Chronic Kidney Disease (CKD) - Conservative Management/ Pre-dialysis Dietetic Guidelines (Stages 4-5).

Transcription

1 University Hspitals Cventry & Warwickshire NHS Trust Clinical Guideline (full) Chrnic Kidney Disease (CKD) - Cnservative Management/ Pre-dialysis Dietetic Guidelines (Stages 4-5). E-Library Reference CG 1336 Versin: Apprving frum (QIPS r equivalent): Specialty Clinical Guideline Lead: Cntributing Authr(s): Department(s) / Primary Speciality: V4 Renal Services Prcedure and Guideline Apprval Grup Rizwan Hamer Carline Bird Renal Dietetic Team Leader carline.bird@uhcw.nhs.uk Renal Apprval Date: Expiry Date: Target Audience: 16 th Nvember 2016 Nvember 2019 All healthcare prfessinals wrking in Renal Services Superseded UHCW Clinical Guideline(s): (if applicable) UHCW Assciated Recrds: Keywrds: Clinical Operating Prcedures relating t this guidance (please list) V3 n Chrnic Kidney Disease (CKD) Predialysis Dietetic n Summary versin available 1

2 Guideline clinical cntent Clinical Guidelines assist in decisin-making; they d nt replace clinical judgement. Regardless f the strength f evidence, it remains the respnsibility f the clinician t interpret the applicatin f the clinical guidance t lcal circumstances and the needs and wishes f the individual patient. Where variatins f any kind d ccur, it is imprtant t dcument the variatins and the reasn fr them in the patient s health recrd. If in dubt, seek senir advice. Intrductin (Why this Trust-wide Clinical Guideline is necessary. Include reference t any relevant natinal guidelines, statutry requirements r ther recmmendatins Identify the risk(s) the guideline will address.) The target audience fr these guidelines is the renal multidisciplinary team including cnsultant nephrlgists, specialist registrars, specialist nurses, dietitians and pharmacists. This is a lcally adapted guideline based n natinal recmmendatins and applies t patients with chrnic kidney disease (CKD) stages 4-5. Summary (Summarise the main pints f the guidance. Use flw diagrams where apprpriate and limit t a single side f A4) All renal patients with a glmerular filtratin rate (GFR) <29ml/min, shuld be referred t a renal dietitian fr nutritinal assessment (KDIGO,2012). Patients attending a pre-dialysis clinic shuld have an estimated glmerular filtratin rate (egfr) available n CRRS, and be reviewed by the renal dietitian every 3-6 mnths. The dietetic CKD guidelines highlight the imprtance f renal dietetic referral, and when dietary adaptatins are required. A dietetic CKD management prgramme encmpasses; bld pressure cntrl, reductin f prteinuria, treatment f hyperlipidaemia, smking cessatin and dietary advice, treatment f anaemia, treatment f acidsis and metablic bne disease, and the prvisin f timely and understandable infrmatin and educatin (NICE 2008). NICE 2014 recgnises the imprtance f dietary advice, in the management f hyperkalaemia, hyperphsphataemia, and salt and water 2

3 intake fr peple with advanced CKD (egfr <20ml/min/1.73m2). This advice shuld be given by an apprpriately trained prfessinal, such as a renal dietitian. Recmmendatins fr guideline cntent: Ideal Bdy Weight (IBW) shuld be calculated using a BMI f 20kg/m² where the patient s BMI is <20kg/m², 25kg/m² where the patient s BMI is > 25kg/m², and actual BMI if the patient s BMI is between 20 and 25kg/m² (Renal Assciatin, 2010) Energy: Aim fr 30-35Kcal/ Kg/ IBW (EDTNA, 2002; DOQI, 2002; Renal Assn, 2010) Reduced intakes (30 Kcal/Kg/IBW/ per day) may be apprpriate in the elderly, and patients with reduced activity (agreed best practice). Where apprpriate individuals with CKD shuld be encuraged t undertake physical activity cmpatible with cardivascular health and tlerance, and t achieve a healthy BMI within (20-25 kg/m 2 ) (KDIGO, 2012). Patients with a BMI > 30kg/m2 r <20 kg/m² shuld be referred t a Dietitian fr advice (Renal Assciatin Guideline, 2011). Prtein: Aim fr g/Kg/IBW (Renal Assciatin 2010, Natinal Service Framewrk) Prtein shuld be biased in favur f high bilgical prtein (HBV), until further evidence accumulates. 70% HBV prtein is recmmended lcally. Ptassium: Aim fr 1mml/Kg/IBW/d (EDTNA,2002,KDIGO,2012) All pre-dialysis patients shuld maintain their serum ptassium between mml/l (Renal Assciatin 2002).Nn-dietary causes f raised ptassium shuld be cnsidered n assessment (e.g. medicatins, dehydratin, infusins, bld transfusins, hyperglycaemia). In patients with chrnic kidney disease, dietary mdificatin t avid r reduce intake f high ptassium fds may als be f benefit (Renal Assciatin Hyperkalaemia 3

