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Medical nutrition therapy for Hemodialysis

A post-case study discussion on end-stage renal disease patient undergoing hemodialysis

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Medical nutrition therapy for Hemodialysis

  1. 1. Medical Nutrition Therapy for ESRD - Hemodialysis Dietitian - Jake Brandon M. Andal
  2. 2. Case 3: ESRD Hemodialysis • GFR = 12 mL/min • Kidney not immediately available, hemodialysis was recommended • Arteriovenous fistula was created on his left forearm • BP na d serum potassium level has risen and BUN is 110 mg/dL • HD is twice a week • Instructed to continue phosphate binders and calcium supplements • Post-dialysis weight gain is 54 kg
  3. 3. Pathophysiology • End Stage Renal Disease can result from a wide variety of different kidney diseases – Diabetes Mellitus – Hypertension – Glomerulonephritis or Acute Kidney Failure – Chronic Kidney Failure • Diagnosis: Stage 5 CKD, BUN 100 mg/dL, Cr 10-12 mg/dL
  4. 4. Medical Treatment • Options include – Dialysis <3 – Transplantation – Medical management progressing to death 
  5. 5. Dialysis • Px may choose if he/she prefers: – Outpatient dialysis facility – Hemodialysis at home – Peritoneal Dialysis • Continuous Ambulatory Peritoneal Dialysis (CAPD) • Continuous Cyclic Peritoneal Dialysis (CCPD)
  6. 6. Factors to consider in type of Dialysis Treatment • Availability of family/friends/caretaker to assist therapy • Type of water supply ate home • Previous abdominal surgeries • Membrane characteristics of Peritoneal Membrane • Body size, cardiac status, presence of vascular access • Desire to travel
  7. 7. What is Hemodialysis? • Hemodialysis requires permanent access to blood stream through a FISTULA – If the patient’s blood vessels are fragile, a GRAFT is necessary • Large needles are inserted into the fistula or graft each dialysis and removed when dialysis is complete • HD’s fluid is similar to that of a Human’s Plasma • Waste Products and Electrolytes are removed by diffusion, ultrafiltration, and osmosis from the dialysate • Usually 3 to 5 hours ; newer treatments are shorter
  8. 8. What is Peritoneal Dialysis • Uses the body’s PERITONEUM • Dialysate containing High-dextrose solution is installed in the peritoneum – Diffusion ; blood  dialysate (wastes) – Osmosis (water) • Advantage compared to HD: avoids large fluctuations in blood chemistry, longer residual renal function and ability of the patient to live a normal lifestyle • Complications: Peritonitis, Hypotension and WEIGHT GAIN • Icodextrin – superior fluid removal without dextrose absorption
  9. 9. Evaluation of Dialysis Frequency • Kinetic Modeling – Measures the removal of urea from the patient’s blood over a given period – Kt/V • K – Urea Clearance • t – Length of time of dialysis • V – Total Body Water Volume • Urea Reduction Ratio – Looks ate the reduction of urea after dialysis
  10. 10. GOALS?????
  11. 11. Medical Nutrition Therapy Goals • Prevent deficiency and maintain good nutrition status through adequate protein, energy, vitamin and mineral intake • Control edema and electrolyte imbalance by controlling sodium, potassium and fluid intake • Prevent or retard development of renal osteodystrophy by controlling calcium, phosphorus, Vitamin D and PTH
  12. 12. Medical Nutrition Therapy Goals • Enable the patient to eat a palatable, attractive diet that fits his or her lifestyle as much as possible • Coordinate with the Healthcare Team • Provide initial nutrition education, periodic counseling and long term monitoring of patients
  13. 13. PROTEIN NEEDS • Dialysis drains body protein • 1.2 g of Pro for patients who receive HD three times a week • Albumin is a limited factor of protein nutriture, but is routinely used in evaluating ESRD’s NS • Patients with Uremia have greater chances of lowered protein intake • Patients may tolerate other sources of meats better • Phosphate restriction may be lifted to allow dairy products
  14. 14. Energy • SHOULD BE ADEQUATE TO SPARE PROTEIN • 25 kcal – 40 kcal/g of body weight • Higher needs for patients in PD
