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Clinical Nutrition 3 > Renal Nutrition in ESRD - Part 1 > Flashcards

Renal Nutrition in ESRD - Part 1 Flashcards

1
Q

What are the two leading causes of kidney disease?

A
  • Diabetes

- Renal Vascular disease

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2
Q

_____ of new renal failure patients are 65 years or oder

A

53%

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3
Q

A person can lose more than ___ of their kidney function before symptoms appear

A

50%

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4
Q

When is dialysis indicated?

A

When GFR <15

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5
Q

(T/F) Dialysis fully performs the work of healthy kidneys

A

False, only partially

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6
Q

Dialysis replaces ____ of kidney function and does not _____

A

50%, reverse kidney function

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7
Q

3 main functions of dialysis

A
  • Clearing wastes (urea) from blood
  • Restoring electrolyte balance in blood
  • Eliminating extra fluid from the boydy
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8
Q

3 types of HD?

A
  • Intermittent
  • Nocturnal
  • Short-daily
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9
Q

Which HD are at the hospital?

A

-Intermittent, 3x/week and each session is 4 hours at the hospital

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10
Q

Types of PD?

A
  • CAPD

- CCPD

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11
Q

CAPD?

A

Continuous Ambulatory Peritoneal Dialysi

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12
Q

CCPD?

A

Continuous Cycle Assisted Peritoneal Dialysis

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13
Q

What is CRRT? Where is it done?

A
  • Continuous Renal Replacement Therapy

- Done in the ICU setting, 24 hours/day

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14
Q

Types of CRRT?

A
  • CVVH (Continuous venovenous hemofiltration)

- CVVHD (Continuous venovenous hemodialysis)

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15
Q

How does dialysis work?

A

Blood is removed from the patients artery, and will filter through the dialyzer - diffusion, osmosis and ultrafiltration will clean the blood, and then the clean blood is returned into the body.

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16
Q

3 mechanics of hemodialysis?

A
  • Diffusion
  • Osmosis
  • Ultrafiltration
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17
Q

3 components of hemodialysis?

A
  • Dialyzer
  • Dialysate
  • Water
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18
Q

Diffusion?

A

High to low movement which occurs across a semi-permeable membrane in the dialyzer

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19
Q

Osmosis?

A

Movement of water from low to high concentration

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20
Q

Ultrafiltration?

A

Removal of excess fluid

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21
Q

Which component allows for the mechanics of hemodialysis?

A

The dialyzer

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22
Q

What provides the semi-permeable membrane between the patients blood and the dialysate solution?

A

The dialyzer

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23
Q

What is the dialysate?

A

-Fluid containing physiological concentration of various soluties

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24
Q

K concentrations of dialysate?

A

0, 1, 2, 3,4

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25
Q

What is K2?

A

Less K+ will be returned back to the blood

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26
Q

What is K3?

A

More potassium returned to the blood

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27
Q

Why is it important that treated, purified water is used?

A

As patients are exposed to up to 120-180L of water per Tx

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28
Q

Patient with serum potassium >5 mmol/L? Which K concentration?

A

K2 as less will be returned to patients blood

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29
Q

When are patients weighed when on dialysis? What does this allow us to predict?

A
  • Patients weighed before and after
  • After = their dry weight, as all the fluids are removed, and we assume that the weight gained between sessions is fluid
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30
Q

What may we infer when there is greater than expected weight gain prior to dialysis?

A

The patient is not adhering to their fluid restriction

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31
Q

What is dry weight?

A
  • No fluid (euvolemic)
  • No signs/symptoms of dehydration
  • Goal weight-post dialysis
  • Used in determining how much fluid will be removed during dialysis
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32
Q

What is the fluid weight? What is the goal?

A
  • Weight accumulated between dialysis sessions

- Goal of 1 kg/day

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33
Q

When is fluid weight likely to increase?

A
  • When patients are not respecting their fluid restriction

- In stage 5, when nearly no urine output is occuring

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34
Q

What is the goal weight gain per day? What does this correlate with?

A
  • 1 kg/day

- 1 L of fluid = 1 kg

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35
Q

How can we determine if the patient is losing weight?

A
  • If there is no”accumulation of fluid”

- We may think either (1) they are not drinking enough or (2) they are losing lean body mass

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36
Q

How can we discriminate weight loss due to sub-optimal fluid intake and lean body mass loss?