4 Guidelines, 2014). Aim fr a nrmal range f serum bicarbnate (22-29mml/L). Mineral bne management; All pre-dialysis patients shuld maintain their serum phsphate between mml/l (Renal Assciatin CKD MBD, 2015) and patients with a phsphate greater than 1.4 mml/l shuld be referred t a renal Dietitian fr dietary advice (WMRN reginal bne management guidelines, 2010). Serum calcium shuld be maintained between mml/l (crrected fr serum albumin) (Renal Assciatin CKD MBD, 2015). In the presence f hypercalcaemia all calcium therapies shuld be reviewed. The phsphate binders used lcally are initially Calcium acetate (Phsex & Renacet), Calcium carbnate (Calcichew), Lanthanum (Fsrenl), Sevelemer hydrchlride (Renagel) and Sevelemer carbnate (Renvela). Calcium acetate shuld be used as first line where apprpriate (NICE 2013) In cases where a vitamin D deficiency is detected clecalciferl r ergcalciferl shuld be used as crrective treatment (NICE, 2014). In patients with an increasing ipth remaining persistently abut the upper limit fr the assay used, an active vitamin D analgue such as alfacalcidl r calcitril shuld be cnsidered (KDIGO 2009, Renal Assn 2010, NICE 2014). Dietary phsphate assessment and cnsideratin f phsphate restrictin and/r phsphate binders shuld be cnsidered in patients with an increasing ipth level even if the serum phsphate level is within the target range (agreed best practice). Salt: Aim <100mml/day sdium (<6g salt/day) (Sign 2007 and 2008) This shuld help ptimise bld pressure, reduce cardivascular risk and imprve edema. Patients with end stage renal failure r nephrtic syndrme may require a fluid restrictin. Targets fr bld pressure cntrl are less than 140/90mmHg r 130/80mmHg fr diabetic patients with prteinuria greater than 1g/24hurs. Salt substitutes that cntain 4

5 ptassium salts shuld be avided in CKD. CKD- Chrnic Kidney Disease IBW- Ideal bdy weight ipth- Intact Parathyrid hrmne MAC- Mid-arm circumference SGA- subjective glbal assessment MBD- mineral bne disease Guideline details (This is the main bdy f the guideline cntaining the detailed requirements, which will supprt implementatin and decisin-making. Use subheadings as required.) Assessment The pre-dialysis referral criteria shuld be used by nurses and dctrs t ensure apprpriate patients are referred fr nutritinal review (See Appendix A). HBA1c cntrl shuld be targeted in the pre-dialysis dietary assessment. KDIGO 2012 recmmends a target HBA1c f apprximately 7% (53mml/ml) t prevent r delay prgressin f the micrvascular cmplicatins f diabetes, including diabetic kidney disease. This target can be extended in individuals with cmrbidities, limited life expectancy r risk f hypglycaemia. Patients with a glmerular filtratin rate (GFR) <29ml/min, shuld be referred t the dietitian fr nutritinal assessment. They shuld be ffered dietary advice abut ptassium, phsphate, calrie and salt intake apprpriate t the severity f CKD (NICE 2008, amended 5

