STUDY YAAAAAS Flashcards
Predialysis Energy: 30-35 kcal/kg dry weight PRO: 0.6-0.8 g/kg dry wt. FAT: 30% of kcal and 10% or less saturated Fluid: 500 mL/day + urine output
Dietary recommendations for Predialysis, Dialysis, Polycystic Kidney Disease (PKD)
- K: 4000 mg stages 2-3 and 2400 mg stages 4-5
- Vitamins: no vitamin A b/c @ toxicity risk
- Avoid high K foods like noni-juice and star fruit
Dietary recommendations for Predialysis, Dialysis, Polycystic Kidney Disease (PKD)
Dialysis PRO: 1.0-1.5 g PRO/kg dry wt. FAT: 30% of kcal and 10% or less saturated Fluid: 1000 mL/day + urine output *Prealbumin is always false high*
Dietary recommendations for Predialysis, Dialysis, Polycystic Kidney Disease (PKD)
Hereditary: Grape-like cysts and as cysts obstruct/occlude
Lost salt w/ high urine output — increase salt intake
Dietary recommendations for Predialysis, Dialysis, Polycystic Kidney Disease (PKD)
Treatment for Hypercalciuria
K+ wasting diuretic (thiazide diuretic)
Phos: restricted to 800-1600 mg/day
K: restrict to 1500-3000 mg/day (39 mg = 1 mEq)
Na: 2000 mg/day
Dialysis
1 mEq K =
39 mg
1 mEq Na =
23 mg of Na
Norvasc
Ca Channel blocker for high BP – NO ____________!
Norvasc and Rocaltrol: functions, etc.
NO GRAPEFRUIT!
Rocaltrol (calcitriol)
Active vitamin D (1,25 – Dihydroxycholecalciferol)
Binds to Ca and inc. absorption – hypercalcemia risk
Treats elevated iPTH in CKD pt.
Norvasc and Rocaltrol: functions, etc.
Wt. gain between dialysis treatments should NOT exceed 1-2 lbs/day
Common to see 2-4 lb gains from Mon-Wed and 3-5 lb gains over the weekend
Look at pre and post dialysis weight and interpret fluid status: good or bad?
Hectoral, Zemplar –> derivatives of Vit. D
High blood phosphorus and low blood Ca can stimulate body to produce iPTH
Sensipar – helps control hyperparathyroidism
More effective @ lowering iPTH than vit. D
Meds. used to treat elevated iPTH in CKD pt.
BUN and Creatinine – always high
Retinol Binding Protein (RBP) – carries vitamin A in blood, generally false high and not ideal marker
Look at albumin and changes overtime
Look at renal pt. lab value and make assessment of PRO status
Calcium channel blocker for high BP
No Grapefruit or Seville oranges
Pt. on Norvasc: if any food med. interactions
Management: maintain normal serum phosphorus, calcium, and parathyroid hormone levels
Parameter Target Range
Corrected total serum Ca = 8.4-9.5 mg/dl
Serum Phosphorus = 3.5-5.5 mg/dl
Ca x P = 22 mEq/L
Pt. on HD is @ risk for renal bone disorder (osteodystrophy): what tx plan to decrease risk?
Hyperphosphatemia Mgmt: severe = serum ___—___ mg/dL
If serum P is less than 7 mg/dL then Ca supp. may be used to bind P
avoid Ca supp. as long as possible b/c @ risk for soft tissue calcification
Pt. on HD is @ risk for renal bone disorder (osteodystrophy): what tx plan to decrease risk?
7-15
Decrease or avoid vit. D andCa
Hypercalcemia Mgmt:
________– Calcium-sensing Receptor (CaR) modulator , help control hyperparathyroidism
help control hyperparathyroidism
*Sensipar
Vitamin D Therapy – will help suppress iPTH and help normalize serum Ca
1,25 dihydroxy D3
Hectoral oral or IV (doxercalciferol) and Zemplar: vitamin D2
Pt. on HD is @ risk for renal bone disorder (osteodystrophy): what tx plan to decrease risk?
Parathyroidectomy – if all else fails to dec. iPTH, remove parathyroid
Calcific Uremic Arteriolopathy (calciphalaxis) – keep iPTH and Ca levels normal to prevent this
Pt. on HD is @ risk for renal bone disorder (osteodystrophy): what tx plan to decrease risk?
cardiac problems like arrhythmias, weakness, GI problems, death
Hyperkalemia
Hypoguesia, Hyposmia, poor appetite, rash, poor wound healing, immune and sexual dysfunction, poor growth in kids
Avoid laxatives w/ magnesium: Milk of Magnesia and Mineral Oil
Zinc deficiency
Muscular weakness, cardiac arrhythmias (irregular heart beat), high plasma TG
Carnitine deficiency
inc. iron absorption and serum ferritin is > **300mg/dL
Hereditary disorder where iron stores may reach 20-40 grams (N= 1-3 grams)
Hemochromatosis
S and S: cirrhosis, liver cancer, diabetes, bronze skin, cardiomyopathy, arrhythmias, heart failure, abdominal pain, arthritis
Hemochromatosis
Antioxidant –> anticancer, anti-diabetic, anti-atherosclerotic
Promotes muscle development, decrease fat deposition
May lower plasma TC, TG, and; improve utilization of FA by heart
Found in beef, lamb, turkey, and dairy fats
What is CLA? – Conjugate Linoleic Acid
Stanol ester –> blocks cholesterol absorption
2-3 g/day will lower LDL by 6-15%
What is Benecol? — Stanol Ester
Need 5-50 mg/day B6 supp.
