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ESRD

Discussion of the disease

• CKD is a syndrome of both progressive and irreversible loss of excretory, endocrine, and metabolic functions of the kidney

• Etiology

o Diabetes, hypertension and glomerulonephritis are the leading causes of kidney failure

o Ethnicity – African Americans four times more likely, native Americans and Hispanics are two times as likely as white Americans

o Family history

o Chronic kidney disease leads to a buildup of fluid and waste products in the body. This condition affects most body systems and functions, including:

▪ Blood pressure control

▪ Red blood cell production

▪ Vitamin D and bone health

• Diagnostic measures

o National Kidney Disease Education Program has definded CKD as having a GFR of less than 60/mL minute for three months or longer.

o The stage of CKD is determined by the GFR, which measures the rate at which substances are cleared from the plasma by the glomeruli in the kidneys.

• Medical and Surgical Treatment:

o There are two types of renal replacement therapy for individuals – type is decided on by both the patient and physician based on multiple factors

▪ Hemodialysis

• Is the most common form of treatment

• In order to perform hemodialysis an access must be created that allows blood to flow out of the body to be filtered and then be put back in. There are three access types:

o Catheter, graft and fistula is preferred and most common

o Fistulas are less likely to form blood clots or become infected, and historically last longer than the other access types.

• In-center hemodialysis are prescribed 3 times a week for an avg. of four hours

o Daily home dialysis and nocturnal home dialysis can also be done but create stress and need a trained partner

▪ Peritoneal

• Access to the patients blood supply is gained by a catheter surgically placed in the peritoneal cavity

• A dialystate is inserted that lines the peritoneal wall allowing passage of molecules across the membrane and into the dialystate.

• Two types of PD exist

o Continuous ambulatory PD (CAPD)

▪ Requires no machine and change it four times a day – most sleep with it at night

o Continuous Cycling PD (CCPD)

▪ Does require a machine - fills and empties the abdomen 3-5 times during the night

▪ Renal transplantation is the other method of treatment

• Very risky and need to consume immunosuppressors the rest of their life.

▪ Psychological

• Depression is common in dialysis patients

• Recommended to consult with social workers, and gain support from family

• Medical Nutrition Therapy

o Nutrition Assessment

▪ Majority of individuals with CKD have comorbid conditions like hypertension or diabetes

▪ Malnutrition is very common in patients with CKD especially those on dialysis

• PEM is most severe

▪ Signs and symptoms prevent themselves when GFR falls below 30 mL/minute

▪ Important to access for usual dietary intake and intolerances because dietary restriction is elongated for CKD

o Nutrition Diagnosis

▪ Nutrition implications are complex with CKD and many diagnoses are often present including:

• Inadequate energy intake

• Excessive fluid intake

• Excessive protein intake

• Excessive mineral intake (potassium, phosphorus, sodium)

• Involuntary weight loss/weight gain

• Food and nutrition knowledge deficit

• Undesirable food choices

o Nutrition intervention

▪ Nutrition intervention in ESRD are to meet energy requirments, prevent malnutrition, minimize uremia, maintain blood pressure, and fluid status

▪ Hemodialysis diets are high in protein and control intakes of potassium, phosphorus and sodium.

• Protein loss is approximately 10 to 12 grams of free amino acids per day and 5 to 15 per day of albumin

• General recommendations are 1.2 grams of protein/kg of body weight

• 50% of protein should be high biological value

▪ Limit fluid intake

• It will make it much easier on the patient – avg. fluid intake is limited to 32 oz.

o Liter of water weighs 2.2 pounds

o Monitor and Evaluate

▪ Classified as either

• Clinical

o Biochemical measures and hematological measures

• Patient behavioral

o Meal planning, meeting nutrient needs, awareness of potential food and drug interactions

