Medical Nutrition Therapyfor ESRD - HemodialysisDietitian - Jake Brandon M. Andal

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

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

Medical Treatment

• Options include

– Dialysis <3

– Transplantation

– Medical management progressing to death

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)

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

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

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

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

GOALS?????

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

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

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

Energy

• SHOULD BE ADEQUATE TO SPARE PROTEIN

• 25 kcal – 40 kcal/g of body weight

• Higher needs for patients in PD

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 mayerequire extra sodium

• Frequent dialyses, daily PD, daily nocturnal dialysis – higher allowance for sodium and fluid

Potassium

• Restriction would be based on the frequency of Hemodialysis

• Be careful: Low sodium foods contain potassium chloride as a salt substitute

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

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

Lipids

• Risk of atherosclerotic cardiovascular diseases

• Elevated TG without increase in cholesterol

• Low cholesterol levels may lead to mortality of ESRD

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

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

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

Dietary Computations

• EBW = 27.38 – 27 kg

• EBW = 0.38 L

• Estimated Dry Weight – 53.62 kg

• Estimated BMI = 18.0 (Underweight)

Total Energy Requirement

• = DBW x 35 kcal/DBW

• =65 kg x 35 kg

• = 2275 kcal ῀ 2250 kcal

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

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

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

Fluid and Restriction

• Fluid

– 750 mL – 1000 ml / Day

• Calcium

– 1000 mg – 1800 mg (supplements as needed)

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

Distribution to Exchanges

Food GroupEx 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

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