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Nutrition in Kidney Diseases Nutrition in Kidney Diseases

Functions of KidneyFunctions of Kidney

Excrete waste materialExcrete waste material: end products of : end products of protein metabolism (urea, uric acid, protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and water and nutrients, dead renal cells, and toxic substancestoxic substances

Electrolyte balanceElectrolyte balance

Hormonal regulationHormonal regulation

Blood pressure regulationBlood pressure regulation

Glucose homeostatisGlucose homeostatis

ETIOLOGYETIOLOGY

Diabetes mellitus (28%)Diabetes mellitus (28%) Hypertension (25%)Hypertension (25%) Glomerulonephritis (21%)Glomerulonephritis (21%) Polycystic Kidney Diease (4%)Polycystic Kidney Diease (4%) Other (23%): Obstruction, infection, etc.Other (23%): Obstruction, infection, etc.

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Diabetes50%

Hypertension27%

Glomerulonephritis13%

Other10%

Primary Diagnoses for Primary Diagnoses for Patients Who Start DialysisPatients Who Start Dialysis

United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG

www.hypertensiononline.org

Chronic Renal FailureChronic Renal FailureDevelops slowly, number of functioning nephrons Develops slowly, number of functioning nephrons constantly diminishing.constantly diminishing.

Uremia is a resultUremia is a result

Symptoms:nausea, headache, coma, convulsions. Symptoms:nausea, headache, coma, convulsions.

Severe renal failure will result in death unless Severe renal failure will result in death unless dialysis used.dialysis used.

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Clinical pathophysioloyClinical pathophysioloy

Metabolic acidosis: result in;Metabolic acidosis: result in;– Muscle breakdown Muscle breakdown – Bone dissolving Bone dissolving

Hyperkalemia Hyperkalemia Hypertension Hypertension Negative N balanceNegative N balance Insulin resistanceInsulin resistance HyperphosphatemiaHyperphosphatemia Anemia Anemia

Progression of chronic renal failureProgression of chronic renal failure

Factors causing progressionFactors causing progression sustaining primary diseasesustaining primary disease systemic hypertensionsystemic hypertension Intraglomerular hypertensionIntraglomerular hypertension ProteinuriaProteinuria NephrocalcinosisNephrocalcinosis DyslipidaemiaDyslipidaemia Imbalance between renal energy demands Imbalance between renal energy demands

and supplyand supply

CRFCRF

Reversible factors in CRFReversible factors in CRF HypertensionHypertension Reduced renal perfusion (renal artery stenosis, Reduced renal perfusion (renal artery stenosis,

hypotension , sodium and water depletion, poor hypotension , sodium and water depletion, poor cardiac function)cardiac function)

Urinary tract obstructionUrinary tract obstruction InfectionInfection Nephrotoxic medicationsNephrotoxic medications Metabolic factors(calcium phosphate products Metabolic factors(calcium phosphate products ))

Slowing the Progression of Chronic Slowing the Progression of Chronic Renal FailureRenal Failure

Control BP to <130 /80Control BP to <130 /80 DietDiet AnaemiaAnaemia Calcium and PhosphateCalcium and Phosphate DyslipidaemiaDyslipidaemia ObesityObesity Smoking CessationSmoking Cessation

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Dietary Treatment of Renal DiseaseDietary Treatment of Renal Disease

Extremely complicated.Extremely complicated.Intended to reduce the amount of excretory work Intended to reduce the amount of excretory work demanded of the kidneys while helping them demanded of the kidneys while helping them maintain fluid, acid-base, and electrolyte balance.maintain fluid, acid-base, and electrolyte balance.In CRF may have protein, sodium, potassium In CRF may have protein, sodium, potassium and phosphorus restricted.and phosphorus restricted.

