Q.590. What is the effect of dialysis on nutritional requirement?
HEMOIALYSIS
Q.590. What
is the effect of dialysis on nutritional requirement ?
A. Routine
care of Dx ptn should including review of nutritional status, which’s usually performed
by renal dietitian. DX carries special nutritional demands for the ptn.. HDX
usually associated é loss of protein in Dzt. & increased protein catabolism. So, 🠝in
protein & caloric intake usually
warranted to maintain neutral N2 balance. Water-soluble vitamins
shd be supplemented as follows:
o
Vit. C. 🠞100 mg/d.
o
Folic a.🠞one mg/d.
o
Vit. B6🠞10 mg/d.
-P.D.
ptn. absorbs 70
% of the Glucose infused in Dzt, So 🠞Reduce CHO intake.Typically
5-15 g. proteins,
mainly albumin🠞lost
daily in Dzt., which’s incr.
in episodes of peritonitis & remains so few weeks after resolution.Other
f. con-tributing to malnutrition are present in Q.(causes of malnutrition in
ESRD).
Q.591. What are the causes of malnutrition in ESRD patients? 🍲🥫😋
A. I. Reduced intake:
1) Inadequate dialysis.
2) Poor dentition.
3) Depression.
4) Slow gastric emptying.
5) Cultural food preference.
6) Inability
to obtain or prepare food.
II Metabolic abnormalities:
1. Metabolic acidosis.
2. Insulin resistance.
3. Altered amino acid metabolism.
III. Endocrine abnormalities:
1) Insulin resistance.
2) Hyperliptinemia.
3) IGF-1 resistance.
4) PTH-induced catabolism
IV. Systemic inflammation.
V. Intercurrent illness.
Q.592. How to assess nutrition in patient with
ESRD ?
A. Assessment for nutrition in
patient with ESRD:
1)
Presence of G.I.
Sm.: (Anorexia, n. & v).
2)
Changes in the target
weight.
3)
Assessment of food
intake (food diary).
4)
PCR &
nPNA.
5)
Pl. Proteins: [albuminuria
& transferrin ].
6)
BUN &
Cr.
7)
DEXA (Dual
Energy X-ray Absorptiometry).
8) BIA (Bioimpedance analysis).
Q.593. How
to treat malnourished ESRD patient (see also options for
nutritional intervention)?
A. Treatment
malnourished ESRD patient:
(1) Etiology
us. multifactorial, so, identify any reversible cause, then
target to it.
(2)
Determine adequacy
of DX dose frequently é evidence
of malnutrition.
(3)
Treat
inflammation, whatever the source.
(4)
Correct
metabolic acidosis.
(5)
Nutritional
support (conflicting
data), should be considered in all malnourished ptn.
(6)
Incr.
protein & caloric supplies by the consultation of renal dietitian.
(7)
Use
Nasogastric tube in specific cases. Avoid PEG in PD ptn,
but can be in HDX .
(8)
Keep
the GIT route as the “most physiological” way for nutritional
support.
(9)
If
enteral feeding is ineffective🠞use TPN (hospitalized ptn é intercurrent illness).
(10) TPN delivered during.
DX.🠞
additional nutritional support. & compensate for a.a. loss
in Dzt. Benefit is modest.
(11) Amino acid Dzt PD is a.a. novel form nutritional supplementation to avoid glucose load & allow a.a.
absorption. Benefit only observed é short term.
(12) G.H.,
anabolic steroids & appetite
stimulant 🠞all of no clear indication for use.
Q.594. What are the options for nutritional intervention?
A. Nutritional intervention:
1) Oral supplement.
2) Nasogastric/Nasojejunal / PEG. (Percutanous Endoscopic Gastrostoy)
feeding.
3) Intradialytic parentral nutrition.
4) Amino acid Dzt (PD).
5) TPN (Total parenteral
nutrition).
6) Growth Hormone (G.H.).
7) Anabolic steroids.
8) Appetite stimulus.
Q. 595. What are the maximum
allowed renal
figures for better bone metabolism
in HDX.?
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A. |
(1) S. Ca. 8 |
(Monthly) |
[2.37] mol/L = [9.5] mg/dl |
(K/DOQI 2003) |
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(2) S. PO4
8 |
(Monthly) |
[1.78] mol/L = [5.5] mg/dl |
(K/DOQI 2003) |
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(3) Ca/PO4
Pr.8 |
(Monthly) |
[55] mg2/dl2
|
(K/DOQI 2003) |
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(4) iPTH 8 |
(Monthly) |
300 pg/ml |
(K/DOQI 2003) |
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Bi-PTH 8 |
(Monthly) |
160 pg/ml |
(K/DOQI 2003) |
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(6) S. Alum. 8 (7) Total elemental
Ca+ (as binder): 8 (8) total Ca+ intake: 8 |
(UDR) |
60 μg/l 1500 mg/d. 2000 mg/d. |
UK-RAG (K/DOQI, 2003). (K/DOQI, 2003). |
- N.B. Target levels: Ca+ : 2.1-2.37 mmol/L.
