MNT 2 Final Exam -Acid-base balance & Renal

Movement of fluid across semi-permeable membrane from a lower concentration of solutes to a higher concentration of solutes

osmosis

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\*water moves into teabag)

Movement of fluids through a membrane

Filtration

Form of filtration that provides additional pressure to achieve more concentrated filtration

Ultrafiltration

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*squeeze extra fluid through the membrane*

Preferred permanent access site for dialysis

AV fistula

Fluid used by the dialysis procedure to assist in removal of metabolic by-product, wastes, and toxins

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1. If a pt has hyperkalemia, then _____ will be added
2. If a pt has hypokalemia, then _____ will be added

1. Dialysate
2. No K will be added (0 k bath)
3. K will be added (1 or 2 k bath)

high sodium food is considered:

>400 mg/Na/serving

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\*General rule: ≤ 2.4 g/d

What does “leaching” k from vegetables mean?

The process by which the K is leached from the potato is changes the texture of the potato (%%pull some of K out and into the water%%)

How much K is in a potato?

\~600 mg

A procedure done by a machine that functions as an artificial kidney that removes excessive and toxic by-products of metabolism from the blood; also called renal replacement therapy

Dialysis

What are they two types of RRT?

1. Hemodialysis
2. Peritoneal dialysis

When is dialysis needed?

Needed for end-stage renal disease

Most common type of dialysis and conducted in a dialysis center. How often is it administered?

1. HD


1. 3x/week 4h each time (individualized based on pt status)

utilizes the abdominal wall of the pt as the semi-selective membrane. Used at home

1. PD

T/F: Dialysis requires a semi-permeable membrane that allows passage of water and small to mid MW molecules and ions, excludes large MW molecules (PRO)

True

Used with acute renal failure or before HD/PD begins

1. Continuous renal replacement therapy

Passage of particles through a semipermeable membrane

Diffusion

Match the drugs:


1. Dec K+
2. Dec plasma PO4
3. Lower BP
4. Dec Bp
5. Dec chol, CVD

1. Tums (kaexilate)
2. Phosphate binders
3. ACE inhibitor
4. Metformin, diabetes
5. Lipator, zocor


1. \

Define:


1. NIDDK
2. KDOGI
3. CKD
4. RRT

1. National Institute of Diabetes and Digestive and Kidney Diseases
2. Kidney Disease Improving Global Outcomes
3. Chronic kidney disease
4. Relative retention time??

Kidney handles K well until GFR …..

Potassium for HD pt

2-3 g K+/d

Why would you need to restrict K when on an ACE inhibitor?

1. This drug dec aldosterone -→ Inc K

Why reduced activation of Vit D in CKD?

1. B/c pt cannot consume dairy
2. Vit D activation occurs in the kidney

Low potassium foods (200 mg or less)

1. Apple juice/applesauce
2. Cranberry juice
3. Carrots
4. kale
5. corn

What is osteodystrophy? What minerals is it apart of?

1. Osteitis fibrosa, osteomalancia
2. Ca and Phos

Foods higher in potassium (more than 200 mg)

1. Oranges/orange juice
2. Cantaloupe
3. Avocado
4. potatoes
5. Sweet potatoes/yams

Recommendations for fluid

1. ≥1 L fluid output: 2 L fluid intake
2. ≤1 L fluid output: 1-1.5 L fluid intake
3. Anuria: 1 L fluid intake + 2 g Na diet
4. HD: If edema occurs


1. Intake = output + 500 mL (covers insensible losses)

What GFR reflects the kidney fx of a healthy adult

130 mL/min/1.73m^2

BUN:Cr ratio normal range

10-15

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Which hormone decreases BP?

Aldosterone

The majority of bicarbonate is reabsorbed in the

Proximal convoluted tubule

Consequences of high solute load

1. Fever
2. Weight loss
3. Oliguria
4. Hypernatremia

Fx of parathyroid hormone

Increase calcium concentrations in blood

Potassium control…

Diet, drugs, dialysis

Phosphorus controls…

Diet and drugs

Protein controls

Diet, dialysis

Fluid is managed with…

Diet, drugs, dialysis

Kayexlate

1. Cation exchange resin used for trt of hyperkalemia

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May increase losses of Mgand Ca; inc serum Na

Kayexlate

T/F: You should use kayexlate with a high K diet

False, low K diet

How is kayexlate administered?

Orally

High in water soluble vitamins lost in dialysis, lower in _____ soluble vitamins retained in dialysis

Nephrovite, fat

Stimulates erythropoiesis (RBC) production

EPO (epogen, procrit)

What should you do with Fe and Ca with EPO drug?

1. Give w/ Fe supplement if Fe stores inadequate
2. Don’t give at the same time as Ca supplement

Want ferritin >______ ng/mL for EPO

>100

controls hyperphosphatemia by binding phosphorus from food in GI tract

Phosphate binders

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reduce the amount of phosphate being absorbed in the blood stream

Why are phosphate binders given 1/2 before 1/2 after eating?

1. Taking a dose on an empty stomach can cause nausea and vomiting
2. Helps prevent phosphorus from being absorbed into the bloodstream by “binding” to the food and carrying it through the rest of the gut

Consequences of long-term use with phosphate binders

1. Al (aluminum containing) deposits in bone and brain -→ Alzheimer’s
2. If \[Phos\] >6.0 use AI containing Phos binders %%short term%%
3. Ca-containing binders (tums) don’t use when serum \[phos\] >6.0 or if serum Ca product >60


1. Can cause calciphylaxis in soft tissue

T/F: Only give Aluminum phosphate binders short term d/t toxicity tissues

True

Active vitamin D supplements

Rocaltrol (po) / Calcijex (IV)

Why are vitamin D supplements used?

