Transcript File - Anna Willis Dietetics Portfolio

Dialysis In Kidney Disease
Carmody Sagers
Anna Johnson
Anna Willis
Lamli Lam
Review of Kidney Function
• Kidney is responsible for:
– Filtering blood
– Maintaining balance of fluid, electrolytes, solutes
– Secreting renin to control blood pressure
– Producing erythropoietin
– Producing active form of vitamin D
– Eliminating calcium and phosphorus
So what happens in kidney failure?
• High level of circulating waste products
(azotemia)
• Decreased Glomerular Filtration Rate (GFR)
• Shift in fluid and electrolyte balance
• Cessation of production of hormones
These things lead to…
• Uremia
– Malaise
– Weakness
– Nausea and vomiting
– Muscle cramps and itching
– Neurological impairment
• Edema
• Renal osteodystrophy
• Severe anemia due to lack of EPO
Treatment for Renal Failure
• Two options:
– Dialysis
• The process of diffusing blood through a
semipermeable membrane for the purpose of
removing toxic materials and maintaining the acid-base
balance
• Two kinds: hemodialysis & peritoneal dialysis
– Kidney Transplant
Diagnosis
• Uremia
• BUN >100 mg/dl
• Creatinine 10-12 mg/dl
Prevalence
• As of 2008
– 547,982 U.S. residents had ESRD
• 205,724 of the cases resulted from diabetes
– 382,343 U.S. residents were receiving dialysis
treatments
Comorbidities
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Diabetes
High Blood Pressure
Cardiovascular Disease
Congestive Heart Failure
Lung disease
Peripheral Vascular Disease
Malnutrition
Normal Ca/P Metabolism
• Maintenance of calcium-phosphorus
homeostasis is an important and complex
process
• Involves the interactions of parathyroid
hormone (PTH), calcitonin, and active vitamin
D
• The three main organs involved are the gut,
kidney, and bone
Normal Ca/P Metabolism
• The kidney produces the active form of
vitamin D and eliminates both calcium and
phosphorus
• Active vitamin D promotes absorption of Ca by
the gut and is needed for bone remodeling
• Vit D also suppresses PTH production, which is
responsible for mobilizing Ca from bone
Normal Ca/P Metabolism
Ca/P Metabolism in CKD
• As GFR decreases, phosphorus is retained in the
plasma and serum Ca levels decline
• Kidneys have a decreased ability to produce
vitamin D
decreased gut absorption of
calcium
reliance on PTH to main Ca levels
through bone resorption
• Results in hyperparathyroidism, phosphate
retention, and hypocalcemia
• In the diet, calcium intake must be kept high and
phosphorus intake must be kept low
Ca/P Metabolism in CKD
Bone disease
Ca/P Metabolism in CKD
Dialysis
What is the purpose of dialysis?
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Removes waste from the blood
Removes excess water from the blood
Helps control blood pressure
Helps balance K, Na, Ca, and HCO3
– This depends on the electrolyte concentration in
the dialysate
• Does not correct the endocrine functions of
the kidney
Properties of solutions
How does dialysis work?
• The dialysis membrane, keeps the blood
separate from the dialysis fluid.
– A thin layer of natural tissue (in PD)
– A synthetic plastic (in HD)
• Dialysis fluid or dialysate is a plasma-like fluid
where waste and excess water go when they
leave the blood
– These processes are called diffusion and osmosis.
How does dialysis work? (cont)
• Excess fluid is removed from the blood
through ultrafiltration.
• In HD, the fluid is simply drawn from the blood
by the dialysis machine.
– The amount of water to be removed can be varied
by changing the dialyzer’s settings.
• In PD dextrose is added to the dialysate to
draw water out by osmosis.