A

Measuring blood pressure

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37
Q

If a patient loses body weight and their dry weight is NOT adjusted, what can we expect their BP to be?

A

-Expected to be higher, as we determing their fluid requirment per (kg), therefore if the patient has lost weight and it is not accounted for, we are overcompensating fluids and thus increasing blood pressure

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38
Q

Any less than ___ per day is suspect for weight loss

A

1 kg

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39
Q

What are the two types of access?

A
  • Central Venous Catheter

- Arterio-Venous Fistulas

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40
Q

What is the CVC?

A
  • May be used in the acute setting, less preferred
  • Catheter placed in the subclavian or the jugular
  • More prone to infection, less freedom with daily living
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41
Q

What is the AV fistula?

A
  • Preferred in the chronic patient, preferred and safer
  • The artery and the vein are anastomosed, and required needle access at every dialysis
  • Higher survival rates, and less infection
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42
Q

What is the caveat in AV fistulas?

A

-Aesthetically unpleasing due to “bumps” on arms, more patients opt for catheters

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43
Q

What is PD?

A

-Home therapy, where a sterile catheter is surgically implanted into the peritoneum

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44
Q

Mechanics of PD?

A

-After the sterile catheter is surgically implanted, a special dialysate solution is run through the peritoneal cavity to draw wastes out of the blood, then the fluid is drained

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45
Q

How does PD filtration work?

A
  • Gravity assisted bags
  • an exchange process of draining and filling (30-40 minutes) and dwell time of the solution in the cavity typically takes (4-6 hours) and needs 4 exchanges per ay
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46
Q

What are the nutritional implications of PD patients who carry 2-2.5L of solution per day in the peritoneum?

A
  • Reflux
  • Early satiety
  • Compression of organs
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47
Q

What will patients usually start on? How can they progress?

A
  • CAPD
  • Continuous Ambulatory Peritoneal Dialysis ( 4 exchanges/day)
  • Manual exchanges
  • Progress to CCPD which can bed done overnight if they are good candidates
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48
Q

What does CCPD stand for?

A

-Continuous Cycle-Assisted Peritoneal Dialysis

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49
Q

What is CCPD?

A
  • PD will occur during the night (automatic)

- 3-5 exchanges per night

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50
Q

caveat in CCPD?

A

Sometimes filtration during the night is not sufficient, and will need to supplement with CAPD during the day

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51
Q

What is the PD dialysate solution?

A

-Dextrose based, which acts to provide the osmotic pull

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52
Q

Dextrose concentrations available?

A
  • 0.5%, 1.5%, 2.5%, 4.25%

- Higher the concentration ,greater the osmotic pull

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53
Q

What kind of solution will be desirable if a PD patient requires more fluid removal?

A

Higher concentration of dextrose

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54
Q

Nutritional concerns with dextrose dialysate?

A
  • Consider kcals from dextrose absorption

- Hyperglycemia, medication adjustment

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55
Q

What happens over the long, term chronic exposure to the dialysate dextrose?

A
  • Sclerosing of the peritoneal membrane

- This will cause less efficiency of the dialysis, potentially requiring the patient to switch medications

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56
Q

Special solutions with less dextrose?

A
  • Nutrineal
  • Extraneal
  • Physioneal
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57
Q

What is nutrineal?

A
  • 1.1% amino acids with glucose polymers

- Good is patient is malnourished

58
Q

Extraneal?

A
  • Icodextran containing - 1/2 the calories of dextrose but same osmotic pull
  • Will by-pass the sclerosing effects of dextrose
59
Q

Physioneal?

A
  • Most biocompatible solution

- Less sclerosing of the P membrane

60
Q

When is less dextrose absorbed?

A

-From CCPD (overnight cycler)

61
Q

Amount of dextrose absorbed in CAPD?

A

60-70% absorbed

62
Q

Amount of dextrose absorbed in CCPD?

A

-40-50%

63
Q

What is PET?

A

The Peritoneal Equilibration Test

-Used to assess permeability of the peritoneal membrane

64
Q

What will give us the % dextrose absorption?

A

PET

65
Q

1.5% dextrose administered on CCPD, how much absorbed? How many kcal?

A

15 g

20-26 kcal/L

66
Q

4.25% dextrose administered on CAPD, how much absorbed? How many kcal?

A

42.5 g

87-102 kcal/L

67
Q

A patient is prescribed a 4 x 2L exchange.3 exchanges of 2.5% and 1 exchange of 4.25%, how many g of dextrose absorbed? How many kcals?

