Completion Applicable Review 1.The intern will discuss with the rotation coordinator the normal function and physiology of the kidney.
2.The intern will discuss with the rotation coordinator the role of nutrition for renal disease. Include in the discussion but not limited to all the following that are applicable! a. etiology and treatment and pre"ention b. pathophysiology c. metabolic#nutritional alterations including bone and mineral metabolism d. current medical treatments#trends $. %iscuss the dietitian&s role as part of the health care team Assess '. (sing height#weight#labs and other pertinent information the intern will assess the appropriateness of! a. the )%&s order b. diet c. energy#protein#nutrient re*uirements +. The intern will obtain diet histories ,------- ./oal of $ or more0 1. The intern will complete nutrition care plans ,------ ./oal of $ or more0 Educate 2.The intern will utili3e the diet history and care plan as well as any other pertinent educational material to instruct patients and#or family member on his#her specific dietary regimen. , ------ ./oal of $ or more0 Document 4. 5bser"e the documentation process ,--------./oal of $ or more0 Observe 6. 5bser"e patient and staff when dialysis is being '#11 RENAL WORKSHEET 1. Define the following terms related to renal disease! 172 Azotemia! is a medical condition characteri3ed by abnormally high le"els of nitrogen7containing compounds .such as urea creatinine "arious body waste compounds and other nitrogen7rich compounds0 in the blood. It is largely related to insufficient filtering of blood by the kidneys. Uremia! a condition in which nitrogenous waste .urine0 builds up in the body resulting in malaise weakness nausea and "omiting muscle cramps neurologic impairment itching and a metallic taste in mouth. (nder normal circumstances kidneys filter urea from the blood and it is e8creted through the urine. If the kidneys are not working properly urea will build up in the blood and become to8ic to the body. Anemia: a condition characteri3ed by a lack of red blood cells .9:C0 in the blood. Anemia is common in C;% patients because the kidneys are not producing a hormone called erythropoietin .<=50 that is in"ol"ed in the production of 9:C. 9:C carry o8ygen to cells and when the blood is deficient in 9:C 5rgans lose energy due to the lack of o8ygen. Hyperkalemia! >igh potassium le"els in the blood. This can occur when the kidney fails to filter potassium from the blood causing a dangerously high amount of buildup. =otassium&s role in the body is to control muscle and ner"e functioning. If there is a buildup in the blood the C;% patient will e8perience irregular heartbeats or heart failure. >igh potassium food sources should be limited. Oliguria! ?ow urinary output of less than +@@m?#day. This small amount of output is not sufficient in eliminate all of the daily waste. This is a sign that the kidneys are not filtering waste products and e8creting urine efficiently. %ialysis patients will ha"e oliguria because treatments may only occur three times per week. 5liguria will cause fluid retention and edema. The normal amount of urine output is about $'7 +@ ounces per day. Anuria: a passage of less than +@ m? of urinary output per day due to the kidneys& inability filter and e8crete waste from the body. <dema shortness of breath and weight gain can be caused by anuria. A patient who has been on hemodialysis for si8 months will not ha"e urinary output. roteinuria: An abnormal amount of protein in the urine that results from the kidneys not filtering the blood properly. Hyperphosphatemia! The buildup of phosphate in the blood due to the kidneys inability to remo"e#e8crete e8cess amounts. Symptoms include! an8iety fatigue breathing difficulties sores and itching bone pain bone weakness and decreased mobility. %ialysis patients are often re*uired to take phosphate binders with their food to decrease absorption. Aoods rich in phosphorus include! meats dairy nuts dried beans sodas canned and processed foods. Acidosis! The build7 up of acid in the blood which causes the blood p> to drop below 2.$+. The kidneys function in acid# base balance by e8creting acid in the urine and regulating the bicarbonate concentration in the blood. )etabolic acidosis can result when this acid# base balance is disrupted with a decrease in bicarbonate or increased acid. Symptoms include! increased rate and depth of breathing confusion and headaches. Sei3ures coma and death are e8treme outcomes. A diet high in alkaline foods like fruits and "egetables and low in meat decreases the risk of acidosis. Anephric! ?ack of functioning kidneys. This occurs in the last stage of chronic kidney disease .C;%0. Bithout functioning kidneys waste products and fluid builds up to unsustainable le"els in the body. Aluid build7 up causes fluid retention in the tissues and bloodstream. Bithout functioning kidneys electrolytes including magnesium sodium and potassium become unbalanced. (nhealthy le"els of electrolytes result in fluid retention irregular heart rhythm and an abnormal mental state. >ormone imbalances also result from this condition affecting bone health blood pressure and 9:C formation. These patients re*uire dialysis in order to li"e. !dema! Swelling that is caused by fluid retention which may result from the kidneys inability to e8crete e8cess fluid. <dema often occurs in the legs and feet. <dema puts a lot of strain on the