Nutrition Needs for Hemodialysis

NL is a 44-year-old African American female who started hemodialysis yesterday. NL reports her physical activity level is sedentary, height: 50, admit weight is 170# and postdialysis weight is 165#. Her current symptoms include anorexia, N/V, 4 kg recent weight gain, edema, shortness of breath, pruritus, and inability to urinate. PMH: HTN. 1. What is her Standard Body Weight (SBW)? The NHANES table is posted on Angel for reference. Do you need to adjust her body weight based on her SBW? What is the comparative standard to make this decision? If so, please show work to adjust her weight. Her SBW is 60kg (132lbs). %SBW (165/132)100= 125%. Since she above 115% of her SBW her weight does need to be adjusted Adjusted body weight: 165 + (132-165).25= 165 165+ (-33).25= 156.75lbs 157lbs (71.3kg) 2. Calculate the nutrition needs for NL (using the appropriate wt) and explain the rationale for each.

Nutrient

Recommended Intake (list standard and final Pt totals)

Rationale

Energy

2,497 kcal (35kcal/kg/day)

Protein (g and % kcals)

86g 14% of kcals (1.2g/kg/day) At least 50% from high biological value 72g (less than 5g saturated) 26%

Fat (g and % kcals)

CHO (g and % kcals)

374g 60%

Potassium

2-3g/day

The current guidelines recommend for HD patients under 60, 35kcal/kg of body weight. The rationale is to increase energy intake to ensure adequate energy intake. Low body weights are linked to increased mortality rates so higher intakes are recommended to prevent further weight loss and promote weight maintenance/gain. Pts with CKD have a high incidence of PEM underscores related to poor nutrient intake resulting from anorexia, academia, etc and also due to being in a hypercatabolic state. Therefore a high intake of pro in order to maintain adequate nutrient intake is recommended. The current guidelines recommend the TLC diet guidelines (25-30% kcal from fat <7% from sat fat) It is important to decrease the chance of CVD in patients with impaired kidney function. Kidney function affects insulin and correlates with diabetes along with hypertension both of which are already precursors for CVD, so they are highly susceptible to CVD. CKD patients require a low fat diet in order to decrease the chance of further complications in relation to increasing risk for CVD, they also require a high protein diet so the remaining calories must come from CHO. High fiber diets protect the heart and also may help with GI distress associated with dialysis. Limit CHO high on glycemic index, inability of insulin degradation makes it essential to balance carbohydrates and reduce high glucose intakes to prevent hypoglycemia CKD affects the excretory function of the kidneys. Potassium is excreted by the kidney and therefore in patients with CKD who cannot probably perform this function, must be restricted. High intakes will lead high serum k levels (above 6 mEq/L) is life threatening. Dietary restriction, avoidance of salt substitutes and possible medication is recommended.

Sodium

2g/day

Phosphorus

800-1,000mg/day

Calcium

<2 g/day

Fluid

Urine outputs +1,000cc Typically not more than 1L

CKD affects the excretory function of the kidneys. Sodium is also excreted by the kidney and therefore in patients with CKD who cannot probably perform this function, must be restricted. Sodium is normally not reflective of dietary intake but is hormone regulated. However it does influence fluid balance and in CKD patients who are not regulating fluid balance properly, it is important to restrict. Normal kidney function would excrete Na and regardless of intake serum Na would not be effected. However this function is lost and all sodium from the diet is retained and water begins leaving cells and move to extracellular compartments. As a result edema, hypertension and increased weight gain between treatments occur. Phosphorous is another mineral that is not properly excreted and dialysis is limited at assisting so therefore must be restricted. High levels lead to hyperphosphatemia which lead to hyperparathyroidism. Restriction is needed to control levels of serum P and PTH in the blood. Calcium should be taken in adequate amounts unless serum levels are low. Calcium homeostasis and balance is greatly affected by CKD. Ca absorption in the SI, resorption from bone, serum Ca levels are all distorted in CKD patients. For example the secondary hyperparathyroidism leads to high serum Ca levels and loss of Ca from the bone. Due to these mechanisms being distorted it is hard to tell the intake of Ca in the patient. Therefore it is recommended that adequate intake values be met each day to maintain balance. However hypercalcemia is a serious issue that can lead to metastic calcification therefore serum levels must be monitored and Intake recommendations changed accordingly. Phosphorous levels also need to be monitored in order to make proper recommendation of foods that will keep balance of the Ca-P (e.g. low phosphorous, high calcium foods in patients with hyperphosphatemia). Since fluid balance is effected, fluid intake, urine intake and sodium intake must all be restricted and monitored to prevent edema and fluid overload. Fluid is measured by outputs since dialysis is removing the excess fluid, in patients on HD fluid balance is monitored by urine outputs. If too much fluid is administered the body will retain it leading to increased weight gain, fluid overload, hyponatremia.