Hemodialysis vs. Peritoneal
• Hemodialysis-through dialysis needles and tubing
connected to your arm blood is pumped through
a dialyzer (artificial kidney) that cleans the waste
products from your blood then returns it to your
body
• Peritoneal dialysis- through a catheter dialysate is
pumped into the peritoneal cavity, waste
products diffuse from the blood into the
dialysate. This fluid is withdrawn and discarded
and new solution is added.
Hemodialysis
• External artificial kidney (hemodialyzer)
connected to a dialysis machine
• 200 ml of blood goes through the machine at a
time
• Treatment 3x/week. Each treatment lasts from 35+ h
• Home dialysis treatments can be daily for 1.5-2.5
h or nocturnally 3x/week for 8 h
• Surgery is necessary to create access to the
bloodstream
Dialyzer
Access to bloodstream
• Fistula- artery and vein are connected
• Looped graft- artificial vessel is inserted
– If patient’s blood vessels are too fragile
• Catheter- used until patient’s permanent
access can be created or matured (can take
several months)
– usually short term
Access points for hemodialysis
Fistulas
• enlarged vein (usually in your
arm)
• created by connecting an artery
directly to a vein, allows
greater blood flow into the vein
• As a result, the vein enlarges
and strengthens, making the
insertion of needles for
hemodialysis treatments easier.
• Aneurysm- localized dilation of
a blood vessel
• Anastomosis- surgical
connection between two
structures
Types of Peritoneal Dialysis (PD)
• Continuous Ambulatory PD (CAPD)
– Requires no machine
– Dwell time of 4-6h, 4-5x daily, 24h treatment
– Process of draining and refilling takes about 30-40 minutes
• Continuous Cyclical PD (CCPD) or Automated PD (APD)
– machine called a cycler to fill and empty your abdomen
three to five times during the night while you sleep.
– In the morning, you begin one exchange that lasts the
entire day.
– You may do an additional exchange in the middle of the
afternoon without the cycler to increase the amount of
waste removed and to reduce the amount of fluid left
behind in your body.
Peritoneal Dialysis
CAPD Exchange
Peritoneal Equilibration Test
• Used solution is collected from one exchange to a 24h
period to see the effectiveness of a dose of PD.
• This solution is compared to blood and urine samples from
the same time period
• The peritoneal transport rate varies from person to person
• Used to see how effective the current PD schedule is in
clearing the blood of urea.
• From all the samples, one can compute a urea clearance
and a creatinine clearance rate-normalized to body surface
area.
• The residual clearance of the kidneys is also considered.
Based on these measurements, one can determine
whether the PD dose is adequate.
Peritoneal Equilibration Test (cont)
• If the laboratory results show that the dialysis schedule is
not removing enough urea and creatinine, the doctor may
change the prescription by
– increasing the number of exchanges per day for patients treated
with CAPD or per night for patients treated with CCPD
– increasing the volume-amount of solution in the bag-of each
exchange in CAPD
– adding an extra, automated middle-of-the-night exchange to the
CAPD schedule
– adding an extra middle-of-the-day exchange to the CCPD
schedule
– using a dialysis solution with a higher dextrose concentration
Choosing the right treatment
• Evaluate which treatment would work best
with your lifestyle
– There are pros and cons for each type
• Patients can talk with their physician about
combining treatments
– Some people use PD every day, but get HD once a
week if PD treatments are not removing enough
waste from the blood
Pros and Cons of In-Center HD
• Pros
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• Cons
• Treatments are scheduled by
Facilities are widely available.
the center and are relatively
fixed.
Trained professionals are with
• You must travel to the center
you at all times.
for treatment.
You can get to know other
• This treatment has the strictest
patients.
diet and fluid limits of all.
You don't have to have a
• You will need to take-and pay
for-more medications.
partner or keep equipment in
• You may have more frequent
your home.
ups and downs in how you feel
from day to day.
• It may take a few hours to feel
better after a treatment.
Pros and Cons of Home HD
• Pros
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You can do it at the times you choosebut you still must do it as often as your
doctor orders.