Management of Wilson’s disease and Rheumatoid Arthritis
Penicillamine
Lose weight if obese, low fat diet
Limit alcohol and high glycemic index CHO
Dietary recommendations for pt. w/ Familiar Dislipidemia
combines 3 or more HIV drugs to dec. viral load
Take a multi-vitamin mineral supplement daily and avoid food borne illnesses
AIDS pt w/ different disorders of large or small bowel: what recommendations to make
“Highly Anti-Retroviral Therapy” (HAART) -
Due to hyperlipidemia:
Maintain IBW, 30% kcal from FAT, lower saturated, trans fats, and TG (simple sugars)
Increase physical activity
AIDS pt w/ different disorders of large or small bowel: what recommendations to make
“Highly Anti-Retroviral Therapy” (HAART) -
- Diarrhea*
- Severe small bowel disease – often parenteral nutrition required
- Partial small bowel disease – fat >20% kcals, low fiber/residue, lactose free, avoid caffeine; but rarely parenteral nutrition is required
- Large bowel problems – same as above
AIDS pt w/ different disorders of large or small bowel: what recommendations to make
Exercise and lose weight if obese Avoid elevated or low plasma TG Intake smaller amounts of alcohol Statins and Niacin Stop smoking Avoid androgenic and anabolic steroids Avoid beta andrengenic blocking agents
Ways to help elevate HDL
Statins lower CRP
Decreased by stop smoking, omega 3 FA, exercise, avoid android obesity, more sleep, reduce stress
Therapies to lower CRP
Ex. RA, lupus**, cancer, chronic infections, inflammatory bowel disease (IBD)
Diseases associated w/ being a cause of Anemia of Chronic Disease
Salt substitutes – Morton lite and cardia
Squash, noni juice and star fruit
Foods high in potassium
Retinol Binding Protein – carries vit. A and always elevated, causing a false high pre-albumin
Albumin – physiological stress and PRO malnutrition causes low albumin
Trying to assess hemodialysis pt. PRO status: pro and cons w/ looking at RBP vs. albumin
Cyclosporine
Hypomagnesmia, hyperkalemia, hyperlipidemia, increase BG, and hyperuricemia
Don’t take with grapefruit
Side effects of Cyclosporine, Mineral Oil, Cholestyramine, and Methotrexate
Mineral Oil
May reduce absorption of vitamin A,D,E,K, calcium, carotenoids, and phosphate
Side effects of Cyclosporine, Mineral Oil, Cholestyramine, and Methotrexate
Cholestyramine
Always mix the powder into liquid
Long term therapy – depletion of fat soluble vitamins so vit. A, D, E, K supp. recommended
Folic acid deficiency may occur and 5 mg supp. recommended
Side effects of Cyclosporine, Mineral Oil, Cholestyramine, and Methotrexate
Methotrexate
If chemotherapy agent – avoid folate
If taken for other disorders, folate supplement may be taken prophylactically
Side effects of Cyclosporine, Mineral Oil, Cholestyramine, and Methotrexate
This leads to exudative diarrhea - Inflammation of gut, excretion of blood, mucus, plasma proteins, and electrolytes
Pt. has Radiation Enteritis, and Ulcerative Colitis (UC): what kind of diarrhea would they have
Which antacid is most likely to cause diarrhea
Milk of Magnesia
Serum or plasma folate 100 mg FIGLU excretion*
Folate (B9) and Cobalamin (B12) anemia: lab test and abnormalities in complete blood count
Folate (B9)
- High Methamalonic Acid (MMA) > 3.5 mg*
* Schilling Test (B12 absorption) – deficient if less urine excretion*
Folate (B9) and Cobalamin (B12) anemia: lab test and abnormalities in complete blood count
Cobalamin (B12)
Levadopa
High PRO – decrease drug’s effectiveness, eat less PRO at night
B6 can convert L-dopa to dopamine outside the brain → lessening the effect
Possible interactions and things to avoid: LDOPA, Tetracycline, Nardil, and Isoniazid
Avoid high fortified foods (ex. cereal) and; supplements of B6 – don’t completely eliminate though
Don’t take with iron – absorption is decreased
Levadopa
Tetracycline
Calcium, iron, magnesium – form a chelate, reducing absorption of both the med and mineral
Should not be taken 3 hours before or 2 hrs. after – divalent or trivalent cations or Na bicarb.
