Nutritional Markers in hemodialysis
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Transcript Nutritional Markers in hemodialysis
Julie Atteritano, RD, CDE, CDN
Biochemical
marker reflecting
visceral protein stores
Most common protein found in the
blood
Produced by the liver (9-12g /day)
Life span 12-20 days
Maintains
intravascular oncotic pressure
Transports small molecules in the blood
such as billirubin, Ca+, Mg, Progesterone,
and medications
Provides the body with necessary protein
needed to maintain growth and repair
tissue
Stabilized serum albumin equal to or
greater than the lower limit of the
normal range.
Approximately 4.0mg/dl
K/DOQI
Increased
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morbidity and mortality
Serum albumin concentrations are identified
as the most powerful indicator of mortality
Risk of death in patients with serum albumin
concentration < 2.5gm/dl was 20 fold than
that of patients with serum albumin 4.04.5gm/dl
Serum albumin 3.5- 4.0gm/dl resulted in a 2
fold increase in relative risk of death
(Lowrie et al.)
Edema
and ascites
Decreased healing
Increased risk of infection
Protein
Energy Malnutrition (PEM)
Caloric and protein intake are inadequate
to meet nutrition needs
** Patients on hemodialysis have a higher
Resting Energy Expenditure than patients in
Stage 2 CKD
** Goal for intake- 30-35Kcal/Kg
1.2- 1.4 gm/Kg protein
Inflammation
Characterized by acute phase proteins
C- reactive protein (CRP), Alpha -1 acid
glycoprotein (a1-AG), Ferritin, Ceruloplasm
Inflammation secondary to infection, trauma,
obesity, poorly controlled DM
Hydration
status
Proteinuria
Metabolic acidosis
Ensure
adequate caloric and protein intake
Increase intake of high biological value (HBV)
proteins (Chicken, turkey, fish, red meat,
eggs)
Nutritional supplementation: Nepro, Liquid
protein supplements (Liquacel, Prostat),
whey protein powder
Intradialytic
Parenteral Nutrition (IDPN)
Amino acids (AA), Dextrose, and lipids
delivered directly into the blood stream
during hemodialysis
Potassium
is a mineral and an
electrolyte
Potassium
is an electrolyte which means it
conducts electricity in the body along with
Na+, Ca+, Mg, and chloride
Responsible for skeletal and smooth muscle
contraction (crucial for heart function)
Plays a role in biochemical reactions and
energy metabolism
Catalyst in the synthesis of amino acids from
protein sources
Low : less than 3.5mg/dl
Goal :3.5mg/dl – 5.5mg/dl
High : 5.6mg/dl – 6.0mg/dl
Unsafe: > 6.0mg/dl
K+
levels > 5.5mg/dl
Causes of Hyperkalemia include:
Dietary
K+
indiscretion
shifts from intracellular to extracellular
space (Caused by metabolic acidosis,
NSAID’s, non-selective Beta-blockers)
K+ bath (3K+,4K+)
Non-compliance with treatment Rx
Nausea
Weakness
Numbness
and tingling
Irregular heart beat
Heart failure
Sudden death
Goal
for intake 2,000mg K+ per day
Avoid/limit high K+ foods
Avocado (1oz) 144mg
Banana (small) 422mg
Cantaloupe/honeydew (1 cup) 388mg
Orange (small) 240mg
Mango/papaya 323mg
Dried fruit (ex-Apricots 10 halves:470mg)
Potato/sweet potato 512-694mg
Tomato (1 cup canned) 1098mg
Spinach
(1 cup cooked) 839mg
Winter squash (1 cup) 494mg
Dried
beans and peas
(ex: kidney beans 1 cup 713mg)
Milk (1 cup) 382mg
Yogurt (8oz) 579mg
Salt substitutes
Apples
Berries (strawberries and blueberries)
Cabbage
Canned peaches and pears