You don't have to travel to a center,
more friendly for work and travel
You gain a sense of independence and
control over your treatment.
Newer machines require less space
and are portable.
You will have fewer ups and downs in
how you feel from day to day.
Your diet and fluids will be much closer
to normal
You can spend more time with your
loved ones.
• Cons
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You must have a partner, who is also
trained.
Helping with treatments may be
stressful to your family.
You need space for storing the
machine and supplies at home.
You will need to learn to put in the
dialysis needles.
Daily and nocturnal home
hemodialysis are not yet offered in all
locations.
Pros and Cons of PD
• Advantages
• Fit your treatment around your
lifestyle
• Independence – mostly you
perform the treatment yourself
• Fewer visits to the dialysis unit
(usually once a month)
• Works during sleep time for some
people
• Continuous therapy is gentler and
more like your natural kidney
function
• Portable and flexible – easy to take
your treatment with you when you
travel
• Less fluid and diet restrictions
• No needles
• Better blood pressure control
• Disadvantages
• You need to be well trained
• Permanent catheter access
required
• Some risk of infection
• May show a slightly larger
waistline (due to carrying
fluid)
• Storage space required in your
home
• Possible changes in your
appearance due to
medications side effects
CAPD & CCPD
CLINIC HD
HOME HD
Can I do dialysis at
home?
YES
NO
YES
Can I still work or
attend school fulltime?
YES
NOT ALWAYS
YES
Can I still travel?
YES
POSSIBLY
POSSIBLY
Do I need to have
needles inserted every
time?
NO
YES
YES
Will it make me tired?
POSSIBLY
POSSIBLY
POSSIBLY
Can I arrange my
dialysis at convenient
times?
YES
POSSIBLY
YES
Do I need to have
equipment/supplies at
home?
YES
NO
YES
Hemodialysis
In Center
Schedule
Three treatments a
week for 3 to 5 hours
or more.
Peritoneal Dialysis
Home
More flexibility in
determining your
schedule of
treatments.
CAPD
CCPD
Kidney Transplantation
Deceased
Four to six exchanges a Three to five
You may wait several
day, every day.
exchanges a night,
years before a suitable
every night, with an
kidney is available.
additional exchange
begun first thing in the
morning.
Living
If a friend or family
member is donating,
you can schedule the
operation when
you're both ready.
After the operation, you'll have regular
checkups with your doctor.
Location
Dialysis center.
Home.
Availability
Available in most
communities; may
require travel in some
rural areas.
Generally available,
Widely available.
but not widely used
because of equipment
requirements.
Widely available.
Equipment
and Supplies
No equipment or
supplies in the home.
Hemodialysis machine Bags of dialysis
connected to
solution take up
plumbing; chair.
storage space.
Cycling machine; bags No equipment or supplies needed.
of dialysis solution.
Training Required
Little training required; You and a helper must You'll need to attend several training sessions. You'll need to learn about your medications
clinic staff perform
attend several training
and when to take them.
most tasks.
sessions.
Diet
Must limit fluids, sodium, potassium, and
phosphorus.
Must limit sodium and calories.
Level of Freedom
Little freedom during
treatments. Greater
freedom on
nontreatment days.
More freedom to set
your own schedule.
You're still linked to a
machine for several
hours a week.
You can move around,
exercise, work, drive,
etc., with solution in
your abdomen.
You and your helper
are responsible for
cleaning and setting
up equipment and
You must perform
You must set up your
exchanges four to six cycler every night.
times a day, every day.
Level of Responsibility Some patients prefer
to let clinic staff
perform all tasks.
Any clean environment that allows solution
exchanges.
The transplant operation takes place in a
hospital.
Transplant centers are located throughout the
country. However, the demand for kidneys is
far greater than the supply.
Fewer dietary restrictions.
You're linked to a
Offers the greatest amount of freedom.
machine during the
night. You're free from
exchanges during the
day.