Possible interactions and things to avoid: LDOPA, Tetracycline, Nardil, and Isoniazid
Can alter activity of folate, K, B6, B12, vit. C and K if longer than 2 weeks (may need supplement)
Taking 500 mg vit. C w/ drug may increase blood levels of med
Tetracycline
INH (Isoniazid)
Avoid Swiss/Cheshire cheese, tuna, skipjack, sardinella – histamine and tyramine containing foods
Interferes w/ B6 metabolism – interferes w/ PLP and excretion of both is increased
Possible interactionsand things to avoid: LDOPA, Tetracycline, Nardil, and Isoniazid
PLP is needed to convert tryptophan to Niacin**, so 200-400 mg/day of niacin – with pellegra
INH (Isoniazid)
MAOI’s Nardil
Avoid consumption of high tyramine*** foods
Cheese, smoked/pickled fish, non-fresh meat and liver, chianti and vermouth wine, broad beans, banana peels, meat extracts, yeast extract, dry sausage, sauerkraut, beer and ale
Possible interactions and things to avoid: LDOPA, Tetracycline, Nardil, and Isoniazid
Chron’s disease and ulcerative colitis; inflammation* of the bowel
Inflammatory Bowel Disease
Possible cause - bacterial overgrowth in the SI, hypermotility or abdominal brain gut connection exacerbated by stress
Irritable Bowel Syndrome (Spastic Colon)
Signs and Symptoms: gas, bloating, abdominal pain, cramps, spastic contractions, constipation and/or diarrhea, fecal incontinence, anxiety, back pain, mucous in stool
Irritable Bowel Syndrome (Spastic Colon)
For Hypertension:
2-3 servings/day of low fat dairy products - on the test it says 5 servings/day so it won’t be the answer
7-8 servings per day of whole grain
8-10 servings/day of fruit and vegetables
DASH diet: what it’s high and low in
Polyuria, polydipsia, or oliguria
Low plasma albumin – due to loss of PRO in urine
Look at pt. lab values, S and S: determine whether they have Nephrotic Syndrome, Carnitine deficiency, Polycystic kidney disease, and Acute Glomerulonephritis
Nephrotic Syndrome
Most common in kids 3-21 yrs. who have had beta hemolytic group A strep infection
Hematuria, albuminuria, azotemia, HTN, and edema
Look at pt. lab values, S and S: determine whether they have Nephrotic Syndrome, Carnitine deficiency, Polycystic kidney disease, and Acute Glomerulonephritis
Acute Glomerulonephritis
Hematuria, proteinuria, infection, and flank pain
Look at pt. lab values, S and S: determine whether they have Nephrotic Syndrome, Carnitine deficiency, Polycystic kidney disease, and Acute Glomerulonephritis
Polycystic Kidney Disease
Muscular weakness
Cardiac arrhythmias (irregular heart beat)
High plasma TG
Look at pt. lab values, S and S: determine whether they have Nephrotic Syndrome, Carnitine deficiency, Polycystic kidney disease, and Acute Glomerulonephritis
Carnitine Deficiency
Absorbed in the bloodstream and provides quick energy for body and not as likely to be stores as fat
Acts as a CHO not FAT and goes to liver to be used as an immediate energy source
MCT oil: how it’s absorbed and possible side effects
Side Effects:
Ketone build up in DM, cause severe problems in liver disease, and upset stomach
MCT oil: how it’s absorbed and possible side effects
Ulcerative Colitis (UC) – DON’T go on TPN
Crohn’s - may help pt. go into remission
Severe vomiting and Diarrhea
Any disease of the SI causing malabsorption
Look at pt.’s condition and determine whether they need to be on TPN or not
High output (over 500) fistula
Short bowel/ major surgical resection
Severe gastritis or bleeding ulcers
Look at pt.’s condition and determine whether they need to be on TPN or not
Acute bowel ischemia, severe total ileus, and severe acute pancreatitis
Complete mechanical bowel obstruction
Severe damage to a large part of the SI
Look at pt.’s condition and determine whether they need to be on TPN or not
Name of formula for Chron’s Disease pts.
MODULEN IBD by Nestle’s – contains TGF-B2 which inhibits IFN-g, lowering MHC Class II PRO
Low in Omega 6 and decreases inflammation of SI
Peptamen – Peptide-based elemental diet for GI-impaired children ages 1-10
Methotrexate: no folate supp. if for chemo and Dilatin: give minimum amt
{refer to #72}
Look at blood values, meds, S and S, and make dx of what is causing their anemia
Macrocytic Anemias
Effect B12:
Pernicious anemia, GI problems, and elderly
Meds: nitrous oxide, cholestyramine, INH, metformin, H2 receptor blockers, PPIs (prolisec and prevacid), Nexium, Dilantin
Look at blood values, meds, S and S, and make dx of what is causing their anemia
MACROCYTIC large RBC’s, high MCV NORMOCYTIC normal size RBC’s, normal MCV MICROCYTIC Small RBC’s, low MCV
CLASSES OF ANEMIA
COPD → chronic obstructive lung disease
Pt. w/ COPD taking Mylanta, Ldopa, Nardil and Warfarin: know side effects, nut. Interactions of these meds, know foods to restrict, or supplements to take
Mylanta – antacid (contains Mg)
Phosphate deficiency risk w/ chronic use – inc. risk w/ low phosphorus and PRO intake
Deficiency risk: vitamin A, folate, thiamin, fluoride, and iron
