Ellie Stanger,

Tessie Atwater,

Summer White,

McKenzie Driscoll

DIALYSIS

PATHOPHYSIOLOGY

Chronic Kidney Disease

•A wide range of kidney lesions characterized by a slow, steady decline in renal function

•A number of other kidney diseases can lead to renal failure

•Some patients with CKD can be stable for months or years, while others progress to renal failure and dialysis

•CKD is defined as GFR<60 mL/min/1.73 m2 for 3 months OR individuals with kidney damage, regardless of GFR

•

•In response to a decreasing GFR, the kidneys adapt to prevent it from decreasing further

•Short-term improvement in filtration rate but long-term loss of nephrons and progressive renal insufficiency

•Once patient has lost ½ to 2/3 kidney function, progressive loss of function continues, regardless of underlying disease

National Kidney Foundation’s GFR calculator

http://www.kidney.org/professionals/kdoqi/gfr_calculator.cfm

HOW IT STARTS

•Vascular includes large vessel disease such as bilateral renal artery

stenosis and small vessel disease such as ischemic nephropathy, hemolytic-uremic syndrome and vasculitis

•Glomerular includes primary glomerular disease such as IgA nephritis and secondary glomerular disease such as diabetic nephropathy and lupus nephritis

•Tubulointerstitial including polycystic kidney disease, drug and toxin-induced chronic tubulointerstitial nephritis and reflux nephropathy

•Obstructive such as with bilateral kidney stones and diseases of the prostate

•In rare cases, pin worms infecting the kidney can also cause nephropathy

KIDNEY DISEASE CLASSIFICATION

•DM

•HTN

•Autoimmune diseases (like lupus, HIV and IgA nephropathy)

•Genetic diseases (like polycystic kidney disease)

•Injuries

•Some medicines or other drugs

•The three most common causes (DM, HTN & glomerulonephritis) account for 75% of adult cases

ETIOLOGY

•DM

•HTN

•CV disease

•Family history of kidney disease

•African American, Hispanic, Native American or Asian

•Over 60 years old

Risk Factors

During Stage 4, a fistula or peritoneal catheter is typically placed so it has several weeks to heal before patient needs to start dialysis

END-STAGE RENAL DISEASE (ESRD)

•90% of ESRD patients have diabetes mellitus, HTN or glomerulonephritis •No lab values correspond directly with beginning of symptoms, but BUN >100 mg/dL and Cr 10-12 mg/dL are usually close •Normal BUN = 6-21 mg/dL and Cr = 0.7-1.2 mg/dL

END-STAGE RENAL DISEASE (ESRD)

Kidneys cannot sufficiently excrete waste products, maintain fluid and electrolyte balance and produce hormones

As renal failure progresses, uremia develops—syndrome of malaise, weakness, N/V, muscle cramps, itching, metallic taste in mouth, neurologic impairment

END-STAGE RENAL DISEASE (ESRD)

When a patient progresses to Stage 5 CKD, it’s considered renal failure/ESRD

Options are dialysis, kidney transplant or medical management progressing to death

DIAGNOSIS

• Most people don’t exhibit symptoms in early stages

• Symptoms begin to appear during later stages as damage worsens

• Fluid retention

• Dehydration

• ↓ urination

• Fatigue

• Confusion

• N/V

• Loss of appetite

• Pale skin

• Kidney failure has usually progressed significantly by the time

symptoms appear

• ESRD is not reversible

KIDNEY FAILURE SYMPTOMS

• BUN

• Creatinine

• Albumin

• Na/K

• P/Ca

• PTH

• Hct/Hgb

• Urinalysis

Volume, urea, protein,

Na

Normal Levels for

Dialysis

• BUN: 50-100mg/dL

• Creatinine:

<15mg/dL

BIOCHEMICAL DATA

Normal for Dialysis High Serum Levels Low Serum Levels

Sodium 135-145mEq/L Check fluid status Check fluid status

Potassium 3.5-5.5mEq/L Avoid foods with more than

250mg/serving (<2000

mg/day)