Po4
:
1.13-1.78 mmol/L
= 3.5-5.5 mg/dl.
Ca/PO4 Pr.: 55
mg2/dl2
iPTH
: 150-300
pg/ml
-If Po4 level>
2.26 mmol/L. Aluminum
based binders may be
used NOT > 4 w. and for one course ONLY (K/DOQI, 2003).
Q. 596. What are the target
levels for better anemia
control in H.DX. patients ?
A. Target levels:
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H.B. 8 |
Monthly |
11-12 g/dl. Not > 13 |
(K/DOQI 2006) (UK-RAG): 10.5 -12.5 g/dl) |
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Retics HB. 8 |
UDR |
> 29 pg/ml |
(K/DOQI 2006) |
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TSAT 8 (for iron def.) |
3rd M.ly |
20-50 % |
(K/DOQI 2006) |
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S. Ferritin. 8 (for overload) |
3rd M.ly |
200–500 ng/ml |
(K/DOQI 2006) |
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Q. 597. What are the recommended levels for dyslipidemia & D.M. in H.DX.?
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A. |
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Triglycerides8 |
3 Monthly |
< 200 mg/dl < 2.26 mmol/L |
(2006 K/DOQI) |
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LDL. 8 |
3 Monthly |
< 100 mg/dl < 2.59 mmol/L |
(2006 K/DOQI) |
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Non- HDL 8 cholesterol.
8 |
UDR |
< 130 mg/dl < 3.36 mmol/L |
(2006 K/DOQI) |
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HbA1C 8 |
3 Monthly |
< 7.5 % |
(UK – RAG) |
Q. 598. What are the recommended target levels for nutritional intake?
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A. |
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protein 8 |
1.2 g/kg B.W/d. |
(2003 K/DOQI) |
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Energy 8 |
35 kcal/d. if ptn. < 60 y 30-35 kcal/d. if ptn > 60 y |
(2003 K/DOQI) |
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NaCl
8 |
5 gm/d. |
(2006 K/DOQI) |
Q. 599. What are the recommended
parameters for adequate dialysis?
A. Adequacy: Three essential parameters: 👌
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I.
“UREA KINETIC”
MODELING : |
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Sp. Kt/V 8 |
Monthly |
1.2 minimum 1.4 target |
(2006 K/DOQI) |
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e. Kt/V |
8
Monthly |
1.2 target 1.4 F/comorbid |
(2007 EBPG) |
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URR 8 |
Monthly |
65% minimum 70% target |
(2006 K/DOQI) |
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II.
“NUTRITIONAL” PARAMETER FOR ADEQUACY : |
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BMI 8 |
3 Monthly |
>23 |
2007 EBPG |
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nPCR 8 |
Monthly |
> 1.0 g/kg |
2007 EBPG |
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Albumin 8 |
Monthly |
> 40 g/L |
2006 K/DOQI |
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Pre-Alb 8 |
UDR |
> 30 g/L |
2006 K/DOQI |
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S.cr. 8 |
Monthly |
>10 mg/dl > 884 μmol/L |
2006 K/DOQI |
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III.
“DIALYSIS TIME” FOR 3/W. H.DX.: |
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At least 12 h./w. |
(2007 EBPG) |
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At least 3 h./ session |
(2006 K/DOQI) |
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1. Stage 0 : GFR >90 mL/min/1.73 m2 + Risk of CKD 🠞Screen &
Risk factor.
2. Stage I.: GFR >90 mL/min/1.73 m2 + Evidence of Kidney
damage🠞Dgx & ttt.
of comorbid dis.
3. St. II. : GFR: 60-89 mL/min/1.73 m2 , Mild 🠋GFR🠞Estimate progression.
4. St. III. : GFR: 30-59 mL/min/1.73 m2, Moderate 🠋GFR🠞Evaluate &
ttt complc.
5. St. IV. : GFR: 15-29 mL/min/1.73 m2, Severe 🠋GFR🠞Prepare for RRT.
6. St. V. : GFR: <15 mL/min/1.73 m2 , R.F. (ESRD) 🠞RRT.
- Risk f.: [H.T.- D.M.- Dyslipidemia- SLE- Analgesic abuse-Anemia].
-Evidence of “Kidney damage”:
i. Persistent
microalbuminuria.
ii. Persistent
Proteinuria.
iii. Persistent
Hematuria.
iv. Structural
abn. (U/S, Other radiological tools).
v. Tissue
evidence (Biopsy):
Proven Ch. G.N.
- Proteinuria =
Ur. Protein excretion > 0.5 g/24 h. & URAR = > 30 mg/mmol.
[According to draft NICE National Clinical guidelines for management of adults é
CKD].
{The classification is based on the NKF
K/DOQI.}
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