body and increases the person&s risk for CC%. Symptoms include! weight gain shortness of breath discomfort and high blood pressure. Urine output! the "olume of urine output correlates with renal functioning. Bell7functioning kidneys filter 2@@ *uarts of blood and produce $'7 +@ o3. of urine daily. A decrease in urine output could be indicati"e of A9A where many patients can only create 11 ounces of urine per day. ?ow urine output increases fluid retention resulting in swelling of the legs feet and ankles. eritoneum: is the serous semi7permeable membrane that forms the lining of the abdominal ca"ity. %uring peritoneal dialysis a catheter is inserted into this membrane and the peritoneum holds dialysate which acts in place of the kidneys to filter to8ins and fluid from the blood. Dialysate: is a cleansing fluid containing a high7de8trose concentration that is inserted "ia a =% catheter into the peritoneum during peritoneal dialysis. /lucose in the dialysate pulls to8ins and fluids across the semipermeable membrane and pre"ents it from passing back through the peritoneum. %iffusion carries waste products from the blood through the peritoneal membrane and into the dialysateD water mo"es "ia osmosis. This fluid is then remo"ed and replaced with fresh dialysate. This process is called an e8change and can occur manually or through a cycler machine. olyuria! <8cessi"e urination commonly seen in uncontrolled diabetes. (sually the kidneys filter glucose from the blood and then reabsorb them into the bloodstream for energy. In uncontrolled diabetes a high amount of glucose in the blood will cause an increased amount of glucose lost in the urine. This causes higher urinary output because glucose is an osmolyte which pulls water into the urine. An e8cessi"e "olume of urination for an adult is more than 2.+ liters of urine daily. "enal osteodystrophy! is a bone disease linked to kidney failure. This condition affects up to 6@E of dialysis patients. Through this disease bones become thin and weak or malformed. Symptoms can be seen in growing children with kidney disease e"en before they start dialysis. 5lder patients and women who ha"e gone through menopause are at greater risk for this disease. A# $istula: is a surgically created connection of an artery to a "ein. This is the Fgold standardG access for hemodialysis patients because they ha"e low complication rates a lower tendency to clot allows greater blood flow is functions for a longer period of time and are more cost effecti"e. Bhen the fistula heals and matures it pro"ides good blood flow and therefore increases the effecti"eness of hemodialysis. The AC fistula becomes a natural part of the body when it is created. %hunt! An e8ternal de"ice that connects a tube from the artery to the "ein. This shunts the blood from the tube in the artery to the tube in the "ein. This process was used as an early form of dialysis. Hematuria: The presence of red blood cells in the urine which can be caused by inflammation of the glomerulus of the kidneys. Two types of blood in the urine e8ist. :lood that can be seen in the urine is called gross hematuria. :lood that cannot be seen in the urine e8cept when e8amined with a microscope is called microscopic hematuria. )ost people with microscopic hematuria do not ha"e symptoms. =eople with gross hematuria ha"e urine that is pink red or cola7colored due to the presence of red blood cells .9:Cs0. Dry &eight: The lowest weight a dialysis patient can reach safely without e8cess fluid that builds up in between treatments' Accurately assessing dry weight is essential to ensuring that hemodialysis treatment is effecti"e and safe. The FidealG dry weight also known as the Ftarget weightG is the weight clinicians hope a patient will achie"e at the end of each >% session. As the patient reaches pre"ious dry weight through solute remo"al the hemodialysis treatment is reaching optimum results. Bithout accurate dry weight assessment patients could suffer from one of two dangerous outcomes including hyper"olemia or hypo"olemia. >yper"olemia is characteri3ed as a fluid o"erload which can result from the o"erestimation of dry weight. )aHor risks associated with this de"elopment include! hypertension left "entricular hypertrophy and cardio"ascular disease. 5n the other hand if dry weight is set too low hypo"olemia can occur prompting hypotension cramps di33iness ischemia and the loss of residual renal function. 2. (riefly describe each of the following abbreviations often found in the medical records of renal patients: )*+,)- A"$ .Acute "enal $ailure/: sudden decline in renal function with waste retention. A9A occurs when the kidneys fail to function because of circulatory glomerular or tubular deficiencies. A9A can be caused by damage to the internal organs o"er7e8posure to metals sol"ents certain antibiotics and medications kidney infection or obstructions in the urinary tract or renal artery. Illness or surgery increases risk of A9A. The patient may e8perience shock or trauma decreasing blood pressure and blood flow. As a result the kidneys will not recei"e enough o8ygen to filter blood as efficiently. (rine output decreases fluid retention increases and nausea "omiting drowsiness and numbness in the hands and feet may result. Bith A9A patients gradually impro"e although some loss of function may be permanent. !