question

AKI goals

answer

manage symptoms until function returns

question

CKD goals (stage 1-4)

answer

Prevent/delay further damage to kidney

question

end stage renal disease goals (stage 5)

answer

maintain nutritional status; manage/prevent complications of ESRD

question

kidney transplant goals

answer

maintain nutritional status; address side effects of meds

question

nephrolithiasis goals

answer

reduce risk for stone formation

question

Functions of the kidney 1) 2) 3) 4) 5)

answer

Fluid and electrolyte balance Excretion of waste products Urea, uric acid, creatinine, ammonia Blood pressure regulation Renin-angiotensin system RBC production Kidney produces erythropoetin Calcium-phosphorus homeostasis Kidney converts 25-hydroxyvitamin D3 to 1, 25 dihydroxyvitamin D3 (calcitriol)

question

AKI prerenal causes

answer

inadequate renal perfusion Severe dehydration Circulatory collapse

question

AKI intrinsic causes

answer

diseases within renal parenchyma Trauma, surgery, septicemia Nephrotoxicity - abx, contrast, other Vascular disorders Acute glomerulonephritis - poststreptococcal, SLE

question

AKI postrenal obstruction causes

answer

benign prostatic hypertrophy tumor kidney stones

question

treatment? duration? what does hemodialysis help with? recovery phase

answer

Treatment involves addressing the cause Duration - few days to several weeks Hemodialysis may be needed temp. Correct uremia Prevent hyperkalemia Reduce acidosis Remove fluid if pt oliguric (<500 cc urine/d) Recovery phase - increase in urine (diuretic phase) followed by return of waste elimination

question

If patient is uremic with poor intake, what will help?

answer

nutrition support may be needed shown to positively affect pt survival meet pts requirements to avoid protein catabolism

question

protein needs not on dialysis, not catabolic- on dialysis or CRRT- catabolic d/t severe trauma, sepsis-

answer

Not on dialysis, not catabolic - 0.8 g/kg/d protein On dialysis or CRRT - 1.2-1.5 g/kg/d protein Catabolic d/t severe trauma, sepsis - 1.2-1.5 g/kg/d protein

question

AKI protein needs high biological value proteins low biological value proteins

answer

High Biological Value Proteins Eggs, meat, poultry, fish, cheese, soy Low Biological Value Proteins Cereals, grains, nuts, vegetables Majority of protein s/b HBV

question

AKI medical nutrition therapy Caloric needs why do you avoid overfeeding? how to meet caloric needs w/out protein stress ___ glucose tolerance and ____ triglycerides

answer

Caloric needs: spare protein Estimate 20-35 kcals/kg/d dry wt (or IBW) Avoid overfeeding excess CO2 prodn use of commercial renal formulas low in protein and electrolytes helpful; added vegetable oils, margarines, sugar to boost kcals stress decreased glucose tolerance, increased triglycerides

question

Potassium- monitor frequently

answer

Meet needs according to serum levels Tissue destruction ↑serum potassium oliguric phase - <2000 mg/d diuretic phase - Replace losses

question

Sodium- monitor frequently

answer

Sodium - monitor frequently Avoid hyponatremia Oliguric phase - 500-1000 mg/d Diuretic phase - replace losses

question

Phosphorous

answer

monitor-may be increased in oliguric phase

question

patients with AKI may experience salt and water overload during the _____ salt and water depletion during the ____

answer

salt and water overload during oliguric phase salt and water depletion during recovery phase

question

in the recovery phase what three ions may need to be replaced

answer

Na, K, and Phosphorous

question

AKI fluid needs

answer

500 cc and output

question

Fluid input

answer

IV Fluids /meds Blood products PO fluids-in diet and with po meds PO diet - allow 500 cc for fluid in foods

question

fluid output

answer

500 cc/d for insensible losses urine output Other sources of fluid output: emesis, diarrhea, body cavity drains, skin and respiratory losses dialysis

question

patients on hemodialysis 3days per week can tolerate how much?

answer

Patients on hemodialysis three days per week can tolerate 1000 cc/d. Patients dialyzing more frequently can tolerate more fluids.