Pt. w/ COPD taking Mylanta, Ldopa, Nardil and Warfarin: know side effects, nut. Interactions of these meds, know foods to restrict, or supplements to take
not common in CRF pts., heart problems, respiratory problems
Hypophosphatemia
anorexia, hyperreflexia, high heart rate, bone problems, calcification of soft tissues if Ca is also high
Hyperphosphatemia
confusion, GI disturbances, weakness
Hyponatremia
Anticoagulant
Keep steady vit. K intake – large inc. in dose may decrease anticoagulant effects; abrupt decrease may increase effect and result in bleeding
Warfarin: side effects and nutrient interactions
Don’t take CoQ10 – may interact adversely
Don’t take iron, mg, or zinc within 2 hours as absorption may be decreased
Warfarin: side effects and nutrient interactions
CHO = 1.0
FAT = 0.71 (using fat for energy)
PRO = 0.83
RQ mixed diet = @ 0.85
Estimate RQ value of pt. and what is a good value
Ethanol = 0.67; 1.3 = invalid (error in calculation)
RQ of 0.85-0.95 is desirable for pt. on vent
Estimate RQ value of pt. and what is a good value
Jejunal and Ileal resection →Increased risk of hyperoxaluria** and Oxalate Kidney Stones
Make recommendations pt. w/ Short Bowel Syndrome to decrease risk of kidney stones
Avoid high oxalate foods and increase calcium and fluid intake
Avoid: beets, chocolate, coffee, cola, nuts, rhubarb, spinach, strawberries, tea, wheat bran
Make recommendations pt. w/ Short Bowel Syndrome to decrease risk of kidney stones
OXEPA
Low CHO, calorically dense enteral formula
Minimize CO2 production. High CO2 levels can complicate weaning in vent.-dependent patients
OXEPA formula and ingredients that make it unique
OXEPA
EPA (sardine oil), GLA (borage oil), and 25% fat as MCT
Meets 100% RDI for 24 key vitamins in 1420 kcals
Fortified with antioxidants, natural vit. E, beta-carotene, and vit. C
OXEPA formula and ingredients that make it unique
Low CHO and high FAT – so less CO2 generated which dec. RQ
Usual balance of CHO, FAT in formula for pulmonary patient
Foods with Gluten/Gliadin:
All wheat (gliadin), rye (secalin), malt, barley (hordein), and maybe oats
Spelt, triticale, kamut
Millet, sorghum, buckwheat, quinona, amaranth,
Identify foods w/ gluten
distilled alcohol, white vinegar (contaminated?)- so I guess it is better to avoid them
There’s a question about this… Which food could someone with gluten sensitivity not eat? gravy
Identify foods w/ gluten
Vitamin E
Synthetic Vit. E – “acetate,” all-rac, dL (“don’t like”)
Natural – RRR, d
Lowers/interferes Tamoxifen effects
Breast cancer pt. taking Tamoxifen: possible interactions
Avoid Soy
Genistein, most prevalent isoflavone in soy, can stimulate estrogen receptor-positive (ER+) breast cancer growth and interferes w/ antitumor activity of Tamoxifen at low levels
Breast cancer pt. taking Tamoxifen: possible interactions
Carcinoma in situ: non-invasive
Early stage of cancer when it’s confined to layer of cells where it began
“in situ” – means cancer cells stay confined to ducts (ductal carcinoma in situ, DCIS) or lobules (lobular carcinoma in situ, LCIS)
Definitions: ductal, lobular, in situ, invasive (breast cancer)
Invasive (Infiltrating) Carcinoma:
Cancer has invaded into deeper tissues in the breast or spread to other organs in the body and no longer confined to ducts (IDC)/lobules (ILC) where it began
Definitions: ductal, lobular, in situ, invasive (breast cancer)
Genisten – the most prevalent isoflavin in SOY
Avoid Phytoestrogen
Isoflavinoids, lignans
Foods to avoid by women w/ ER+ breast cancer
Hypolipoprotenemia – Abetalipoteinemia: causes poor absorption
RBC hemolysis retinopathy, peripheral neuropathy w/ hyporeflexia and ataxia (no coordination)
S and S Tocopherol (vit. E) deficiency: what lipidemia puts you at risk for deficiency
Kidney Stones (Nephrolithiasis) High fluid intake @ 2000-3000 mL/day
Recommendations for Primary Hyperoxaluria, Calcium Oxalate, and Uric Acid Kidney Stones
Primary/Idiopathic
Restrict oxalate if it is in stones
High oxalate foods – beets, chocolate, coffee, cola, nuts, rhubard, spinach, strawberries, tea, wheat bran
Try restriction of Na and animal PRO and restrict dietary Ca to DRI
Recommendations for Primary Hyperoxaluria, Calcium Oxalate, and Uric Acid Kidney Stones
Primary Hyperoxaluria (PH) Type 2 – stones are often calcium oxalate and may lead to CKD 400-600 mg/day B6 (pyridoxal phosphate)
Recommendations for Primary Hyperoxaluria, Calcium Oxalate, and Uric Acid Kidney Stones
Uric Acid Stones
**Low PRO/purine diet and/or Citrate or bicarb supp. to make urine more alkaline*
Recommendations for Primary Hyperoxaluria, Calcium Oxalate, and Uric Acid Kidney Stones
Saturated – because it inhibits clearing
Kind of fat is most likely to influence LDL levels and how
Increase plasma HDL, TG accumulation and VLDL production
Decrease LDL oxidation
What lipids can be effected by alcohol consumption
K+ sparing diuretics: Aldactone, Dyrenium, and Midamor
ACE Inhibitors – Benazepril and Ramipril
Beta Blocker – Lopressor
Cyclosporine
Cardiac Meds and diuretics: which frequently cause hyperkalemia
800-1000 mg/day folic acid (B9) supp.
