Nutritional Management on Renal DiseaseNurpudji A Taslim, Nutrition DepartmentSchool of Medicine Hasanuddin UniversityMakassar 2005

Renal Function1. WASTE FORMATION & HOMEOSTASIS- UREA- REGULATION OF OSMOLALITY AND FLUID- REGULATION OF Na & K- REGULATION OF H+- REGULATION OF Ca & PO4- BALANCED2. PROTEIN EXCRETION METABOLISM3. ENDOCRINE- RENIN SINTHYSIS- ERYTHROPOETIN SINTHYSIS- ACTIVATIONI 25 OH CHOLECALCIFEROL- ADH ACTION- ALDOSTERON

DIAGNOSTIC TEST1. BLOOD- CREATININE- BUN (BALANCED URINE NITROGEN)- CCT (CREATININE CLEARANCE TEST)2. URINALISIS- UUN ( Urea Urine Nitrogen)-PROTEIN ALBUMIN3. VISUAL- IVP (intra venous pyelography)- ARTERIOGRAM- BIOPSI- CT-SCAN-SONOGRAM

KLASIFIKASIGlomerular Nephritic syndromNephrotic syndromTubular & intertitiumARFPyelonephritisOthers : others tubular or intertitiumProgress nature of renal diseaseESRDNephrolithiasisRheumatoid disorder

Patofisiologi inflamationOsteoarthritisRheumatoid arthritisSjogrenSistemac Lupus Erythromatosus

NEPHRITIC SYNDROMGNAGNA --- Inflamasi loop glom kapilerakut, self limitimg, singkat, hematuriainfeksi sal. Nafas atasGNC --- bila berlanjut menjadi kronisCausa: primer: Primer IgA nepphropathy, hereditary nephritissekunder: SLE, Vasculitis, GNA associated endocarditis

Medical nutrition therapyAKUT : a. Antibioticb. Maintain nutrition status--- resolve spontaneouslyc. Reduced protein and Kalium --- uremiad. Reduced natrium---- hipertensi

CLINICAL SYMPTOM : DECREASED OF GRF

NEPHROTIC SYNDROMGNCPatogenesisLoss of glom barrier to proteinHipoalbuminemiaHiperkolesterolemiaHiperkoaguabilityAbnormal bone metabolismeCausa:DM, SLE, AmyloidosisPeny utama pada ginjal

SINDROMA NEPHROTICCLINICAL SYMPTOM: Oedem, hematuri, proteinuria, hipoalbuminemia, azotemia ( NH++ >>), oligouri ( < 600cc).

NUTRITION CARE Energi Range 35 60 /kg BB/hr Protein 0,8 1 gr Fat Moderate Na+ ModerateK Monitoring --- Hipokalemia

GOALMAINTAIN OPTIMAL NUTRITIONMAINTAIN NUTRITIONAL STORESMINIMIZE DISEASE METABOLISMPREVENT PROGRESSIVITAS OF DISEASESLOW DIALYSIS OCCURANCE

high protein diet --- increasedurinary losess (Mitch, 1996)

ACUT RENAL FAILURECausa : Sudden reduction in GFR Renal shockdown ----- trauma or bleeding Decreased ability to excrete the daily product of metabolic waste Clinical symptom:a. Diuretic Phase : prod urine 450 ccb. Oligourie phase ( 7-12 hr)uremiaHigh level of K, Mg and Phospat Low level of Na, Calciumacidosis

Medical nutrition therapyManage for: uremia, metabolic acidosis, imbalanced fluid and electrolyteMolina (95)Early nutritional intervention --- positive affect patient survivalProteinPN --- in case of vomiting and diarrheaCHO--- not effective--- decreased breaking of protein 50%Mixed CHO, lipid and AA --- prevent catabolism of proteinProtein --- 0,5 0,8 gr/KgBB/hrDialysis--- 1-2gr /KgBBKaliumEspecially---dialyses patientsMonitoring KGlucose, insulin, bicarbonate ---- K inside cell

CHRONIC RENAL FAILURECausa : Chronic infectionProgressif glomerolus diseasesChronic Hipertension Nefrophaty DMHidronefrosis BilateralAnalgesic drug (Phenacetine)

Symptom : uremiaAcid-base unbalanced Electrolyte unbalanced

Clinical : anemia, anxiety, lose weight, pain (bone, joint), hypertension

Standard Nutrition Assessment on CRFParameter Normal ModerateSevere Dry weight % RBW 85-95 75-85 < 75

