Sodexo DI

SODEXO NY / PHILADELPHIA METROPOLITAN

DIETETIC INTERNSHIP PROGRAM
ADVANCED LEVEL
RENAL MODULE
TERMINOLOGY
Define the following terms:
Anuric the absence or suppression of urine
Azotemia an elevation of BUN and creatinine levels; pre-renal azotemia
refers to elevated levels resulting from problems in the systemic circulation
that decreases flow to the kidneys, intra-renal azotemia is also known as
acute kidney injury with problems due to the kidney itself, and post-renal
azotemia refers to elevated levels resulting from an obstruction in the
collecting system
Dry weight body mass without extra fluid; frequency and duration of
hemodialysis treatments targets the amount of fluid removal to restore what
is estimated to be dry weight, meaning the lowest weight tolerated without
developing low blood pressure
Erythropoietin a hormone produced primarily in the kidneys; when the
kidneys are unable to make this hormone patients are at risk for anemia
Glomerular Filtration Rate (GFR) a test used to check how well the kidneys
are working by estimating how much blood passes through the glomeruli
each minute; normal 90-120 mL/min/1.73 m2, levels below 60 over 3 months
suggests chronic kidney disease
IDPN
Interdialytic Weight Gain (IDWG) an indicator of compliance to a fluid
restricted diet
Oliguric urine output less than 1 mL/kg/h
Renal Osteodystrophy a bone disease that occurs when the kidneys fail to
maintain proper levels of calcium and phosphorous in the blood which causes
bone and joint pain and an increased risk of fractures
Renin an enzyme secreted by and stored in the kidneys that promotes the
production of angiotensin that helps mediate extracellular volume and
arterial vasoconstriction
Uremia a syndrome associated with fluid, electrolyte, and hormone
imbalances and metabolic abnormalities which develop along with
deterioration of renal function
QUESTIONS
1. Review kidney size and weight.
The kidneys are typically 10-12 cm in length, 5-7 cm in width, and 2-3
cm in thickness and weigh about 0.25 pounds.
2. What are the essential functions of the kidney?
The kidneys filter about 120 to 150 quarts of blood to produce about 1
to 2 quarts of urine, composed of wastes, and extra fluid each day.
They prevent the buildup of wastes and extra fluid in the body and
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keep levels of electrolytes stable, such as sodium, potassium, and
phosphate. The kidneys also produce the hormones erythropoietin and
calcitriol, as well as the enzyme renin.
3. Describe the following diseases of the kidneys and identify the
main principles of treatment:
a. Chronic Glomerulonephritis inflammation of the glomeruli;
control high blood pressure or underlying disease such as lupus
or infection
b. Hypertensive Nephropathy chronic hypertension that damages
the blood vessels, controlling blood pressure to prevent further
kidney damage; eventually leading to dialysis
c. Nephrotic Syndrome protein is present in urine, decreases
albumin; maintain adequate protein levels, low sodium diet
d. Polycystic Kidney Disease a genetic disease characterized by
cysts filled with water-like fluid present on the kidneys; do well
with kidney transplants
e. Pyelonephritis kidney infection or UTI that affects the kidneys;
treated with antibiotics, may cause permanent kidney scars
leading to CKD
f. Systemic Lupus Erythematosus (SLE) an autoimmune disease
in which the body's immune system mistakenly attacks healthy
tissue; can cause inflammation in the kidneys
4. In a table format, describe the differences diet and treatment
for acute, chronic and end stage renal disease.
Diet

Treatment

Acute
Protein: <0.8
g/kg body weight
(short duration),
up to 1.4 g/kg
body weight
(catabolic state)
Kcal: 20-30
kcal/kg body
weight/day
Sodium
restriction

Chronic
Protein: <0.6 g/kg
body weight
(close to 0.8 g/kg
to keep lean body
mass), 10% of
calories preserves
kidney function
and reduces
albuminuria
Phosphorous: 812 mg/g
protein/day

Renal Module

Monitor
hydration
status
Vasodilators
Possibly

Angiotensin
blockers
Control blood
pressure
Glycemic

ESRD on HD
Protein: 1.2-1.4
g/kg body weight
Sodium: 2-3 g/day
Potassium: 2-3
g/day based on
protein level
Phosphorus: 8-12
mg/g protein/day
(1200 mg/day)
Calories: 30-35
kcal/kg body
weight
Fluid: 500-750
ml/day + urine
output x 24 hours
(32-40 oz; 10001200 ml)
Hemodialysis
Peritoneal
dialysis
Renal
transplantation
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dialysis