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Dietary Treatment of Renal DiseaseDietary Treatment of Renal Disease

Sufficient calories necessary: 25 to 50 kcal per Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight.kilogram of body weight.Energy requirements should be fulfilled by Energy requirements should be fulfilled by carbohydrates and fat.carbohydrates and fat.Protein increases the amount of nitrogen waste Protein increases the amount of nitrogen waste the kidneys must handle.the kidneys must handle.Diet may limit protein to 40 grams( at least 0.5 Diet may limit protein to 40 grams( at least 0.5 g/kgg/kg ) based on glomerular filtration rate and weight.) based on glomerular filtration rate and weight.

CRFCRF

Diet therapyDiet therapy Protein restriction (0.5-0.8mg/kg/d)Protein restriction (0.5-0.8mg/kg/d) Adequte intake of calories(30-35kcal/kg/d)Adequte intake of calories(30-35kcal/kg/d) Fluid intake:urine volume +500mlFluid intake:urine volume +500ml Low phosphate diet(600-1000mg/d)Low phosphate diet(600-1000mg/d) Supplement of EAA(ketosteril)Supplement of EAA(ketosteril)

FluidFluid Unrestricted until urine output declinesUnrestricted until urine output declines Urine output plus 1000 cc/dUrine output plus 1000 cc/d

Evaluate effect on blood pressure andEvaluate effect on blood pressure and

cardiac functioncardiac function

SodiumSodium SodiumSodium 2-4 g/d (43 mEq = 1 g)2-4 g/d (43 mEq = 1 g) Variable with urine output and disease Variable with urine output and disease

etiologyetiology

Evaluate effect on hypertension control and Evaluate effect on hypertension control and cardiac functioncardiac function

PotassiumPotassium

Accumulates in CKD stage 5Accumulates in CKD stage 5 Hyperkalemia →cardiac dangerHyperkalemia →cardiac danger Restrict to 2-4g/d (26 mEq=1g)Restrict to 2-4g/d (26 mEq=1g)

Hyperkalemia & EKGHyperkalemia & EKG K > 5.5 -6K > 5.5 -6 Tall, peaked T’sTall, peaked T’s Wide QRSWide QRS Prolong PRProlong PR Diminished PDiminished P Prolonged QTProlonged QT QRS-T merge – sine QRS-T merge – sine

wavewave

Hyperkalemia SymptomsHyperkalemia Symptoms WeaknessWeakness LethargyLethargy Muscle crampsMuscle cramps ParesthesiasParesthesias Hypoactive DTRsHypoactive DTRs DysrhythmiasDysrhythmias

Nutrition Implications of ARFNutrition Implications of ARF

ARF causes anorexia, nausea, vomiting, ARF causes anorexia, nausea, vomiting, bleedingbleeding

ARF causes rapid nitrogen loss and lean ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism)body mass loss (hypercatabolism)

ARF causes ARF causes ↑ gluconeogenesis with insulin ↑ gluconeogenesis with insulin resistanceresistance

Dialysis causes loss of amino acids and Dialysis causes loss of amino acids and proteinprotein

Uremia toxins cause impaired glucose Uremia toxins cause impaired glucose utilization and protein synthesisutilization and protein synthesis

Treatment Goals for Treatment Goals for Renal Failure Renal Failure

Correct electrolytesCorrect electrolytes Control acidosisControl acidosis Treat significant hyperphosphatemiaTreat significant hyperphosphatemia Treat symptomatic anemiaTreat symptomatic anemia Initiate dialysis for hyperkalemia or acidosis not Initiate dialysis for hyperkalemia or acidosis not

controlled, fluid overload, controlled, fluid overload, ↑ in BUN>20 mg/dl/24 ↑ in BUN>20 mg/dl/24 hours or BUN>100 mg/dlhours or BUN>100 mg/dl

Evaluate drugs for renal effectEvaluate drugs for renal effect Avoid/treat infectionAvoid/treat infection

