Renal Nutrition in ESRD - Part 2 Flashcards
What is CKD-MBD?
Chronic Kidney Disease Mineral Bone Disease
What is CKD-MBD characterized by?
- Abnormal levels of Ca, Phos, PTH and active Vit D
- Abnormal bone morphology
- Calcification of blood vessels and other soft tissues
What is renal osteodystrophy
- Abnormal bone morphology
- Calcification of the joints
What is metastic calcification?
The calcification of blood vessels and other soft tissues
Prevalence of renal osteodystrophy (RO)?
0More than 50% of patients with CKD by the time GFR <50 ml/min
What is the leading cause of RO?
-Hyperphosphatemia
What is metastic calcification?
The deposition of calcium crystals in soft tissues
Why does phosphate influence the crystallization of calcium?
PO4 will bind to Calcium, forming an insoluble precipitate, therefore high levels of PO4 can lead to metastic calcification and RO
What is calciphylaxis?
When blood vessels are calcified, and can develop severe ulcers and amputations
How must phosphate be controlled?
Almost always in excess in blood
- Diet
- Phosphate binders
- Dialysis
How much phos does dialysis remove/session?
800 mg
What is the phosphorus recommendation per day?
800-1200 mg day, which is very difficult to achieve with high protein requirements
What is organic phosphate? How much is typically absorbed?
From whole foods
50-60%
What is inorganic phosphate? How much is typically absorbed?
From food additives
100% absorbed
We will be focused on reducing phosphorus from food additives first
Discus the risk:benefit of lowering phosphate
- Lowering phosphate by decreasing protein intake may lead to increased death risk in HD patients
- Controlling phosphorus while maintaining high dietary protein intake may be associated with the best survival in HD patients
Organic plant protein phosphorus absorption and examples?
- Nuts, seeds, chocolate, beans
- 20-40&
Organic animal protein phosphorus absorption and examples?
- Fish, meat, chicken, eggs, milk and dairy
- 60-60%
What are the two types of phos binders?
Calcium and non-calcium based
Calcium based phos binders?
- Calcium carbonate
- Tums
Regular 500 mg phos binder =
200 mg elemental calcium
Extra strength 750 mg phos binder =
300 mg elemental calcium
Ultra 1000 mg phos binder =
400 mg elemental calcium
Key concept with phos binders?
MUST be taken with food
What is a non-calcium, non-metal, 800 mg phos binder which will lower LDL?
-Renagel
What is a non-calcium 800 mg phos binder which will lower LDL and may improve bicarbonate levels? Which population may this be recommended for?
- Renvela
- Pre-dialysis to correct bicarbonate levels
What is a non-calcium, chewable phos binder which may risk lanthanum accumulation?
Fosrenol
How can we nutritionally intervene with phos binders?
- Suggest crushing and mixing up into liquids
- Ensure that they are taken with their meals, and prescribed customized to their usual-intake (i.e. 3 vs 5 meals per day)
Provide some practical steps to control serum phosphate levels
- Limit dietary phos while meeting protein needs
- Titrate binder dosage to meal and snack
- Evaluate actual P intake to plan the initial and subsequent phos binder doses
What is contraindicated for constipation intervention in ESRD?
-We cannot suggest increasing fibres, fluids or exercise
What may be attributed to constipation?
Phos binders
How can we attenuate and pre-emptively address constipation in PD?
-Will immediately have stool softeners and laxatives, even if there is normal BM
Why is preventing constipation crucial in PD?
Constipation can cause increased pressure in the peritoneum, which can (1) displace the catheter and (2) increase risk of bacterial translocation and infection of the perioneal membrane
Which commonly used laxatives are contraindicated?
- Milk of magnesia
- Magnolax
- Citro-mag
- Fleet Phospho-soa
Examples of stool softners?
- Docusate sodium
- Docusate calcium
- Laculose
Examples of bulking agents?
- Unifibre
- Benefibre
- -> Not used very foten
Which bulking agents are contraindicated?
Metamucil and Prodiem