%"D .!nd %tage "enal Disease/: the complete or almost complete failure of kidney function as e8emplified by an e/A9 of less than 1+. %ialysis or a kidney transplant is needed to maintain safe le"els of salt body fluid and waste products throughout the body when kidney function is not sufficient. It is imperati"e for someone suffering from <S9% to maintain fluid balance and remo"e ade*uate amounts of waste to pre"ent bodily harm. Aailure to undergo sufficient dialysis treatment can cause edema and hypertension which result in immense amounts of pressure on the lungs and heart. Symptoms include loss of appetite nausea "omiting headaches fatigue inability to concentrate itching making little to no urine swelling around the eyes and ankles muscles cramps tingling and changes in skin color. H(# .High (iological #alue/: complete proteins that contain all 6 essential amino acids. <ggs meat fish poultry cheese and milk are sources of >:C protein. =atients with C;% who are not on dialysis need to limit their protein intake due to the kidneys inability to sufficiently filter wastes that are produced during protein breakdown. 5n the other hand those that are on dialysis will ha"e an increased protein need due to dialysis filtering e8tra amino acids from the blood. Aor renal patients not on dialysis it is recommended that much of their protein intake is of >:C source for it is essential to maintain ade*uate protein le"els in the body which are necessary to pre"ent protein catabolism and pro"ide essential amino acids needed for repair and maintenance. 0$" .0lomerular $iltration "ate/! is a test used to measure kidney function. This test determines the rate at which blood is filtered by the glomeruli in the kidneys per minute. The e/A9 .estimated /A90 is based on a serum creatinine test where the blood is tested for creatinine le"els. Creatinine in the blood accumulates during decreased kidney function because it is not properly filtered and e8creted into the urine. Age gender race height and weight is also used in calculating e/A9. Although kidney function declines naturally with age kidney function declines drastically with C;%. 9esults! Stage 1 .Normal or minimal kidney damage0! /A9! I 6@712@ m?#min# 1.2$ m2 Stage 2! /A9! 1@7 46 m?#min# 1.2$ m2 Stage $! /A9! $@7+6 m?#min# 1.2$ m2 Stage '! /A9! 1+726 m?#min# 1.2$ m2 Stage + .;idney Aailure0! /A9! J1+ m?#min# 1.2$ m2 UO .Urinary Output/: a marker of acute kidney inHury but also to guide fluid resuscitation in critically ill patients. A decrease of urine output may be associated to a decrease of glomerular filtration rate due to decrease of renal blood flow or renal perfusion pressure. 1"$ .1hronic "enal $ailure/: the slow gradual loss of kidney function. An e/A9 of J1@ m?#min# 1.2$ m 2 is indicati"e of kidney damage. Causes include! lupus ATS chronic >TN prolonged urinary obstruction nephrotic syndrome =;% %) and cystinosis. Some forms of C9A can be slowed down or controlled but this condition is not curable. H23 .Hypertension/! characteri3ed by a sustained systolic and diastolic blood pressure of K1'@#6@. >ypertension nearly doubles the risk for heart attack stroke and heart failure. >igh blood pressure causes damage to blood "essels including those in the kidneys. In this case the kidneys will not be as effecti"e in filtering the blood resulting in e"en higher blood pressure. >TN is one of the leading causes of <S9%. Beight maintenance .or loss if o"erweight0 e8ercise and a diet high in fruits "egetables whole grains and low7 fat dairy can help control >TN. Sodium should be limited. Symptoms of hypertension include! fre*uent headaches impaired "ision S5: nose bleeds chest pain di33iness failing memory snoring and /I distress. U"" .Urea "eduction "atio0! a blood test that determines effecti"eness of dialysis by comparing the amount of urea reduction before and after dialysis. The patient is considered well dialy3ed if serum urea reduction is 1+E or more during dialysis. 2H .arathyroid Hormone0! a protein hormone that is important in bone growth secreted by the parathyroid gland. =T> is in"ol"ed in the regulation of calcium phosphorous and Citamin % in the blood. The =T> stimulates calcium resorption from the bone when blood calcium le"els are too low. If the kidneys cannot filter phosphorous in the blood =T> le"els rise causing e8cess calcium resorption into the blood. %iseased kidneys also cannot acti"ate "itamin % lea"ing intestines unable to absorb calcium. The bones weaken when there is not enough calcium and can result in pain fractures and osteoporosis. 4D3 .4ntradialytic parenteral nutrition/: is a supplemental form of parenteral nutrition prescribed to pro"ide malnourished hemodialysis patients with the protein calories and other nutrients that their body needs for strength and energy. !O .!rythropoietin/: is a hormone that controls red blood cell production. It is a cytokine .protein signaling molecule0 for erythrocyte .red blood cell0 precursors in the bone marrow. This hormone is synthesi3ed in the kidneys. 5t6#: a number used to *uantify hemodialysis and peritoneal dialysis treatment ade*uacy. An ideal measurement is 1.' or more per >% treatment or 2 or more for more =% treatment. ;L dialy3er clearance tL time on dialysis CL "olume of body water in a gi"en patient 7' Describe the significance of each of the following laboratory tests often ordered for renal patients and list the normal ranges: )) 8ab 2est 3ormal "ange %ignificance (U3 .blood urea nitrogen/ 27 2@ mg#d?
