3. Etiology of CKD
• Most common causes:
• Diabetes (39% of patients)
• Hypertension (28%)
• Glomerulonephritis (13%)
• Hereditary cystic and congenital renal disease
(4%)
• Interstitial nephritis and phyelonephritis (4%)
• Neoplasm/tumor (2%)
4. Pathophysiology of CKD
Kidney injury
Destruction of nephrons
Renal function and GFR
Adaptation causes nephron size and
glomerular pressure
Increased glomerular pressure causes
loss of nephrons
5. Stage 5 CKD: End Stage Renal
Disease
• Kidney function inadequate to sustain
life (50-66% of normal function lost)
• GFR < 15 mL/min/1.73m2 (or dialysis)
• Requires renal replacement therapy
• Renal Transplant
• Dialysis
5
6. Risk Factors
• Proteinuria
• Ethnicity
• Gender
• Smoking
• Heavy consumption of non-narcotic
analgesics, particularly phenacetin
6
7. United States ESRD Incidence
32000
31000
Number of Cases
30000
29000
28000 2009
27000 2010
26000 2011
25000
24000
Q1 Q2 Q3 Q4
Quarter
United States Renal Data System
8. United States ESRD Prevalence
610000
605376
Number of Cases
600000 598409
590000 592367
586445
580000 578637
570000 571414
560000
550000
Quarter
9. Indications to begin dialysis
• Diabetics: Creatinine clearance is < 15
mL/min
• Non-diabetics: serum creatinine reaches 6
mg/dL
10. Additional Indications
Symptoms
• Pericarditis
• Uncontrollable fluid overload
• Pulmonary edema
• Uncontrollable and repeated hyperkalemia
• Coma
• Lethargy
• Less Severe Symptoms
• Azotemia
• Nausea
• Vomiting
12. Dialysis Health Care Team
• Patient
• Dialysis Nurse
• Dialysis Technician
• Nephrologist
• Nephrology Social Worker
• Renal Dietitian
13. Therapeutic Modalities
• Hemodialysis
• In center dialysis
• Home hemodialysis
• In center nocturnal dialysis
• Peritoneal Dialysis
• Continuous ambulatory peritoneal dialysis
• Continuous cycling peritoneal dialysis
14. Hemodialysis
• Waste products filtered from blood by a
semipermeable membrane and removed
by the dialysis fluid, or dialysate.
• In-center: 4 hours, 3 days a week
• Home: may be daily
• Nocturnal In-center: 6-8 hours, 3
nights/week
16. Arteriovenous Fistula
Venous Needle
• Radial artery to
Arterial Needle
cephalic vein
Vein
• 4-6 weeks to
become fully
functional
AV
Fistula
Artery
• Subclavian route
can be used
temporarily
17. Arteriovenous Graft
Artery • Used when veins are
Vein
Graft
not adequate
Connection • Polytetrafluroethylene
Graft (teflon) tube
• Needles placed in
graft
Venous
Needle Arterial Needle
23. Peritoneal Dialysis
• Peritonealcavity: reservoir for dialysate
• Peritoneum: semipermeablemembrane
across which excess body fluid and
solutes are removed
• Polyurethane or silicone catheter
Peritoneal Capillaries Peritoneal Cavity
Fluid
Urea
Creatinine
Potassium
Sodium
Chloride
Lactate
Glucose
24. Peritoneal Dialysis
Continuous Automated PD
Ambulatory PD
• 2.0-2.5 L dwells • 3-10 dwells nightly
• 4-8 hours • Continuous Cycling PD–
• 4 times/day 1 dwell during the day
• Nocturnal Intermittment
PD- dry during day
25. PD Transport
• Diffusion
• Uremic solutes and potassium
• Peritoneal capillary ➔ dialysis solution
• Glucose, lactate, and calcium
• Dialysis solution ➔ peritoneal capillary
• Ultrafiltration
• Water and associated solutes
• Peritoneal capillary ➔ dialysis solution
• Absorption
• Water and solute
• Peritoneal cavity ➔ lymphatic system
26. Calculation of Glucose Absorbed in
Peritoneal Dialysis Patients
• 60% of daily dialysate glucose load is
absorbed
glucose absorbed (kcal) = (1-D/D0)xi
where D/D0 is the fraction of glucose
remaining and xi is initial glucose
27. MNT Objectives in Dialysis