Add one high K food per

day

Calcium 8.5-10.5mg/dL Temporarily stop Ca

supplements

May need Ca supp and

active vit D

Phosphorus 3-6mg/dL Limit dairy Add 1 serving/day of dairy

or high P food

BUN

50-100mg/dL Underdialysis Inadequate oral intake; loss

of muscle

Creatinine

<15mg/dL Dialysis normally controls creatinine; Low creatinine may

indicate low body muscle

PTH 200-300pg/mL Indicates bone loss; active vit D No treatment available

• Affects more than 20 million Americans (1 in 9)

• 398,861 ESRD pts were being treated with some form of dialysis in

2009

• 172,533 had kidney transplants

• Cost for treating ESRD patients cost over $40 billion in 2009

• 40-50% pts starting dialysis have diabetes

MORBIDITY

United States Renal Data System’s 2010 Annual Data Report and 2011 Annual Data

Report

•Stage 5 chronic

kidney disease

•85-90% loss of kidney

function

•Kidneys no longer

remove waste and

fluids

WHEN IS DIALYSIS NEEDED?

• Solute (pink circles) moves from blood to dialysate (dashed arrows) in response to a concentration gradient (diffusion)

• There’s a forced movement of water (blue circles) to try to maintain osmolarity

• This flux of solute and water (ultrafiltration) may be enhanced by

1. increased osmotic pressure (i.e. glucose in peritoneal dialysis fluid) or

2. increased hydrostatic pressure (created mechanically as transmembrane pressure in hemodialysis)

PRINCIPLES OF DIALYSIS

MECHANISMS CONT.

1. Hemodialysis (HD) In-center

At home

2. Peritoneal Dialysis

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Continuous Cycling Peritoneal Dialysis (CCPD)

TYPES OF DIALYSIS

• Dialysis machine • Dialyzer

“artificial kidney” removes wastes and extra fluids from blood

• Most common form of dialysis

• Requires a permanent “access” to bloodstream 1. Arteriovenous fistula 2. Artificial loop graft 3. Central venous catheter (temporary)

HEMODIALYSIS

HEMODIALYSIS

• “Gold Standard” for long-term vascular access

Low rates of complications, clotting, and infection

• Connects artery directly to vein

• Increased pressure inside vein makes it stronger and larger over time

• Easier for repeated dialysis needle insertions and allows increased blood flow

• ~3 months before starting dialysis so fistula can heal

• Can last for several years

• Approximately 500 ml’s are outside the body at a time

• Blood leaves the fistula at a rate of 400 ml/mi

FISTULA

• During each treatment two needles, that are attached to plastic tubes, are inserted into access Needle sticks are one of the hardest parts of hemodialysis treatment for some people

• Blood pumped from body to the dialysis machine through one of the plastic tubes

• After blood is cleaned, it is carried back to body through a second tube

• Blood is cleaned by the dialyzer

HEMODIALYSIS PROCESS

• “Artificial kidney”; plastic tube containing thousands of small fibers

through which blood is passed

• 2 sections, one for blood and one for dialysate, separated by a

semipermeable membrane

thin surface with tiny holes that allows small particles (waste products &

excess fluid) pass through, but keeps large particles (blood cells) back

• Dialysate

Solution of water, electrolytes, and salts

Pumped around fibers

Pulls waste products from blood into dialysate via diffusion

Extra fluid is removed via filtration

• Dialyzer can be reused more than once if it is cleaned before each use

and tested each time to make sure it still works

DIALYZER

DIALYZER

• Blood is tested 1x/month to see if dialysis is removing enough wastes

• 2 formulas:

1. Kt/V

a measure of the dialyzer size, time, and the amount of fluid in your body; should always be at least 1.2 {K= how much urea is removed; T= amount of time on dialysis; V- volume of urea in your body (blood, urine, body fluid)}

2. Urea reduction ratio (URR)

test that shows how much urea is removed during dialysis treatment; URR should always be at least 65%.