Given to maintain serum Ca WNL and suppress PTH levels in order to prevent 2\* hyper PTH and metabolic bone disease

Identify foods high in K, Phos, or both

1. Banana: high K, low Phos
2. Soybeans: High K, high Phos
3. Milk: High K, High Phos
4. Coffee creamer: low K, low phos
5. Steak: low K, high Phos
6. Sprite: low K, low Phos
7. Potato: high K, low Phos
8. PB: High K, high Phos
9. Eggs: low K, low Phos

Identify how each food category does for PRO, K, Phos

When should you not use active vit D supplements?

1. Ser phos > 6.0 mg/dL
2. Ser Ca >11.5 mg/dL
3. Ca\*PO product >60
4. Intact PTH

Describe the function of ACE inhibitors

Rennin -→ angiotension I -→ angiotension II (vasoconstriction) -→ aldosterone resorbs Na+ -→ Inc BP

What are common ACE inhibitors?

1. Capoten
2. Vasotec
3. %%pril -→ MOST COMMON%%
4. Lotensin
5. Altace

May cause elevated K due to renal K resortion

ACE Inhibitor

If serum K > 5.6 mEq/L, dietary *should be restricted &* ________ containing salt substitutes avoided on what drug?

K, K, ACE inhibitor

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\*\*\*If pt is near the end of life, don’t restrict, remember Campbell’s story in class

Why would you need a K restriction when on an ACE inhibitor?

This drug dec. ADH -→ Inc \[K\]

Is N balance appropriate method to assess protein status for a renal patient?

Not useful in renal pt d/t decrease N clearance

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(aka N is being reabsorbed and not excreted)

The amount of N waste and minerals that must be excreted daily by the kidneys.

What is RSL

A diet high in RSL requires what?

Increases fluid

Indicator of renal fx. What indicates “good” function

GFR, >125 mL/min/1.73m^2

Part of RASS system, reabsorb Na for BP control

Aldosterone

Permeability of distal tubule and collecting duct to increase H20 resorption

ADH

4 classic renal indicators

BUN, Serum Cr, Serum K, Serum PO4 or PHOS

Other labs that influence renal disease

1. Sodium
2. Albumin
3. PAB
4. Calcium
5. TG/Cholesterol
6. H/H

In anthropometrics, weight is complicated by _____

1. Fluid retention


1. Weight is complicated by fluid status

4 descriptive criteria for edema-free BW

aka dry weight


1. Weight at normal hydration, not edematous
2. Normal BP
3. No evidence of edema
4. Serum Na+ WNL

What is dialysis pt dry weight?

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1. Weight at end of dialysis WHEN normal BP is reached

What is standard body weight (SBW)

1. %SBW = Actual body weight / SBW x 100

An indicator of nutritional status (similar to IBW)

SBW

SBW >115% is considered ____ __&

1. obese
2. malnutrition

How do you calculate ABW?

ABW = BWef = BWef + (\[SBW - BWef\] \* 0.25)


1. Use wt

List…


1. NIDDK
2. KDOQI
3. CKD
4. RRT

1. National Institute of Diabetes and Digestive and Kidney Disease
2. Kidney Disease Outcomes Quality Initiative
3. Chronic Kidney Disease
4. Renal replacement therapy

Define CKD

1. Presence of irreversible nephron damage
2. Inability of kidney fx to return to normal after ARF OR progressive renal decline from disease

Dx criteria for CKD

1. GFR

What are the risk factors of chronic kidney disease?

1. Have DM
2. High BP
3. Family hx of kidney failure
4. Older
5. Belong to a population group with a high rate of diabetes

Characteristics of CKD

1. Severity defined by decreased Cr and urea clearance
2. increase serum Cr and urea

Symptoms of CKD

1. Severe headache
2. Dyspnea
3. Pitting edema of extremities
4. Failing vision
5. Decrease appetite
6. N/V
7. Abdominal and or joint pain

Stage 1 CKD

1. Kidney damage w/normal or increased GFR


1. GFR ≥90

1. Decreased renal reserve/renal impairment
2. Asymptomatic; decreased 50-60% renal fx

Stage 1 CKD

Stage 2 CKD

1. Kidney damage w/mild decrease in GFR

1. Renal insufficiency/milkd azotemia
2. Increase BUN and CR
3. Dec. 80% renal fx

Stage 2 CKD

Stage 3 CKD

1. Moderate dec, in GFR
2. GFR = 30-59

Moderate azotemia, increase BUN and CR

Stage 3 CKD

GFR in stage 2 CKD

60-89

Stage 4 CKD

1. Severe decrease in GFR
2. GFR = 15-29

What stage do you prepare for RRT

Stage 4

Stage 5 CKD

1. Kidney failure (uremia)
2.

What are our main goals for CKD MNT?

1. Still provide adequate energy to maintain/achieve IBW and *prevent malnutrition*


2. Prevent/alleviate symptoms of *uremia*
3. *Treat micronutrient deficiencies*
4. *Normalize blood lipids*

CKD progression of tx

1. Conservative management with diet and drugs
2. Dialysis (RRT; along with diet and drugs) Hemodialysis and peritoneal dialysis
3. Transplant

General nutrition intervention for Stages 1-2

General nutrition intervention for Stages 3-4

General nutrition intervention for Stage 5

What does a complete protein mean?

has all 9 essential AA

Most plant sources are _____ PRO and are considered

Incomplete, low biological value

Predialysis is considered what stage? Dialysis?

1. Stages 3-4 2/3 HBV
2. Stag3 5: 50% HBV