Vitamins in ARFVitamins in ARF

Vitamin A: elevated vitamin A levels are known Vitamin A: elevated vitamin A levels are known to occur with RFto occur with RF

Vitamin B – prevent B6 deficiency by giving 10 Vitamin B – prevent B6 deficiency by giving 10 mg pyridoxine hydrochloride/daymg pyridoxine hydrochloride/day

Folate and B6: supplement when homocysteine Folate and B6: supplement when homocysteine levels are highlevels are high

Vitamin C: <200 mg/day to prevent Vitamin C: <200 mg/day to prevent ↑ oxalate↑ oxalate Activated vitamin DActivated vitamin D Vitamin K: give Vitamin K especially to pts on Vitamin K: give Vitamin K especially to pts on

antibiotics that suppress gut production of Kantibiotics that suppress gut production of K

Minerals in RFMinerals in RF

↑ ↑ potassium, magnesium, and phos occur potassium, magnesium, and phos occur often due to ↓ renal clearance and ↑ protein often due to ↓ renal clearance and ↑ protein catabolismcatabolism

↓ ↓ potassium, mg and phos can occur with potassium, mg and phos can occur with refeedingrefeeding

CRRT pts can have ↓ K+, phosCRRT pts can have ↓ K+, phos Mg deficiency can cause K+ deficiency Mg deficiency can cause K+ deficiency

resistant to supplementationresistant to supplementation Vitamin C, copper, chromium lost with CVVHVitamin C, copper, chromium lost with CVVH

Fluid in ARFFluid in ARF

Depends on residual renal function, fluid Depends on residual renal function, fluid and sodium status, other lossesand sodium status, other losses

Usually 500 mL/day + urine outputUsually 500 mL/day + urine output

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Target Lipid LevelsTarget Lipid Levels

BestBest BorderlineBorderline

Chol Chol <200 gm/dl<200 gm/dl 200-239200-239

LDLLDL <100<100 100-159100-159

HDLHDL >40>40 <40<40

TGTG <150<150 150-159 150-159

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DialysisDialysis

Done be either hemodialysis or peritoneal dialysis.Done be either hemodialysis or peritoneal dialysis.

Hemodialysis requires permanent access to the Hemodialysis requires permanent access to the bloodstream through a fistula.bloodstream through a fistula.

Hemodialysis is done 3 times a week for 3-5 hours Hemodialysis is done 3 times a week for 3-5 hours at a time.at a time.

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DialysisDialysis

Peritoneal dialysis makes use of the peritoneal Peritoneal dialysis makes use of the peritoneal cavity.cavity.

Less efficient than hemodialysis.Less efficient than hemodialysis.

Treatments usually last about 10 to 12 hours a Treatments usually last about 10 to 12 hours a day, 3 times a week.day, 3 times a week.

Complications include peritonitis, hypotension, Complications include peritonitis, hypotension, weight gain.weight gain.

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Diet During DialysisDiet During Dialysis

Dialysis clients may need additional protein.Dialysis clients may need additional protein.Amount must be carefully controlled.Amount must be carefully controlled.

Hemodialysis: 1.0 to 1.2g/kg of protein to make up Hemodialysis: 1.0 to 1.2g/kg of protein to make up for losses during dialysis.for losses during dialysis. Peritoneal dialysis: 1.2 to 1.5g/kg protein. Peritoneal dialysis: 1.2 to 1.5g/kg protein.

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Diet During DialysisDiet During Dialysis

75% of this protein should be high biological value 75% of this protein should be high biological value (HBV) protein, found in eggs, meat, fish, poultry, (HBV) protein, found in eggs, meat, fish, poultry, milk, and cheese.milk, and cheese.

Potassium is usually restricted.Potassium is usually restricted.

A typical renal diet could be written as “80-3-3” A typical renal diet could be written as “80-3-3” which means 80g protein, 3g sodium, and 3g which means 80g protein, 3g sodium, and 3g potassium daily.potassium daily.

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