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.? 

A.	(1) S. Ca.    8	(Monthly)	[2.37]  mol/L = [9.5]    mg/dl	(K/DOQI 2003)
	(2) S. PO4    8	(Monthly)	[1.78]  mol/L = [5.5]    mg/dl	(K/DOQI 2003)
	(3) Ca/PO4 Pr.8	(Monthly)	[55]   mg2/dl2	(K/DOQI 2003)
	(4) iPTH      8	(Monthly)	300  pg/ml	(K/DOQI 2003)
	Bi-PTH    8	(Monthly)	160  pg/ml	(K/DOQI 2003)
	(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:

	H.B.            8	Monthly		11-12 g/dl.  Not > 13	(K/DOQI 2006)   (UK-RAG):      10.5 -12.5 g/dl)
	Retics HB.  8	UDR		> 29 pg/ml	(K/DOQI 2006)
	TSAT          8 (for iron def.)	3rd  M.ly		20-50 %	(K/DOQI 2006)
	S. Ferritin. 8  (for overload)	3rd  M.ly		200–500 ng/ml	(K/DOQI 2006)

 Q. 597. What are the recommended levels for dyslipidemia & D.M. in H.DX.? 

A.
	Triglycerides8	3 Monthly	< 200 mg/dl < 2.26 mmol/L	(2006 K/DOQI)
	LDL.                8	3 Monthly	< 100 mg/dl < 2.59 mmol/L	(2006 K/DOQI)
	Non- HDL      8 cholesterol.  8	UDR	< 130 mg/dl < 3.36 mmol/L	(2006 K/DOQI)
	HbA1C           8	3 Monthly	< 7.5  %	(UK – RAG)

Q. 598. What are the recommended target levels for nutritional intake? 

 

A.
	protein 8	1.2   g/kg B.W/d.	(2003 K/DOQI)
	Energy 8	35    kcal/d. if ptn. < 60 y 30-35  kcal/d.      if ptn > 60 y	(2003 K/DOQI)
	NaCl    8	5 gm/d.	(2006 K/DOQI)

Q. 599. What are the recommended parameters for adequate dialysis? 

A. Adequacy:  Three essential parameters:    👌

I.            “UREA KINETIC”  MODELING :
	Sp. Kt/V 8			Monthly		1.2 minimum 1.4 target			(2006 K/DOQI)
e. Kt/V		8      Monthly			1.2 target           1.4 F/comorbid			(2007 EBPG)
	URR       8			Monthly		65% minimum  70% target			(2006 K/DOQI)
II.          “NUTRITIONAL” PARAMETER FOR ADEQUACY :
	BMI       8			3 Monthly		>23			2007  EBPG
	nPCR     8			Monthly		> 1.0   g/kg			2007  EBPG
	Albumin 8			Monthly		> 40    g/L			2006  K/DOQI
	Pre-Alb  8			UDR		> 30    g/L			2006  K/DOQI
	S.cr.       8			Monthly		>10    mg/dl > 884 μmol/L			2006  K/DOQI
III.       “DIALYSIS TIME” FOR 3/W. H.DX.:
			At least 12   h./w.				(2007 EBPG)
			At least 3  h./ session				(2006 K/DOQI)

 

Q. 600.  Describe the classification of chronic kidney disease?

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.}