Renal 2- Babos- Nutrition And Chronic Kidney Disease

Front 1

Definition of CKD

Back 1

Kidney damage for 3 or more months as defined by structure/function abnormalities w/wo decreased GFR seen either as
Pathological abnormalities of
Markers of kidney damage

2. GFR < 60ml/min/1.73m2 for 3 or more months c/s kidney damage

Front 2

Stages of Chronic Kidney Disease, serum creatin becomes a marker, when?

Back 2

Serum Creatinine as Marker
at stage 3

Front 3

Risk of malnutrition in CKD

Back 3

Anorexia is a symptom of CKD
Chronic inflammation leads to sequestration of iron, increased glucagon levels, insulin resistance, and protein catabolism
Peritoneal dialysate can lead to significant glucose loads
Renal replacement therapy (RRT) leads to losses of dialyzable substances
Amino acids (6-10g fasted, 8-10g fed per HD session)
Water soluble vitamins
Trace elements

Front 4

Malnutrition in CKD
Acidemia promotes

Back 4

Decarboxylation of branched chain amino acids
Protein catabolism
Bone resorption (PO4 as buffer)
Treat with Bicarbonate, citrate or acetate salts of lytes

Front 5

Malnutrition in CKD
Low calcium stimulates

Back 5

release of parathyroid hormone
Parathyroid hormone stimulates gluconeogenesis
Ultimately, most CKD patients will be in a state of protein-calorie deficit

Front 6

High protein consumption _

Back 6

accelerates progression of diabetic nephropathy
Increased glomerular filtration and intraglomerular pressures?

Front 7

In late stages of CKD (pre-dialysis) and protein

Back 7

protein restriction is usually recommended

Front 8

Alpha keto and hydroxy acids

Back 8

Alpha-keto and alpha-hydroxy derivatives of essential amino acids can be given as a “sink” for excess N AND as a source of new amino acids via transamination:
Leucine
Isoleucine
Valine
Tryptophan
Methionine
Phenylalanine
Threonine, Lysine, and Histidine do not undergo transamination so cannot be replaced this way

Front 9

Chronic renal replacement and amino acids: glutamine**

Back 9

Glutamine is removed significantly by renal replacement
During hypercatabolic states (inflammation, sepsis), glutamine use increases
Glutamine renal catabolism increases where the kidney is trying to eliminate H+

Front 10

Other nutritional disturbances

Back 10

Elevated homocysteine
Loss of carnitine:
Carnitine facilitates transfer of long chain fatty acids into muscle mitochondria; depletion leads to derangement of fatty acid oxidation
Lost during dialysis
Requires Lys, SAMe, B6, and C for synthesis

Front 11

Loss of carnitine

Back 11

Carnitine facilitates transfer of long chain fatty acids into muscle mitochondria; depletion leads to derangement of fatty acid oxidation
Lost during dialysis
Requires Lys, SAMe, B6, and C for synthesis

Front 12

Water Soluble Vitamins

Back 12

Patients are on a restricted diet, are generally anorectic, AND lose vitamins during dialysis

Front 13

Which vitamin is important for transamination reactions?

Back 13

B6

Front 14

Which vitamin will help reduce hyperhomocysteinemia?

Back 14

folate or B9

Front 15

Which vitamin to prevent scurvy?

Back 15

C

Front 16

Which vitamin to prevent Wernicke’s encephalopathy?

Back 16

thiamine Vitamine B1

Front 17

LAB test measures what?
Serum Iron

Back 17

Iron available for Hb synthesis

Front 18

LAB test measures what?
TIBC = total iron binding capacity

Back 18

Capacity of blood to carry iron

Front 19

LAB test measures what?
TSAT

Back 19

Transferrin saturation

Front 20

LAB test measures what?
Serum ferritin

Back 20

Indirect measure of iron stored

Front 21

Anemia:
what drugs u need?

Back 21

Epoetin alpha (Epogen® or Procrit®) and darbepoetin (Aranesp®)
MOA: stimulate erythropoietin receptor to increase erythropoiesis

Front 22

What do you monitor with anemia?

Back 22

must have adequate Fe stores!! Measure and replete before using EPO
Hb target < 12 g/dL
Blood pressure

Front 23

Side effects
of epotein alpha and darbepoetin

Back 23

pure red cell aplasia due to anti-EPO antibodies (SQ dose)
ERYTHROPOIETIN INCREASES HCT AND THEREFORE VISCOSITY; INCREASED VISCOSITY CAN INCREASE MORTALITY
hypertension
thrombotic events and mortality
seizures

Front 24

Rate to steady state levels depends upon life span of

Back 24

RBC (steady state: rate in = rate out)

Do not adjust dose more often than every 2-4 wks

Front 25

Hematocrit directly related to ___

Back 25

viscosity, and viscosity directly related to resistance

Front 26

Parathyroid: bone and kidney
Constant high levels:

Back 26

Cause osteoblasts to activate osteoclasts; net = increased Ca and PO4 resorption from bone
Increases activation of Vitamin D in kidney
Increases Ca++ renal reabsorption and decreases PO4 reabsorption
Increases hepatic gluconeogenesis = contribute to protein waste

Front 27

Intermittent parathyroid is mimicked by_____

Back 27

teriparatide

Front 28

1,25 dihydroxy vitamin D: bone, kidney, and gut

Back 28

Increases Ca and PO4 abs’n in gut
Increases Ca and PO4 resorption from kidney
Increases Ca and PO4 resorption from bone

Front 29

Calcitonin

Back 29

bone and kidney – opposite of parathyroid
Inhibits osteoclasts
Increases calciuria and phosphouria

Front 30

Goals: Ca PO4 and PTH in CKD

Back 30

Reduce phosphate from diet: dietary measures and phosphate binders
Achieve Ca goal: 1,25 dihydroxy D3 and analogs + calcium supplements
Control PTH: calcimimetics
Prevent calciphylaxis (precipitation of calcium phosphate in tissues) by keeping Ca++ x PO4 < 55

Front 31

Reduce Phosphate Levels

Back 31

Dietary reduction at stage 3
Phosphate binders – bind to inorganic phosphate, preventing absorption by enterocyte
Sevelamer (Renalgel®)
No contribution to Ca x PO4
Lowers cholesterol also
Lanthanum (Fosrenol®)
Not systemically absorbed, no contribution to Ca x PO4
Calcium acetate (PhosLo®) and Calcium carbonate (Tums®)
Best at more acidic pH (what impact of PPI?)
Will help manage metabolic acidosis
Risk of vascular calcification and calciphylaxis
Magnesium salts
Diarrhea, accumulation
Aluminum salts
Al toxicity

Front 32

List some high phosphate foods

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Beer
Cheese (hard cheeses)
Chocolate
Cola
Dairy
Legumes (dried)
Nuts
Organ meats
Seafood
Seeds and whole grains

Front 33

Achieve Calcium /Vitamin D3 Goals

Back 33

Dihydroxy D3 (Calcitriol or Rocaltrol®) suppresses PTH
Lowers PTH Ca set point
Increases available Ca (increased absorption in GUT, increased release from bone)
Upregulates D3 receptors
Side effects
↑Ca and PO4
↑PO4 →↑PTH
Vitamin D receptor activators (VDRA): Paracalcitol and doxercalciferol less risk of hypercalcemia

Front 34

Vitamin D and analogs

Back 34

Forms that require renal activation
Ergocalciferol (D2)
Cholecalciferol (D3)
Activated forms
Calcitriol (1,25 dihydroxy D3) Rocaltrol®)
Paricacitol (Zemplar®)
Doxercalciferol (Hectorol®)

Front 35

Reduce Parathyroid Hormone

Back 35

Calcimimetic
Cinacalcet (Sensipar®)
MOA – stimulates Ca receptors to reduce PTH secretion
ADE: GI, hypocalcemia (thus don’t start unless [Ca++] WNL), monitor Ca frequently at initiation
DI: potent inhibitor of 2D6

Front 36

↑Parathyroid hormone
In kidney

Back 36

Increase Ca++ reabsorption
Activates 25 hydroxylase to increase 1,25 Vit D3

Front 37

↑Parathyroid hormone
In bone

Back 37

Increases Ca++ resorption from bone so Increase plasma Ca++

Front 38

Cinacalcet is

Back 38

is a “fake” calcium that stimulates Ca++ sensors to ↓ PTH release

Front 39

Teriparatide (Forteo) is

Back 39

an analogue used intermittently to treat osteoporosis (not CKD)!

Front 40

1,25 dihydroxy D3

Back 40

Works in gut, kidney AND bone to increase [Ca++]
In CKD, hydroxylation in kidney is impaired. MUST give calcitriol or analogs, not other vitamin D’s

Front 41

Phosphate binders

Back 41

Give with meals and snacks!
Calcium ACETATE may replace Ca++, ↓PTH< bind PO4 AND help with acidosis (but risk of calciphylaxis)
Sevelamer reduces phosphate AND lipids (remember colesevelam?)

Front 42

Calcitonin

Back 42

opposes effects of parathyroid hormone, put Ca++ into bone, so reduce Ca++ from plasma.

Front 43

___is second most common cause of death in CKD patients!

Back 43

infection

Front 44

Risk of Infection
Management

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Hygiene
Maintain nutrition
Vaccinations
Hep B, S pneumococcus, Influenza
Consider Hep A, tetanus, varicell,a H influenza

Front 45

– accumulates in renal impairment; low K+ increases risk of toxicity

Back 45

Digoxin

Front 46

oto, nephrotoxic, NM block

Back 46

Aminoglycosides

Front 47

cause seizures

Back 47

Fluoroquinolones