Carrots
Cauliflower
Cucumber
Eggplant
Green beans
Grapes
Lettuce
Non-dairy creamer
Onion
Rice milk
Sorbet
Watermelon
K+
< 3.5mg/dl
Causes:
- Decreased po intake
- Excessive diarrhea or vomiting
- Certain medications (ex- diuretics)
- Need for K+ bath change (3K+,4K+)
Muscle
weakness and cramping
Fatigue
Confusion
Problems with muscle coordination
Irregular heart beat
Heart failure
Dietary
intervention: Liberalization
Phosphorus
is a mineral
Most abundant after Calcium (Ca+)
85% found in bones
14% spread throughout soft tissue
1% in blood and extracellular fluid
Responsible
for the growth, maintenance,
and repair of tissues and cells
Production of genetic building blocks
(DNA/RNA)
Energy production: helps change protein,
fat, and carbohydrates into energy
Combines with Calcium (Ca+) to form
calcium phosphate (predominant mineral
in bone)
Low: less than 3.5mg/dl
Goal: 3.5mg/dl – 5.5mg/dl
High: greater than 5.5mg/dl
PO4
> 5.5mg/dl
As kidney function diminishes
(decreased GFR), the kidney loses the
ability to excrete PO4
Leading to elevated serum PO4 levels
Calcium-
phosphorus deposits
- heart
- skin
- lungs
- blood vessels
Red eyes
Bone disease
- bone and joint pain
- weak brittle bones
Increased risk of mortality
Lower PO4 diet
Goal for intake 800- 1,000mg per day
Avoid high PO4 foods
- Dairy products (milk, cheese, ice cream,
yogurt)
- Chocolate
- Dark cola (Coke and Pepsi)
- Nuts and nut butters
- Organ meats
- Cream soups
- Processed meats
- Whole grain bread
Phosphorus
-
binders
Calcium Carbonate: TUMS
Calcium Acetate: Phoslo
Sevelamar Hydrochloride: Renvela
Lanthanum Carbonate: Fosrenol
Greatest
limitation is Compliance!!
PO4
level < 3.5mg/dl
Possible causes:
- Poor po intake
- Need for binder dosage adjustment
Consequences:
- Decreased appetite
- Confusion
Dietary Strategies:
- Dietary liberalization
- Binder dosage decrease or D/C
Decreased Renal
Function
Decreased 1,25 (OH)
Vitamin D
PTH
Phosphate Retention
Ca+
Secondary Hyperparathyroidism
PO4
Calcium
is a mineral
Most abundant mineral in the body
99% of calcium in the body is in bones and
teeth
1% of calcium is found in the blood and
soft tissues
Forms
strong bones and teeth
Aides in muscle contraction and
relaxation
Transmits nerve impulses
Aides in blood clotting
Assists in enzymatic reactions
Involved in the process of cell
division and multiplication
Serum levels of corrected total Ca+
should be maintained within the
normal range for the laboratory
used, preferably toward the lower
end: 8.4mg/dl – 9.5mg/dl
(K/DOQI)
Corrected
Ca+ > 10.2 mg/dl
Causes:
- Increased Ca+ intake (Ca+ based binders,
Ca+ supplements or high Ca+ foods)
- Too much Hectorol/Zemplar (Active form of
Vitamin D)
Treatment:
- Avoid foods high in Ca+
- Change to non- calcium based binder
- Decrease Hectorol/Zemplar dose
CALCIFICATION
Ca+ < 8.4mg/dl
Causes:
- Inadequate Ca+ intake
- Vitamin D deficiency
- High PO4 levels
- Calcimimetics
Treatment:
- Increase Ca+ intake or begin
supplementation
- Initiate or increase Hectorol/Zemplar dose
- Decrease PO4 levels to restore balance
between Ca+, PO4 and PTH
Paresthesia,
bronchospasm,
laryngospasm, tetany, and
seizures
How
can we work together as a
health care team to promote patient
compliance and improve patient
outcome??
Thank
you so much for your time
and attention!!
Hope you all learned a new thing or
two!!