TSFmen4-6

Renal Failure DietGOAL1. ADEQUATE FOOD, NOT MAKE HEAVIER RENAL FUNCTION2. DECREASED OF UREUM & CREATININ LEVEL3. MINIMIZED SALT RETENSION

REQUIREMENT1. HIGH Biologi value of Protein2. Limitation of Salt ( Heavy HT, >> K, edema, Oligo /anurie)3. Limitation of K (Glom function or prod urine > fluid

Others Tubular & Intertitial disease 1. Chronic Intertitial NephritisCause: Analgesic abuse, Sickle cel anemia, DM, Vesico urethral refluxTherapy:Increased fluid intake2. Fanconis SyndromIn ability to re-absorbsi proper amount of glucose, AA, phospate, bicarbonate in proximal tubulus

ANAKPolyurieRickettsGrowth retardationvomitingGEJALAAcidosisHipokalemiaPolyurieOsteomalacia

GEJALA KLINIK

PYELONEPHRITISInfection bacteria at the kidneyAvorn et al (94) & Hovell et al (98)Therapy cranberry or blueberry juice will decreased bacteria

SJOGRENS SYNDROMTabara & vara-Cristo,2000, Chronic inflammatory disorder, characterized by poly-glandular tissue destructions leading to: KeratoconjunctivitisDiminished prod of tears and salivaXerostomiaxeropthalmia

Dietary ManagementRelief of symptoms and eating discomfortLack of appetite, weight loss, fatigue, difficulty chewing and swallowing Ready-to-eat foodSweetened lemon dropsIron, B12 and folate as well balance diet (Lundstom and Lindstom,2001)

SCLERODERMAEscott-Stump,2002, Is a progressive characterized by deposition of fibrous connective tissue in the skin and visceral organs, including GITOne of manifestation of sclerodermaRaynauds Syndrome (ischemia or coldness in the small extremitiesfinger--- difficulty preparation and consumption of mealGIT symptoms , weight loss, renal dysfunction & multiple organ system dysfunction my result

Medical ManagementDisease is rogessive and current treatment produces are cureSide effects may results as discussion above

Medical Nutrition TherapyDysphagiaMalabs of lactose, vit, FA, mineralsNeed high Energy, high protein through NGF as a supplement PN diarre persistent

SYSTEMIC LUPUS ERTHEMATOSUS (SLE)Etiologi tdk jelasA genetic predispositionGenetic marker HLAHuman leukocyte AgPresence of anti-DNA abEnvironmental factors viral infectionPrevalence women and childbearing age in Americans and Caucasians1954 survival rate 50%, today 97%25% DEVELOPS SJOGRENS SYNDROM

MEDICAL MANAGEMENTSLE autoimmune diseaseaffects all organ system

Steroidused as therapy affect nutrient metabolism, needs and excretion

Renal function is deranged exessive excretion of protein, Na, fluid, calcium

DRUGTHERAPYCorticosteroid alter of protein, Na, fluid, calcium needPlaquenil ( antimalaria) effective in clearing upskin lessions ( SEnausea,cramping abd, diarrhea)Immunosuppresantazathioprine---in the event of brain or renal involment, but GIT effects may occur

MEDICAL NUTRITION THERAPYNo specific dietary guidelinesDiet based on individual needPrioritiessequelae of disease and pharmacologic effects on organ function and nutrition metabolismRestricted---sodium and fluids intakeLimitationsfat intakeLeiba et al (2001)--- protein, calorie and diet low in fat---reduction in immune-complex deposition in the kidney and protein urie and may prolong the lifespan

Diet VariationLOW PROTEIN DIET I : 20 gr - CCT 5-20 cc/, ureum 100 mg

2. LOW PROTEIN DIET II 40 gr - CCT 20 30 cc/, Konservatif

3. LOW PROTEIN DIET III60 gr - CCT 30-50 cc/, MILD CRF

PROTEIN LIMITATION BASED ON GFRGFRPROTEIN ALLOWANCEcc/menitg/dayg/kgBB/day

>25 no restriction no restriction20-2560-90 1.315-2050-70 1.010-1540-55 0.7 5-10 40 u/ pria 0,5-0,6 35 u/ wanita

MONITORING PROTEIN HOMEOSTASIS1. Based on renal damaged indicator higher / lower of muscle mass loss

2. Creatinine clearanceGfr renal damaged low creatinin clearance pada renal failure level of creatine serum high

3. SUN (SERUM UREA NITROGEN) OR BUN indicator of renal functionStabil PROTEIN DIETSUN increased increased PROTEIN INTAKE. Dehidrasion / catabolic state ( operasi, burn, infection, fracture drug catabolic: steroidLEVEL 60- 80 mg/dl ACCEPTABLE> 80 uremia< 40 malnutrisi4. Urea clearance filtration capability