You may get less hemodialysis than you need if:

• The dialyzer is too small for you

• Your fluid goal is figured or set wrong

• Your access isn’t working well

• You shorten or skip a treatment

EFFECTIVENESS OF HEMODIALYSIS

In-Center

• 3x/week

• 3-5 hours/session

• Strict schedule

Home

• Flexible schedule

• Daily for 1.5-2.5 hours

• Or nocturnally 3x/week for

8 hours

HD: LOCATION OF TREATMENT

PROS

• Trained professionals

• Medical help is readily

available in case of

emergency

• 3x/week, 4 days off

CONS

• Must travel to dialysis

center

• Fixed diet and fluid

restrictions

• Treatment times

scheduled by dialysis

center

• 2 needle insertions every

visit

HD: IN-CENTER PROS & CONS

PROS

• Same person always helps you

• More control over dialysis times and treatments (within the doctors orders)

• No travel to dialysis clinic

• Comfort and privacy of own home

• Being able to eat and drink when you choose

CONS

• You and care partner need several weeks of training Training for home HD is not offered by all dialysis centers

• Care partner generally needs to be present during all treatments

• Need room for storage and supplies

• Need to call paramedic for help in an emergency

• Some plumbing and wiring changes may be necessary in home to accommodate machine

HD: HOME PROS AND CONS

1. Hemodialysis (HD)

In-center

At home

2. Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis (CAPD)

Continuous Cycling Peritoneal Dialysis (CCPD)

TYPES OF DIALYSIS

• Uses peritoneum as filter Peritoneum: A natural membrane that covers the abdominal organs and lines the abdominal wall

• Peritoneum is a porous membrane that allows wastes and fluid to be filtered from the blood

• Permanent access to peritoneal cavity required (catheter)

Surgical procedure to insert a small, soft tube through the abdominal wall and into peritoneal cavity

Catheter carries the dialysis solution into and out of abdomen

Healing takes about 3 weeks

• 2 types of peritoneal dialysis (PD): Continuous ambulatory peritoneal dialysis (CAPD)

Continuous cycling peritoneal dialysis (CCPD)

PERITONEAL DIALYSIS

• Catheter fills abdomen with high dextrose dialysate

• Walls of abdominal cavity, lined with peritoneal membrane, allows waste products and extra fluid to pass from blood into dialysis solution

• After the completed “dwell time” (time solution is in abdomen) the solution is drained and thrown away

• Process of draining and filling abdominal cavity is called an “exchange” and takes 30-40 minutes

• A typical PD schedule calls for 4 exchanges/day, each with a dwell time of 4-6 hours

• Different types of PD have different schedules of exchanges

PD: HOW IT WORKS

1. Continuous Ambulatory Peritoneal Dialysis (CAPD)

• No machine reqiured 4-5 times/day

every 4-6 hours drain solution, containing the wastes, then repeat cycle with fresh bag of solution

One evening exchange with long overnight dwell time while asleep

• 24 hour/day treatment • Free to do normal activities

while the dialysis solution dwells in the abdomen in-between exchanges

2. Continuous Cyclic Peritoneal Dialysis (CCPD)

• Machine called a “cycler” fills and drains dialysate while asleep

• In the morning, begin 1 exchange with a dwell time that lasts the entire day

• More flexibility for during the day

• May preform an exchange during the day if needed

TYPES OF PD

Peritoneal Equilibration Test (PET)

• Important in determining correct prescription for PD

• Takes samples of dialysis fluid and blood

• Measures how much glucose and waste products (urea and creatinine) are drawn into the dialysate solution over a 4-hour dwell time

Measures amount of glucose remaining in dialysate; if glucose levels are low, body may be absorbing too much glucose during dwell time

Kt/V Clearance test

• Takes samples of used dialysate over 24-hours and a blood sample; compare the amount of waste in the used solution to the waste in blood

• Using this data it measures the amount of waste (urea) from the bloodstream

EFFECTIVENESS OF PD

PROS

• Relatively independent

• Control over schedule

• No needles required

• Less restricted diet

• Simple to learn and

preform

CONS

• Permanent external catheter (body image)

• Dialysis fluid in abdomen may be uncomfortable

• Risk of peritonitis (infection), caused by bacteria entering catheter

• Some people get tired of daily dialysis schedules

• Possible weight gain (glucose content of dialysate results in higher intake of kcals)