A

479-561 kcals

68
Q

Why may some people lose weight when they switch from PD to HD?

A

Not getting the same extra kcals from dextrose each day, and if they don’t increase their oral intake they may lose weight

69
Q

For energy, when is IBW used in PD calculation?

A

When BMI >30 (Obese)

70
Q

Each bag of PD is how many litres?

A

2 L

71
Q

What is a short dwell? Long dwell

A 
Short = 6 hours
Long = 8 hours
72
Q

% of AAs absorbed in Nutrineal?

A

60%

-1.1% aa solution

73
Q

Is dextrose absorbed in Nutrineal?

A

No

74
Q

% of icodextan in Extrarenal? % absorbed?

A
  • 7.5%

- 25%

75
Q

1 x 2L exchange of Extraneal is prescribes. How many kcals in one dwell period?

A

128 kcals

76
Q

Energy for HD and PD >65 y/o?

A

30 kcal/kg

77
Q

Energy for HD and PD = 65 y/o?

A

35 kcal/kg

78
Q

(T/F) We must consider kcals from dialysate in HD

A

False, in PD only

79
Q

(T/F) We must increased protein intake in PD

A

T, as the peritoneal membrane becomes more permeable, more protein losses which must be supplemented through diet

80
Q

Protein in HD?

A

1.2 k/kg/day >50% HBV

81
Q

Protein in PD?

A

1.3-.15 g/kg/day >50% HBV

82
Q

Phosphorus in HD and PD?

A

800-1200 mg/day

83
Q

Sodium in HD?

A

2000 mg

84
Q

Sodium in PD?

A

2000-3000 mg/day

85
Q

Why is sodium and potassium threshold more liberal in PD?

A

-PD is a gentler dialysis than HD, and PD patients are likely to have some kidney function left, thus will be able to filter some sodium and potassium

86
Q

The ____ function is preserved much better with PD compared to HD

A

residual

87
Q

Calcium in HD and PD?

A

<2000 mg/day

88
Q

Caveat in HD and PD regarding calcium?

A

-Upper limit it 2000 mg/day, but phosphate binders may provide 1500 mg, therefore leaving only 500 mg for dietary consumption

89
Q

Fluid HD?

A

1000 ml/day + urine output

90
Q

Fluid PD?

A
  • Likely these patients are still producing urine, and may even pose a risk for dehydration
  • Ultrafiltration + urine output
91
Q

(T/F) Protein requirements are only higher for PD

A

F, are higher for PD and HD, but highest in PD

92
Q

Serum urea goal in dialysis?

A

15-30 mmol/L

93
Q

How much AA lost across the dialysis membrane during each H treatment?

A

10-12 g of aa

94
Q

How many g of AA lost during PD? Peritonitis?

A

6-9 g/day

12-20 g

95
Q

Why is a standard multivitamin discouraged in renal patients?

A
  • We want to avoid over supplementing Vitamin A and Vitamin D
  • Normal formulations may be toxic as filtration decreases
96
Q

special MV supplements which are appropriate?

A
  • Replavite

- Diamine

97
Q

How can we attenuate excess phosphate, in attempts to meet protein requirement?

A

Meet the protein requirement even though it exceeds the phosphate requirement, and then add phosphate binders

98
Q

Which fruits contains a neurotoxin which can cause toxicity in patients at later stages of CKD or dialysis?

A 
Star fruit
Symptoms include:
-Persistant hiccups
-Vomiting
-Muscle weakness
-Muscle twitching
99
Q

Prevalence of malnutrition in CKD?

A

> /= 20-25%?

100
Q

Prevalence of protein-energy wasting in dialysis patients?

A

20-60%

101
Q

___ of hemodialysis patients die in the first 5 years after starting dialysis

A

2/3

102
Q

What are the two driving forces which lead to protein-energy wasting?

A
  • Uremia build up

- PD treatment

103
Q

How does uremia lead to PEW?

A
  • Inflammation
  • Hyper-catabolism
  • Chronic acidosis
104
Q

How does PD lead to PEW?

A
  • Loss of nutrients n dialysate
  • Appetite loss due to glucose absorption from dialysate
  • Abominable discomfort induced by dialysate
105
Q

How can we attempt to attenuate malnutrition in dialysis?

A
  • LIBERALIZE the diet if their potassium and phosphate is OK

- Then, proceed with supplements

106
Q

Two low potassium, phosphate, sodium and high protein supplements?