This test is primarily used along with the creatinine test to e"aluate kidney function in a wide range of circumstances to help diagnose kidney disease and to monitor people with acute or chronic kidney dysfunction or failure. As kidney function decreases the :(N will increase. /i"en as part of a :)= or C)=. 1reatinine @.17 1.+ mg#d? /i"en with C)= or :)= along with :(N tests to monitor kidney function. )easures amount of creatinine present in the blood or urine. Baste product from muscle breakdown of creatinine that is e8creted by the kidneys. Increased creatinine le"els in the blood suggest diseases or conditions that affect kidney function. These can include! damage to or swelling of blood "essels in the kidneys .glomerulonephritis0 bacterial infection of the kidneys .pyelonephritis0 death of cells in the kidneysM small tubes .acute tubular necrosis0 prostate disease kidney stone or other causes of urinary tract obstruction reduced blood flow to the kidney due to shock dehydration congesti"e heart failure atherosclerosis or complications of diabetes. otassium $.+7+.+ mg#d? (sed to detect concentrations that are too high .hyperkalemia0 or too low .hypokalemia0. The most common cause of hyperkalemia is kidney disease. )any drugs can decrease potassium e8cretion and result in this condition. >ypokalemia can occur if someone has diarrhea and "omiting or if is sweating e8cessi"ely. =otassium can be lost through the kidneys in urineD in rare cases potassium may be low because someone is not getting enough in their diet. 1alcium 4.'71@.2 mg#d? :lood calcium le"els do not indicate le"els of bone calcium but rather serum calcium le"els. Calcium absorption use and e8cretion are regulated and stabili3ed by a feedback loop in"ol"ing =T> and "itamin %. Conditions and diseases that disrupt calcium regulation can cause inappropriate acute or chronic ele"ations or decreases in calcium and lead to symptoms of hypercalcemia or hypocalcemia. A blood calcium test is ordered to screen for diagnose and monitor a range of conditions relating to the bones heart ner"es kidneys and teeth. This test is gi"en as part of a :)= or C)=. hosphorous $.+7+.+ mg#d? =hosphorous if not filtered properly from the kidneys increases calcium resorption from the bone. The patient may need phosphate binders and ade*uate dialysis to control this range. Albumin $.'7+.' g#d? %ialysis increases protein catabolism which could cause a decrease in albumin le"els since it is a protein. This causes fluid to leak from blood "essels into the tissue causing edema. It is difficult for dialysis to remo"e the fluid from the tissue. ?ow albumin le"els can reflect diseases in which the kidneys cannot pre"ent albumin from leaking from the blood into the urine and being lost. In this case the amount of albumin or protein in the urine also may be measured. Hemoglobin K11 g#d? <"aluates hemoglobin content in blood. >emoglobin is found in 9:Cs which are produced by <=5. A decrease in hemoglobin content could indicate that <=5 is not being synthesi3ed properly a sign that there is a kidney malfunction. Hematocrit $27 '6E )easures the E of 9:Cs in the blood. A low E could indicate se"ere and chronic kidney diseases due to decreased production of erythropoietin a hormone produced by the kidneys that stimulates 9:C production by the bone marrow. 9 sat 1+7+@E .males0D 127'+E females )easures the amount of iron that is bound to transferrin for transportation. This percentage decreases in the presence of anemia which is common in renal patients due to the inability of the kidneys to produce <=5 .a hormone produced by the kidneys that stimulates 9:C production by the bone marrow0. $erritin 127 $@@ ng#m? .males0D 1271+@ ng#m? females If the kidneys are not producing <=5 9:C production decreases. Aerritin is the storage form of iron and low "alues indicate a low production of 9:C. Aerritin is an acute phase reactant and can be increased in people with inflammation li"er disease chronic infection autoimmune disorders and some types of cancer. Aerritin is not typically used to detect or monitor these conditions. 2ransthyretin .pre, albumin/ K4 mg#d? This test measures the amount of prealbumin in the blood. If the kidneys are not breaking down protein properly this could reflect a high transthyretin le"el. %ue to its short half7life the test reflects only the current nutritional status of the patient. (U3: creatinine ratio 1@!1 7 2@!1 %etermines the cause of increased concentrations of :(N and creatinine. If the ratio is high it may be due to a decreased blood flow to the kidneys increased protein or /I bleeding. A decreased ratio is associated with li"er disease. +' 1onvert the following: :- m!; 3a to <<mg 3a mgL m<* 8 atomic weight# "alence mg NaL 1@ 8 2$#1 L 1$4@mg Na :- m!; 5 to <<mg 5 mgL m<* 8 atomic weight# "alence mg ; L 1@ 8 $6#1 L 2$'@mg ; => m!; 3a to <<mg 3a mgL m<* 8 atomic weight# "alence mg NaL 4+ 8 2$#1 L 16++mg Na => m!; 5 to <<mg 5' mgL m<* 8 atomic weight# "alence mg ;L 4+ 8 $6#1 L $$1+mg ; >' (riefly describe the major functions and parts of the kidney' )? )ost indi"iduals ha"e two kidneys about the si3e of a fist located on either side of the lower back. <ach kidney contains up to a million functioning units called nephrons. A nephron consists of a filtering unit of tiny blood "essels called a glomerulus attached to a tubule. Bhen blood enters the glomerulus it is filtered and the remaining fluid then passes along the tubule. In the tubule chemicals and water are either added to or remo"ed from the filtered fluid according to the bodyMs immediate needs. The final product of kidney function is urine which we e8crete.