• Storage space needed for supplies

PD: PROS & CONS

• Dialysis is very expensive

• Medicare and Medicaid will pay 80% of the cost

• Private health insurance or state medical aid also help with costs

COSTS OF DIALYSIS

• Many dialysis patients live normal lives apart from the time needed for

treatment

• Maintaining an active lifestyle is important to health and well-being

• Studies have suggested that more frequent dialysis treatments have

improved quality of life, compared to those on conventional dialysis

• Take all medications, follow diet carefully, do all dialysis treatments

(do not skip treatments)

QUALITY OF LIFE

• Calcitriol

Ca regulator

Treatment for hypocalcemia in dialysis patients

Treatment for secondary hyperparathyroidism in predialysis patients

Active vit D3

↓ PTH

↑ Ca and P

With dialysis consume ↓ P diet and adequate Ca (↑ Ca absorption)

• Zemplar

IV form of Calcitriol

• Hectorol

MEDICATIONS

• Sensipar

Hyperparathyroidism treatment (↓ PTH)

Calcium imitator drug

• EPO

Anti-anemic; stimulates RBC production

May need Fe, vit B12, or folate supplements

↑ BP, ↑ RBC, Hgb, and Hct

MEDICATIONS

• Phosphate binders

Renegel, Fosrenal, Renvela, Tums

Taken with meals to ↓ P absorption

Consume low P diet

MEDICATIONS

• Most common transplant in the U.S.

• Kidneys can be donated by the living or deceased

• Dysfunctional kidney is not typically removed

• 3-4 hr procedure

KIDNEY TRANSPLANT

• Better quality of life

• Living donor kidneys usually do better

than a kidney from the deceased

PROGNOSIS AFTER TRANSPLANT

MNT

HEMODIALYSIS &

PERITONEAL DIALYSIS

• Prevent deficiency and maintain good nutrition status

• Control edema and electrolyte imbalance

• Prevent or retard the development of renal osteodystrophy

• Enable the patient to eat a palatable, attractive diet

• Coordinate patient care

• Provide nutrition education

MNT GOALS - DIALYSIS

• Dialysis drains some body protein

• Protein intake must be increased accordingly

Hemodialysis - 1.2g/kg

Peritoneal Dialysis – 1.2-1.5 g/kg

• At least 50% should be HBV protein

• Monitor serum BUN, Cr levels, uremic symptoms, and weight

Prealbumin (metabolized by the kidney) not a good nutritional marker

• Challenging to consume adequate protein due to uremia

• Phosphorus restriction may be lifted to meet protein needs

PROTEIN - DIALYSIS

• Should be adequate to spare protein for tissue protein

synthesis and to prevent its metabolism for energy

• Needs: varies between 25-40kcal/kg

Lower end for PD & transplant

Higher range for nutritionally depleted

ENERGY - DIALYSIS

• Must be assessed frequently

• Hemodialysis: Level of fluid intake is prescribed based on

urine output plus 500 to 1000 mL per day

• Allows for weight gain of 4 – 5lb between dialyses

Goal for fluid gain : <4% of Body weight

2-3g Na restriction will usually meet these guidelines

Only liquids at room temperature qualify as fluids

FLUID - DIALYSIS

• 2-3 gram/day

Avoid:

salt in cooking

salt at the table

salted, smoked, or cured meat or fish

salted snack foods, canned soups, or high-

sodium convenience foods

• Salt intake drives fluid consumption

SODIUM - DIALYSIS

• Sucking on a few ice chips

• Chewing Gum

• Cold sliced fruit

• Frozen fruit

• Add lemon or lime juice to water

• Sour candies

• Take pills with soft foods instead of liquids

• Using artificial saliva

DEALING WITH THIRST WITHOUT DRINKING

Usually reduced to 2.3-3.1 g

• Patients on high flux dialysis or with increased dialysis times or frequencies will be able to

tolerate higher levels

• Some low-sodium foods contain potassium chloride

• If diet history does not reveal the reason for elevated serum potassium check non dietetic