NUTRITION CARENUTRIENT OLIGOURIE DIURETIC

1. ENERGY 40-55 kcal/kg 40-55 kcal/kg (High in trauma) (high in trauma) 2. CHO 50-70%- Need supplement-3. PROTEIN 0,5g/kg 80% HBV 0,8 g/ kg or more 1-1,5 g/kg dialysis If fasting4. Fluid + 500 cc increasing as needed5. Na + 500-1000 mg/d replace losses6. K+ 1000 mg/d replace losses7. Fat = dialysis = dialysis

Progresivitas of Diseases (CRF)STAGE % LOST GFR (cc/min)

1. Decreased 55% 55-125 renal reserve

2. Renal Insuficiency 80% 30-55

3. Renal Failure90% 12,5-30

4. Uremia / uremia >90% < 12,5 syndrome (ESRD)

OPTIONS- THERAPY OF ESRD

CONSERVATIF MANAGEMENT

2. DIALYSIS A. HEMODIALISISB. PERITONEAL-DIALISIS

3. TRANSPLANTASION

KONSERVATIF MANAGEMENTLIMITATION SYMPTOM

PREVENT IRREVERSIBLE RENAL DAMAGED

3. MAINTAIN OF HEALTH BEFORE DIALYSIS OR TRANSPLANTASION

TYPE OF DIALYSIS

A. HEMODIALYSBY MACHINE ( venous )3-4 hours /d, 3 4 x week

B. PERITONEAL DIALYSIS Intermittent ( IPD)Continous ambulatory ( CAPD)Continous Cyclic

NUTRITION MANAGEMENT ON RENAL TRANSPLANTASIONADEQUATE FOODCHO 40 50 % FROM TOTAL CALORIESPROTEIN 1.2- 1.5 gr ADJUST TO NORMAL LEVEL (LAB AND ELECKTROLYT BALANCE)LIMITATION OF Na+ 2 - 4 gr / dayK+ AS NEEDED

RENAL STONECausa:1. Environment Factor2. Tractus Urogenitalia 3. Matrix Organik stone

A. ENVIRONMENTAL FACTOR1. CALSIUM ( 96%)N eksresi 100 175 mghipersecresion : high intake Ca, high Vit.Dlong imobilisasion, hiperparathyroidrenal tubular asidosis, high calsiurie idiopatik2. CYSTEIN ( herediter )

B. TRACTUS UROGENITAL CHANGED OF URINE PHYSICALLY

CHANGED OF URINE CONCENTRATION

CHANGED OF URINE BALANCED

C. MATRIX BATU ORGANIK RECURRENT INFECTION DEFICIENCY OF VITAMIN A( DESQUAMATION OF CEL EPITHEL) DOT CALCIFICATIONRANDALLS PLAQUE

CLINICAL SYMPTOMSKOLIK, DEMAM, LEMAHTHERAPY1. High fluid2. Change pH from acid --- alkalis3. Elimination food contain nutrient--- contribute to stone development 4. Binding agent ecretion through fesese.g. sodium phytate --- for calsiumaluminium gel --- for phosfatGlycine --- for oksalat

THERAPY

Susunan Kimia Modifikasi zat Gizi Diet Ash1. Calsiumlow calsium acid ashPhospatlow phospatOxalatlow oxalat

2. As. Urat low purine alkaline ash

3. Cystinelow methionine alkaline ash

VARIATION DIET

1. LOW CALCIUM HIGH ASH CAID

2. HIGH DIET ASH ALKALIS

3. LOW PURINE DIET

LOW CALCIUM DIET HIGH ASH ACID FLUID > 2500 cc/day Low calcium Limitation food intake contains: PROTEIN : milk, cheese, schrimp, crab, rilis, salt fish, sarden, animal brain, ren, liver, cor CHO : potatoes, sweet potatoes, cassava, biscuit, cake contain milk VEGETABLE : Spinach, mangkok leaf, melinjo leaf, papaya leaf, lamtoro leaf, cassava leaf, talas (taro) leaf, d.katuk leaf, kelor leaf, jtg pisang, melinjo, sawi, leunca FRUITS : All Fermented Fruits OTHERS : SOFT DRINK contains soda, alcohol, coclate, yeast

HIGH DIET ASH ALKALIS

Especially for Cysteine stone and Uric acid

1. Fluid > 2500 cc/day

2. Low AA (contain Sulfur)

3. Vegetables < 300 gr/day

4. Fruit < 300 gr/day