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CKD Stage 5
Outline
•   Stage 5 CKD
•   Hemodialysis
•   Peritoneal Dialysis
•   MNT
•   Patient Assessment
•   Complications
•   Questions?
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%)
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
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
Risk Factors
•   Proteinuria
•   Ethnicity
•   Gender
•   Smoking
•   Heavy consumption of non-narcotic
    analgesics, particularly phenacetin




                                          6
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
United States ESRD Prevalence
                  610000
                                                      605376
Number of Cases


                  600000                           598409
                  590000                     592367
                                       586445
                  580000         578637
                  570000   571414
                  560000
                  550000




                                      Quarter
Indications to begin dialysis
• Diabetics: Creatinine clearance is < 15
  mL/min
• Non-diabetics: serum creatinine reaches 6
  mg/dL
Additional Indications
       Symptoms
    •    Pericarditis
    •    Uncontrollable fluid overload
    •    Pulmonary edema
    •    Uncontrollable and repeated hyperkalemia
    •    Coma
    •    Lethargy
•       Less Severe Symptoms
    •    Azotemia
    •    Nausea
    •    Vomiting
Main Goals of Dialysis
 Remove                Maintain
   Fluid                 Fluid
   Waste Products        Electrolyte
    ○ Urea                Acid-base balance
    ○ Creatinine
    ○ Potassium
    ○ Phosphorous
    ○ Sodium
Dialysis Health Care Team
•   Patient
•   Dialysis Nurse
•   Dialysis Technician
•   Nephrologist
•   Nephrology Social Worker
•   Renal Dietitian
Therapeutic Modalities
•   Hemodialysis
    • In center dialysis
    • Home hemodialysis
    • In center nocturnal dialysis
•   Peritoneal Dialysis
    • Continuous ambulatory peritoneal dialysis
    • Continuous cycling peritoneal dialysis
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
Access
• Arteriovenous Fistula
• Arteriovenous Graft
• Central Venous Catheter
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
Arteriovenous Graft
             Artery           • Used when veins are
   Vein
              Graft
                                not adequate
              Connection      • Polytetrafluroethylene
    Graft                       (teflon) tube
                              • Needles placed in
                                graft
 Venous
 Needle     Arterial Needle
Central Venous Catheter




   Blood to
   dialysis   Blood from dialysis
   machine    machine
Hemodialysis
Dialysate
•   Highly purified water
•   Sodium
•   Potassium
•   Calcium
•   Magnesium
•   Chloride
•   Bicarbonate
•   Dextrose
Mechanisms of transport
• Diffusion
• Ultrafiltration (convection)
        • Hydrostatic ultrafiltration
          • Transmembrane pressure (blood- dialysate)
          • Ultrafiltration coefficient (KUF): water permeability

    •   Osmosis
Peritoneal Dialysis
      Infusion                Drain

                  Dialysis
                  Solution



                 Peritoneum

                 Abdominal
                 Cavity




                              Catheter
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
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
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
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
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
Renal MNT
Treatment          Pre-Stage 5 CKD   Hemodialysis       Peritoneal
                                                        Dialysis
Protein (gm/kg     .6-.8             ≥1.2 for stable    1.2-1.3 for stable
SBW)                                 patients           patients

                   65% HBV           ≥ 50% HBV          ≥ 50% HBV
Energy             35                30-35              30-35
(kcal/kg/SBW)
Phosphorus         800-1000          800-1000           800-1000
(mg/kg SBW)        (10-12 mg/gm      (10-12 mg/gm       (10-12 mg/gm
                   protein)          protein)           protein)

Potassium (mg/d)   Typically         2000-3000          3000-4000
                   unrestricted
Sodium (mg/d)      1000-3000         2000-3000          2000-4000
Fluid (ml/d)       Typically         750-1000 + 24 hr   2000
                   unrestricted      urine output
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
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
Phosphorus Binders
•   Calcium acetate (Phos-Lo)
•   Calcium carbonate (Tums, Calci-Chew)
•   Calcium citrate (Citracal 950)
•   Magnesium carbonate (MagneBind 200)
•   Lanthanum carbonate (Fosrenol)
•   Sevelamer hydrochloride (Renagel)
•   Aluminum hydroxide (Amphojel)
•   Aliminum carbonate (Basaljel)
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
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
Vitamin & Mineral
 Supplements