6 2014). Where dietary interventin is agreed this is in the cntext f educatin, detailed dietary assessment and supervisin t ensure that malnutritin is prevented (NICE 2008). Appendix B indicates the Natinal Service Framewrk (NSF) classificatin f CKD, and the recent NICE guidelines n CKD classificatin taking int accunt GFR and albumin creatinine rati (ACR). Weight, height, BMI, and where applicable % weight lss shuld be measured in all patients with CKD stage 4-5 (Renal Assciatin 2010) The Nutritin & CKD guideline (Renal Assciatin, 2010) encurages regular screening f CKD 4-5 patients (2-3 mnthly where GFR <20) and suggests using the fllwing parameters fr screening. Actual Bdy Weight (ABW) (< 85% f Ideal Bdy Weight (IBW)) Reductin in edema free bdy weight (f 5% r mre in 3 mnths r 10% r mre in 6 mnths) BMI (<20kg/m2) The abve nutritinal screening methds can be used by all clinical staff. Subjective Glbal Assessment (SGA) (B/C n 3 pint scale r 1-5 n 7 pint scale) In additin the RA recmmends auditing the regularity f this nutritinal screening, fr example, the percent f CKD 4-5 nndialysis patients wh have had an SGA cmpleted in the last 12 mnths. (See Appendix Ci & Cii) All patients attending the pre-dialysis clinic shuld have the 6

7 pprtunity t attend an educatinal day, including a sessin cnducted by a renal dietitian/dietetic assistant. 2. Nutrient intakes During the dietary assessment f pre-dialysis patients the fllwing aspects f the diet shuld be cnsidered: (i) Energy Aim: T achieve / maintain an IBW and nitrgen balance The recmmended dietary energy intake is 30-35Kcal/Kg/IBW per day (Renal Assciatin 2010) Lwer intakes (30Kg/IBW/per day) may be apprpriate in lder adults (thse >60 years f age), and patients with reduced activity (agreed best practice). Where apprpriate individuals with CKD shuld be encuraged t undertake physical activity cmpatible with cardivascular health and tlerance, t achieve a healthy BMI within (20-25kg/m2) (KDIGO, 2012). Renal patients are at high risk f hyperlipidaemia and cardi-vascular disease (CVD) shuld be advised n healthy lifestyle chices (KDIGO, 2013). Individuals with a lw BMI shuld be assessed by a dietitian and where apprpriate advised n ways t increase their energy intake and bdy weight. Individuals with a BMI > 30kg/m2 shuld be referred t a dietitian fr 7

8 advice (Renal Assciatin Guideline, 2011). (ii) Prtein Aim: T maintain nitrgen balance A dietary prtein intake f g prtein/kg/ibw shuld be recmmended (Renal Assciatin 2010, Natinal Service Framewrk). 70% HBV prtein is recmmended lcally (agreed best practice). NICE 2014 advised nt t ffer lw-prtein diets (dietary prtein intake less than g/kg/d) t peple with CKD. Diets cntaining less than 0.75g prtein/kg/ibw can increase risk f prtein energy malnutritin and therefre shuld nt be recmmended. SIGN 2008 highlights issues f; malnutritin, cmpliance and palatability with lw prtein diets. Where patients are unable t meet their prtein r energy requirements, despite dietary advice, nutritinal supplementatin shuld be discussed with the patient, and prescribed if apprpriate. Patients prescribed nutritinal supplements shuld be reviewed mre frequently (at least 3 mnthly) s that nutritinal intake can be recalculated and apprpriateness f supplements re-assessed (agreed best practice). All patients shuld be assessed fr signs f malnutritin using the nutritin screening guidelines (see Appendix C i & Cii). 8