question

what is the leading cause of chronic kidney disease (CKD)?

answer

diabetes

question

what is the second leading cause of CKD?

answer

uncontrolled or poorly controlled high blood pressure is the second leading cause

question

Stages of CKD Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

answer

Stage 1 - kidney damage exists but GFR > 90 ml/min/1.73 m² Stage 2 - GFR 89-60. Stage 1 and 2 (referred as "at risk"); generally not treated. Stage 3 - GFR 59-30 (moderate); Stage 4-GFR 29-15 (severe). Stage 5 - GFR < 15 is ESRD requiring dialysis or kidney transplantation

question

interventions that delay progression

answer

ACE inhibitors BP control Blood sugar control Protein restriction?

question

Prevention of uremic complications

answer

Malnutrition Anemia Osteodystrophy Acidosis

question

Modification of Co- morbidity

answer

cardiac disease vascular disease neuropathy in diabetics retinopathy in diabetics

question

preparation for RRT

answer

education informed choice of RRT timely access placement timely initiation of dialysis

question

Nutritional management in stages 1-4 reduction in leads to symptoms of uremia

answer

A reduction in waste excretion, fluid and electrolyte balance and decreased calcitriol and eythropoeitin production leads to azotemia, edema, secondary hyperparathyroidism, anemia, HTN and dyslipidemia in CKD. Symptoms of uremia - malaise, weakness, nausea/vomiting, etc lead to a decreased quality of life for patients and eventually, as GFR decreases to <15, renal replacement therapy (RRT) or transplant is needed

question

goals of stage 3-4

answer

Stages 3-4 Protein restriction? Sodium restriction/ Fluid ? Potassium increase or decrease Phosphorus restriction Ca, Vitamin D3 , renal vit Promote optimal BG , BP and lipids

question

goals of stage 5

answer

Hemodialysis Peritoneal Dialysis Transplant

question

Does protein restriction slow the progression of diabetic nephropathy

answer

kind of...initial results weren't conclusive, but the secondary analysis showed a slowed progression of advanced renal disease

question

carbs in CKD diet are fruits, starches, and vegetables controlled in this diet? what are some examples of protein free carbs? increased blood sugars cause ____proteinuria which leads to ____serum albumin

answer

In protein restricted diets, starches, vegetables and fruits will be controlled with protein restriction. Protein free carbs such as hard candies, popsicles, marshmallows, sugar can add calories to protein restricted diet - caution with diabetics. ↑blood sugars cause ↑proteinuria which leads to ↓serum albumin

question

abnormalities of dyslipidemia

answer

hypercholesterolemia hypertriglyceridemia increases in LDL and VLDL cholesterol

question

dyslipidemia contributes to

answer

coronary atherosclerosis increased incidence of myocardial infarction

question

what is dyslipidemia associated with?

answer

more rapid decline of kidney function

question

what kind of fats should you be eating in a CKD diet?

answer

monounsaturated and polyunsaturated fats lipid lowering medications often needed

question

CKD diet for stage 3-4 protein restriction what do you need for nephrotic syndrome energy carbohydrates lipids

answer

Protein restriction 0.6 g/kg/d - 0.75g/kg/d (NKF), 0.8 g/kg/d (ADA) Nephrotic Syndrome - meet needs for protein losses 0.8-1.0 g/kg/d Energy - meet caloric needs 30-35 kcals/kg/d to spare protein. Carbohydrates - meet caloric needs; maintain optimal blood glucose (HbA1c goals vary depending on patient age and comorbidities Lipids - meet caloric needs; use monounsaturated and polyunsaturated fats; limit saturated fats and cholesterol

question

HbA1c goals for healthy individuals with diabetes HbA1c goals for pts who are older and have multiple co morbidities

answer

HbA1c goals for healthy individuals with diabetes is <7.0, patients who are much older and/or have multiple comorbidities (HbA1c < 8.0 or 8.5)

question

CKD diet pre-dialysis stage 3-4 sodium potassium phosphorous calcium supplements

answer

Sodium - 2 gm/d Potassium - Monitor; may need to supplement if pt on potassium losing diuretics; may need to limit if not. Phosphorus - restrict to 800 mg - 1000 mg/d. Calcium - monitor; 1200 mg/d Supplementation of renal vitamin (B, C) and Vit D3, EPO (erythropoeitin)

question

PEM and inflame related to good dialysis outcome?