• Consider blood pressure control, maintenance of body mass

• Prognosis

o The leading cause of death in patients with chronic kidney disease is cardiovascular disease

o Life expectancy depends on age and additional medical problems associated

o An individual between the age of 45-55 has 70% chance for five year survival

o Some kidney disease patients on dialysis are very ill and long-term survival is not anticipated because dialysis can be tedious and cause medical complications

Instruction Materials – Renal hemodialysis diet

1. General instructions and focus

a. Meet nutritional requirements, prevent malnutrition, minimize uremia, maintain blood pressure and fluid status

2. Diet instruction for you

a. Create a diet high in protein, with control of potassium, phosphorus, sodium, and fluids

|Nutrient (Adjusted Edema-Free Body Weight) |Direction |

|Protein |106 grams of protein per day – 50 % must be high biological value|

|Energy |3000-3100 kcal (35 kcal/kg– under 60 years old) |

|Fat |750 – 1050 kcal from fat or 83.3 – 116.6 g of fat |

|Cholesterol |Less than 200 mg/day |

|Fiber |20-30 g/day |

|Potassium |2 grams per day |

|Sodium |2 grams per day |

|Phosphorus |800 mg per day |

|Fluid |1 L/day |

Therapuetic lifestyle changes for client

• Increased Protein Consumption

o 106 grams per day or 425 kcal (15%)

▪ Based on 1.2g/kg of body weight

▪ Why Increase protein?

• Loss of free amino acids in the body of a hemodialysis diet is approximately 10-12 g per day

• Carbohydrates

o 450 grams per day or 1,800 kcal (60%)

• Fat

o 83 grams per day or 750 kcal (25%)

• Fluid

o No more than 1 L of fluid per day of fluid

o It is important to only drink when thirsty

Interdialytic weight gain should be no greater than 5% body weight, which is equivalent to no more than 1 liter of fluid per week

Meet daily requirements of all vitamins

• Avoid high doses of Vitamin A and C

• Avoid magnesisum

• Supplementation of Vitamin B12, folic acid and Vitamin C is required to meet nutritional needs

Sample Menu

• Recommended foods

o Eat a high protein food at every meal of the day

▪ Fish, meat, poultry, fresh pork, or eggs

o Whole grain breads and cereals are a great way to obtain good calories

o Dairy foods low in phosphorus

▪ Cream cheese, ricotta cheese, Unsalted butter, Sherbert (instead of ice cream)

o Fruits

▪ Apple, berries, pineapple, watermelon, grapes

o Low potassium vegetables

▪ Broccoli, carrots, celery, cucumber, onion, squash

o Sherbert is great for desert of meals

• Foods to avoid

o All fruit juices have sources of potassium

▪ Avoid – oranges and orange juice, kiwis, prunes and prune juice, raisins, bananas, melons

o Potatoes (including French fries), tomatoes and tomato sauce, asparagus, avocado

o Avoid any fast food or deep fried food

Monitor and Evaluation

• Monitor lab values of serum albumin, serum creatine, serum potassium, BUN, sodium, phosphorus and hope to maintain a within normal range

Great websites to consult:

U.S. Department of Health and Human Services



Nephrology Physicians



References:

Finkelstein, F., & Finkelstein, S. (2000, October). Oxford journals . Retrieved from

Initia, R. (2012, March). National kidney foundation. Retrieved from

Rubin, R. (2009, August 24). Usa today. Retrieved from

The renal association. (2011, November). Retrieved from

National Kidney and Urologic Diseases Information Clearinghouse. (2008, August 1). Eat right to feel right on hemodialysis. Retrieved from

Nephrology Physicians. (n.d.). Nephrology physicians, llc. Retrieved from

Mayo Clinic Staff. (2012, July 06). Mayo clinic. Retrieved from

Chronic kidney disease (ckd). In (2012). U.S. Department of Health. Retrieved from

American Kidney Fund. (2010, December). Chronic kidney disease. Retrieved from

(2011). Treatment methods for kidney failure: Hemodialysis . National Institute of Diabetes and Digestive and K. Retrieved from

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