Nutrition Final Exam (Week 13)

Kidneys keep ______ and _______ in the circulation. Everything else enters the _______________.
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- aim is to manage complications
- slight increase in protein ingestion to minimize muscle wasting
** too high and will damage kidneys
- adequate energy to prevent weight loss (35kcal per body weight)
- low sodium, to reduce edema
- may require more K
- low saturated and trans FA and refined sugars
- may will use lipid lowering medications because dietary change isn't enough
-supplement vitamin D, iron, and calcium
- involves rapid deterioration of kidney function- in a matter of hours or days
- Symptoms:
*increased nitrogenous wastes
*** leads to uremia
*reduced urine volume
* increased levels of creatinine
*increased electrolytes
* "emias"- phosphotemia, hyperkalemia, hypernatremia
* patients often develop hyperglycemia and hypertriglyceridemia
- causes: reduced blood flow to the kidney, damage to the kidney, obstruction of the ureter/urethra
hypernatremia causesedema: swelling in the hands, face, feet, anklesNutrition therapy for Acute Kidney Injury- enough calories to maintain muscle mass (20-30 kcal/kg/day) - protein levels depend on the state of the kidneys (see other card for details) - add 400-600 ml fluid - constantly monitor blood electrolytes - if nutrient support needed: enteral is preferred; parenteral if severely malnourishedIf body is not in a catabolic state and the patient is not on dialysis ___________ protein ingestion to _____________.- slight increase - 1.0g/kg/dayIf body is in a catabolic state and the patient is on dialysis ___________ protein ingestion to _____________.- double * safe because dialysis removes the nitrogen that would be producedChronic Kidney disease (What is it? How is it evaluated and diagnosed? What causes it?)- what is it?: gradual (years), irreversible deterioration of kidney function - in the early stages patients are able to compensate - late stages: will need transplant/dialysis Diagnosis: - GFR tells team how far the disease has progressed - albuminuria principle sign - Causes: hypertension or diabetes - Symptoms: altered electrolytes - mild acidosis -uremic syndrome - malnutrition - hypertensionHow do aldosterone, PTH, and GRF change in a patient with Chronic Kidney Disease? What are the consequences of these changes?- aldosterone is increased to prevent the rise in K but increases Na reabsorption (so what's the dang use ya know?) - PTH increases, prevents the rise in Phosphorus but leads to decreased plasma calcium, decreasing bone density - GFR decreases, electrolytes increase and hormones are inadequaterenal osteodystrophy- increased PTH - decreased serum calcium - acidosis - decreased vitamin D - bone lossUremic Syndrome: Final Stages of Kidney Disease- kidney hormone release altered: erythropoietin and Vitamin D decreased - altered heart function - neuromuscular disruption - suppressed immune systemdialysis (goals, hemodialysis and peritoneal)Goal: remove excess fluid and wastes from blood hemodialysis: blood circulated through dialyzer peritoneal: infused into peritoneum and then removed (contains glucose for osmotic effect)Nutrition therapy for those with Chronic Kidney Disease: energy requirements (those on dialysis/peritoneal)-30-35 g/kg BW/day - may require oral supplementation - muscle wasting is common during dialysis - long term peritoneal dialysis leads to weight gain; make sure to account for the calories of glucoseNutrition therapy for those with CKD: protein requirements (How does it differ in early dialysis/late?)- early: moderate protein restriction * do this to reduce nitrogen waste produced (uremia) and reduce the risk of hyperphosphatemia - Stage 4: continue reduced protein (0.6-0.75 g/kg BW/day * include plant proteins (less phosphorus and less damage), low protein pasta and breadNutrition therapy for those with CKD: lipid requirements- limit saturated and trans fats, refined sugar and alcohol -unsat fats are groovyNutrition therapy for those with CKD: sodium and fluid requirements (How does it differ once the patient is on dialysis?)- requirements are based on total urine output, BW, and blood pressure - intake should match output - monitor BW and BP to determine if the fluid intake is too high - if on dialysis: control water and Na gain to 2 lbs per day *excess will be removed by dialysisNutrition therapy for those with CKD: potassium requirements (when should it be restricted?)- not an issue until end stage - restrict if the patient is hyperkalemic or has diabetic nephropathy - restrict foods high in potassium (salt substitutes)Nutrition therapy for those with CKD: calcium, vitamin D, and phosphorus requirements (common deficiency?, what supplements are needed?)