answer

PEM and inflame common in ESRD population and related to poor dialysis outcome

question

diet for hemodialysis protein- needs are increased energy sodium potassium calcium phosphorous fluid supplements

answer

Protein - 1.2 -1.4 g/kg/d Standard BW 50% HBV Energy - 35 kcals/kg/d <60 y/o 30 kcals/kg/d ≥60 y/o Sodium - 2 gm/d Potassium - 2-3 g/d Calcium - ≤ 2000 mg/d diet and meds Phosphorus - 800-1000 mg/d/phosphate binder often needed Fluid - 1000 cc/d + urine output Supplements - Renal Vitamin - water sol vits lost in dialysate (B, C) qd Vit D3 - active Vit D given IV during treatment Fe - given IV during treatment

question

good sources of protein

answer

poultry eggs/ egg whites protein supplements beef, lamb, veal fresh pork seafood fish

question

High potassium foods to avoid

answer

bananas avocados kiwi pumpkin tomato mango artichoke oranges cantaloupe

question

high phosphorus foods to avoid

answer

packaged products nuts/peanut butter milk, ice-cream

question

what happens with increased sodium intake

answer

edema dyspnea HTN cramping and BP drops during dialysis

question

Immunosuppressive drug side effects

answer

Increased appetite , wt gain, glucose intolerance, ↑ protein catabolism, hyperlipidemia, sodium retention, inhibition of normal calcium, phosphorus and Vit D metabolism (hypercalcemia, hypophosphatemia, hyperkalemia with cyclosporine

question

diet after transplant protein energy carbohydrates fat

answer

Protein - 1.3-1.5 g/kg/d initially post op, decreasing to 1.0 g/kg/d as pt recovers from surgery and immunosuppressive drugs decreased. Energy - 30-35 kcals/kg/d initially decreasing to 25-30 kcals/kg/d maintenance and weight management Carbohydrates - controlled if BG elevated Fat - <10% saturated, 30% total fat, MUFAs and PUFAs

question

diet post transplant sodium- restricted if what is present? potasium- restricted if you are taking what? calcium supplementation phosphorous

answer

Sodium - restricted if edema present, otherwise liberal Potassium - monitor; may need to restrict if on cyclosporine Calcium - supplementation d/t steroid ↓ calcium absorption Phosphorus - may need supplement initially d/t ↑ bone uptake post-op If rejection occurs, renal diet restrictions needed

question

types of stones that can develop

answer

Calcium oxalate - 60% cases Calcium phosphate - 10% cases Uric Acid - 5-10% cases Struvite - 5-10% cases Cystine - 1% cases

question

what is an important risk factor for urolithiasis how many cups per day?

answer

Low urine volume most important risk factor for urolithiasis 10-12 cups /d recommended; ½ water

question

diet for nephrolithiasis what is the goal? what increases oxaluria

answer

Calcium restriction increases oxaluria Pyridoxine deficiency increases endogenous oxalate production Pts with fat malabsorption develop hyperoxaluria Vit C supplementation ↑ hyperoxaluria Animal protein ↑ oxaluria and calciuria Sodium ↑calciuria Potassium - high intake reduces kidney stone formation Carbohydrates - refined ↑calciuria; high fiber↓

question

what foods raise urinary oxalate excretion

answer

rhubarb spinach strawberries wheat bran nuts beets tea

question

diet for nephrolithiasis protein sodium potassium calcium adequate B6 vitamin intake fluid intake recommendations

answer

Protein - 0.8 g/kg/d SBW - plant strong Sodium - 4 gm/d - choose potassium rich low oxalate fruits and veges Calcium - DRI 1000-1200 mg/d Adequate B6 vitamin intake Fluid intake recommendations: 10-12 cups fluid/d; ½ H20; one overnight

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