3. Evaluate NLs chemistry report and explain the labs relationship to her diagnoses.

NLs Lab values

Expected outcome in HD

Relationship to renal disease

Albumin 3.4

> 4.0 g/dL

This is the most abundant blood protein so when protein levels are low due to the body wasting (malnutrition) albumin levels decrease. Also due to damage to glomeruli there is albumin loss in the urine due to impaired filtration ability. The glomeruli filters become damaged and allow larger particles, that were supposed to be filtered back into the blood, to fall through and excreted in the urine.

NLs Lab values

Expected outcome in HD

Relationship to renal disease

Hg

10.9

11.0 g/dL - 12.0 g/dL

Hct

32%

33% to 36%

Na

146

136-145 mEq/L

K PO4

5.8 7.0

3.5-5.5 mEq/L 3.5-5.5 mg/dL

pH

7.46

7.35 7.45

Total CO2 20

23-30 mEq/L

BUN

55

8-18 mg/dL in nonCKD and stablized in CKD

Kidney function is needed for erythropoietin secretion (needed for RBC formation in bone marrow). Impaired kidney function is thus linked to anemia since erythropoietin is no longer being properly secreted leading to decreased RBC production. Kidney function is needed for erythropoietin secretion (needed for RBC formation in bone marrow). Impaired kidney function is thus linked to anemia Sodium is high in renal disease patients because the excretory function of the kidneys are impaired and it is not being excreted properly. Fluid balance is greatly affected by Na levels and is also not being maintained properly. Retention of Na in the blood is a sign of CKD Potassium levels are high due to impaired excretory function of the kidneys Phosphorous levels are high due to impaired excretory function of the kidneys. Phosphorous retention occurs early in CKD and becomes very elevated by stage 5, cause of secondary hyperparathyroidism. The pH is high since the kidneys function is impaired, proper acid base balance is not occurring. Carbonic acid-bicarbonate buffer system is stressed due to kidneys not excreting wastes properly. Patient is at severe risk for acidosis (loss of bicarbonate production + Nitrogenous waste build up) Proper Kidney function is needed to regulate carbonic acid loss, when function is impaired the ability to regulate acid-base balance is gone. Any CO2 available must be used in the carbonic-acidbicarbonate buffering system. Waste products normally excreted by the kidneys are building up and CO2 is required to buffer them and maintain body pH. Therefore CO2 decreases due to its elimination by the lungs as well as being bound to H+ ions not excreted by kidneys These levels are very high in kidney malfunction because without functioning kidneys urea is not excreted and builds up in the blood. BUN is directly correlated to protein intake so during too much or too little (wasting) intake these levels will also increase

Creatinine

8.5

0.6-1.2 mg/dL in non-CKD and stablized in CKD

Creatinine is a by-product of muscle in the body and is excreted by the kidneys. When kidney functions stop then it is not excreted and levels are raised.

Glucose

90

70-110 mg/dL

Her level is normal, however impaired function of the kidney interrupts the degradation of peptide hormones such as insulin so she is at risk for becoming hypoglycemic

NLs Lab values

Expected outcome in HD

Relationship to renal disease

Ca

8.4

8.4 mg/dL

Urinary Protein: positive 2+

Negative

Kidneys are responsible for maintaining the calcium-phosphorous bone homeostasis and activating calcitriol (which maintain blood levels of Ca, by activating absorption in the SI) so she is at risk for becoming Ca deficient due to malabsorption. This also puts her at risk for many bone related disorders/diseases (renal osteodystrophy/metastatic calcification). Since her level is normal she should be given adequate amounts and have levels monitored closely. Impaired kidney function has caused albumin to be spilled into the urine as a result of damaged glomeruli. Glomeruli are supposed to filter the blood (removing waste products), large proteins such as albumin are not supposed to pass into the urine but if the glomeruli are damaged then it can occur.

4. Explain why the following medications were prescribed to manage her clinical condition at this time. Medication Indications/Mechanism Nutritional Concerns

Vasotec

Erythropoietin

ACE (angiotensin converting enzyme) inhibitor. Impaired glomeruli function will cause the kidneys to activate the RAS which will increase blood pressure. Kidneys secrete renin and form angiotensin I and angiotensin converting enzyme is needed to create angiotensin II which causes thirst, vasopressin and vasoconstriction (high BP). Vasotec inhibits this last action therefore inhibiting the activation of angiotensin I This is a hormone normally secreted by the kidneys and needed for RBC formation (MOA: binds to erythropoietin receptor activating a signaling cascade that causes bone marrow to produce more red blood cells). It is necessary to help reverse the underlying cause of her anemia.

Reduce alcohol intake This drug could increase potassium levels in the blood so potassium should be limited and salt substitutes avoided.

