MNT exam 4

Kidney, Critical Care, Cancer, Bariatric Surgery, Genetic Metabolic Disorders

Nephrons

Basic functioning unit of the kidney (~1 million nephrons per kidney)

Glomerular Filtration

initial filtration similar to blood. Secretion of molecules from blood through nephron into the urine

What is GFR?

Glomerular Filtration Rate - the filtration ability of the glomerulus. Calculated by the clearance of creatinine

GFR and its association to creatinine

Inverse, more creatinine in the blood = low GFR

Physiological functions of the kidney

Excretory (cleans blood) Metabolic (acid/base balance), Endocrine (erthropoietin - RBC production)

Acute Kidney Injury (AKI)

Rapid reduction in GFR without decreased urine output. Possible causes: severe dehydration, trauma, rhabdomyolysis

AKI MNT: PROTEIN

non dialysis: Low protein 0.5-0.8g/kg

Dialysis: high protein at least 1.2 if not 1.5-2.5g/kg

AKI MNT: Energy

25-40 kcal/kg of DRY weight

AKI MNT: sodium

Restrict based on fluid retention ( 2-3g/day)

Chronic Kidney Disease (CKD)

Slow decline in kidney function. Risk factors: diabetes, HTN, glomerulonephritis

CKD PRO Recommendations

Stage 1-2: 0.8 g/kg/day

Stage 3-5: 0.6 g/kg/day

CKD Energy Recommendations

25-35 kcal/kg/day (protect protein)

Peritoneal Dialysis

Uses semi-permeable peritoneum where a catheter is implanted through the abdomen, dialysate infused into peritoneum.

Can be continuous and ambulatory or cyclical

Peritoneal Dialysis Diffusion and Osmosis

Dialysate does not contain urea, K, or creatinine. Compounds move down concentration gradient from the blood to the dialysate in peritoneal cavity.

Dialysate is hypertonic because of dextrose, water will enter dialysate.

Hemodialysis (HD)

system to clean blood, filter acts as a artificial kidney, contains dialysate fluid.

Hemodialysis Composition and Frequency

Fluid composition similar to normal plasma, 3-5 hours, for 3 days a week. —> long or more frequent dialysis associated with better outcomes.

Hemodialysis Access

Must have a permeant high blood flow access. Ex: fistula, graft

2 needles are inserted into fistula or graft, 1 to remove blood other to return

Energy and Pro in HD and PD

Energy: 25-40 kcals / kg

Pro: increased requirement due to inflammation and infection —> 1.0-1.2 g/kg/day

Phosphorus in HD and PD

Adjust to control serum levels as it is ubiquitous in our diet. increased phosphorus associated with mortality

Lifestyle Risks for Cancer

Red meat, processed meat, alcohol

Decreases the risk for cancer

Antioxidants, phytochemicals, omgea-3 fatty acids, fiber, soy, coffee, tea

What is cancer

uncontrollable growth of abnormal cells caused by an error or mutation in DNA responsible for cell growth—> cells grow and reproduce abnormally. Cancer cells look identical to healthy cells making it difficult to kill

Goals of Cancer MNT

Prevent or reverse nutrient deficiencies, preserve LBM, Min nutrition related symptoms and complications, decrease the risk of infections, maximize healing, Maintain strength and energy

Energy Needs for Cancer patients

Usually 30-35 kcal/kg/day

Cancer MNT: PRO

increased needs 1.2-2.0 g/kg/day

Cancer MNT: hydration

fluid status influenced by fever, edema, fistulas, vomiting and diarrhea etc. Avoid dehydration

Common Cancer side effects

Diarrhea, Nausea / vomiting, constipation, sore mouth or throat, altered smell or taste, poor appetite

Cancer Cachexia

Chronic systemic inflammation that depletes LBM and causes progressive weight loss, weakness—> focus on nutrient dense foods, small frequent meals, consider EN

What is Neutropenia

Severely immunosuppressed condition where a neutropenic diet is needed to prevent food borne illness. Focus on food safety by avoiding fast food, restaurants. Hand washing is very important.

what is shock

condition of severe impairment of tissue perfusion (lack of blood flow)

What is MODS?

Multiple organ dysfunction syndrome: multiple vital organs shut down because of trauma or shock

What is the Ebb phase:

Initial temporary shock that lasts 12 -24 hours. Causes hypovolemia, tissue hypoxia, and reduced cardiac output & body temp

what is the flow phase

follows resuscitation and restoration of O2 transport. Causes increased cardiac output, O2 delivery, body temp, energy expenditure. Increased: glucose production FFA, epinephrine

What are cytokines

peptides released in response to stress, synthesized at the site of injury or by immune system, involved in cell to cell communications.

Systemic Inflammatory Response Syndrome (SIRS)

inflammatory response in critical care common complication of MODS

MNT for SIRS

Early feeding (EN >PN), Glycemic control, avoid overfeeding, high protein (1.2-2.0g), use Penn state equation for vented patients

Stages of critical care for burns

phase 1= shock & hypovolemic, phase 2= hyper metabolic, phase 3= anabolic.

MNT for Burn patients

Minimize metabolic response by controlling environment temperature.

Energy: high kcal & protein ( could be 2x normal requirements)

PRO: 20 to 25% kcal from protein

Bariatric Surgery candidates

BMI greater than or equal to 40 or 35 (sometimes 30 with complications). Evidence of failed weight loss, need to undergo comprehensive assessment including psych.

Type of Bariatric Surgery: Laparoscopic Banding

Inflatable silicone band placed around upper part of the stomach that is tethered to tubing and port that is accessible and adjustable. Restricts intake without neural or hormonal influence.

Types of bariatric surgery: Gastric Sleeve

removes around 80% of the stomach where the remainder resembles a bananas. complications and micro nutrient deficiencies.

Types of bariatric surgery: Gastric bypass (RYGB)

small gastric pouch created, distal jejunum attached to new pouch. The entire duodenum and proximal jejunum bypassed. At risk for micronutrient deficiencies but surgery can be reversible, stomach can still secrete enzymes.

what is dumping syndrome

Hypertonic foods and liquids move quickly into the proximal small intestine.

Early 10-30 min postprandial dumping syndrome

GI and vasomotor symptoms: abdominal pain, bloating, N/V, diarrhea, headache, flushing, fatigue, hypotension due to fluid shift into SI lumen

Late 1-3 hours postprandial dumping syndrome

Vasomotor symptoms, weakness confusion, shakiness, hunger, hypoglycemia

rapid digestion, absorption of CHO = exaggerated insulin response.

Dumping syndrome MNT

At risk for weight loss and malnutrition, protein and fat better tolerated than CHO, Solids better tolerated than liquids ( limit liquids with meals )