9 (iii) Ptassium Aim: T maintain serum ptassium levels between mml/l (Renal Assciatin, 2002; SIGN, 2008) Where apprpriate a patient will be advised n a lw ptassium diet; aiming fr a maximum ptassium intake f 1 mml/kg/ibw (agreed best practice). The Renal Assciatin hyperkalaemia guidelines (2014) recmmend that all patients with mild (K mml/l) r mderate (K mml/l) hyperkalaemia have a review f their medicatin and diet and regular mnitring f serum ptassium; the urgency f assessment and frequency f ptassium mnitring will depend n individual circumstances, and bichemical levels. Nn dietary surces f ptassium shuld always be cnsidered (see Appendix D) A patient's level f dietary ptassium restrictin shuld be altered depending n the serum ptassium level. Aim fr a nrmal range f serum bicarbnate (22-29 mml/l) t help crrect the effects f metablic acidsis. (iv) Mineral bne management; Aim: T maintain serum phsphate levels between mml/l (Renal Assciatin 2015) The serum calcium shuld be maintained between nrmal labratry levels mml/L (crrected fr serum albumin), with 9

10 avidance f hypercalcaemic episdes (Renal Assciatin, 2015). It is recmmended that therapeutic decisins are based n the clinical situatin, and trends in parameters, rather than a single labratry value (Renal assciatin 2015) The phsphate cntent f the diet shuld first be reduced thrugh prcessed fds and additives befre prtein surces f phsphate are cnsidered. Referral t a renal dietitian will ensure a suitable step wise apprach t phsphate reductin. 50% f the phsphate we eat culd cme frm fd additives. 90% f phsphate frm additives is absrbed by the bdy cmpared t nly 40 60% f phsphate naturally fund in fds (Kamyar et al,2010) In patients with hyperphsphataemia and persistent hypercalaemia the dse f calcium based phsphate binders, and/r vitamin D analgues shuld be reduced. They shuld als be reduced in the presence f arterial calcificatin, adynamic bne disease and in the presence f ver-suppressin f PTH (KDIGO, 2009). Where apprpriate and required nn calcium binders shuld be used. Generally PTH levels are elevated when GFR falls belw 60ml/min (stage 3) and secndary hyperparathyridism begins. Dietary phsphate restrictin, phsphate binders, and/r vitamin D analgues shuld be cnsidered in patients with an increasing PTH level, which remains persistently higher than the upper reference limit fr the assay, nce vitamin D levels have been crrected, even if the serum phsphate level is within the target range (agreed best practice). Patients shuld als be advised n the apprpriate timing f phsphate binders with high phsphate fds. Irn tablets and phsphate binders shuld nt be taken tgether because this 10

11 decreases the effectiveness (refer t phsphate binders diet sheet n the e-library). The phsphate binders used lcally are initially Calcium acetate (Phsex & Renacet), Calcium carbnate (Calcichew), Lanthanum (Fsrenl), Sevelemer hydrchlride (Renagel) & Sevelemer carbnate (Renvela). Calcium acetate shuld be used as first line where apprpriate (NICE 2013) The management f hyperphsphataemia clinical guidelines (NICE 2013) recmmends calcium acetate as an effective first-line treatment fr adults. In thse patients wh are unable t tlerate calcium acetate, in its different manufactured frms, calcium carbnate is an effective alternative. Hwever phsphate binders and use shuld be individualised and based n the presence f ther cmpnents f CKD-MBD, tlerance, and side effect prfile (KDIGO 2009, Renal Assn 2010) Renal Assciatin 2015 highlights a reasnable case exists fr the measurement and crrectin f vitamin D. 25- hydrxyvitamin D shuld be measured at baseline with a view t crrectin f insufficiency r deficiency (>75nml/L = repletin, nml/L = insufficiency, <37.5nml/L = deficiency). In cases where a vitamin D deficiency is detected clecalciferl r ergcalciferl shuld be used t treat this (NICE, 2014) Vitamin D analgues shuld be used t dwn regulate PTH and renal stedystrphy. It is imprtant t mnitr calcium and phsphate cncentratins in peple receiving alfacalcidl r calcitril supplements (NICE 2014). 11