• Maintain protein and kcal balance
• Prevent dehydration or fluid overload
• Maintain normal potassium and sodium
blood levels
• Maintain acceptable serum phosphorus
and calcium levels
29. Renal MNT
Treatment Hemodialysis Peritoneal Dialysis
Fat 25-35% of total kcal 25-35% of total kcal
Cholesterol < 200 mg/day < 200 mg/day
Fiber 20-30 g/day 20-30 g/day
Calcium ≤1500 mg/day from 3000-4000
phosphate binders
≤2000 mg/day total
30. Adjusted Edema- Free Body
Weight
Calculating protein and energy
requirements for underweight and obese
patients
aBWef = Bwef + [{SBW-Bwef} x 0.25] Bwef
SBW determined from NHANES II data
32. Calcium
Low serum calcium due to
Alterations in vitamin D metabolism
Decreased absorption of calcium from gut
Elevated phosphorous levels
Restriction of high calcium foods
Calcium Supplementation
Should not exceed 2,000 mg/day
Coronary calcification
33. CKD Response to Low
Serum Calcium and/or High
Phosphorus in CKD Stage 5
Calcitriol
Secondary Osteitis
Serum Ca PTH Bone Calcium- Parathyroid
Hyperparathyr Fibrosa
Serum PO4 Secretion Turnover PO4 Hyperplasia
oidism Cystica
Renal
Resorption
35. Patient Recommendations
Foods to enjoy
Fresh meat, fish and poultry
Enriched bread, pasta and rice
Allowed vegetables and fruits
Olive oil, butter, or margarine
36. Protein
Foods to Enjoy Food to Limit
• Fish • Processed meats
• Seafood • Cheese
• Beef • Buttermilk
• Poultry • Canned/frozen
• Pork dinners
• Other Meats • Canned soup
• Eggs • Fast foods
• Cottage Cheese • Beans
• Peanuts/peanut
butter
37. Calories
Foods to Enjoy: Foods to Limit:
• Candy • Candy with
• Cake chocolate, nuts or
• Pie (with allowed
peanut butter
fruits) • Cream pies
• Donuts • Sweet potato pie
• Honey • Pumpkin pie
• Syrup • Milkshakes
• Vanilla Wafers • Nuts
• Toaster Pastry • Potato Chips
• Butter • Ice cream
38. Phosphorus
Limit or avoid:
• Dairy products
• Dried Beans
• Nuts and Seeds
• Protein Foods: Enhanced
meats, liver, organ meats.
• Whole grains and cereals:
bran, granola, brown rice, whole grain
breads & cereals.
• Other: Beer, colas, pizza, cocoa, macaroni
41. Sodium
Instead of: Try this:
• Canned vegetables • Fresh or frozen
vegetables, cooked
• Processed meats • Unprocessed meats
cooked without salt
• Convenience/ready • Buy fresh
made foods ingredients, cook with
herbs
• Fast Foods
• Pack sandwiches using
fresh, unsalted
• Salted snack foods ingredients
(chips, pretzels, etc.)
• Eat fresh, crisp fruits and
42. Helpful Fluid Tips
• Each morning, measure fluid allowance
in water and store in container
• Every time you drink fluid, pour out an
equal amount.
• Drink only when thirsty
• Satisfy thirst- cold/frozen fruit
• Rinse mouth frequently- don't swallow
• Chew gum
• Have a piece of hard sour candy
44. Nutritional
Indicators, Target, and
Frequency
Indicator Target Frequency
Serum Albumin ≥ 4.0 mg/dL Monthly
Serum Prealbumin >30 mg/dL As needed
Serum Cholesterol > 150-180 mg/dL As needed
Lipid Profile LDL: < 100 mg/dL As needed
HDL: > 150 mg/dL
Triglycerides: < 150 mg/dL
Serum Creatinine > 10 mg/dL Monthly
(pre-dialysis treatment)
nPNA (protein equivalent of > 1.0 HD: Monthly
total nitrogen appearance PD: Every 4
normalized to body weight) months
Nelms et al.
45. Nutritional
Indicators, Target, and
Frequency
Indicator Target Frequency
% Usual Dry Weight after HD N/A Monthly
or post-drain with PD
% Standard Body Weight N/A Every 4
months
BMI Upper 50th percentile Monthly
23.6 kg/m2 for men
24 kg/m2 for women
SGA ≥ 6-7 Biannually
4 item, 7 point scale
Anthropometrics and DEXA N/A As needed
Serum Bicarbonate ≥ 22 mmol/L Monthly
Nelms et al.