Avoid PABA or iron – both lessen med. effect
Pt. on Sulfasalazine (Mesalamine): know supps. they should take and any restrictions
Histamine receptor blockers → Axid, Pepcid, Tagamet, and Zantac
Different antacids and acids suppressing meds in GERD: which are PPIs and H2 blockers
Antacids
Mylanta, Maalox, Tums, or Rolaids etc
Gaviscon → foams and ↓ acid reflux into esophagus
Different antacids and acids suppressing meds in GERD: which are PPIs and H2 blockers
Proton Pump Inhibitors (PPI’s) → Nexium, Prevacid, and Prilosec
Work best to ↓ acid production
Different antacids and acids suppressing meds in GERD: which are PPIs and H2 blockers
Ex. Antacids may ↓ absorption of iron, thiamin, phosphorus, and vitamin A
Ex. PPI’s and Hist blockers may cause a ↓ in vitamin B-12 absorption
Ex. Lower stomach acid may ↓ calcium, magnesium, and iron absorption
Different antacids and acids suppressing meds in GERD: which are PPIs and H2 blockers
High PRO intake and Metoclopramide (Reglan) - speed gastric emptying
Different antacids and acids suppressing meds in GERD: which are PPIs and H2 blockers
Zinc – high dose may induce copper deficiency, so monitor
500-1000 µg/day Folate (B9) and Cobalamin (B12)
Retinol (vit. A), RBP, riboflavin, vit. E and C
Sickle Cell Anemia
Homozygote who may have intermediate or major disorder
IRON OVERLOAD
Same deficiencies as Sickle Cell
Thalassemia Major = “Cooley’s Anemia”
Genetic defect in the LDL receptor so LDL is not cleared out of the blood effectively
High total cholesterol (TC) and LDL
Abnormality causing Type A hyperproteinliponemia: what is elevated in plasma
For after BMT – low bacterial diet to lower infection risk
Raw and undercooked brewer’s yeast, meats, fish
NO CHEESE! – Cottage cheese was an example on the test
Neutopenic diet: what it is and identify foods that wouldn’t be allowed
K+ sparing: Aldactone, Dyrenium, and Midamor
K+ wasting: Diuril, Lasix, Thiazide
K sparing vs. K wasting diuretics
Aldactone, Dyrenium, and Midamor
K+ sparing
Diuril, Lasix, Thiazide
K+ wasting
Predialysis Protein: 0.6-0.8 g/kg body wt (dry weight)
Given descriptions of renal pt: know grams of PRO/day recommended {calc. g per body wt}
Hemodialysis → Dietary Protein Intake (DPI): ~1.0-1.5 g/kg dry body wt. (½ should be HBV)
Given descriptions of renal pt: know grams of PRO/day recommended {calc. g per body wt}
Peritoneal Protein: 1.2-1.5 g/kg dry wt/day
Given descriptions of renal pt: know grams of PRO/day recommended {calc. g per body wt}
↑ output or cause discomfort – nuts, corn, chocolate, lettuce, oranges, milk, alcohol, tomatoes
Food that causes intolerance w/ Ileoanal Reservoir
Avoid insoluble fiber in foods: like fruit peels, mushrooms, corn, celery, lettuce, bean sprouts, coleslaw, coconut, pineapple, nuts, seeds, tough meat shrimp or lobster
Food that causes intolerance w/ Ileoanal Reservoir
Foods that may cause gas and odor:
Asparagus, dried beans/peas, mustard, cabbage family, onions, carbonated beverages, eggs, strong flavored cheeses, melons, spiced foods, fatty foods (pastries/deep fried), whips and meringues
Food that causes intolerance w/ Ileoanal Reservoir
Foods that contribute to anal irritation:
Certain raw fruits and vegetables (e.g., oranges, apples, coleslaw, celery and corn)
popcorn, nuts, coconut, dried fruit (ex. Raisins, figs), seeds, spicy, and oriental veggies
Food that causes intolerance w/ Ileoanal Reservoir
High PRO – decrease drug’s effectiveness, eat less PRO at night
B6 can convert L-dopa to dopamine outside the brain →lessening the effect
Avoid high fortified foods (ex. cereal) and supplements of B6 – don’t completely eliminate though
Levadopa
Don’t take with iron – absorption is decreased
Levadopa
Anticonvulsant osteomalacia may occur – need vitamin D2 (ergocalciferol)
Calcium supp. may decrease absorption
Dilantin
Take minimum folate to treat deficiency — dec. anti-convulsant effect
Whole formulas like Complete – slightly dec. levels
Whole blenderized TF and standard TF= increase therapeutic levels
Dilantin
Monitor water, Na, Cl, K, Mg
Hypokalemia Risk and risk increases med. toxicity
Increase Thiamin excretion and cause depletion which may worsen heart failure
Lasix – K wasting diuretic
Keep steady vit. K intake – large inc. in dose may decrease anticoagulant effects; abrupt decrease may increase effect and result in bleeding
Don’t take CoQ10 – may interact adversely
Warfarin (Coumadin) – anticoagulant
- Alcohol tends to increase plasma HDL, decreasing CVD risk*
- Alcohol increases levels of clot dissolving enzyme*
- Inhibits FA oxidation in liver → TG accumulation (fatty liver) and increased production of VLDL*
What happens if a person has 4 alcohol drinks a day: what would go up in their blood?