The kidneys filter and return about 2@@ *uarts of fluid daily to the bloodstream. About two *uarts are remo"ed from the body in the form of urine and about 164 *uarts are reco"ered. The urine we e8crete has been stored in the bladder for anywhere from 1 to 4 hours. The kidney is responsible for the following functions! &aste e@cretion7 9emo"al of the waste products of metabolism. .(rea uric acid creatinine0 Acid,base balance7 ;idneys regulate p> by eliminating e8cess > N O P and controlling composition of the blood. :lood plasma p> is maintained by the kidney at a neutral p> of 2.'. (rine is either acidic or alkaline. ; N and phosphate re*uire renal control as well. (lood ressure 1ontrol7 =lay an important role in blood pressure management through the renin7angiotensin system. Bhen blood pressure is too low renin is secreted. 9enin acts on the blood protein angiotensinogen con"erting it to angiotensin I. Angiotensin I is then con"erted to angiotensin II which stimulates the secretion of aldosterone by the adrenal corte8. Aldosterone stimulates increased reabsorption of Na N from the kidney tubules which causes an increase in the "olume of water that is reabsorbed from the tubule. This increase in water reabsorption increases the "olume of blood which ultimately raises the blood pressure. lasma volume and osmolality, A rise or drop in osmotic pressure due to too little or too much water is detected by the hypothalamus which notifies the pituitary gland. A lack of water causes the posterior pituitary gland to secrete antidiuretic hormone which results in water reabsorption and an increase in urine concentration. Tissue fluid concentration then returns to normal. Hormone secretion7 <=5 is secreted for 9:C production. (rodilatin is a natriuretic peptide that mediates natriuresis. Cit %$ is con"erted from its inacti"e form .%20 to its acti"e form 12+7dihydro8y"itamin % in the pro8imal tubule.
1arnitine synthesis7 Carnitine carries AAs to mitochondria for muscle fuel. ?ysine methionine "it C iron "it :1 and niacin are needed to produce carnitine. 0lucose homeostasis7 9ole in gluconeogenesis and glucose counterregulation. rostaglandin !?7 )aHor renal cycloo8ygenase metabolite of arachidonic acid that impacts renal hemodynamics and salt and water e8cretion. :' Describe each of the following types of dialysis' 8ist the advantages and disadvantages of each type' eritoneal dialysis .D0 is a treatment that remo"es wastes chemicals and additional water from the body through the lining of the abdomen to filter blood. A dialysis solution consisting of minerals and de8trose dissol"ed in water tra"els through a catheter into the abdomen. The mi8ture is responsible for pulling waste chemicals and e8cess water from the blood "essels of the peritoneal membrane into the solution. Se"eral hours later the used solution is remo"ed from the abdomen taking the wastes from blood with it. The cycle is then repeated with the abdomen being refilled with fresh dialysis solution. The cyclic process of draining and refilling of the dialysis fluid is called an e8change. This kind of treatment does re*uire a surgically placed catheter into the abdomen or chest of the patient. This treatment option re*uires indi"iduals to ha"e a strong internal locus of control for it is their responsibility to ensure that treatments are performed supplies are a"ailable and sterile procedures are followed. eritoneal dialysis
1ontinuous Ambulatory eritoneal Dialysis .1AD/ %ialysate is placed into the peritoneal ca"ity .membrane inside of the abdomen0. %ialysate pulls to8ins and fluid across the membrane of the peritoneum. The dialysate solution is drained and replaced e"ery $7' hours manually. This process does not re*uire a machine. Ad"antages! can be performed at home or Fone the goG easier to tra"el work or attend school fewer dietary restrictions no weekly appointments necessary no tra"el time#money needed to attend appointments. %isad"antages! burden on time to manually change dialysate e"ery few hours may cause weight gain and difficulties in controlling glucose risk of infection may not be an option if the patient has had pre"ious operations on the abdomen must keep up with all supplies and keep process sterile must ha"e some e8plicit training. 1ontinuous 1yclical eritoneal Dialysis .11D/ =eritoneal dialysis occurs o"er 47 1@ hours while the patient is hooked up to a machine called a cycler which automatically e8changes the dialysate. =atients typically undergo this process while they are sleeping and the %ialysate is left in the abdomen during the day. Ad"antages! allow dialysis to occur while the patient is sleeping patient is able to li"e normal life during the day can be done at home .sa"ing money and time on tra"el0 fewer dietary restrictions easily becomes routine %isad"antages! may be uncomfortable to use while sleeping may cause weight gain and difficulties in controlling glucose may not be an option if the patient has had pre"ious operations on the abdomen increased risk of infection must be hooked up to machine for 471@ hours at the time must keep up with all supplies and keep process sterile must ha"e some e8plicit training. 