- if phosphate is high, restrict in order to lower PTH (PTH regulates blood calcium levels) - vitamin D deficiency is common 70-80% of CKD patients, use supplementation -foods high in Ca also high in P - need supplementation of calciumNutrition therapy for those with CKD: vitamin and mineral requirements (what is excreted when on dialysis? What needs to be ingested? What vitamins should be limited? what deficiency is common?)- multivitamin recommended for all - water soluble vitamins and trace minerals are lost on dialysis - Patient will need: *higher B6 and folate * limit vitamin C to 100 mg/day due to risk for kidney stones * vitamin A not recommended, because it is elevated during CKD * iron deficiency is common in those with CKD- use IV supplement (more successful)Nutrition therapy for those with CKD: enteral and parenteral nutrition- Kcal dense with lower protein and electrolytes than standard formula - can combine parenteral formula with hemodialysis treatment - only used in those who are malnourishedKidney transplants: Why do it? Availability? What symptoms do patients have as a consequence?- limited availability, 20% of those with end stage renal disease - restores function allowing a more liberal diet - immunosuppressive therapy required - Symptoms: nausea, diarrhea, vomiting, glucose intolerance, infections, electrolyte imbalanceNutrition therapy for those with CKD: Kidney transplant (diet after transplant? How do people who are on immunosuppressive drugs need to alter their diet?- after transplant return to normal diet - maintain healthy body weight and reduce risk of CVD - immunosuppressive drugs: alter electrolyte balance, may require more calcium (if corticosteroid), limit refined carbs if hyperglycemickidney stonesFactors impacting formation of kidney stones Dehydration (low urine volume) - promote crystallization Change in urine pH - some stones form more in acid while other in alkaline Metabolic abnormalities - impact substances that promote or inhibit crystallization Obstruction - reduced urine flow encourages precipitation Renal disease - calcification of tissues and phosphate accumulationcalcium oxalate kidney stones-common in those with elevated urine Ca (hypercalciuria) - Caused by excessive Ca absorption, impaired Ca reabsorption, elevated PTH or Vit D - Low urinary citrate - citrate normally complexes with calcium - Elevated urinary oxalate (hyperoxaluria) promotes - metabolite binds Ca - Elevated by increased production (metabolism) or absorption (fat malabsorption) - Fats bind to minerals that normally bind to oxalate to reduce absorption ( oxalate absorption)calcium phosphate kidney stonesform in those with hypercalciuria and alkaline urineuric acid kidney stonesacidic urine or urine with excess uric acid (gout - elevated blood uric acid) Diet rich in purines (animal proteins) contribute to high uric acid Acidity promotes crystallization of uric acidcystine kidney stonesresults from cystinuria when tubules unable to absorb amino acid cystinestruvite kidney stonescomposed of magnesium ammonium phosphate (form in alkaline urine)renal colic- pain in the ureter due to stone passing - severe pain, nausea, and vomiting commonurinary tract complication sue to kidney stone- urgency - frequent urination - inability to urinate - can lead to kidney infectionprevention of kidney stones: calcium oxalate- less likely to occur in dilute urine (drink 12 cups of water a day) - reduce calcium and oxalate - adjust levels of sodium and protein *protein: 0.8-1.0g/kg/day * sodium: 2-3g/day - ingest calcium in foods and will bind to oxalate to reduce - limit Vitamin C supplementsprevention of kidney stones: uric acid, cystine and struvitelow purine (protein) diet impossible to maintain - drugs available to treatvasculature of the liver- hepatic portal vein: 3/4 of the blood feeding the liver - hepatic artery: 1/4 of the blood - capillaries in intestines to veins to liver sinusoids to right atriumfunction of the liver- receives nutrients absorbed in the intestines and stores them; releases when necessary - produces bile - contains enzymes that break down drugs - releases proteinsThe liver stores glucose as ___________. It also transports and removes ________ with the help of _____proteins.- glycogen - lipids; lipoproteinsThe liver produces bile from ____________ for _________ digestion and absorption.- cholesterol - lipidWhat proteins does the liver release?- clotting factors - angiotensinogen - complement - albuminFatty liver develops when:there is an imbalance between fat produced/absorbed and fat removedFatty Liver (What is it? What are some of the possible causes?)- Excess fats are packed into VLDL and exported - lipids accumulate in the liver when: * there are defects in metabolism * excessive alcohol consumption * exposure to drugs/toxins - increase risk when patient is insulin resistant - accompanies Type II diabetes, metabolic syndrome and obesity - other risks: protein malnutrition and long term parenteral nutritionConsequences of fatty liver (What happens if not treated? Blood enzymes?)