control
Protein
restriction
Smoking
cessation
Management
of obesity

5. What are the symptoms of uremia?

Symptoms include nausea, vomiting, fatigue, loss of appetite, altered
mental status, hyperpigmentation, pericarditis, prolonged bleeding
time, ammonia-like breath, and tremors.
6. What causes anemia in patients with renal failure?
When the kidneys are damaged they do not make enough
erythropoietin so the bone marrow makes fewer red blood cells which
causes anemia.
7. Name three main factors known to cause alteration in calcium
metabolism in chronic renal failure?
High PTH causes high calcium and high phosphorus. Low PTH causes
adynamic bone disease. High phosphorus can cause low calcium.
Vitamin D can increase calcium in the blood by increasing absorption in
the gut. Calcium-based binders can also cause high calcium levels.
8. Name the steps that lead to secondary hyperparathyroidism.
When the kidneys are unable to remove phosphorous from the blood
and unable to produce enough calcitriol this leads to low levels of
calcium in the blood which causes the parathyroid glands to increase
PTH production. The parathyroid glands eventually do not respond
properly to calcium and vitamin D. High PTH levels can lead to
weakening of the bones, calciphylaxis, cardiovascular complications,
abnormal fat and sugar metabolism, itching, and anemia.
9. What is diabetic gastroparesis? Why does this occur in
diabetic patients on dialysis?
Diabetic gastroparesis is delayed gastric emptying. This is possibly due
to the length of dialysis treatment and not being able to eat for
extended periods of time. This can lower blood sugars and cause the
gut to slow down. If eating on dialysis could cause a drop in blood
pressure possibly leading to cardiac arrest.
Answer these questions during your rotation:
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10.
How is fluid allowance determined for patients on
hemodialysis?
This is based on fluid gains and urine output. Generally, patients are
allowed 32-40 oz or 1000-1200 mL/day.
11.
How much weight gain is allowed for hemodialysis
patients between dialysis treatments?
Ideally, 2-3 kg is acceptable. Up to 4 kg is able to be removed during
hemodialysis.
12.
What causes muscle cramping in dialysis patients? What
dietary advice can be given to a dialysis patient to prevent
muscle cramping?
Cramping is caused by too much fluid removal or the rate of fluid
removal being too high trying to remove fluid before the fluid moves
into the vascular space.
13.
What percentage of protein prescribed for renal patients
should be of high biological value?
>50% of protein should be HBV protein.
14.
Why is the diet more liberalized with patients on
peritoneal dialysis compared to hemodialysis?
The diet is more liberalized because they are getting more dialysis
which removes more protein and potassium. PD patients in general do
not need to restrict potassium. Albumin can be low due to protein
removal. Most PD patients still need to use binders.
15.

What can cause itching in renal patients?

High phosphorus and uremia can cause itching.

16.

How is plasma phosphorus levels controlled?

A low phosphorous diet, having good clearance, and using binders

control phosphorous levels.
17.
Why is constipation a common complaint with renal
patients?
It is common because of the fluid restriction, a lower fiber diet, and
using binders.

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18.
What is metastatic calcification? What lab
measurements should be monitored to prevent metastatic
calcification?
Vascular calcification is when blood vessels become rigid due to
calcium deposits. This can affect all organs, cardiac function, and blood
circulation which can cause wounds. Calciphylaxis is a severe
widespread form of calcification with non-healing wounds. The labs
that should be monitored are PTH, calcium, phosphorous, and alkaline
phosphatase.
19.
An elevated alkaline phosphatase level may indicate
what?
Elevated alkaline phosphatase levels indicate bone disease.
20.

What waste products are removed in dialysis?

Fluid, potassium, sodium, phosphorous, urea, and creatinine are

removed.
Renal Worksheet
Medications/Drug Nutrient Interactions
1. Complete table prior to your rotation.

Medication
Amphogel
Aranesp
Chromagen
Citracal
Dialyvite
Diatx
Epogen

Drug Name
aluminum
hydroxide
epoetin alfa
ferrous salts
calcium citrate
N/A
N/A
epoetin alfa

Feosol

ferrous salts

Ferrlecit
Fosrenol

ferrous salts
lanthanum

Hectorol

calcitriol
bismuth
subsalicylate
N/A
N/A
ferrous salts
ferrous salts

Kayexalate
Nephrocaps
Nephrovite
Niferex
Nu-iron
Renal Module

Indication

Oral, IV or
both

antacid; phosphate binder

antianemic
antianemic
antacid; phosphate binder
multivitamin for dialysis
multivitamin for dialysis
antianemic
antianemic; mineral
supplement
antianemic; mineral
supplement
phosphate binder (ERSD)
hyperparathyroid
treatment

oral
IV
oral
oral
oral
oral
IV

antihyperkalemia
multivitamin for dialysis
multivitamin for dialysis
antianemic
antianemic

oral
oral
oral
oral
oral

oral
IV
oral
both

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Oscal
Phoslo
Renagel
(Renvela)
Renax

calcium carbonate
calcium acetate

antacid; phosphate binder

phosphate binder (ESRD)

oral
oral

sevelamer HCl
N/A

phosphate binder (ESRD)

multivitamin for dialysis
calcium regulator; active
vit D
hyperparathyroidism
treatment
antianemic
hyperparathyroidism
treatment