3octurnal 4ntermittent eritoneal Dialysis .4D/ A catheter is placed inside and outside of the body for the dialysate to flow into and out of the abdominal ca"ity. =% occurs as the patient is sleeping much like what is characteri3ed in CC=% e8cept that the patientMs abdominal ca"ity is left empty during the day. Ad"antages! allow dialysis to occur while the patient is sleeping patient is able to li"e normal life during the day can be done at home .sa"ing money and time on tra"el0 fewer dietary restrictions easily becomes routine %isad"antages! may be uncomfortable to use while sleeping may not be an option if the patient has had pre"ious operations on the abdomen increased risk of infection must be hooked up to machine for 471@ hours at the time must keep up with all supplies and keep process sterile must ha"e some e8plicit training. Hemodialysis .HD/ cleanses and filters blood using a machine to momentarily rid your body of harmful wastes e8tra salt and additional water. >emodialysis assists in controlling blood pressure and helps regulate important chemicals including! potassium sodium calcium and bicarbonate. %uring hemodialysis blood tra"els through tubes into a dialy3er which is a special filter that functions as an artificial kidney. Then the prepared blood flows back into the body. The hemodialysis machine monitors blood flow and remo"es wastes from the dialy3er. Treatment is usually done three times a week and lasts from $ to + hours each. This kind of treatment re*uires immediate access to the blood stream. The two most common types of access are fistulas and grafts. >emodialysis is typically completed in a dialysis center by speciali3ed technicians that are closely managed by nurses and doctors. In ha"ing in7center treatment the burden of ha"ing to plan each treatment is eliminated for each patient is gi"en a fi8ed time slot three times per week on )onday7Bednesday7Ariday or Tuesday7Thursday7 Saturday. This permits the patient to e8hibit an e8ternal locus of control for the responsibility of the treatment e8cept for transportation to the clinic falls into the hands of the dialysis center&s employees. Hemodialysis Ad"antages! ?ess responsibility placed on the patient no need for e8tensi"e training and lower risk of infections %isad"antages! more costly more dietary restrictions tra"eling to and from appointments costs time and money ha"e to plan life around appointments. :' $or the following stages6types and6or treatments of renal disease* define* e@plain etiology and give the nutritional recommendations .include calorie* protein* sodium* fluid* potassium and phosphorous/: )? Acute 0lomerulonephritis: sudden inflammation of the glomeruli in the kidneys. These tiny filters remo"e e8cess fluid electrolytes and waste from your bloodstream and pass them into your urine. Typically occurs due to damage of the glomeruli form infection lupus or kidney disease. Symptoms include hematuria and hypertension. 1hronic 0lomerulonephritis: silent gradual inflammation of the glomeruli in the kidneys* often leading to complete kidney failure. This condition can be hereditary caused by changes in the immune system or de"elop after one acute attack of the disease. 3ephritic syndrome! inflammation of the capillary loops of the glomerulus. This often leads to hematuria and can lead to complete kidney failure. >ypertension mild loss of renal function IgA nephropathy and hereditary nephritis are associated with nephritic syndrome. Acute "enal $ailure .A"$/: sudden drop in kidney functioning resulting in a build7up of wastes in the blood. A9A can be caused by damage to internal organs o"er7 e8posure to metals sol"ents certain antibiotics and medications kidney infection or obstructions in the urinary tract or renal artery. Illness or surgery increases risk of A9A. The patient may e8perience shock or trauma decreasing blood pressure and blood flow. As a result the kidneys will not recei"e enough o8ygen to filter blood as efficiently. (rine output decreases fluid retention increases and nausea "omiting drowsiness and numbness in the hands and feet may result. !nd %tage "enal Disease: last stage of C;%. In"ol"es the complete or almost complete failure of kidney function as e8emplified by an e/A9 of less than 1+. %ialysis or a kidney transplant is needed to maintain safe le"els of salt body fluid and waste products throughout the body when kidney function is not sufficient. It is imperati"e for someone suffering from <S9% to maintain fluid balance and remo"e ade*uate amounts of waste to pre"ent bodily harm. The <S9% patient cannot sur"i"e without dialysis or a kidney transplant. . 