Taking an iron supplement is advised to ensure enough iron in the blood available for RBC production. High levels of aluminum will decrease the effectiveness Having too little protein, B12 or folate will also cause decreased effectiveness

Medication

Indications/Mechanism

Nutritional Concerns

Fergon

Vitamin/mineral supplement

Calcitriol Synthetic Vit D

Glucophage

Iron supplement. To treat anemia. Her body is depleted of erythropoietin to make RBC and thus anemia results. Her body must make up for the loss of red blood cells once the erythropoietin becomes present again in her body (through medication). She will need iron to help with the production of these RBC for this reason and because her restricted diet, supplementation is needed to guarantee enough iron is present in the blood. Due to impaired renal metabolism, inadequate intake, impaired GI absorption and losses due to dialysis, it is necessary to supplement the following. Thiamin, Riboflavin, niacin, pantothenic acid, B6, biotin, B12, Vitamins C,A,E,K , folic acid and copper. These are essential for numerous metabolic function and deficiencies will lead to malnutrition and complications This hormone is activated by the kidney and is responsible for maintaining blood levels of Ca+ by activation of SI absorption of Ca+. Without proper functioning the parathyroid is triggered to secrete PTH and excrete Ca+ and P from the bone, increasing risk for osteodystrophy. This medication will regulate the absorption of Ca+ in the GI tract. It corrects both hypocalcemia and secondary hyperparathyroidism This is used to control blood sugar, since impaired kidney functions leads to a decreased ability to properly degrade insulin, patients are at risk for hypoglycemia. This medication works by suppressing the production of glucose by the liver (gluconeogenesis) while also increasing insulin sensitivity (by decreasing GI absorption of glucose and increasing peripheral glucose uptake by phosphorylation of GLUT4 factor)

Iron is best absorbed taken on an empty stomach with either water or fruit juice (vitamin c rich may benefit even more) about one hour before meals. If upset stomach occurs, supplement may be taken after meals.

Serum Calcium times phosphate must not be >70mg2/dL2 No doses of other vitamin D given, and diet should not provide in excess of RDA for vitamin D Low-phosphate diet dietary intake of calcium minimum 600mg/day RDA(800-1000mg/day) At risk for lactic acidosis-no alcohol consumption Malabsorption of B12 may occur, supplementation may be needed

Medication

Indications/Mechanism

Nutritional Concerns

Sodium bicarbonate Levels should be at or above 22mmol/L

Phos Lo

Patients with CKD have decreased bicarbonate production due to a drop in GMF rate, this results in metabolic acidosis. The kidney is no longer able to produce bicarbonate and secrete it into the blood in order to maintain its proper pH. Sodium bicarbonate is administered to help reverse the metabolic acidosis and maintain normal body pH which has been thought to reduce the decline of renal function in the patient. The correction of acidemia has shown to increase serum albumin, decrease degradation of proteins, and increase BCAA and essential AA concentrations in plasma. May promote greater weight gain Used to prevent high blood phosphate levels in patients on dialysis. Phosphate is not being excreted by the kidneys and dialysis can only remove so much from the blood Phos Lo (calcium acetate) can be used to help keep these levels low by binding with phosphate from the diet and allowing it to pass through the body.

Contains sodium

Diet low in phosphate

5. Write a Nutrition Prescription for NL (including total kcal, grams protein, K, P, Na, and fluid needs). Complete the meal plan template on Angel. Create a 1-day diet that complies with your Nutrition Prescription. Provide a nutrient analysis to assure consistency with all components of the prescription (kcals, pro, cho, fat, K, P, Na. Print Pie chart for Calories & Fat and Bar chart for Vitamins & Minerals). Outline an educational session that you would conduct with NL. Nutrition Prescription: 2,497kcal/day. 14%pro (86g) 26% Fat (72g) 60% CHO (374g) Fluid: 1L/day Nutrition Education: Goal/objective: NL will understand basis of renal diet composition. NL will be able to choose foods that will provide adequate kcal, fat and protein while still staying under restrictions of sodium, potassium, phosphorus and fluid. Introductions: During this educational session I would discuss with NL the restrictions that are incorporated into her new renal diet. I will provide a basis for the reasoning behind these restrictions and their importance and relation to her condition. During this time I will also outline the consequences of not consuming a diet that follows these restrictions Next I will educate NL on food choices that do fit in with her new diet. I will outline foods low in Na, K, P and fat. I will then educate her on foods high in these nutrients and foods that should be provided. Indicating that carbs that are white and not whole grain are preferred, and that fruits and vegetables will need to be limited.

Activity: At this time I will have NL identify out of a group of vegetables which ones are low potassium, which ones are low phosphorus, and which of them are high in these nutrients. I will have her do a similar activity after using fruits. NL will then be educated on meats that fit well into her diet and abide by the restrictions. I will explain to her the importance of having a high protein diet in her condition and that at least 50% should be HBV, and give her examples of them. NL will also be educated on the TLC diet, the components and basis of the diet and food options that can be incorporate into this diet. A brief explanation of the importance of low fat diet because of the correlation of CVD, diabetes and CKD will also be discussed Activity: During this time I will have NL make herself a meal plan for one day. Breakfast, lunch and dinner using foods previously discussed. When she is done I will make proper corrections and suggestions so she is able to meet her nutrient needs and follow the restrictions.