12 (v) Sdium and fluid balance Aim: T advise patients n hw t cntrl their dietary intake f sdium and imprve bld pressure cntrl and fluid balance. (DOQI and Hypertensin guidelines). NICE and SIGN bth emphasize the imprtance f gd BP cntrl (<130/70mmHg) in rder t dwn regulate prteinuria and CKD prgressin. All pre-dialysis patients (with the exceptin f salt lsers ) shuld be advised n a reduced sdium intake <100mml/day (<6g/day f salt) (EDTNA 2002, Renal Assciatin, 2011, SIGN 2008). Targets fr bld pressure cntrl are less than 140/90mmHg r 130/80mmHg fr diabetic patients with prteinuria greater than 1g/24hurs. Sdium restrictin shuld be priritised individually with cnsideratin fr a patients nutritinal status. Patients shuld be advised n the best ways t manage their prescribed fluid allwance and salt restrictin shuld always be prescribed in cmbinatin with this. Fluid restrictins are nt nrmally prescribed unless a patient has nephrtic syndrme, r end stage renal failure (ESRF). This may be 500ml + previus day s fluid utput, but always check with a member f the medical team. NB: A cnsultant may still request a fluid restrictin fr certain patients. 12

13 (vi) Vitamins Aim: T ensure adequate intakes f vitamins and minerals. The dietitian will assess adequacy f vitamin intake, and advise n supplementatin if apprpriate. There is n real guidance in the natinal standards n the level f vitamin supplementatin in predialysis patients. Hwever, agreed best practice is that the B vitamins, Flate, and Vitamin C are mst cmmnly deficient in patients n a lw ptassium diet. Supplementatin with Vitamin A is nt advised as this can accumulate t harmful levels in renal failure. Als ver supplementatin with Vitamin C is nt encuraged because f its links with the frmatin f renal stnes. Experimentally it has been fund that 1-4g f Vitamin C has been required t increase Oxalate excretin and hence the risk f renal stne disease (Williams et al, 1990). The dietitian will review patients t help avid any inapprpriate restrictins, which may be decreasing the patient's vitamin intake unnecessarily. Nte: Patients shuld be discuraged frm taking herbal remedies as there is n medical evidence t supprt these, and sme Chinese remedies have been fund t be harmful in CKD (SIGN 2008). Implementatin (If the guideline relates t a service, pathway r external agency, prvide details and reference any assciated clinical perating prcedure (COP) r crprate business recrd (CBR) ) N/A Training (Prvide details f hw any assciated training is delivered, target audience, and if nline training is available 13

14 prvide link. If training prvided in Trust r Departmental inductin, please specify t which staff grups.) N/A Patient Infrmatin (Reference any assciated Patient infrmatin leaflets) There are a number f Patient Infrmatin Leaflets available n this subject Audit & Mnitring (Detail hw the implementatin and effectiveness f the clinical guideline will be mnitred) Aspect being mnitred Audit f nutritinal screening fr CKD 4-5 nt n dialysis Audit f serum bichemistry levels Mnitring methd Prtn and dietetic recrd cards Pre-dialysis data base Respnsible department(s) Frequency Grup / cmmittee receiving reprt & respnsible fr actins Dietetics annually Renal Dietetics Team Dietetics annually Renal multidisciplinary team End f Gvernance cntent Guideline References CEBIS Evidence Summary (, NICE Guidelines, and ther Natinal Guidance. Other natinal guidance may include thse issued by speciality cllege, patient safety agency, mnitring agencies, r ther external gverning bdies ) References cited in guideline Grade* KDOQI Clinical Practice Guidelines fr Nutritin in Chrnic Renal Failure (2000) and KDOQI Clinical Practice Guidelines fr Bne Metablism and Disease in Chrnic Kidney Disease (2002) 1-5 Eurpean Guidelines fr the Nutritinal Care f Adult Renal Patients (2002) 1-5 KDIGO- Clinical Practice Guidelines fr the Diagnsis, Evaluatin, Preventin & Treatment f Chrnic kidney disease and mineral and bne disrders (CKD- MBD), Renal Assciatin Guidelines - Nutritin(2010) 1-5 West Midlands guidelines fr management f CKD related mineral and bne disrders in HD patients (WMRN) KDIGO Clinical practice guidelines fr the evaluatin and management