You must take immunosuppressants every
day for as long as the transplanted kidney
functions.
Risk factors associated
• Peritonitis is still a common problem that sometimes makes continuing PD
impossible.
• Here are some general rules:
• Store supplies in a cool, clean, dry place.
• Inspect each bag of solution for signs of contamination before you use it.
• Find a clean, dry, well-lit space to perform your exchanges.
• Wash your hands every time you need to handle your catheter.
• Clean the exit site with antiseptic every day.
• Wear a surgical mask when performing exchanges.
• Here are some signs to watch for:
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Fever
Nausea or vomiting
Redness or pain around the catheter
Unusual color or cloudiness in used dialysis solution
A catheter cuff that has been pushed out
Cost of dialysis
• Dialysis is very expensive
• The federal government (Medicare and
Medicaid) will pay 80% of the cost
• Private health insurance or state medical aid
also help with the costs
Dialysis and Lifestyle
• We do not yet know how long patients on dialysis
will live. We think that some dialysis patients may
live as long as people without kidney failure.
• Many patients live normal lives except for the
time needed for treatments.
• Dialysis centers are located in every part of the
United States and in many foreign countries. The
treatment is standardized.
• Many dialysis patients can go back to work
– Jobs that require lots of physical labor may be too
strenuous
Compliance
• At least ½ of hemodialysis patients are
noncompliant and 1/3 of PD patients are as
well
• It increases a patient’s risk of hospitalization
and death
• The reasons most linked to noncompliance are
psychosocial issues, younger age and smoking
• Treatment regimen can be modified to
increase compliance
Dialysis and kidney function
• Does dialysis cure kidney disease?
– No. Dialysis does some of the work of healthy
kidneys, but it does not cure your kidney disease.
• You will need to have dialysis treatments for
your whole life unless you are able to get a
kidney transplant.
Vocabulary Review
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Dialyzer
Diffusion
Osmosis
Ultrafiltration
Fistula
Dwell time
Exchange
Vocabulary Review
• Dialyzer- external artifical kidney
• Diffusion- passage of particles through a semipermeable
membrane
• Osmosis- movement of fluid across a semipermeable
membrane
• Ultrafiltration- additional pressure to squeeze extra fluid
through the membrane
• Fistula- surgical linking of an artery to a vein, providing
access to blood vessels
• Dwell time- how long dialysate is in the peritoneum
• Exchange- Once diffusion is complete, all fluid and waste
are drained from your peritoneal cavity and replaced with
fresh dialysate
Kidney Transplants
Transplants
A surgical implantation of a kidney from a
• Living related donor- only need one donated kidney
to replace two failed kidneys
• Living nonrelated donor
• Deceased donor
Tissue type between the donor and recipient need to
match.
Rejection of the transplant or infection secondary to
immunosuppressive drugs are major complications.
Complications
This surgery can sometimes result in:
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Blood clots
Bleeding
Leaking or blockage of the ureter
Infection
Failure/rejection of donated kidney
Organ Donors
Those patients awaiting kidney transplants far
outnumber the kidneys available to donate. The
waiting time for a kidney transplant can be a year or
longer.
Becoming an organ donor is fairly easy. Registration
is done at a local driver’s license bureau.
www.shareyourlife.org
Medications for Transplants
Long-term medications
• Glucocorticol steroids
• Prednisone
• Cyclosporine
• Azathioprine
• Mycophenolate mofetil
• Tacrolimus
• Sirolimus
• Thymoglobulin
• Atgam
The doses of these medications are decreased over time
until a “maintenance level” is reached.
Corticosteroids
Associated with:
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Accelerated protein catabolism
Hyperlipidemia
Sodium retention
Weight gain
Glucose intolerance
Inhibition of normal calcium, phosphorus, and
vitamin D metabolism
Cyclosporine and Tacrolimus
Associated with:
• Hyperkalemia
• Hypertension
• Hyperlipidemia
MNT for Transplants
Protein
• High protein diet for the first month
• 1.3-1.5 g/kg
• In cases of fever, infection, surgical/traumatic stressesincrease protein requirement to 1.6-2 g/kg
Fluid
• Must be monitored closely
• While on dialysis, patients require a fluid restriction.
