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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

Diabetic nephropathy glomerular anatomy
Diabetic NephropathyGlomerular Anatomy



↑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