Stephanie Ruel

Sodexo/St. Joseph’s Medical Center

MNT for the CKD Patient Complicated by a Pressure

Ulcer

Controversy of recommendations

Studies: Inconclusive or inadequate

Abstract

Anatomy and PhysiologyEtiology and pathologyMedical managementMedical Nutrition TherapyThe PatientConclusionFuture studiesRecommendations

Introduction

Chronic Kidney Disease

FunctionsMetabolic waste removalElectrolyte balanceFluid balanceBlood pressure controlpH regulationPlasma volume and osmolalityGlucose homeostasisHormone secretion (erythropoietin)Carnitine synthesis

Anatomy & Physiology of the Kidneys

Anatomy

Anatomy

Afferent arterioleGlomerulusBowmans’s capsuleProximal tubuleEfferent arteriolePeritubular

capillariesRenal vein

Proximal tubule

Glomerulus: Selective permeability

UltrafiltrateSelective resportion and excretion

Physiology: Electrolyte Balance

Tubule Efferent arteriole

= fluid homeostasis

Physiology: Electrolyte Balance

Electrolytes

Two main systems:VasopressinRenin-angiotensin aldosterone

system (RAAS)

Physiology: Fluid Balance

↑Blood osmolality or ↓blood pressure

HypothalamusPituitary gland

Kidney ↑blood pressure ↓blood osmolality

Vasopressin

Vasopressin

↓blood pressureAngiotensinogen

KidneyAngiotensin I

Angiotensin II

Adrenal Aldosterone

↑blood pressure

Renin-Angiotensin Aldosterone System

Renin

Lungs

RAAS

Etiology & Pathology

Diabetes Hypertension Family historyEthnicityAutoimmune diseaseInfectionSevere dehydrationAcute renal failure (ARF)

Etiology & Pathology

44%

of new CKD diagnoses caused by diabetes

Diabetic Nephropathy

Diabetic NephropathyGlomerular Anatomy

mesangium

↑blood glucose afferent arteriole dilationaltered hemodynamic regulation↑blood flow to glomerulus

Hypertrophy damage to podocytes Hyperfiltration and mesangial cellsHyperperfusion

altered permeabilityof glomerulus= PROTEINURIA

Hyperglycemia

Inflammatory mediatorsProinflammatory cytokines

Oxidative stressInflammation

FibrosisGlomerulosclerosis

Kimmelstiel-Wilson lesions

Proteinuria

DefinitionHypertension:

Systolic >140mm Hgor

Diastolic >90mm HgPrehypertension:

121/81mm Hg – 139/89mm HgNormal blood pressure:

<120/80mm Hg

Hypertension

Cause and effectBlood vessel remodelingInflammationOxidative stressArteriosclerosis

Hypertension

Endothelial lesions in blood vessels caused by buildup of hyaline

Decreased action of smooth muscle cells

Inhibited autoregulationIschemic tubulointerstitial injury

Hyaline Arteriosclerosis

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

Dietary Protein

Medical Management

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

Diagnosis

Stage

eGFR (mL/min/1.73m2)

Description

1 >90 Kidney damage with normal or increased GFR

2 60-89 Kidney damage with mildly decreased GFR

3 30-59 Moderately decreased GFR

4 15-29 Severely decreased GFR

5 <15 or dialysis Kidney failure

Item Normal ValueIn CKD, may

be:

Potassium 3.5-5.3meq/L Elevated

Phosphorus 3.4-5.9mg/dL Elevated

Blood urea nitrogen (BUN)

9-20mg/dL Elevated

Creatinine 0.5-1.3mg/dL Elevated

Albumin 3.5-5g/dL Decreased

Sodium 135-150meq/L Elevated

Urine protein Negative Positive

Blood pressure <120/80mm Hg Elevated

Laboratory Values

Hypertension: 80-85% Angiotensin Receptor Blockers (ARBs)

Angiotensin Converting Enzyme (ACE) Inhibitors

Diuretics

Antihypertensive Therapy

Albuminuria >300mg and all diabetic CKD (without hypertension)ARBsACE Inhibitors

Albuminuria <30mg and BP >140/90mm HgTarget BP <140/90mm Hg

Albuminuria >30mg, BP >130/80mm HgTarget BP <130/80mm Hg

Blood Pressure Control/RAAS

Highest risk category for development of cardiovascular disease (CVD)

CVD as cause of death before end-stage renal disease (ESRD) and dialysis

Statins

Improving Cardiovascular Health

Target HbA1C ~7.0%Hypoglycemia risk

Medication and lifestyle modification

Glycemic Control

Metabolic Bone DiseaseParathyroid hormone (PTH)CalciumPhosphorus

PotassiumMetabolic acidosisAnemia

Overview of Additional Complications

Smoking cessationPhysical activity

Weight managementFunctional capacity

Non-pharmacological Interventions

AllopurinolAvosentanMesenchymal stem cells

New Medication and Treatment

GFR <10ml/min/1.73m2

Symptoms:Electrolyte abnormalitiesAcid-base disturbanceUncontrolled BP and fluid balanceUremiaCognitive impairmentDecline in nutritional status