1hronic "enal $ailure: progressi"e loss in kidney function. %iabetes and hypertension are the leading risk factors for C;%. 1alories rotein 3a $luid 5 hosphorous Acute /lomerulonep hritis .%iet restricted to treat underlying disease0 $@7 '@kcal# kg I:B @.1 g#kg kilogram I:B adHusted depending on the glomerular filtration rate plus gram7for7 gram replacement of urinary protein losses Cariable At liberty Cariable potassium restriction in hyperkalemia .potential symptom0 @.47 1.2g# day or 47 12mg#kg I:B Chronic /lomerulonep hritis $@7 '@kcal# kg I:B @.17@.4g# kg I:B 27$g#day At liberty Cariable @.47 1.2g# day or 47 12mg#kg I:B Nephritic Syndrome $@7 $+kcal# kg I:B @.171.@g# kg I:B Cariable 2@@@7 $@@@mg# day At liberty CariableD may need to increase to co"er for losses from medication @.47 1.2g# day or 47 12mg#kg I:B Acute 9enal Aailure $@7 '@ kcal#kg dry :B# day @.47 1 g#kg I:B Increase as /A9 returns to normal 1@E >:C 2@7 '@ m<*#day .'1@7 62@ mg0 9eplace output from pre"ious day plus +@@ m? $@7 +@ m<*# day .112@7 16+@mg0 Cariable <nd Stage 9enal %isease .no dialysis0 .with transplant0 '71 weeks after! $@7 $+ kcal# kg I:B K1 weeks! achie"e I:B '71 weeks after! 1.$7 2g#kg I:B K1 weeks! 1g#kg :B 2@@@7 $@@@mg# day At liberty Cariable At liberty but calcium must be 12@@mg#day <nd Stage 9enal %isease .peritoneal dialysis0 $@7$+ kcal#kg I:B 1.271.+g# kg I:B +@E from >:C sources 2@@@7 '@@@ mg# day )inimu m 2@@@ m?## day urine output $@@@7 '@@@ mg#day @.47 1.2g# day <nd Stage 9enal %isease .hemodialysis0 $+ kcal# kg I:B 1.2g# kg I:B +@E from >:C sources 2@@@7 $@@@ mg# day 2+@7 1@@@ m?# day urine output 2@@@7 $@@@ mg#day or '@ mg#kg I:B @.47 1.2g# day or J12mg#kg I:B Chronic 9enal Aailure $+ kcal# kg I:B @.1mg#kg# day +@71@E >:C Cariable At liberty CariableD may need to increase to co"er for losses from diuretics @.47 1.2g# day or 47 12mg#kg I:B =' !@plain the rationale for the restriction and the symptoms of e@cess for each of the above nutrient alterations' )? 1alories6!nergy: intake should be ade*uate to spare protein for tissue protein synthesis and to pre"ent its metabolism for energy. rotein: reduction in protein intake may decrease proteinuria without ad"ersely affecting serum albumin. >igh amounts of protein is belie"ed to increase glomerular pressure leading to accelerated loss of renal function. If dialysis treatment is started protein intake must be increased accordingly for this treatment is a drain on body protein. 3a: >ealthy kidneys filter and e8crete e8tra sodium through the urine. Bhen renal conditions occur the body is not able to get rid of sodium and it can build up. This e8tra sodium can lead to e8tra fluid buildup in the body resulting in swelling increased weight gains ele"ated blood pressure and possibly difficulty with breathing .shortness of breath0. Increased sodium in the diet can also lead to increased thirst which can lead to further fluid retention in renal patients. $luid: /oing o"er the recommended fluid allowance can lead to fluid build7up in the body. This build up causes swelling and increases blood pressure. Too much fluid can build up in the lungs making it difficult to breathe. 5! too much potassium can build up when the kidneys no longer function properly. %angerous heart rhythms may result which can lead to death. hosphorous: if the kidneys cannot filter phosphorous in the blood =T> le"els rise causing e8cess calcium resorption into the blood. The bones weaken when there is not enough calcium and can result in pain fractures and osteoporosis. A' 4dentify the role of the following medications in the management of renal disease: hosphate (inders .Oscal* 2ums* $osrenol* hos8o* "enagel* "envela* %ensipar/: A build7up of phosphate occurs as kidneys lose the ability to filter phosphate from the blood. This build7up causes the release of =T> stimulating calcium resorption from the bone into the blood. This is a condition called secondary hyperparathyroidism. 5scal Tums Aosrenol =hos?o 9en"ela and 9enagel are medicines that bind to phosphate from food sources pre"enting the body from absorbing phosphate and allowing it to be remo"ed from the body. This pre"ents the release of =T> to stimulate calcium resorption from the bone. 5scal Tums and =hos?o contain calcium further enhancing calcium absorption in the body. Sensipar does not bind to phosphate but is used to treat secondary hyperparathyroidism by signaling the body to produce less =T>. #itamin D %upplements ."ocatrol* 1alcije@* Hectoral* Bemplar/: Acti"e "itamin % maintains normal =T> le"els which may be warranted in renal patients. %iseased kidneys cannot acti"ate "itamin % lea"ing intestines unable to absorb calcium. Although dairy contains "itamin % it must be limited due to the phosphorous content in these foods. =atients who are not undergoing dialysis may need "itamin % in the form of oral supplements such as 9ocaltrol CalciHe8 >ectoral and Qemplar. Qemplar is commonly administered intra"enously in dialysis patients. 