PAD → blocking or narrowing of arteries in extremities (legs are most common)
Blood flow decreases in arteriosclerosis – buildup of fatty substances in wall of artery
Peripheral Vascular Disease : what it is and S and S
Signs and Symptoms:
Intermittent claudication (tissues don’t received enough oxygen especially when walking)
Pain when walking or w/ activity
Peripheral Vascular Disease : what it is and S and S
Phosphate, Magnesium, Potassium, Calcium… Thiamin
Minerals commonly low in Refeeding Syndrome
Bile Acid Binding Resins to lower cholesterol
Always mix the powder into liquid
Long term therapy – depletion of fat soluble vitamins so vit. A, D, E, K supp. recommended
Folic acid deficiency may occur and 5 mg supp. recommended
Questran (Cholestyramine)
IBS, RA, and anti-inflammatory
800-1000 mg/day folic acid (B9) supp
Don’t take PABA or Iron – decreases effect
Sulfasalazine (Mesalamine)
Uses: Anti-arrythmia, inotropic agent, CHF
Monitor serum K, Na, Ca, Mg, and avoid hypo/hyper – may affect heart rhythm
Avoid licorice – has glycyrrhizic acid
Digitalis (Digitoxin)
AST, ALT, — Jaundice
Gamma-glutamyl transpeptidase (GGTP, GTP, GGT) rise
Lab value high in Hepatitis
EPA, DHA in salmon and other fatty fish
Omega 3 PUFA
linoleic and arachidonic
safflower,
evening primrose seed oil
Omega 6 PUFA
oleic and palmitoleic
olive, canola, peanut
Omega 9 MUFA
no double bonds
Coconut, palm
Saturated FA
1 cup = 8 oz = 240 mL = 240 cc
1 fl. ounce = about 30 mL
Gives pt. menu: calculate how many cc of fluid
Test Diet for Phenocytomachroma → over-secretion of the adrenal medulla gland
Vanillylmandelic acid (VMA) and homovanillic acid (HVA) are elevated in urine
VMA test: what is it
lower total cholesterol (NO GRAPEFRUIT)
Lipitor and Crestor – most effective in lowering TG
Inhibit HMG-CoA reductase
Need CoQ10 supp.
Statins
binds bile to lower cholesterol
Colestid, Questran, Welchol, and Zetia
Bile Binding Resins
lowers TG lipolysis and production of TG carrier PRO
Fenofibric acid and Fenofibrate
Fibric Acid Derivative
VITAMIN, 1000-3000 mg QD (once a day)
Dec. VLDL, LDL, and IDL → lowers TG
Nicotinamide has no lipid lowering effect
Niacin (Nicotinic Acid)
Defected LDL receptors
Omega 3, Saturated fat, trans FA
Some are cholesterol responders and dietary cholesterol intake causes their TC and LDL-C to rise
Causes of elevated LDL
Polygenic hypercholesterolemia →hyperresponsive to sat fat and high chol. absorption and poor LDL clearance due to defective apo B-100 and/or apo E 4
Familial defective apo B-100 → LDL not recognized by receptor
Causes of elevated LDL
graft or tissue from someone other than pt. who is non-identical (matching sibling)
Allogeneic
produces right sides weakness or paralysis, cautious behaviors, aphasia** (speech and communication problems), and dysphagia**
CVA in the LEFT side of brain
produces left side weakness or paralysis, impatience, impulsiveness, lack of inside and problems w/ spatial relationships
CVA in the RIGHT side of brain
clot stops blood supply to an area of brain (more common in elderly)
anticoagulants (Heparin, Coumadin), anti-platelets (Aspirin), Plavix
Ischemic Stroke
blood leaks into brain tissue (more common in younger people)
Do NOT take anti-coagulants, anti-platelets, Plavix, etc.
Hemorrhagic Stroke
Ex. Young female with heavy periods – iron deficiency (microcytic anemia)
Ex. dialysis patients – need EPO shot, normocytic anemia
Ex. children have higher risk of lead poisoning (microcytic anemia)
Groups are at high risk for different anemias
large RBC, high MCV (>100 fl), high LDL, iron, and bilirubin
Macrocytic Anemia
Pernicious anemia –diminishes IF synthesis in parietal cells
Low IF due to gastric problems
Poor absorption due to ileal problems – NEED IV!
Elderly have difficulty freeing B12 from food b/c low stomach acid – high need
B12 (cobalamin) deficiency
Pregnancy, malabsorption syndromes, hyperthyroidism, cirrhosis, and alcohol problems
B9 (folate) deficiency
small RBC, low MCV (
Microcytic Anemias
Thalassemia – Mediterranean, Middle Eastern, and South East Asia
Sideroblastic – enzyme defect
Iron Deficiency
anemia due to low erythropoietin (EPO) – DIALYSIS PATIENT!