Dialysis

Renal Replacement Therapy

Treatment of choiceEarlier decision:

GFR <20ml/min/1.73m2

Irreversible progression for 6-12 months

Impact:Reduction of dietary restrictionsDelays or eliminates need for

dialysisMedications to prevent rejection =

↓immunity

Renal Transplant

Pressure Ulcers

Functions:Conduct sensory data to the brain via nerve

endings located in the skinProtect the bodyRegulate body temperatureSynthesize vitamin DStore energy and water

Anatomy & Physiology of the Integumentary System

Etiology & Pathology

Injury to the skin and/or underlying tissue as a result of pressure, friction, shear, or ischemiaRisk factors:ImmobilityPoor perfusion of blood supplyMoistureAnemiaAgeNutrition status

Development of Pressure Ulcers

10-18%

Inflammasomes in kertinocytesActivation of inflammatory cytokines

Danger signals and wound healing

Youth vs. Aging

Inflammasome Activity

Stage Description

ISkin intact but with non-blanchable redness for >1 hour after relief of pressure

IIBlister or other break in the dermis with partial thickness loss of dermis

III

Full thickness tissue loss. Subcutaneous fat may be visible, destruction extends into muscle; undermining or tunneling may occur

IV

Full thickness skin loss with involvement of bone, tendon, or joint; often includes undermining and tunneling

UnstageableFull thickness tissue loss in which base of ulcer is covered by slough and/or eschar in the wound bed

Suspected Deep Tissue

Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying tissue from pressure and/or shear

Stages of Pressure Ulcers

A: Stage IB: Stage IIC: Stage IIID: Stage IV

Stages of Pressure Ulcers

Medical Management

Risk assessment (Braden Scale score)Proper positioning and rotationSupport surfacesPain managementInfection managementWound cleansingDebridementDressingsBiophysical agents

Prevention & Care

Medical Nutrition Therapy(MNT)

AssessmentDiagnosisInterventionMonitoringEvaluation

Nutrition Care Process

MultidisciplinaryAnthropometricsMedical and social historiesMedicationsAnalysis of laboratory values

Assessment

Diet and diet historyNutrition statusComorbid conditionsLab values of BUN, potassium,

phosphorus, albumin, urinalysisAssess for education needs

Nutrition Assessment for CKD

Nutrient Dietary Recommendation

Energy 23-35kcal/kg/dayProtein (without

DN)0.6-0.8g/kg body weight

Protein (presence of DN)

0.8-0.9g/kg body weight

Sodium <2.4g/day

Potassium(stages 3-4)

<2.4g/day

Phosphorus 800-1000mg/day

Calcium(stages 3-4)

2g/day

Vitamin DSupplementation if 25-hydroxyvitamin D

<30ng/ml

IronSupplementation if:

Serum ferritin <100ng/ml andTransferrin saturation <20%

Fluid Varies with medical status

Nutrition Prescription for CKD

MNT for Hypertension and DiabetesDiabetes: glycemic control through consistent-carbohydrate diabetes meal planning

Hypertension:

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

The Role of Dietary Protein

Comprehension of and adherence to dietary recommendations

Maintenance of ideal body weightBlood glucose controlBlood pressure controlNormalization/improvement of

nutrition-related laboratory values

Monitoring & Evaluation

Dietary intake as related to needsStaging of pressure ulcer and changes

in stage/healingUsefulness of laboratory valuesUnintentional weight changesMobility assessmentAssess for education needsAdditional risk factors/comorbid

conditions

Nutrition Assessment for Pressure Ulcers

Based on limited, small studies and expert opinion:

Nutrition Prescription for Pressure Ulcers

Nutrient Recommendation

Energy30-35kcal/kg IBW (up to 40kcal/kg for repletion)

Protein 1.25-2g/kg

ZincIf deficiency is suspected,

220mg ZnSO4 bid for <3 weeks

Arginine/Glutamine

Inconclusive support, but may be supplemented if not

contraindicated

Fluid30-35mL/kg, minimum 1500mL

unless contraindicated

Necessity of protein in tissue-building

Ability of body to utilize protein in wound-healing

Nitrogen loss in wound exudateAttaining a positive nitrogen balanceProtein as energy in catabolism

