine output
- PD = usually no fluid restriction unless you are fluid overloaded
- phosphate: all categories = 800-1000mg/day
- calcium: predialysis 1000-1500mg/day
HD = 2000mg/day, max with 1500mg from binders, calcium can calify the arteries
- magnesium: all categories 200-300mg/day, need to make sure magnesium is at least 1.0 because a lot of cardiac events happen when magnesium is low
- sodium: all categories 1500-2300mg/day, PD = 2000-3000, if patient had conjestive heart failure = catious about adding more sodium to diet
- potassium: all categories 2000-3000mg/day but adjust with certain meds such as Coversyl a heart and blood medication = adjust diet lower than 2000mg because potassium will go up with this med, more restrictive with HD, on predialysis patients are on a lot of water pills to get rid of fluids
PD patients don't have to watch their potassium too closely, but good to check up once a year
- fibre = 40-45% of cals from carbs should come from whole grains
20-30g of fibre
PD = catheter is put in the abdominal area and is pushing against bowels and causes pressure = constipated more frequently
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What are some low potassium fruits?
- apples, apple sauce
- apricots
- berries
- cherries
- clementine
- dried apples
- grapes
- kiwi
- lemons, limes
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What are some high potassium fruits?
- avocado
- banana
- cantaloupe
- dried fruit: raisins, dates
- honeydew
- mango
- orange juice, pomegranate juice, prune juice
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What are some low potassium vegetables?
- alfalfa sprouts
- asparagus
- canned bamboo shoots
- celery
- corn
- cucumber
- lettuce
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What are some higher potassium vegetables?
- acorn squash
- artichoke
- edamame
- beans
- beet greens
- Brussel sprouts
- pumpkin
- tomatoes
- double boiling takes the most potassium out of vegetables
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What is the phosphorus pyramid?
- dietary tool for phosphate management in dialysis and CKD patients
- top = processed foods
middle = meat and fish, grains and veggies
bottom = oils, veggies, eat more often
- spinach becomes higher in potassium when it's cooked because it is denser
- inorganic food additives have more absorption of phosphorus 95 to 100% absorbed
- organic = 20 to 60% absorbed
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What is IDPN?
- Intradialytic Parenteral Nutrition
- intravenous infusion of essential nutrients given during HD
- recommended for 3 months in acute care durations and may become a chronic nutrition intervention in some cases
- IDPN is infused into the venous medication port at the extracorporeal circuit
- safe and convenient way to replenish protein and energy stores
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What is a bedside ultrasound?
- a practical and reliable measurement tool to assess quadriceps muscle later thickness (QMLT) pre and post IDPN treatment
- see the biggest change in the middle of the upper femur and biggest improvement in muscle
- 15g of carbs must be consumed after the dialysis unit since the pancreas is still producing a little bit of insulin and prevents rebound of hyperglycemia
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What is the three-step implementation of IDPN?
Step 1: survey malnutrition in your unit
Step 2: implement a standard practice of IDPN
Step 3: monitor patient and measurable outcomes: measuring sugars all the time
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When is it a good time to give nutrition on HD?
- when urea is the lowest because it is a chaotropic agent (disrupts hydrogen bonding in aqueous solution, unravels the tertiary structure of proteins by destabilizing internal, non-covalent bonds between atoms)
- need to stabilize and get the urea down so that the patient can start utilizing the protein
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Who can benefit from IDPN treatment?
- short gut patients
- chemo patients
- post-surgery
- SGA C patients: severely malnourished
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What is L-Carnitine?
- a chemical that is made in the brain, liver, and kidneys
- helps the body turn fat into energy, important for heart and brain function and muscle movement
- HD and PD patients have lower amounts of L-Carnitine, but in Canada, it is not supplemented
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What is the serum albumin pathway?
- there is no storage in the liver for albumin
- the body makes albumin daily ~15 - 16g/day in the nucleus to the ribosome - endoplasmic reticulum - Golgi apparatus - released by the hepatic cells
- size of serum albumin is quite large and keeps intervascular cells fluid in
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What is leucine?
- an essential amino acid used in the biosynthesis of proteins
- leucine can actually speed up the recovery process by increasing glucose intake
- leucine signals for insulin to be released from the pancreas without the presence of carbs
- leucine can have a positive two-fold effect on glucose uptake into muscle cells