Aplastic Anemia
Myelopathic Disorders – disorder of spinal cord or bone marrow
Normocytic Anemia
Sickle-Cell Anemia –African-Americans, but some from Italy, Greece, Arab countries, or Asia
Hemolytic Anemia – ex. G6P dehydrogenase deficiency only in men (x-linked)
Normocytic Anemia
an esophageal motility disorder where LES doesn’t relax and no peristalsis
Causes a bag-like* distension of esophagus and caused by defective nerves or maybe a virus
Achalasia
Signs and Symptoms:
Dysphagia for solids and liquids; Wt. loss/ malnutrition; Sub-sternal chest pain
Fullness in chest; Nausea and vomiting; Regurgitation and burning
Achalasia
Ca channel blockers (Nifedipine (Adalat) or Nitrates (isordil) to relax LES
Intrasphincteric injection of botulinum toxin** {relaxes muscles}
Dietary fat may help relax LES
Achalasia
Ca channel blockers (Nifedipine (Adalat) or Nitrates (isordil) to relax LES
Intrasphincteric injection of botulinum toxin** {relaxes muscles}
Dietary fat may help relax LES
Nutrients that may be helpful to lower elevated homocysteine
Supplements of B6 (pyridoxine), B12 (cobalamin), and folate (B9)
*Deficiency of vit. B6, B9, B12 – can elevate plasma homocysteine
Nutrients that may be helpful to lower elevated homocysteine
Renal multi-vit. w/o vitamin A like diatx, renax, dialyvite, nephrocaps, nephrovit
Diatx = more effective in lowering plasma homocysteine b/c has more folate, B12, and B6*
BAD = High (3g/day) niacin intake may cause tHcy to rise in some people
Nutrients that may be helpful to lower elevated homocysteine
Hypokalemia – increase K or take supp.
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Hyperkalemia risk
Hemodialysis
Hypermagnesia risk, don’t take vitamin A, elevated homocysteine and creatinine
Prealbumin is always false high
Both
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Hemodialysis
Age- increases w/ age
Race – African Americans
Male and post-menopausal females
HTN, smoking, DM, Obesity, physical inactivity
Hereditary – inherited hyperlipidemia, history of CAD, blood clotting abnormality
Risk factors of CVD - lipid abnormalities and things in plasma
Elevated total cholesterol (TC) = TC > 200 mg/dL
Elevated low density lipoprotein cholesterol (LDL) = LDL > 100 mg/dL
Elevated TG = > 150 mg/dL
Low high density lipoprotein cholesterol (HDL) = should be > 50 mg/dL
Risk factors of CVD - lipid abnormalities and things in plasma
marker for assessing cholesterol clearing capacity of the blood
Low = high risk of CVD
Apolipoprotein A1
marker for assessing cholesterol depositing capacity of the blood
Apolipoprotein B:
Helps with blood clot formation
Lipoprotein (a)
People w/ elevated CRP have 3-7 fold increase in risk of heart attack and stroke
Marker for inflammation of blood vessel
Risk factors of CVD - lipid abnormalities and things in plasma
Infection w/ organisms such as Chlamydia pneumonia, Helicobacter pylori, herpes simplex virus, hepatitis A and cytomegalovirus may be associated w/ inflammation and CVD risk Gum disease (gingivitis) – also possible risk factor of CVD
Risk factors of CVD - lipid abnormalities and things in plasma
If 2/3 or more of the SI is removed, TPN may be needed to sustain normal nutritional status
Oxalate Kidney Stones {see below}
Fatty acids in bowel bind to Ca, leaving less Ca to bind to oxalate, so more oxalate is absorbed. Also FFA may make gut more permeable which ↑ oxalate absorption
Understand why pt. w/ small bowel resection is @ risk for B12 deficiency. Understand why pt. w/ small bowel resection is @ risk for B12 deficiency, kidney stones, bile salt diarrhea, etc: how to treat them allency, kidney stones, bile salt diarrhea, etc: how to treat them all
Ileal Resection
Terminal ileum – ONLY site where cobalamin (B-12)/gastric intrinsic factor complex is absorbed. IM B-12 injections needed to prevent megaloblastic anemia and neuropathy
Understand why pt. w/ small bowel resection is @ risk for B12 deficiency. Understand why pt. w/ small bowel resection is @ risk for B12 deficiency, kidney stones, bile salt diarrhea, etc: how to treat them allency, kidney stones, bile salt diarrhea, etc: how to treat them all
treats bile salt diarrhea and oxalate kidney stones
Cholestyramine
aka Bassen-Koenzweig Syndrome
Failure to thrive, Fat malabsorption (vomiting, diarrhea, steatorrhea)
Acanthrocytosis (spiked RBC)
Deficiencies in vitamin A (night blindness), D (osteodystrophy), K (easy bruising), E (neuropathy due to poor absorption)
Abetalipoproteinemia (Hypolipoproteinemia)
(3 or more risk factors = syndrome) Abdominal obesity, waist circumference: males > 102 cm (40 in), females > 88 cm (35 in) TG: 1.7 mmol/L or 150 mg/dL HDL: males 130/ 85 mm Hg Fasting BG: > 110 mg/dL
Metabolic X Syndrome
Elevated Troponin I and T
S and S: chest pain, GERD, palpitations, diaphoresis, pallor, nausea, vomiting, confusion, anxiety, tachycardia or bradycardia, abnormal BP, fever, weak, SOB
Myocardial Infarction (MI)
commonly causes by a hereditary lack of xanthine dehydrogenase
S and S: kidney stones, CKD, joint pains, myopathy, acidic urine
Xanthiuria
Insoluble fiber may cause distress and ↑ risk of obstruction in pts. w/intestinal lumen narrowing or partial obstruction. – popcorn, seeds, nuts, fruit peels, broccoli, and dried beans
Pt. w/ Chron’s Disease: know dietary recommendations
Most pts. w/ steatorrhea can be managed on 50-70 g fat/day and can use MCT oil
Gluten or wheat may not be tolerated by some patients
Use of elemental formulas may↓ stool frequency and provide nutrients for the gut such as glutamine
Pt. w/ Chron’s Disease: know dietary recommendations
Calc. PRO/Kcal needs based on normal wt. for ht. and not current wt.