The Role of Dietary Protein

Achievement of ideal body weight/weight maintenance

BMIEvidence of wound healingAdequate nutrient intakeAdequate hydrationComprehension/knowledge of

nutrition recommendations

Monitoring & Evaluation

The Patient

88 year old Caucasian femaleAdmitted for altered mental status and

dehydrationPMH: CKD stage 3-4, HTN, diverticular

disease, dementiaBraden Scale score: 9 (high risk)Upper and lower coccyx stage III pressure

ulcersPoor oral intake and deteriorating mobility

x 3 months

Patient Summary

170# (140% IBW 99-121# upper end of range)Unable to obtain weight history

Height: 5’2”BMI 31.2kg/m2 Stage I obesityDysphagia evaluation: severe oropharyngeal

dysphagia with purees and thickened liquids; high risk for airway obstructionRecommendation: NPO, aggressive oral

care for secretions

Patient Summary

Basic/Comprehensive Metabolic Panel and GFR  Normal 1/13/14 1/8/14

Sodium 135-150mEq/L 140 155H

Potassium

3.5-5.3mEq/L 2.7LL 4.8

Chloride 96-107mEq/L 109H 112H

BUN 9-20mg/dL 50H 114HH

Creatinine

0.5-1.3mg/dL 1.4H 3.1H

Glucose 70-110mg/dL 100 85

Calcium 8.5-10.5mg/dL 8.5 9.3

Albumin 3.5-5g/dL 2.1L 2.9L

eGFR >60ml/min/m2 38L 15L

Laboratory Values

Diagnosis: sepsis of urinary source, acute on chronic renal failure secondary to dehydration, likely aspiration pneumonia

Patient confused and lethargic+bowel sounds, no edemaChest x-ray: bibasilar infiltrates, left

pleural effusion+Urine culture: E.coli+Blood culture: S.capitus

Medical Management

IV fluids for rehydration (D5 ½ NS @100ml/hr)

IV fluids modified for potassium repletion:KCl20mEq/L, D5 ½ NS @50ml/hr

IV antibiotics Zosyn and Vancomycin

Dressing changes for pressure ulcers

Medical Management

Feeding withheld until rehydration and electrolyte balance achieved

Poor venous accessOral secretions, congestion, high

aspiration risk – no nasogastric tube inserted for feeding or medication administration

Care for pressure ulcer poorly documented

Medical Management

High nutritional riskEnergy needs: 30-35kcal/kg adjusted

body weight (BW) = 1800-2100kcal/dayProtein needs: until ARF resolved:

0.8g/kg adjusted BW = 48g/day protein (Once ARF resolved, increase protein to 1.4-1.5g/kg adjusted BW = 85-97g/day protein)

Fluid needs: 1ml/kcal = 1800-2100ml/day

Nutrition Assessment

Inadequate protein-energy intake related to SLP recommendation, poor venous access, no NGT insertion as evidenced by NPO status, no PN/EN support order.

Nutrition Diagnosis

1. Patient will meet >75% energy needs via appropriate route within 3 days.

2. Patient will receive restricted dietary protein until ARF resolved (protein to be increased to promote wound healing once ARF resolved)

Nutrition Goals

1. If patient to remain NPO >3 days, recommend TF via NGT with Suplena goal rate at 42ml/hr continuous; provides 1008ml total volume, 1814kcal, 743ml free H2O, 45g protein. Initiate feed at 20ml/hr increase 10ml/hr q4H to goal.

2. Free H2O autoflush 30ml/hr (total free H2O 1463ml); adjust IVF prn, additional fluids per MD

3. Will follow for updated TF recommendations once ARF resolved

4. Maintain head of bed at least 30-45 degrees during feed, monitor GI signs and symptoms for intolerance and hold feeds if intolerance or residuals >250ml.

Nutrition Interventions

Initiation of TFAdvancement of TF to goal rateTolerance of TFNutrition-related labsWound/skin status

Nutrition Monitoring & Evaluation

Patient received no nutrition support during hospital stay (7 days); patient was made DNR/DNI on last day of admission and discharged into hospice care

Pressure ulcer protocol was poorly documented

Plan of care was poorly communicatedNo attempts were made to place NGT

COMMUNICATION!

Critical Comments

Evidence supporting dietary protein restriction for CKD is stronger than evidence supporting the role of increased dietary protein in wound healing of pressure ulcers

Antihypertensive therapy is more impactful than dietary protein on proteinuria

Non-dietary factors are of greater importance in prevention and treatment of pressure ulcers

Conclusions

Level of dietary protein necessary to preserve lean body mass (positive nitrogen balance)

Temporary increase in dietary protein for wound healing and progression of CKD

Dietary protein increases in a patient with a pressure ulcer and the impact on level of proteinuria

Additional long term study on impact of dietary protein restriction in patients with proteinuria

Additional studies with larger sample size to examine role of dietary protein in wound healing

Future Study

Increased overall energy intake of 30-35kcal/kg

Dietary protein restriction of 0.6-0.8g/kg as a lifestyle

Transient increase of protein to 1.25-2g/kg for up to 8 weeks in presence of a pressure ulcer while monitoring renal function

Liberalization of diet as necessary to achieve recommended energy intake

Consideration of patient’s wishes

Recommendations

References available upon request.