15 f CKD NICE- Management f Hyperphsphataemia- March KDIGO Nv Clinical practice guideline fr lipid management in CKD 1-5 NICE July Early identificatin and management f CKD in adults in primary & secndary care. 1-5 CKD- MBD- Renal Assciatin March Treatment f acute hyperkalaemia in adults- March Kamyar et al Understanding surces f dietary phsphrus in the treatment f patients with CKD. Clin J Am Sc Nephrl 5: *Grade:- The references are graded thrugh the CEBIS prcess accrding t the criteria utlined belw. Grade f evidence Based n 1 Systematic review r meta-analysis 2 Randmised cntrlled trial/s 3 Cntrlled study withut randmisatin (e.g. case cntrlled) r quasiexperimental study, such as a chrt study 4 Descriptive studies such as case series and reprts. 5 Expert pinin, narrative review Add any Appendices belw (Please use a Page Break befre each appendix, and list each clearly in the sectin n the title page. Appendices may include a summary, a flwchart, a prfrma, r ther materials, but its purpse must be clearly identified) 15

16 APPENDICES Appendix A Cventry Renal Dietitians Out patient referral criteria fr renal dietetic review Please refer the fllwing patients fr dietetic review:- Pre-Dialysis patients Stage 4-5 CKD, and any f the fllwing: Phsphate > 1.40mml/L Ptassium > 5.5mml/L with a nrmal bicarbnate (22-29mml/L) Uraemic symptms, including pr appetite r weight lss Any questins abut diet Attending clinic with family r carers wh als need t be present during cnsultatin Pr diabetic cntrl IFCC HbA1c >58mml/ml Hypertensive In additin t the abve please cnsider referring the fllwing patients fr dietetic review:- Phsphate (nrmal range) with increasing PTH and patient is apprpriate t fllw a phsphate restrictin All patients with a GFR <30mls/min Cntact us n , r ext at UHCW NHS Trust r Bleep n 2138,1258, 1261 r

17 Appendix B: Natinal Service Framewrk classificatin f Chrnic Kidney Disease The stages f CKD (Chrnic Kidney Disease) are mainly based n measured r estimated GFR (Glmerular Filtratin Rate). There are five stages but kidney functin is nrmal in Stage 1, and minimally reduced in Stage 2. The KDOQI stages f kidney disease are: Stage GFR* Descriptin Treatment stage Nrmal kidney functin but urine findings r structural abnrmalities r genetic trait pint t kidney disease Mildly reduced kidney functin, and ther findings (as fr stage 1) pint t kidney disease 3A 3B Mderately reduced kidney functin Observatin, cntrl f bld pressure. Observatin, cntrl f bld pressure and risk factrs. Observatin, cntrl f bld pressure and risk factrs Severely reduced kidney functin Planning fr endstage renal failure. 5 <15 r n dialysis Very severe, r end stage kidney failure (smetimes called established renal failure) Treatment chices. * All GFR values are nrmalized t an average surface area (size) f 1.73m 2 17

18 GFR categries (ml/min/1.73m 2 ), descriptin and range Increasi ng risk Classificatin f chrnic kidney disease using GFR and ACR categries- NICE July 2014 GFR and ACR categries and risk f adverse utcmes ACR categries (mg/mml), descriptin and range <3 Nrmal t mildly increased 3 30 Mderately increased >30 Severely increased A1 A2 A3 90 Nrmal and high Mild reductin related t nrmal range fr a yung adult G1 G2 N CKD in the absence f markers f kidney damage Mild mderate reductin G3a Mderate severe reductin G3b Severe reductin G4 <15 Kidney failure G5 Increasing risk 1 Cnsider using egfrcystatinc fr peple with CKD G3aA1 (see recmmendatins and ) Abbreviatins: ACR, albumin:creatinine rati; CKD, chrnic kidney disease; GFR, glmerular filtratin rate Adapted with permissin frm Kidney Disease: Imprving Glbal Outcmes (KDIGO) CKD Wrk Grup (2013) KDIGO 2012 clinical practice guideline fr the evaluatin and management f chrnic kidney disease. Kidney Internatinal (Suppl. 3):