May need to add extra for malabsorption
Pt. w/ Chron’s Disease: know dietary recommendations
Formulas: MODULEN IBD by Nestle’s and Peptamen
During remission or non-acute periods:
Maintain norm. nutrition status: (+300-500kcal to gain wt, 1.5 g pro/kg/day)
Pt. w/ Chron’s Disease: know dietary recommendations
{ damage to lining of intestines (bowels) due to radiation therapy}
Exudative diarrhea
Radiation enteritis
Short Bowel Syndrome (SBS) – or Disease {malabsorption}
30-50% resection: cause some S and S like diarrhea, steatorrhea, bloating, fatigue, and malnutrition
Steatorrhea doesn’t usually dev. unless > 100 cm (~ 3.3 feet) of terminal ileum has been removed
Short Bowel Syndrome (SBS) – or Disease {malabsorption}
Ileum will generally adapt and take over IN TIME
No major malabsorption, but may have lactose intolerance
Most nutrient absorption takes place in the proximal jejunum
Jejunal Resection
May have problems until remaining gut, primarily ileum adjust→hypertrophy and hyperplasia
Avoid lactose and may not tolerate hyperosmotic liquids- gas, bloating, diarrhea
Jejunal Resection MNT
At some risk for hyperoxaluria which may lead to kidney stones due to:
Fatty acids in bowel bind to Ca, leaving less Ca to bind to oxalate, so more oxalate is absorbed. Also FFA may make gut more permeable which ↑ oxalate absorption
May need to↓ intake of high oxalate foods (100-300 mg/day) and ↑ calcium and fluid intake
Jejunal Resection MNT
Site of absorption of cobalamin (B12), chloride, sodium, potassium
Hard for body to make enough and bile salts that are not reabsorbed may cause diarrhea
Ileal Resection
Also this causes poor fat absorption and unabsorbed fats and fatty acids ↑ diarrhea
Risk for hyperoxaluria and oxalate kidney stones is HIGH!!
Loss of ileocecal valves ↑ problems w/malabsorption and diarrhea, and bacterial overgrowth
Ileal Resection
ONLY site where cobalamin (B-12)/gastric intrinsic factor complex is absorbed. IM B-12 injections needed to prevent megaloblastic anemia and neuropathy from developing*
*Terminal ileum
Initially after surgery TPN needed – Wean to elemental or semi-elemental high N formula that is low in fat (may have MCT oil).
Ileal Resection MNT
Usually in SI, especially terminal ileum (ileitis), but may occur in any area of GI tract
Transmural (throughout bowel wall) inflammation w/granulomatous areas – scarring, obstruction, and fistula
Crohn’s Disease - IBD
Usual onset age 15-35 yrs {about ¼ of pts. need surgery}
Crohn’s Disease - IBD
Sulfasalazine – Mesalamine (Asacol)
Supplemental folate {B9} of 800-1000 µg/day is recommended
Cyclosporine and Cholestyramine (binds bile) – fat soluble vit. and folate supps. needed
Treatment/Mgmt of Crohn’s Disease
Inflammation in the colonic mucosa w/sores - Usually in COLON but may be in terminal ileum
Ulcerative Colitis (UC)
Taking 20 grams of psyllium (Plantago ovata) seeds together w/ Mesalamine for 12 months may improve the maintaining of remission in ulcerative colitis
Management of Ulcerative Colitis (UC)
During Remission → no specific diet, avoid diarrhea/discomfort foods, and sm. frequent meals
Ulcerative Colitis MNT
During acute exacerbations → may have 20 + stools per day w/mucous, blood (iron loss), pus and loss of PRO, iron, water , electrolytes, and trace minerals stool
Ulcerative Colitis MNT
During acute exacerbations
TPN or elemental TF may↓ symptoms but generally not found to induce remission – no TPN!
Ulcerative Colitis MNT
To cure UC- a colectomy (surgical removal of colon) followed by an ileostomy (sm. intestine is brought to surface of abdomen to form a stoma) and often creation of an ileoanal reservoir so waste can again be excreted via anus
Ulcerative Colitis MNT