  10-50 mg vitamin B    60-100 mg vitamin C

  1.5 mg thiamin        6μg – 1 mg vitamin B12

  1.7 mg riboflavin     800 μg – 5 mg folic acid

  20 mg niacin          10 mg pantothenic acid

  150 – 300 μg biotin
Patient Recommendations
 Foods to enjoy
   Fresh meat, fish and poultry
   Enriched bread, pasta and rice
   Allowed vegetables and fruits
   Olive oil, butter, or margarine
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
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
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
Potassium
Fruits to Enjoy:     Vegetables to Enjoy
 • Apples             • Asparagus
 • Blackberries       • Bean Sprouts
 • Blueberries        • Broccoli
 • Cherries           • Cabbage
 • Grapes             • Carrot
 • Peaches            • Celery
 • Pears              • Cucumber
 • Pineapple          • Green Beans
 • Strawberries (5    • Potatoes(only if
   med)                 soaked 2-4 hours)
Potassium
Fruits to Limit/Avoid:   Vegetables to
 • Bananas                  Limit/Avoid:
 • Cantaloupe             • Artichokes
 • Dried fruits           • Beans
 • Honeydew               • Fresh beets, beet
 • Mango
                            greens
                          • Chinese cabbage
 • Nectarine
                          • Pumpkin
 • Oranges
                          • Sauerkraut
 • Starfruit
                          • Sweet Potatoes
 • Orange Juice
                          • Tomato
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
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
Nutrition Assessment
• Diet Recall
• Food Diary
• Food Frequency Questionnaire
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.
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.
Behavioral Outcomes
 Meal planning
 Meeting nutrient needs
 Awareness of potential food/drug
  interactions
 Exercise
Comorbid Conditions and
Complications
 Malnutrition
 Cardiovascular disease
 Secondary Hyperparathyroidism
     Osteitisfibrosa
   Anemia
     Recombinant human erythropoietin
     Iron
     Target levels
      ○ Hematocrit: 33-36%
      ○ Hemoglobin: 11-12 g/dL
For Further Reading
•   Daugirdas JT, Blake PG, Ing
    TS.“Handbook of Dialysis Fourth
    Edition" Lippincott Williams
    &Wilkins:2006.
Questions?

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Dialysis

  • 2. Outline • Stage 5 CKD • Hemodialysis • Peritoneal Dialysis • MNT • Patient Assessment • Complications • Questions?
  • 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
  • 11. Main Goals of Dialysis  Remove  Maintain  Fluid  Fluid  Waste Products  Electrolyte ○ Urea  Acid-base balance ○ Creatinine ○ Potassium ○ Phosphorous ○ Sodium
  • 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
  • 15. Access • Arteriovenous Fistula • Arteriovenous Graft • Central Venous Catheter
  • 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
  • 18. Central Venous Catheter Blood to dialysis Blood from dialysis machine machine
  • 20. Dialysate • Highly purified water • Sodium • Potassium • Calcium • Magnesium • Chloride • Bicarbonate • Dextrose
  • 21. Mechanisms of transport • Diffusion • Ultrafiltration (convection) • Hydrostatic ultrafiltration • Transmembrane pressure (blood- dialysate) • Ultrafiltration coefficient (KUF): water permeability • Osmosis
  • 22. Peritoneal Dialysis Infusion Drain Dialysis Solution Peritoneum Abdominal Cavity Catheter
  • 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
  • 28. Renal MNT Treatment Pre-Stage 5 CKD Hemodialysis Peritoneal Dialysis Protein (gm/kg .6-.8 ≥1.2 for stable 1.2-1.3 for stable SBW) patients patients 65% HBV ≥ 50% HBV ≥ 50% HBV Energy 35 30-35 30-35 (kcal/kg/SBW) Phosphorus 800-1000 800-1000 800-1000 (mg/kg SBW) (10-12 mg/gm (10-12 mg/gm (10-12 mg/gm protein) protein) protein) Potassium (mg/d) Typically 2000-3000 3000-4000 unrestricted Sodium (mg/d) 1000-3000 2000-3000 2000-4000 Fluid (ml/d) Typically 750-1000 + 24 hr 2000 unrestricted urine output
  • 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
  • 31. Phosphorus Binders • Calcium acetate (Phos-Lo) • Calcium carbonate (Tums, Calci-Chew) • Calcium citrate (Citracal 950) • Magnesium carbonate (MagneBind 200) • Lanthanum carbonate (Fosrenol) • Sevelamer hydrochloride (Renagel) • Aluminum hydroxide (Amphojel) • Aliminum carbonate (Basaljel)
  • 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
  • 34. Vitamin & Mineral Supplements 10-50 mg vitamin B 60-100 mg vitamin C 1.5 mg thiamin 6μg – 1 mg vitamin B12 1.7 mg riboflavin 800 μg – 5 mg folic acid 20 mg niacin 10 mg pantothenic acid 150 – 300 μg biotin
  • 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
  • 39. Potassium Fruits to Enjoy: Vegetables to Enjoy • Apples • Asparagus • Blackberries • Bean Sprouts • Blueberries • Broccoli • Cherries • Cabbage • Grapes • Carrot • Peaches • Celery • Pears • Cucumber • Pineapple • Green Beans • Strawberries (5 • Potatoes(only if med) soaked 2-4 hours)
  • 40. Potassium Fruits to Limit/Avoid: Vegetables to • Bananas Limit/Avoid: • Cantaloupe • Artichokes • Dried fruits • Beans • Honeydew • Fresh beets, beet • Mango greens • Chinese cabbage • Nectarine • Pumpkin • Oranges • Sauerkraut • Starfruit • Sweet Potatoes • Orange Juice • Tomato
  • 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
  • 43. Nutrition Assessment • Diet Recall • Food Diary • Food Frequency Questionnaire
  • 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.
  • 46. Behavioral Outcomes  Meal planning  Meeting nutrient needs  Awareness of potential food/drug interactions  Exercise
  • 47. Comorbid Conditions and Complications  Malnutrition  Cardiovascular disease  Secondary Hyperparathyroidism  Osteitisfibrosa  Anemia  Recombinant human erythropoietin  Iron  Target levels ○ Hematocrit: 33-36% ○ Hemoglobin: 11-12 g/dL
  • 48. For Further Reading • Daugirdas JT, Blake PG, Ing TS.“Handbook of Dialysis Fourth Edition" Lippincott Williams &Wilkins:2006.

Editor's Notes

  1. number of new cases per population in a given time period
  2. a measure of the total number of cases of disease in a population rather than the rate of occurrence of new cases