19 Appendix Ci: Nutritinal screening: Subjective assessment Height (m) (first cntact nly) Weight (Kg)/ Dry weight (Fr peritneal dialysis patients (PD) at UHCW NHS Trust this is the weight including the fluid frm the bag). (Fr HD patients this is the weight set by medical staff where JVP and chest xray are clear and the patient has n edema). Bdy mass index (BMI) Ideal bdy weight (IBW) is equivalent t: Actual BMI if BMI between 20-25kg/m2 BMI f 20kg/m2 if BMI is less than 20kg/m2 BMI f 25kg/m2 if BMI is greater than 25kg/m2 (Renal Assciatin Guidelines Screening fr under nutritin in CKD) Percent weight lss in a dcumented time perid. Mid-arm-circumference (MAC), grip strength and subjective glbal assessment (SGA) as apprpriate. This shuld be used in thse patients felt t be nutritinally at risk, assessment f dry weight fr thse with edema/ n dialysis. Repeat measurements n a 6-12 mnthly basis t highlight any changes. Remember t dcument this n the apprpriate sheet inside the recrd card, r highlight in the bdy f the ntes, and recrd which arm is measured. Relevant Bichemistry (i.e. thse specified n bld card), and chlesterl, triglycerides, HbA1C, glucse, CRP and magnesium when available. Diet histry/ fd diary Estimated nutritinal requirements. Estimated calrie and prtein intake. 19

20 Appendix Cii: Renal Assciatin Guidelines 2010; Screening fr under nutritin in CKD Screening methds fr under nutritin in CKD We recmmend that all patients with stage 4-5 CKD shuld have the fllwing parameters measured as a minimum in rder t identify under nutritin (1C): Actual Bdy Weight (ABW) (< 85% f Ideal Bdy Weight (IBW)) Reductin in edema free bdy weight (f 5% r mre in 3 mnths r 10% r mre in 6 mnths) BMI (<20kg/m2) Subjective Glbal Assessment (SGA) (B/C n 3 pint scale r 1-5 n 7 pint scale) The abve simple audit measures have been linked t increased mrtality and ther adverse utcmes. 20

21 Appendix D: Factrs affecting serum ptassium levels in renal failure Nrmal serum ptassium levels: mml/l HD patients: mml/l PD patients : mml/l An INCREASE in serum ptassium culd be due t :- Diet High ptassium fds Drugs Erythrpetin (EPO) therapy. Regulan treatment Fybgel treatment ACE inhibitrs, fr example; Captpril, Enalpril, Lisinpril ARBs, fr example lsartan, candesartan, irbesartan Ptassium salts fr example Slw K (ccasinally used where levels are lw. Renal; functin changes and smene frgets t stp them). Ptassium sparing diuretics, e.g. Spirnlactne etc. (Nt usually used in renal failure fr this reasn). Metablic Catablic Pr diabetic cntrl / Insulin deficiency Dehydratin. Acidsis. Hypaldsternism. Infectin / Sepsis. Rapid catablism / Weight lss. Burns. Crush injuries / Rhabdmylsis / Ischaemia. Other Cnstipatin (mre ptassium is generally excreted in the stls f renal patients) A small temprary increase in ptassium f 0.5 mml/l is usual fllwing exercise Bld Transfusin. Haemlysed bld sample. In HD patients, ther factrs t cnsider Inadequate dialysis Incrrect dialysate used Recirculatin Treatment fr high ptassium: 1. Calcium glucnate 2. Dextrse and insulin. This wrks by mving ptassium int the cells; temprary measure 3. Dialysis haemdialysis, haemfiltratin 21

22 4. In exchanges resins e.g. calcium resnium. This binds ptassium in the gut and remves it via the stls. The usual dse is 15g rally 3 r 4 times daily in water r 30g rectally. 5. Dietary ptassium restrictin A DECREASE in serum ptassium culd be due t:- Diet Drugs Over enthusiastic dietary restrictin Diuretics that cause ptassium lss e.g. frusemide (nte: ptassium levels will rise when patient ceases these). Salbutaml rally r high dse inhaled Amphtericin damages the renal tubule and causes ptassium lss frm the bdy. Sdium bicarbnate treatment lwers ptassium. Laxative abuse Increased ptassium lsses Recvery f renal functin while maintaining reduced dietary intake Vmiting Fistula/wund lsses Diarrhea Ilestmy Metablic Alkalsis 22