Transplant patients need to maintain fluid intake
• Encouraged to drink 2 L/day, but overall needs will depend
on urine output
MNT for Transplants
Potassium
• Cyclosporine is associated with Hyperkalemia
• Restrict potassium intake
• Usually temporary
Calcium and Phosphorus
• Patient can get hypophosphatemia and hypercalcemia caused by
bone resorption
• The diet should provide adequate amounts of calcium and
phosphorus
• However, serum levels of these nutrients should be monitored
periodically
• If hypophosphatemia does occur, supplement with phosphorus
MNT for Transplants
Triglycerides and Cholesterol
• If these are high, calorie restriction is needed for those that are
overweight.
• Cholesterol intake less than 300 mg/day
• Limit total fat
• Patients with glucose intolerance need to limit carbohydrates and
maintain a regular exercise program
Sodium
• Moderate sodium restriction (80-100 mEq/day) during periods of
fever, infection, or traumatic stresses
• Helps to minimize fluid retention and controls blood pressure
Post-Transplant Weight Gain
• Very common problem
• This occurs with medication side effects, fewer
dietary restrictions, and no physical exercise
• This problem can be combated by weight
management counseling
• Avoiding/correcting this problem will contribute to
the longevity of the transplanted kidney
Rates of Survival
Living-donor kidney transplants
• 98% of patients live for at least one year after
surgery
• 90% live for at least five years
Deceased -donor kidney transplants
• 94% live for at least one year after surgery
• 82% live for at least five years
Medications for Dialysis
Phosphorus Medications
• Commonly used are phosphate binders, including:
Calcium Carbonate (TUMS, Calci-chew)
Calcium Acetate (PhosLo)
Sevalamer Hydrochloride (Renagel)-reduces serum
phosphorus without raising serum calcium.
Lanthanum Carbonate (Fosrenol)
Aluminum hydroxide (AlternaGEL)
• Common side effects are: hypercalcemia (calcium-based
binders), gastrointestinal upset, diarrhea, gas, severe
constipation-which may lead to perforation of the intestine
which can cause peritonitis or death.
Calcium
• A patient can develop hypocalcemia and hyperphophatemia. Because
calcium is in the dialysate bath, the level of calcium can be increased or
decreased.
• Decreased calcium would aid patients who have developed
hypercalcemia from active vitamin D administration.
• Patients who get too much calcium can develop calciphylaxis which is
when calcium phosphate is deposited in soft tissues.
• Calcium is increased with supplements:
calcium carbonate
calcium acetate
calcium lactate, malate, or gluconate
• Calcium also increased with the 300-500 mg provided in the diet.
• Starting calcium supplementation early can prevent
hyperparathyroidism.
PTH lowering drugs
• Active vitamin D (available as calcitriol, caltrol, and calcijex)to treat hypocalcemia.
• Hectorol and Zemplar-lowers PTH and raises calcium levels.
• Cinacalcet (calcimemetic)-a calcium imitating drug that
binds to sites on the parathyroid gland which gives the
gland a false impression that calcium levels are elevated.
Overview of Drugs
• Phophate binders
Calcium carbonate
Calcium acetate
Sevelamer hydrochloride
Lanthanum carbonate
Aluminum hydroxide
• Iron
IV iron (iron dextran, Aron gluconate, iron sucrose
• Erythropoietin
IV or IM (Epogen or EPO)
• Activated Vitamin D
Oral (Hectorol)
IV (Calcitriol)
• Biphosphonates
Oral (Alendronate-fosamax)
IV (Pamidronate)
Overview of Drugs Cont.