4ron %upplementation .3iferr@ )>-* #enofer* $errlecit/: )any renal patients are anemic because the kidneys lose the ability to synthesi3e the hormone <=5 that stimulates production of 9:Cs. <=5 may be administrated to the patient and re*uires the presence of iron in order to produce 9:Cs. >owe"er much of the body&s iron is lost through hemodialysis and must be replaced with iron supplementation. Niferr8 is a polysaccharide7 iron comple8 that may be gi"en orally to renal patients. :ecause oral iron supplements can cause nausea or stomach aches iron that is administered intra"enously such is commonly preferred. Aerrlecit and Cenofer are iron sucrose inHections that come as solutions to be inHected intra"enously. It works by replenishing iron stores so that the body can make more red blood cells 2ransplant Acceptance Cedicines .3eoral* 1yclosporine* 4muran* 1ell1ept* rednisone/: =atients who undergo a kidney transplant may e8perience an autoimmune response causing the body to reHect the transplant. To pre"ent an immune response kidney transplant patients are often gi"en medication such as Neoral Cyclosporine Imuran CellCept or the corticosteroid =rednisone that decreases acti"ity of the immune system. $luid and !lectrolyte (alance .5aye@alate* 8asi@/: As the kidneys lose the ability to remo"e e8cess fluid in the body edema may result. %iuretics such as ?asi8 help the kidneys take up unneeded water and salt from the body and e8crete it through the urine reducing edema and fluid retention. If the kidneys fail to filter potassium from the blood hyperkalemia can result. This is characteri3ed by a dangerously high amount of potassium in the blood and can cause irregular heartbeat slow pulse and heart failure. ;aye8alate controls high amounts of potassium in the body if kidneys ha"e not properly filtered it from the blood. (, #itamin %upplementation .3ephro,#ite/: Bater7soluble "itamins are flushed out with dialysis and must be replenished daily. ;idney diets are "ery restricted and may not pro"ide ade*uate amounts of the "itamins. Nephro7 Cite may be gi"en as oral "itamin : supplementation to make up for this loss. (lood %ugar 1ontrol .%orbitol/: %iabetes is a common co7morbidity in renal patients. Sugar alcohols such as sorbitol may be recommended for diabetics in order to maintain blood sugar. "eferences: 1. National ;idney and (rologic %iseases Information Clearinghouse. Treatment )ethods for ;idney Aailure! =eritoneal %ialysis. A"ailable at! http!##kidney.niddk.nih.go"#;(%iseases#pubs#peritoneal#inde8.asp8,condition. Accessed Ruly 12 2@1'.
2. )c)ahon : =helan % )urray = et al. 5liguria and Anuria .acute kidney inHury part I0. PACT. 5ctober 2@1@! 17 2'. A"ailable at! http!##pact.esicm.org#media#5liguriaE2@$@E2@5ctE2@2@1@E2@final.pdf. Accessed Ruly 12 2@1'. $. Collins A. C;% and =ublic >ealth Initiati"es. A"ailable at! http!##www.kdigo.org#ControConf#plenary E2@session#=ublicE2@=olicyE2@Initiati"esE2@7AllanE2@Collins.pdf. Accessed! Ruly 1$ 2@1'.
'. Bilkens ; RuneHa C Shanaman <. )edical Nutrition Therapy for 9enal %isorders. In ;rause&s Aood and the Nutrition Care =rocess. 1$th ed. St. ?ouis )5! <l Se"ier SaundersD 2@12!26674$1. +. National Institute of >ealth. )edline=lus. A"ailable at! http!##www.nlm.nih.go"#medlineplus#medlineplus.html. Accessed Ruly 11 2@1'. 1. ;urt3 I ;raunt RA. )etabolic acidosis of C;%! diagnosis clinical characteristics and treatment. Am J Kidney Disease. Rune 2@@+D '+ .10! 624766$. A"ailable at! http!##www.ncbi.nlm.nih.go"#pubmed#1+6+2121. Accessed Ruly 12 2@1'. 2. San )iguel S. >emodialysis dry weight assessment! A literature re"iew. 9en Soc Aust R 1.10 1672'D 2@@6. A"ailable at! http!##www.renalsociety.org#9SAR#Hournal#mar1@#San)iguel.pdf. Accessed! Rune 26 2@1'. 4. <scott7Stump S. 9enal %isorders. In Nutrition and %iagnosis79elated Care. 2th ed. :altimore )%! ?ippincott Billiams S BilkinsD2@12!4+67441. 6. :arnard N% Beissinger 9 Raster :R ;ahan S ?anou AR. <nd7Stage 9enal %isease! Nutritional Considerations. Nutrition )%. A"ailable at! http!##www.nutritionmd.org#health-care-pro"iders#renal#renal-nutrition.html. Accessed! Rune 26 2@1'. 1@. ?egrand ). =ayen %. (nderstanding (rine 5utput in Critically Ill =atients. Ann Intensive Care. 2@11D1!1$. 17$4. A"ailable at! http!##www.ncbi.nlm.nih.go"#pmc#articles#=)C$22''21#. Accessed! Ruly 11 2@1'. 11. ?ab Test 5nline. A"ailable at! http!##labtestsonline.org#understanding#analytes#glucose#tab#test. Accessed! Rune 24 2@1'.
12. <scott7Stump S. 9enal %isorders. >uman ;idney Aunctions. In! <scott7Stump S ed. Nutrition and Diagnosis- Related Care. 2 th ed. :altimore )%! ?ippincott Billiams and BilkinsD 2@12!41@7461.