Nephrology W1D3

Today we shadowed a nurse and a nutritionist giving general advice and information to patients with chronic kidney dz. The nurse gave us a comprehensive packet on CKD. Here are some of the issues brought up in the packet:

• CKD stages 1-5. 
• Stages 1-3 are manageable, 4-5 patients need to be more strictly managed. These are measured by eGFR, which depends on urine protein, creatinine, and age of the patient.
• There are three replacement therapies for CKD
• Hemodialysis (HD) - 3X a week for 4-5 hours. 
• Peritoneal dialysis (PD) - this is done 4X a day, around 20-30 minutes each. 
• also known as "intestinal cleaning". uses the natural human body in which the peritoneum acts as a semi-permeable membrane to eliminate excess water and metabolic waste from the body while infusing peritoneal dialysis soln.
• This can be done at home. Pts are more likely to choose this based on wanting increased quality of life and more control over their care. 
• PD indicated for younger pts, HD indicated for older pts and mid-aged pts with diabetes. PD=HD for young diabetics and mid-aged pts with no DM2.
• Renal transplant - from blood relatives, or pts diagnoses as brain dead with consent of pts family.
• Nutrition is altered accordingly:
• low salt
• low protein in early stages RF: meat should be limited to the size of three fingers. 
• supplement meals with low-protein foods to avoid malnutrition: potato starch, tapioca, agar jelly, granulated sugar, vegetable oil
• avoid: viscera, dairy products, whole grain, dried beans, and nuts
• high protein in late stage RF- to account for hyperfiltration of proteins during dialysis, pts with late stage CKD are given high protein diets.
• low phosphate
• avoid yeast powder, cola, soda pop, egg yolk, star fruit, low-sodium salt (has high phosphate to replace), saltless soy sauce, pickled smoked, sauced foods, canned foods, frozen salted vegetables...
• How to calculate the number of calories allotted for each patient:
• weight x20 = number of calories allowed. Calories should be lowered for pts with infectious dz. 
• we learned a little more in depth about the program for kidney dz patients. nurses often have more time to talk to patients about dialysis, answer pressing questions, and talk them into dialysis. They address the anxieties and concerns of the patients. Dr. Chen explained that pts are very reluctant to start dialysis and if not adequately prepared may detoriorate to a uremic condition and a temporary catheter will have to be placed. By informing potential pts earlier and preparing an AV fistula or PD for them, they are better equipped to handle dialysis when they need to begin. As Dr. Chen said, it's all about staying one step ahead of the dz with awareness and pt health and being prepared to minimize damage and increase quality of life.

• Interestingly, the nurse said that they recommend that pts do NOT supplement their medication with chinese herbs and tonics, as these traditional remedies often contain high potassium, phosphate, and other electrolytes that lead to imbalance. 
• Having a kidney dz seems to really change a pt's lifestyle. The nurse and nutritionist said that it is more important to control the other dz that exacerbate kidney dz, such as htn and dm2. Uncontrolled HTN = fluctuations in bp = damaged kidneys due to fluctuating GFR. Uncontrolled DM2 = non enzymatic glycosylation = damage to glomeruli. By controlling the diet, one can protect the kidney. 
• Renal osteodystrophy or CKMBD( chronic kidney mineral and bone disorder):
• loss of phosphorus homeostasis due to excretion failure in CKD results in hyperphosphatemia.
• skeletal function disorder => excess bone resportion rates compared to bone formation rates. skeleton contributes to hyperphosphatemia. 
• without the ability for phosphates to deposit in bones, a new reservoir must be found. The outcome is that the new reservoir of phosphates is in soft tissue organs including vasculature.
• hyperphosphatemia causes cardiovascular related dz which complicates ESRD and is a common cause of death.