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MNT for the CKD Patient Complicated by a Pressure Ulcer

MNT for the CKD Patient Complicated by a Pressure Ulcer. Stephanie Ruel Sodexo/St. Joseph’s Medical Center. Abstract. Controversy of recommendations Studies: Inconclusive or inadequate. Introduction. Anatomy and Physiology Etiology and pathology Medical management

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MNT for the CKD Patient Complicated by a Pressure Ulcer

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  1. MNT for the CKD Patient Complicated by a Pressure Ulcer Stephanie Ruel Sodexo/St. Joseph’s Medical Center

  2. Abstract • Controversy of recommendations • Studies: Inconclusive or inadequate

  3. Introduction • Anatomy and Physiology • Etiology and pathology • Medical management • Medical Nutrition Therapy • The Patient • Conclusion • Future studies • Recommendations

  4. Chronic Kidney Disease

  5. Anatomy & Physiology of the Kidneys Functions • Metabolic waste removal • Electrolyte balance • Fluid balance • Blood pressure control • pH regulation • Plasma volume and osmolality • Glucose homeostasis • Hormone secretion (erythropoietin) • Carnitine synthesis

  6. Anatomy

  7. Anatomy • Afferent arteriole • Glomerulus • Bowmans’s capsule • Proximal tubule • Efferent arteriole • Peritubular capillaries • Renal vein Proximal tubule

  8. Physiology: Electrolyte Balance • Glomerulus: Selective permeability • Ultrafiltrate • Selective resportion and excretion

  9. Physiology: Electrolyte Balance TubuleEfferent arteriole = fluid homeostasis Electrolytes

  10. Physiology: Fluid Balance Two main systems: • Vasopressin • Renin-angiotensin aldosterone system (RAAS)

  11. Vasopressin ↑Blood osmolality or ↓blood pressure Hypothalamus Pituitary gland Kidney ↑blood pressure ↓blood osmolality Vasopressin

  12. Renin-Angiotensin Aldosterone System ↓blood pressure Angiotensinogen Kidney Angiotensin I Angiotensin II Adrenal Aldosterone ↑blood pressure RAAS Renin Lungs

  13. Etiology & Pathology

  14. Etiology& Pathology • Diabetes • Hypertension • Family history • Ethnicity • Autoimmune disease • Infection • Severe dehydration • Acute renal failure (ARF)

  15. Diabetic Nephropathy 44% of new CKD diagnoses caused by diabetes

  16. Diabetic NephropathyGlomerular Anatomy mesangium

  17. Hyperglycemia ↑blood glucose afferent arteriole dilation altered hemodynamic regulation ↑blood flow to glomerulus Hypertrophy damage to podocytes Hyperfiltration and mesangial cells Hyperperfusion altered permeability of glomerulus = PROTEINURIA

  18. Proteinuria Inflammatory mediators Proinflammatory cytokines Oxidative stress Inflammation Fibrosis Glomerulosclerosis Kimmelstiel-Wilson lesions

  19. Hypertension Definition • Hypertension: Systolic >140mm Hg or Diastolic >90mm Hg • Prehypertension: 121/81mm Hg – 139/89mm Hg • Normal blood pressure: <120/80mm Hg

  20. Hypertension • Cause and effect • Blood vessel remodeling • Inflammation • Oxidative stress • Arteriosclerosis

  21. Hyaline Arteriosclerosis • Endothelial lesions in blood vessels caused by buildup of hyaline • Decreased action of smooth muscle cells • Inhibited autoregulation • Ischemic tubulointerstitial injury

  22. Dietary Protein Studies – Impact of protein restriction and blood pressure control on progression of CKD: Modification of Diet in Renal Disease (MDRD) study Northern Italian Cooperative Study Group Multiple studies with smaller sample size; data from mid-1980’s to mid-1990’s INCONCLUSIVE, INSIGNIFICANT

  23. Medical Management

  24. Diagnosis Irreversible loss of kidney function with decreased glomerular filtration rate (GFR) and/or evidence of kidney damage that persists >3 months, progressive in nature.

  25. Laboratory Values

  26. Antihypertensive Therapy • Hypertension: 80-85% • Angiotensin Receptor Blockers (ARBs) • Angiotensin Converting Enzyme (ACE) Inhibitors • Diuretics

  27. Blood Pressure Control/RAAS • Albuminuria >300mg and all diabetic CKD (without hypertension) • ARBs • ACE Inhibitors • Albuminuria <30mg and BP >140/90mm Hg • Target BP <140/90mm Hg • Albuminuria >30mg, BP >130/80mm Hg • Target BP <130/80mm Hg

  28. Improving Cardiovascular Health • Highest risk category for development of cardiovascular disease (CVD) • CVD as cause of death before end-stage renal disease (ESRD) and dialysis • Statins

  29. Glycemic Control • Target HbA1C ~7.0% • Hypoglycemia risk • Medication and lifestyle modification

  30. Overview of Additional Complications • Metabolic Bone Disease • Parathyroid hormone (PTH) • Calcium • Phosphorus • Potassium • Metabolic acidosis • Anemia

  31. Non-pharmacological Interventions • Smoking cessation • Physical activity • Weight management • Functional capacity

  32. New Medication and Treatment • Allopurinol • Avosentan • Mesenchymal stem cells

  33. Renal Replacement Therapy • GFR <10ml/min/1.73m2 • Symptoms: • Electrolyte abnormalities • Acid-base disturbance • Uncontrolled BP and fluid balance • Uremia • Cognitive impairment • Decline in nutritional status • Dialysis

  34. Renal Transplant • Treatment of choice • Earlier decision: • GFR <20ml/min/1.73m2 • Irreversible progression for 6-12 months • Impact: • Reduction of dietary restrictions • Delays or eliminates need for dialysis • Medications to prevent rejection = ↓immunity

  35. Pressure Ulcers

  36. Anatomy & Physiology of the Integumentary System Functions: • Conduct sensory data to the brain via nerve endings located in the skin • Protect the body • Regulate body temperature • Synthesize vitamin D • Store energy and water

  37. Etiology & Pathology

  38. Development of Pressure Ulcers Injury to the skin and/or underlying tissue as a result of pressure, friction, shear, or ischemia Risk factors: Immobility Poor perfusion of blood supply Moisture Anemia Age Nutrition status 10-18%

  39. Inflammasome Activity • Inflammasomes in kertinocytes • Activation of inflammatory cytokines • Danger signals and wound healing • Youth vs. Aging

  40. Stages of Pressure Ulcers

  41. Stages of Pressure Ulcers

  42. Medical Management

  43. Prevention & Care • Risk assessment (Braden Scale score) • Proper positioning and rotation • Support surfaces • Pain management • Infection management • Wound cleansing • Debridement • Dressings • Biophysical agents

  44. Medical Nutrition Therapy(MNT)

  45. Nutrition Care Process Assessment Diagnosis Intervention Monitoring Evaluation

  46. Assessment • Multidisciplinary • Anthropometrics • Medical and social histories • Medications • Analysis of laboratory values

  47. Nutrition Assessment for CKD • Diet and diet history • Nutrition status • Comorbid conditions • Lab values of BUN, potassium, phosphorus, albumin, urinalysis • Assess for education needs

  48. Nutrition Prescription for CKD

  49. MNT for Hypertension and Diabetes Diabetes: glycemic control through consistent-carbohydrate diabetes meal planning Hypertension:

  50. The Role of Dietary Protein • Dietary protein restriction did not significantly slow progression • Dietary restrictions and nutrition status • BP control was more effective in reducing proteinuria than modifications in dietary protein intake

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