sources

Poor dialysis adequacy

Missed dialysis treatments

Elevated sugar in patients with diabetes

Acidosis

Constipation

Severe GI bleeding, blood transfusions

Blood transfusions

Chemotherapy/radiation

POTASSIUM - DIALYSIS

Not easily removed by dialysis

• Usually restricted to <1200mg/day

• Difficult because of the necessity for high-protein diet

• Highly processed foods have commonly used additives containing

phosphate

• Take phosphate binding medication with each meal or snack

PHOSPHORUS - DIALYSIS

• Maintaining phosphorus-calcium balance is complicated

GFR decreases, serum calcium levels decrease

Decreased ability of the kidney to convert to inactive

Vit D to its active form

The need for serum Ca increases as serum

phosphate levels increase

• Many patients on dialysis suffer from hypocalcemia

regardless of calcium supplementation

CALCIUM AND PARATHYROID HORMONE

• Rapidly lost during dialysis

• Patients who still produce urine may be at increased risk of loss of

water-soluble vitamins

• Folate is highly dialyzable

• Uremic toxins may interfere with the activity of some vitamins

• Water soluble vitamins usually abundant in high potassium foods

• Dialysis diets tend to be low in folate, niacin, riboflavin, and vitamin B6

Renal multivitamin

VITAMINS - DIALYSIS

TRANSPLANTATION

• First 6 weeks after surgery

High protein diet recommended

1.2-1.5 g/kg IBW/day

• Energy

30-35kcal/kg IBW

• 2-3 g Na restriction

• After Recovery

Protein 1 g/kg IBW/day

Low fat diet

Hypophosphatemia and mild hypercalcemia common

Fluid- typically drink 2L a day, but overall needs depend on urine output

Lipids- patients usually have elevated serum trigylcerides or cholesterol

Calorie restriction for those who are overweight

Cholesterol <300mg/day

Limit total fat

TRANSPLANTATION MNT

Therapy Energy Protein Fluid Na+ K+ P

Impaired

renal

function

30-35

kcal/kg IBW

0.6-1.0

g/kg

IBW

Ad libitum Variable

2-3 g/day

Variable; usually ad

libitum

or increased to

cover losses

with diuretics

0.8 – 1.2

g/day or 8-

12 mg/kg

IBW

Hemodialy

sis

35kcal/kg

IBW

1.2 g/kg

IBW

750 –

1000mL/d

ay urine

output

2-3g/day 2-3 g/day or 40

mg/kg IBW

0.8-1.2

g/day or <

17 mg/kg

IBW

Peritoneal

Dialysis

(CAPD)

(CCPD)

30-35

kcal/kg IBW

1.2-1.5

g/kg BW

Ad libitum

( minimum

of

2000mL/d

ay urine

output)

2-4 g/day 3-4 g/day 0.8-1.2

g/day

Transplant

(4-6 wks

after)

30-35

kcal/kg IBW

1.3-2

g/day

Ad libitum 2-3 g/day Varies

May require

restriction with

cyclosporine-induced

hyperkalemia

Calcium 1.2

g/day

No need to

limit

Phosphorus

Transplant

(6 wks or

longer

after)

To

achieve/maintain

IBW:

• Limit simple

CHO

• Fat < 35%

kcals

• Cholesterol

<400

mg/day

• PUFA/SFA

ratio > 1

1g /kg

BW

Ad libitum 2-3 g/day Varies n/a

CASE STUDY

Patient: Enez Joaquin

Ht: 5'

wt: 170lb (with edema)

Age: 26

Sex: Female

Dx: Renal insufficiency secondary to diabetes mellitus

Complaints: anorexia, nausea, vomiting, SOB, pruritus, muscle

cramps, inability to urinate

Low - Na

High- K+, P, Mg, Glucose, BUN, Cr, Cholesterol, Triglycerides

4 kg weight gain due to edema in the last weeks

Clinical symptoms: declining GFR, increasing creatinine and urea,

elevated serum phosphate, normochromic normcytic anemia, will be

receiving AV fistula to begin dialysis

General appearance: overweight, lethargic, BP 220/80, HR 85, RR 25,

mild asterixis

• Dry weight – 161 lbs

• Current weight – 170 lbs (with edema)

• %IBW – 153% (obese)

• IBW- 105 lbs (48)

• BMI – 31.5 (obese)

• Calorie needs at 35 kcal/kg of IBW – 1670kcals

• Protein needs .8g/kg – 38g/day

8-12 g/kg Pho – 380-570mg Phosphorus

2-3 g Na