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MNT for the CKD Patient Complicated by a Pressure Ulcer. Stephanie Ruel Sodexo/St. Joseph’s Medical Center. Abstract. Controversy of recommendations Studies: Inconclusive or inadequate. Introduction. Anatomy and Physiology Etiology and pathology Medical management

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mnt for the ckd patient complicated by a pressure ulcer

MNT for the CKD Patient Complicated by a Pressure Ulcer

Stephanie Ruel

Sodexo/St. Joseph’s Medical Center

  • Controversy of recommendations
  • Studies: Inconclusive or inadequate
  • Anatomy and Physiology
  • Etiology and pathology
  • Medical management
  • Medical Nutrition Therapy
  • The Patient
  • Conclusion
  • Future studies
  • Recommendations
anatomy physiology of the kidneys
Anatomy & Physiology of the Kidneys


  • Metabolic waste removal
  • Electrolyte balance
  • Fluid balance
  • Blood pressure control
  • pH regulation
  • Plasma volume and osmolality
  • Glucose homeostasis
  • Hormone secretion (erythropoietin)
  • Carnitine synthesis
  • Afferent arteriole
  • Glomerulus
  • Bowmans’s capsule
  • Proximal tubule
  • Efferent arteriole
  • Peritubular capillaries
  • Renal vein

Proximal tubule

physiology electrolyte balance
Physiology: Electrolyte Balance
  • Glomerulus: Selective permeability
  • Ultrafiltrate
  • Selective resportion and excretion
physiology electrolyte balance1
Physiology: Electrolyte Balance

TubuleEfferent arteriole

= fluid homeostasis


physiology fluid balance
Physiology: Fluid Balance

Two main systems:

  • Vasopressin
  • Renin-angiotensin aldosterone system (RAAS)

↑Blood osmolality or ↓blood pressure


Pituitary gland

Kidney ↑blood pressure

↓blood osmolality


renin angiotensin a ldosterone s ystem
Renin-Angiotensin Aldosterone System

↓blood pressure



Angiotensin I

Angiotensin II

Adrenal Aldosterone

↑blood pressure




etiology pathology1
Etiology& Pathology
  • Diabetes
  • Hypertension
  • Family history
  • Ethnicity
  • Autoimmune disease
  • Infection
  • Severe dehydration
  • Acute renal failure (ARF)
diabetic nephropathy
Diabetic Nephropathy


of new CKD diagnoses caused by diabetes


↑blood glucose afferent arteriole dilation

altered hemodynamic regulation

↑blood flow to glomerulus

Hypertrophy damage to podocytes

Hyperfiltration and mesangial cells


altered permeability

of glomerulus



Inflammatory mediators

Proinflammatory cytokines

Oxidative stress




Kimmelstiel-Wilson lesions



  • Hypertension:

Systolic >140mm Hg


Diastolic >90mm Hg

  • Prehypertension:

121/81mm Hg – 139/89mm Hg

  • Normal blood pressure:

<120/80mm Hg

  • Cause and effect
  • Blood vessel remodeling
  • Inflammation
  • Oxidative stress
  • Arteriosclerosis
hyaline arteriosclerosis
Hyaline Arteriosclerosis
  • Endothelial lesions in blood vessels caused by buildup of hyaline
  • Decreased action of smooth muscle cells
  • Inhibited autoregulation
  • Ischemic tubulointerstitial injury
dietary protein
Dietary Protein

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



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

antihypertensive therapy
Antihypertensive Therapy
  • Hypertension: 80-85%
  • Angiotensin Receptor Blockers (ARBs)
  • Angiotensin Converting Enzyme (ACE) Inhibitors
  • Diuretics
blood pressure control raas
Blood Pressure Control/RAAS
  • Albuminuria >300mg and all diabetic CKD (without hypertension)
    • ARBs
    • ACE Inhibitors
  • Albuminuria <30mg and BP >140/90mm Hg
    • Target BP <140/90mm Hg
  • Albuminuria >30mg, BP >130/80mm Hg
    • Target BP <130/80mm Hg
improving cardiovascular health
Improving Cardiovascular Health
  • Highest risk category for development of cardiovascular disease (CVD)
  • CVD as cause of death before end-stage renal disease (ESRD) and dialysis
  • Statins
glycemic control
Glycemic Control
  • Target HbA1C ~7.0%
    • Hypoglycemia risk
  • Medication and lifestyle modification
overview of additional complications
Overview of Additional Complications
  • Metabolic Bone Disease
    • Parathyroid hormone (PTH)
    • Calcium
    • Phosphorus
  • Potassium
  • Metabolic acidosis
  • Anemia
non pharmacological interventions
Non-pharmacological Interventions
  • Smoking cessation
  • Physical activity
    • Weight management
    • Functional capacity
new medication and treatment
New Medication and Treatment
  • Allopurinol
  • Avosentan
  • Mesenchymal stem cells
renal replacement therapy
Renal Replacement Therapy
  • GFR <10ml/min/1.73m2
  • Symptoms:
    • Electrolyte abnormalities
    • Acid-base disturbance
    • Uncontrolled BP and fluid balance
    • Uremia
    • Cognitive impairment
    • Decline in nutritional status
  • Dialysis
renal transplant
Renal Transplant
  • Treatment of choice
  • Earlier decision:
    • GFR <20ml/min/1.73m2
    • Irreversible progression for 6-12 months
  • Impact:
    • Reduction of dietary restrictions
    • Delays or eliminates need for dialysis
    • Medications to prevent rejection = ↓immunity
anatomy physiology of the integumentary system
Anatomy & Physiology of the Integumentary System


