2016 Post Graduate Course

Beating the Challenges:

Optimizing the quality of life of Kidney Patients
 Battling Protein and Energy Wasting
in End Stage Renal Disease
AVERAGE DAILY PROTEIN INTAKE: 1.0 gm/kg/day
Recommended protein intake: 1.2gm/kg/day FOR HEMODIALYSIS patients
1.2-1.3gm/kg/day FOR PD patients

DIETARY ENERGY REQUIREMENTS IN ESRD:

35-38 kcal/kg/day for both HD and PD pt. with sedentary to light physical
activity

Incidence of PEW in the ESRD population ranges from 40-70%

EARLY SIGNS of PEW

- Low serum levels (especially albumin levels <3.8mg/dl)
- Reduced Muscle mass (decreased in mid-arm circumference)
- Reduced Body mass
 Factors contributing to malnutrition in CKD
patients
- Patients unable to change protein-restricted diet pre-
HD to a protein rich diet with initiation of HD
- Increased in catabolism during HD procedure causes
losses of up to 8-10gms protein per HD sessions
- Patient not eating meals due to time spent on HD
- Low KT/V or under dialysis
- Inactivity
 Treatment of PEW
- Provide adequate calories
- Provide adequate proteins
- Exercise
- Anabolic agents
 Justifications for not allowing eating during
HD procedure
- Postprandial hypotension
- Aspiration risk
- Infection control and hygiene
- Dialysis staff burden
- Diabetes and phosphorus control
 Importance of Residual Renal Function in
ESRD patients
It refers to THE ABILITY OF KIDNEYS TO ELIMINATE EXCESS WATER AND
UREMIC TOXINS

Benefits of Preserving RRF:

- Long term survival
- Increased in Sodium and Potassium clearance
- Higher serum hemoglobin levels
- Better nutritional status and decreased inflammatory markers

The Loss of RRF appears to occur more rapidly in HEMODIALYSIS as to

compared with PD
 Potential reasons why HD result in loss of
RRF:
- Intermittent Hypotension (rapid fluid loss at short durations)
- More frequent HD sessions
- HD Dialysate activations of nephrotoxic inflammatory mediators
- Non- bio compatible membranes

There are studies involving that the use of newer HD techniques that can
reduce the loss of RRF such as:
- Ultra pure water
- Bicarbonate buffer
- Use of high flux polysulphone membranes
- Avoiding intradialytic hypotension during treatments
Factors to consider in Preventing Loss of RRF
- The use of loop diuretics ( they decrease the need for volume removal with
either form of dialysis)
- The use of Angiotensin converting enzyme inhibitors (ACE inhibitors)
- Aminoglycosides
- Other factors: ( Cardiac dse., High BUA levels, Diabetes, Hypertension)

RRF may decrease rapidly once patients are started on thrice/wk HD

The dose of hemodialysis may be reduced in patients with significant residual
kidney function, provided that KT is measured periodically.
Base on KDOQI guidelines recommended that, for HD schedules of thrice/wk,
there should be a target standard Kt/v of 2.3 per/wk or minimum of 2.1
per wk.
Role of Renal Nurses in helping Preserve RRF
Perform your Pre-Dialysis Assessment:
- Check HD prescription and prepare to adjust the treatment to follow the
prescribed HD dose

During treatment:
- Assess for hypotension, hypoglycemia, weakness, dizziness. Refer to nephrologist
and document accurately

ESRD patients with Good RRF:

- Adequate or more than adequate urine output
- Hemodynamically stable( good BP, afebrile, Acceptable pulses)
- Has consistently adequate lab values monthly
- No other morbidities (Heart dse., Lung dse.)
 Renal Care in Dialysis Patients with
Cardiovascular Disease
CARDIOVASCULAR DISEASE is an important predictor of mortality in patients with ESRD
Almost about 50% of deaths

Characteristics of Cardiovascular Disease in CKD

Arteries are:
- Increased in wall thickness
- Arterial stiffness
- Arterial calcification

Heart is having:
- Myocardial fibrosis
- Left ventricular disfunction
- Valvular disease
- Dysrhythmia
 Risk Factors:
Hypertension
Diabetes
Smoking
Dyslipidemia
Older age

Coronary Heart Disease in ESRD clinical manifestation:

- Angina
- Exercise-induce chest discomfort
- Dyspnea
- Hypotension
- Sudden cardiac arrest
- Arrhythmia
- Silent myocardial Ischemia
 Nursing care:
Vital signs before, during and after HD
- Note for any hypotension, HPN, Irregular HR, faint pulses and Tachypnea

Assess for any signs of fluid overload

- Weight, rales, edema

Vascular access
Bruit and Thrill, its characteristics

Lab results
-electrolytes, CBC and cholesterol

Assess response to dialysis

- Cramps, nausea, vomiting