A
  • Nepro

- Novasource Renal

107
Q

What is IDPN?

A

Intradialytic Parenteral Nutrition

108
Q

How can we ensure the efficiency of ONS?

A
  • ONS should not replace meals, but should be given separately
  • ONS should be give during the dialysis session
  • Late evening ONS may be useful to reduce the length of nocturnal starvation
109
Q

When is IDPN usually admnistered?

A
  • Usually simultaneously while receiving dialysis

- Infusion on 3-in-1 solution providing 1200 kcal and 20 g of protein

110
Q

How many weeks does IDPN need to be administered to see a positive benefit?

A

20 weeks

111
Q

When is IDPN indicated?

A

When the patient is able to meet 50-60% of their daily requirements orally
-Try liberalizing the diet first, supplement then IDPN as a last resort

112
Q

(T/F) IDPN represents full nutritional support, and can meet total nutritional requirements

A

False

113
Q

Complications of IDPN?

A
  • Hyperglycemia
  • Rxn to IV fat emulsions
  • Post IDPN infusion hypoglycemia
  • Fluid overload
114
Q

When is IDPN not ideal?

A

Those on fluid restriction, as IDPN will add an additional 800 ml of fluids

115
Q

Why is it crucial for dialysis patients to limit their fluids?

A

As there is a certain limit to how much fluid the dialysis can remove

116
Q

What will drawing and removing excessive fluids from a patient increase the risk of?

A

Hypotensive episodes

117
Q

When do we want to evaluate bloods?

A

Before, to see how they are managing their diet

-> After dialysis, bloods should be normal

118
Q

High albumin?

A
  • Severe dehydration

- Albumin infusion

119
Q

Low albumin?

A
  • Fluid overload
  • Liver/pancreatic disease
  • Inflammatory Gi disease
  • Infection
120
Q

High sodium?

A
  • Dehydration

- Diabetes insipidus

121
Q

Low sodium?

A
  • Over hydration, starvation
  • Nephritis
  • Hyperglycemia
  • Diabetic acidosis
122
Q

Potassium range in HD?

A

<5.5

123
Q

Potassium range in PD?

A
  1. 5-5.0 mmol/L

- > Normal

124
Q

High potassium?

A
  • High intake
  • K bath (dialysate)
  • Meds (ACEi)
  • GI bleed, hyperG
  • Acidosis
125
Q

Low potassium?

A
  • Low PO intake
  • Vomiting, diarrhea
  • Meds
  • Ka bath (dialysate)
  • Alkalosis
126
Q

Urea goal in ESRD?

A

15-30 mmol/L

127
Q

High urea?

A
  • Poor dialysis clearance
  • Excessive protein intake
  • GI bleed
  • Dehydration
128
Q

Low urea?

A
  • Residual kidney function
  • Malabsorption
  • Low protein intake
  • Over hydration
  • Hepatic failure
129
Q

High creatinine?

A
  • Dehydration
  • Not enough dialysis
  • Muscle breakdown
  • High muscle mass
130
Q

Low creatinine?

A
  • Residual kidney function
  • Over-hydration
  • Low muscle mass
131
Q

Goal HgB in ESRD?

A

<120 g/L

132
Q

High Hgb?

A
  • Too much EPO

- Dehydration

133
Q

Low Hgb?

A
  • Iron deficiency
  • Not enough EPO
  • Blood loss
134
Q

Why is the goal Hgb in ESRD lower?

A

Because we want the blood to be thinner and less viscous to perform successful dialysis

135
Q

High calcium?

A
  • excess Vit D
  • Ca-based phos binders
  • High pth
136
Q

Low calcium?

A
  • Low albumin
  • Insufficient vit D
  • Post parathyroidectomy
137
Q

High phos?

A
  • High protein or phos intake
  • Inadequate binders
  • High PTH
  • Excess calcitriol
138
Q

Low phos?

A
  • Poor PO intake

- inadequate binders (too much)

139
Q

Goal PTH in ESRD?

A

15-65 pmol/L

140
Q

High PTH?

A
  • High turnover bone disease
  • High s. phos levels
  • Not enough calcitriol
141
Q

Low PTH?

A
  • Adynamic bon disease
  • Exces calcitriol -
  • Post parathyroidectomy
  • High s.Ca levels

Clinical Nutrition 3 (30 decks)

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