  15. 15. Fluid and Sodium Balance • Thirst may indicate excessive sodium intake, increased fluid gain and resultant hypertension • Allowed weight gain (fluid gain) for HD patients – 2 to 4 kilograms • Restriction on fluid: 750 ml + urine output • Some patients may have salt wasting tendencies which maye require extra sodium • Frequent dialyses, daily PD, daily nocturnal dialysis – higher allowance for sodium and fluid
  16. 16. Potassium • Restriction would be based on the frequency of Hemodialysis • Be careful: Low sodium foods contain potassium chloride as a salt substitute
  17. 17. Phosphorus • As GFR decreases, phosphorus excretion also decreases • High-protein diet may also be equated to high phosphorus intake • Phosphate binders – May cause GI distress, diarrhea or gas – Severe constipation  intestinal impaction
  18. 18. Calcium and Parathyroid Hormone • ESRD patients  Impaired Calcium and PTH balance • As GFR decreases, serum calcium declines because – Decreased ability to convert Vit. D – Increased need due to high phosphorus intake – Hypertrophy of the Parathyroid gland • Over secretion of PTH • Secondary hyperparathyroidism • Calciphylaxis – Deposition in wound tissues with resultant vascular calcification, thrombosis, non-healing wounds and gangrene
  19. 19. Lipids • Risk of atherosclerotic cardiovascular diseases • Elevated TG without increase in cholesterol • Low cholesterol levels may lead to mortality of ESRD
  20. 20. Iron and EPO • ESRD  inability of the kidney to produce EPO • EPO – stimulates bone marrow to produce red blood cells • There is also a destruction of red blood cells • Lost blood in dialysis  RISK FOR ANEMIA
  21. 21. Vitamins • Water soluble vitamins -> lost during dialysis • Emphasis on Folate • Vitamin B12 is protein bound, thus, losses are minimal • High Phosphorus foods -> High water soluble vitamins • Niacin -> helpful in lowering phosphate levels in ESRD patients
  22. 22. Case Study: Dietary Computations • Desirable Body Weight – (172.27 cm – 100) x .90 – 65 kg • Dry Body Weight – NTBW = 54 kg x .50 – =27 – ATBW = (142 mEq/L / 140 mEqL x NTBW) – =27.38
  23. 23. Dietary Computations • EBW = 27.38 – 27 kg • EBW = 0.38 L • Estimated Dry Weight – 53.62 kg • Estimated BMI = 18.0 (Underweight)
  24. 24. Total Energy Requirement • = DBW x 35 kcal/DBW • =65 kg x 35 kg • = 2275 kcal ῀ 2250 kcal
  25. 25. Protein Requirement • = DBW x 1.2 g/KDBW • = 78 g Pro ῀ 80 g Pro • NPC = 2250 – (80 g Pro x 4 kcal/g) • NPC = 1930 kcal Based on the Diet Manual
  26. 26. Non-Protein Calories Distribution Carbohydrates • 1930 kcal x .70 • = 1351 kcal / (4 kcal/g) • = 337.75 g CHO • = 340 g CHO Fat • 1930 kcal x .30 • = 579 kcal / (9 kcal/g) • = 64.5 g Fat • = 65 g Fat
  27. 27. Phosphorus, Potassium and Sodium Restriction • Potassium – DBW X 40 mg/KgIBW – =2600 mg or 2 g - 3 g Potassium • Phosphorus – DBW x < 17 mg / Kg DBW – = < 1105 mg • Sodium – 2 – 3 g
  28. 28. Fluid and Restriction • Fluid – 750 mL – 1000 ml / Day • Calcium – 1000 mg – 1800 mg (supplements as needed)
  29. 29. Final Diet Prescription • 2250 kcal ; 340 g CHO ; 80 g Pro ; 65 g Fat – 2 – 3 g Potassium – < 1105 Phosphorus – 750 mL – 1000 mL Fluid – 2 – 3 g Sodium – 1000 mg – 1800 mg Calcium
  30. 30. Distribution to Exchanges Food Group Ex CHO (g) PRO (g) FAT (g) KCAL Na K Ca P Moisture Veg A 2 3 1.2 32 4 120 30 30 60 Veg A.1 2 3 1.2 32 4 240 80 30 60 Fruit B (Processed) 3 30 0.6 120 6 180 15 15 126 Sugar A 5 25 100 35 100 75 100 10 Sugar (Free Foods) 10 50 200 0 0 0 0 0 Rice A 8 184 16 800 16 480 120 280 600 Rice B 2 46 8 200 460 120 40 70 20 Meat (Lean) A 6 48 6 246 180 1200 90 420 186 Fat A 2 10 90 80 4 2 2 2 Fat (Free Foods) 9 45 405 0 0 0 0 0 TOTAL 341 75 61 2225 785 2444 452 947 1064
  31. 31. Calcium and Sodium Supplement Computation • Calcium Restriction – 1400 mg • Less: Inherent Calcium – 467 mg • Remaining = 933 mg Ca – Equivalent to (2) 500 mg tablets • Sodium Restriction – 2000 mg (Lower limit) • Inherent Sodium – 815 mg • Remaining = 1185 mg = 2 ¼ tablespoon Salt Solution

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