  • Conduct sensory data to the brain via nerve endings located in the skin
  • Protect the body
  • Regulate body temperature
  • Synthesize vitamin D
  • Store energy and water
development of pressure ulcers
Development of Pressure Ulcers

Injury to the skin and/or underlying tissue as a result of pressure, friction, shear, or ischemia

Risk factors:


Poor perfusion of blood supply




Nutrition status


inflammasome activity
Inflammasome Activity
  • Inflammasomes in kertinocytes
  • Activation of inflammatory cytokines
  • Danger signals and wound healing
  • Youth vs. Aging
prevention care
Prevention & Care
  • Risk assessment (Braden Scale score)
  • Proper positioning and rotation
  • Support surfaces
  • Pain management
  • Infection management
  • Wound cleansing
  • Debridement
  • Dressings
  • Biophysical agents
nutrition care process
Nutrition Care Process






  • Multidisciplinary
  • Anthropometrics
  • Medical and social histories
  • Medications
  • Analysis of laboratory values
nutrition assessment for ckd
Nutrition Assessment for CKD
  • Diet and diet history
  • Nutrition status
  • Comorbid conditions
  • Lab values of BUN, potassium, phosphorus, albumin, urinalysis
  • Assess for education needs
mnt for hypertension and diabetes
MNT for Hypertension and Diabetes

Diabetes: glycemic control through consistent-carbohydrate diabetes meal planning


the role of dietary protein
The Role of Dietary Protein
  • 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
monitoring evaluation
Monitoring & Evaluation
  • Comprehension of and adherence to dietary recommendations
  • Maintenance of ideal body weight
  • Blood glucose control
  • Blood pressure control
  • Normalization/improvement of nutrition-related laboratory values
nutrition assessment for pressure ulcers
Nutrition Assessment for Pressure Ulcers
  • Dietary intake as related to needs
  • Staging of pressure ulcer and changes in stage/healing
  • Usefulness of laboratory values
  • Unintentional weight changes
  • Mobility assessment
  • Assess for education needs
  • Additional risk factors/comorbid conditions
nutrition prescription for pressure ulcers
Nutrition Prescription for Pressure Ulcers

Based on limited, small studies and expert opinion:

the role of dietary protein1
The Role of Dietary Protein
  • Necessity of protein in tissue-building
  • Ability of body to utilize protein in wound-healing
  • Nitrogen loss in wound exudate
  • Attaining a positive nitrogen balance
  • Protein as energy in catabolism
monitoring evaluation1
Monitoring & Evaluation
  • Achievement of ideal body weight/weight maintenance
  • BMI
  • Evidence of wound healing
  • Adequate nutrient intake
  • Adequate hydration
  • Comprehension/knowledge of nutrition recommendations
patient summary
Patient Summary
  • 88 year old Caucasian female
  • Admitted for altered mental status and dehydration
  • PMH: CKD stage 3-4, HTN, diverticular disease, dementia
  • Braden Scale score: 9 (high risk)
  • Upper and lower coccyx stage III pressure ulcers
  • Poor oral intake and deteriorating mobility x 3 months
patient summary1
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 obesity
  • Dysphagia evaluation: severe oropharyngeal dysphagia with purees and thickened liquids; high risk for airway obstruction
    • Recommendation: NPO, aggressive oral care for secretions
medical management2
Medical Management
  • Diagnosis: sepsis of urinary source, acute on chronic renal failure secondary to dehydration, likely aspiration pneumonia
  • Patient confused and lethargic
  • +bowel sounds, no edema
  • Chest x-ray: bibasilar infiltrates, left pleural effusion
  • +Urine culture: E.coli
  • +Blood culture: S.capitus
medical management3
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 management4
Medical Management
  • Feeding withheld until rehydration and electrolyte balance achieved
  • Poor venous access
  • Oral secretions, congestion, high aspiration risk – no nasogastric tube inserted for feeding or medication administration
  • Care for pressure ulcer poorly documented
nutrition assessment
Nutrition Assessment

High nutritional risk

  • Energy needs: 30-35kcal/kg adjusted body weight (BW) = 1800-2100kcal/day
  • Protein 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 diagnosis
Nutrition Diagnosis

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 goals
Nutrition Goals
  • Patient will meet >75% energy needs via appropriate route within 3 days.
  • Patient will receive restricted dietary protein until ARF resolved (protein to be increased to promote wound healing once ARF resolved)
nutrition interventions
Nutrition Interventions
  • 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.
  • Free H2O autoflush30ml/hr (total free H2O 1463ml); adjust IVF prn, additional fluids per MD
  • Will follow for updated TF recommendations once ARF resolved
  • 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 monitoring evaluation
Nutrition Monitoring & Evaluation
  • Initiation of TF
  • Advancement of TF to goal rate
  • Tolerance of TF
  • Nutrition-related labs
  • Wound/skin status
critical comments
Critical Comments
  • 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 communicated
  • No attempts were made to place NGT


  • 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
future study
Future Study
  • 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
  • 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