• Calcium supplements
TUMS, Os-Cal, Calci-chew
• Phosphorus supplements
Kphos, NutraPhos, NutraPhos K
• Calcimimetics
Cinacalcet
• Heavy Metal Chelator- binds aluminum and iron and is
dialyzed off
IV Desferal (deferoxamine or DFO)
• Cation Exchange Resin-for hyperkalemia
Oral or rectal (sodium polystyrene sulfonate or SPS)
Renal Osteodystrophy
• Three types:
Osteomalacia (bone demineralization)
Osteitis fibrosa cystica (caused by hyperparathyroidism)
Metastatic calcification of joints and soft tissues
• A fourth type unique to renal failure patients on active
vitamin D is low turnover bone disease. This bone disease is
characterized by the oversuppression of the parathyroid
gland with too much active vitamin D. It causes decreased
bone formation and fragile bones with very little matrix.
• Control these conditions with the drugs discussed above.
Medical Nutrition Therapy
MNT Goals
• To prevent deficiency and maintain good
nutrition status
• To control edema and electrolyte imbalance
• To prevent or retard the development of renal
osteodystrophy
• To enable the patient to eat a palatable,
attractive diet that fits his/ her lifestyle
Nutrient Requirement Chart
Kcal
Potassium
Phosphorus
750-1000
ml/day + 2000-3000
1.2 g/kg urine output mg/day
2300-3100
mg/day
0.8-1.2 g/day
Peritoneal
30-35
1.2-1.5 minimum of 2000-4000
dialysis (PD) kcal/kg IBW g/kg 2000 ml/day mg/day
3000-4000
mg/day
0.8-1.2 g/day
35 kcal/kg
Hemodialysis
IBW
Protein
Fluid
Sodium
Fluid Intake
• Limited fluid intake 750-1000 ml/day + amount
equal to the urine output
• + Fluid from solid food: 500- 800 ml/day
• Deal with thirst with drinking:
– Sucking on a ice chips, cold sliced fruit, sour candies, using
artificial saliva, or chewing “sports gum”
Goals of fluid gain
• Hemodialysis:
- 4 to5 lb fluid gain of body weight in the
vasculature between treatments
-equals 2% – 5% of body weight
• Peritoneal dialysis:
- No fluid limited
Sodium
• Sodium restriction
- 2000-3000 mg/day
- no salt in cooking, avoids convenience foods
- help to reduce thirsts and fluid intake
- Conditions with salt-losing tendency need 3g or
more sodium per day.
Potassium
• 2300-3100 mg/day for ESRD
• 2000 mg/day for anuric patient
• low-sodium foods & salt substitutes contain
KCl instead of NaCl
• Food Sources: fruits and vegetables
Calcium and Vitamin D
• Increase calcium
- Decrease ability of kidney to covert the
inactive form of vitamin D to , 1,25(OH)2D3
- Therefore cannot increase gut absorption of
calcium
- Must rely on PTH to keep calcium level up
through bone reabsorption
• Vit supplement – only Active D3 form
Phosphorous
• Restrict phosphorous intake:
– 1200 mg/day or less
– 17 mg/kg of body weight
– Food source of P: dairy and meat
• Problem:
– Calcium rich foods (milk) and high-protein diet are
high in phosphorous
– Phosphate have high molecular weight
– Phosphate-binding medication is required
Creatinine
• A normal waste product of muscle breakdown.
• Can be controlled by dialysis.
• Low creatinine level may indicate good dialysis
or low body muscle.
Iron
• Inability od kidney to produce EPO
• EPO is a hormone that stimulates the bone
marrow to produce red blood cells and an
increased destruction of red blood cells
secondary to circulating uremic waste
products
• A synthetic form of EPO, periodic IV, and oral
iron are used to correct the anemia.