oral
oral

Rocatrol

calcitriol

Sensipar
Venofer

cinacalcet
ferrous salts

Zemplar

calcitriol

both
oral
IV
both

2. Identify possible side effects associated with each of the

following:
a. Phosphate binders anorexia, chalky taste, dry mouth, nausea,
vomiting, abdominal pain, bloating, constipation, flatulence
b. Vitamin D supplements (vit D toxicity) anorexia, weight loss,
increased thirst, dry mouth, metallic taste, nausea, vomiting,
constipation, diarrhea, weakness, ataxia, headache, bone pain,
muscle pain
c. Iron supplements anorexia, nausea, vomiting, dyspepsia,
bloating, constipation, diarrhea, dark stools
d. Calcium supplements flatulence, constipation, bloating
e. Vitamin supplements mild diarrhea, nausea, abdominal pain,
severe: rash, hives, itching, swelling of mouth, face, lips, or
tongue
3. Discuss 3 nutritional implications and/or dietary/medical
recommendations to assure adequate utilization and tolerance
to the following:
a.
b.
c.
d.

Phosphate binders take with meals, take correct dose

Vitamin D supplements take with meals
Iron supplements vitamin C can help absorb
Calcium supplements do not take with meals will not absorb as
well
e. Vitamin supplements do not take more than recommended
Hemodialysis Worksheet
1. Explain in general terms the process of hemodialysis.
Blood is removed through the artery and filtered through a dialyzer
next to a dialysate to remove toxins and fluid and blood is then sent
back to the body through the vein.
2. What factors could influence your interview with the patients
in the out-patient dialysis unit?
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Pyscho-social factors, past medical history, diet history, language

barriers, cultural differences in diet, counseling styles (lack of privacy),
and education level or literacy could influence an interview with
patients.
3. Outline an interview planned with a patient that has a high K
level and needs dietary counseling. List the questions you
would ask and materials you could use.
I would first ask for a diet history to determine if there are any foods
the patient is consuming that are very high in potassium. I would
discuss the importance of consuming a diet low in potassium and
review both high and low potassium foods. I could give them education
materials that list foods high and low in potassium.
4. An elderly patient in the unit shows high weight gains between
treatments for a week now. She lives in a nursing home. What
possible options are available to you to try to correct the
situation?
The dietitian could speak with the nursing home dietitian or staff to
discuss giving the patient less fluid and speak with the patient to
remind them of their fluid restriction.
5. What supplements could you suggest to a patient who is losing
weight and is willing to try your recommendations? Assume
the patient is not diabetic. Why would you recommend each
supplement?
A supplement such as Nepro or LiquaCel for additional calories and
protein may be suggested. Both supplements are calorically dense and
appropriate for dialysis patients. A variety of protein bars may also be
beneficial for the same reasons.
6. Which situation could be potentially more dangerous an
elevated K level or an elevated P level? Why?
Elevated potassium could be more dangerous because the symptoms
are more severe and immediate, such as a heart attack.
Peritoneal Dialysis Worksheet
1. Explain in general terms the process of peritoneal dialysis.
Include the difference between CAPD and CCPD.
In peritoneal dialysis the peritoneal cavity is filled with a dialysate which
also the body to act as a dialyzer to remove toxins. The dialysate is then
emptied out of the peritoneal cavity. CAPD is manual PD which must be
done about four times a day and generally takes about 15 minutes and

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more calories are absorbed from the solution. CCPD is continuous PD
which takes about 8 hours and is done using a machine.
2. List the available concentrations of exchanges used and calculate
the calories provided by each.
Available concentrations are 1.5%, 2.5% and 4.25%. 1.5% provides 51
kcal/L, 2.5% provides 85 kcal/L, and 4.25% provides 145 kcal/L. In CAPD
60-76% of calories are absorbed and in CCPD 40-50% of calories are
absorbed.
3. How is teaching a diabetic patient in this area different than in
the HD unit? Include differences in educational materials used
and influences other than diet that affect blood glucose level.
Glucose absorption from the PD dialysate may contribute to excess caloric
intake, weight gain, and high blood sugars. Possibly recommend low carb
or carbohydrate consistent diet.
4. Patients on PD often complain of early satiety. What suggestions
can you give them?
An appetite stimulant may be appropriate. Small, frequent meals
throughout the day can increase protein-energy intake. Drinking fluids
between meals.
5. A female patient, 66 years old, develops peritonitis and is
admitted to the hospital. She is 52 and weighs 125 lbs.
Calculate her protein and calorie needs (do not include calories
from PD exchanges).
56.8 kg * 30 kcal/kg = 1704 kcal * 1.15 factor for peritonitis = 1960 kcal
56.8 kg * 1.5 g/kg pro = 85 g pro
6. Albumin levels are often low in PD patients. What are some of the
possible causes and what educational plans can you develop for
them?
Albumin levels are often low because PD removes more protein from the
body than HD averaging 8 g/day protein losses. 1.2-1.3 g/kg protein is the
recommended intake. There is also more risk for inflammation or infection.
Educational materials can include high sources and amounts of protein.

Renal Module