- inflammation and enlargement of the liver - can progress to cirrhosis, liver failure, liver cancer - abnormal blood enzymes: *alanine *aminotransferase ALT *aspartate *aminotransferase AST *Increased blood triglycerides, cholesterol and glucoseTreatment of fatty liver- eliminate causes - discontinue alcohol and lower blood lipids * often due to CVD - reduce weight * activity, glucose controlHepatitis (what is it? causes?)- inflamed or damaged liver tissue - viral infection, excessive alcohol, drugs, fatty liver, autoimmune diseaseHerbal remedies for hepatitischaparral, germander, kava, skullcap, othersHepatitis A (Cause? Details?)ingestion of food/drink contaminated with fecal material Resolves within a few months with no liver damageHepatitis B (Cause? Details?)infected blood or needles, sexual contact, mother to infant at birth While half of world has had Hep B - chronic illness in 10% of casesHepatitis C (Cause? Details?)- infected blood or needles Chronic illnesses in 50% of cases - leading cause of liver diseaseMany people who have ________________ are unaware, due to lack of ___________.hepatitis, symptomssymptoms of hepatitisEnlarged liver, abnormal blood enzymes (ALT & AST), jaundice, fatigue, nausea, anorexiaNutrition therapy for those with HepatitisMost require no dietary change - eat smaller meals if nausea/anorexia Oral supplements are helpful Avoid food/supplement irritate liver (alcohol, herbal, body building, megadose vitamins)_______________ is the late stage of Chronic Liver diseaseCirrhosisMain causes of cirrhosis- alcohol ingestion - Hepatitis C - fatty liver disease - Hep Bportal hypertension- scarring impedes blood flow releasing vasodilators - increased blood volumeGeneral symptoms of cirrhosis of the liver- portal hypertension - collateral vessels - ascites - elevated blood ammonia - malnutrition and wastingCirrhosis: collateral vessels enlarge and weaken due to ____________.increased resistance of the hepatic portalvarices (what is it? what causes it?)- abnormally dilated vein engorged with blood - if in stomach or esophagus, can rupture - cause: reduced clotting factor in liverascites- abdominal fluid - caused by: *leaking sinusoid of the liver * hypertension * decreased albumin * increased sodium and water - symptoms: early satiety and painCirrhosis: elevated blood ammonia- GI bacteria remove NH3 amino acids and the liver converts them to urea - an injured liver is unable to convert NH3 and much NH3 bypasses liver through collateral vesselsHepatic encephalopathyneural dysfunction cause by increased NH3 and altered amino acids * increased of aromatic AA and decreased branchedPeople with cirrhosis often are malnourished. One contributing factor is the decrease of ________ increases nutrient loss. Patients can end up with a fat soluble vitamin deficiency.bileNutrition therapy for those with cirrhosis of the liver (Calories? Protein? Meal size? Sodium? Supplemental nutrition?)- higher calories; 25-40 kcal/kb body weight * account of ascites and possible fat malabsorption - higher protein; 1.0-1.5 g/kg/day * if encephalopathy- spread amount of protein eaten out throughout the day - restrict sodium to control ascites and portal hypertension; 2000mg per day - supplemental nutrition: energy dense formula, central vein for parenteralliver transplant (risk factors? posttransplant concerns?)- only option for liver failure - malnutrition increases risk; better chance at success if fixed before surgery - posttransplant: * immunosuppressant: leads to hypertension, hyperglycemia, hyperlipidemia and osteoporosis * if prednisone is used- will require insulin * increased risk of infection * protein and energy requirements increase after any surgerygallstones (What are they? What causes them? Symptoms? Risk Factors? Dietary treatment?- crystallized bile - cause: increased bile concentration, reduced motility concentration; can develop after rapid weight loss, long term parenteral feeding or duct obstruction - symptoms: steady severe pain; will usually develop after fatty meal - risk factors: ethnicity native american rates higher; african american and asian are lower; age older more likely; women- 2 times more risk due to estrogen alterations in cholesterol metabolism; pregnancy- especially high in 3rd trimester; obesity dietary suggestions: low fat, small frequent mealsrisks for developing cancer- supplements: beta-carotene supplements, high calcium (1500mg/day)metabolic changes caused by cancer- cytokine release by immune cells and tumor cells - cytokines cause inflammation and catabolic state - increased protein turnover - muscle wasting - lipolysis - can cause insulin resistanceNutrition suggestions for those getting treated for cancer- 2x protein requirement - low microbial diet - no fresh fruit, canned/ cooked is okay - nutrition support: if bone transplant will need high protein/energy; parenteral if inadequate GI function