Water-Soluble Vitamins
• Water-soluble vitamins loss during dialysis
- Dietary restriction (water-soluble vitamins are high
in K+ and P foods)
- loss Ascorbic acid, niacin, riboflavin, and vit. B6
- folate is highly dialyzable (supplement is
recommended)
- Loss of vit. B12 is minimal
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Fat-soluble vitamins do not loss much
Folic acid 3-6 mg/day
Vit. E supplement is not routinely recommended
Avoid vit. K supplements
Lipid
• Atherosclerotic cardiovascular disease is the
most common cause of death among long
term dialysis patients
• Although lipids lowering drug may have
significant impact on management, treatment
of hyperlipidemia still remains controversial.
Enteral Tube Feeding & Parenteral Nutrition
• Enteral Tube Feeding
- ESRD patients usually doing well on
standard formulas
- Refeeding syndrome may occur when
taking a low phosphorus level of the
“renal” products
• Parenteral Nutrition
- Used for malnourished patients with GI
complications
Case Study
Case Study
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EJ
24 y.o.f
Occupation: Secretary
Chief Complaints: anorexia, n/v, weight gain,
edema, malaise, SOB, pruritus, muscle
cramps, inability to urinate
• Poor oral intake due to anorexia and n/v
Anthropometric
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Ht: 5’ (1.5 m)
Wt: 170 lbs (77 kg)
BMI: 33
IBW: 100 lbs
%IBW: 170
Biochemical
• Abnormal Labs:
– Sodium
130 (L)*
– Potassium
5.8 (H)*
– Chloride
91 (L)*
– PO4
9.5 (H)
– Glucose
282 (H)
– BUN
69 (H)*
– Creatinine
12 (H)*
– Calcium
8.2 (L)*
– Cholesterol 220 (H)
– Triglycerides 200 (H)
*indicative of kidney failure
Clinical
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Overweight
Lethargic
Muscle weakness
Dry, yellowish brown skin
Generalized rhonchi with rales, SOB
Edema in extremities, face, and eyes
Elevated blood pressure (220/80)
Normal pulse, normal bowel sounds
Dietary Assessment
Usual dietary intake
• Breakfast
– Cold cereal, bread or fried potatoes, fried egg
• Lunch
– Bologna sandwich, potato chips, Coke
• Dinner
– Chopped meat, fried potatoes
• Snacks
– Crackers and peanut butter
Dietary Assessment
• Current calorie order: 30 kcal/kg or 2300 cal/day
• Estimated calorie needs: 23 kcal/kg or 1800
cal/day
– HEB: 66.5+ (13.7*77)+(5*152)-(6.8*24)= 1700 cal
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Protein needs: 0.8 gm/kg
Fluid needs: 25 ml/kg or 1900 ml/day
Sodium restriction 2-3 g/day
Phosphorus restriction 8-12 mg/day
History
• Mom and dad both dx with type II diabetes
• Type II diabetic for 11 years
• Meds:
– Glucophage
– Vasotec
PES Statement
• Limited adherence to nutrition-related
recommendations related to diagnosis of type
II diabetes as evidenced high blood glucose
levels, obesity, and stage 3 chronic kidney
disease.
Nutritional Intervention
• Reeducate on importance of adherence to
diabetic diet. Assess reasons for past
noncompliance.
• Supplement diet with nutrition shakes
• Encourage cessation of alcohol consumption
• Educate on proper diet for renal disease (low
potassium, phosphorus, sodium)
Sample Diet
• Breakfast
– 1 slice toast with margarine
– 6 oz orange juice
• Snack
– 1 cup cereal with 8 oz milk
• Lunch
– 1 ham and cheese sandwich
– 8 medium carrot sticks
• Snack
– 4 graham crackers
– 8 apple slices
• Dinner
– 1 ½ cups stir-fried chicken with 1 cup rice
– 1 cup sautéed green beans
• Snack
– 1 dinner roll with margarine
– ½ cup peach slices
References
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National Kidney foundation. Dialysis. http://www.kidney.org/atoz/content/dialysisinfo.cfm
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