Diseases of the Renal System - Cengage fileDiseases of the Renal System ... 1.2 million in each kidney 9Glomerulus within Bowman’s capsule •Afferent arteriole – carries blood

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© 2007 Thomson - Wadsworth

Diseases of the Renal System

Chapter 20

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Kidneys - Anatomy

• Regulatory and metabolic functions• Nephron - functional unit; approx.

1.2 million in each kidneyGlomerulus within Bowman’s capsule• Afferent arteriole – carries blood to

glomerulus• Efferent arteriole - carries blood from

glomerulus

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Kidneys - Anatomy

• Nephron – Tubules – see Fig. 20.2Proximal convoluted tubuleLoop of HenleDistal convoluted tubuleColleting duct

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Kidneys - Anatomy

• NephronUltrafiltrate formed by glomerulus• Similar to composition of blood• Filters large proteins and blood cells• Modified by tubules

– Reabsorption of amino acids, glucose, select minerals, water

– Secretion of solutes, water

• 65% of filtered sodium and water reabsorbed (active transport in proximal tubule)

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Kidneys - Anatomy

• Nephron - functionsMaintain extracellular environment for cell functionExcretion of waste products of metabolismMaintain fluid, electrolyte and acid-base balance• Vasopressin – in response to blood

volume, maintains fluid balance

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Kidneys - Anatomy

• Nephron - functionsSecretion of hormones that modulate hemodynamics• Erythropoietin - red blood cell production• Vitamin D – bone metabolism

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The Kidneys

• Diagnostic ProceduresGFR - glomerular filtration rate; rate at which substances are cleared from plasma• normal 135-180 L/day

Clearance calculations – see p. 613Tubular function testsMicroscopic evaluation of the urineRadiologic evaluation (IVP, MRI, ultrasound)Biopsy

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Nephrotic Syndrome

• Deficiency of albumin in blood and its excretion in the urine d/t altered glomerular function – large-molecule proteins and RBCs “leak” into urine

Proteinuria >3.5HyperlipidemiaHypoalbuminemia

• Result of underlying diseaseMore prevalent in children

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Nephrotic Syndrome

• Clinical ManifestationsFrothy urineAnorexia, malaise, puffy eyelids, abdominal pain, muscle wastingAnascarca with ascites, plural effusionAltered blood pressureOliguria d/t hypovolemiaEdemaLoss of zinc, copper, vitamin D; iron bound to proteins lost

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Nephrotic Syndrome

• TreatmentTreat underlying causeReduce cholesterolControl blood pressureReduce protein in urineACE inhibitors and ARBsCheck potassium levels

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Nephrotic Syndrome

• Nutrition TherapySee Table 20.1 Control intake of protein• .8-1.0 g/kg/day• Soy- or flaxseed-based proteins • Protein supplementation no benefit

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Chronic Kidney Disease (CKD)

• Syndrome in which progressive loss of kidney function occurs

Not reversibleProgression to end-stage renal disease (ESRD or CKD stage 5)Renal replacement therapy or transplantRequires medication and specialized diet

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• Risk factors ProteinuriaEthnicity – African American with diabetes highestGender – males SmokingHeavy consumption of non-narcotic analgesicsObesity ???

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• Most frequent causesDiabetesHypertensionGlomerulonephritisHereditary and cystic congenital renal diseaseInterstitial nephritisNeoplasm/tumor

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• Common complicationsMalnutritionCVD – aggressive management recommendedBone and mineral disordersAnemia

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• Stages – see Table 20.2Stages 1 & 2 – kidney damage with:• Normal or increased GFR, mild decrease

in GFRStage 3• Moderate decrease: GFR 30-59 mL/min

Stage 4• Severe decrease: GFR 15-29 mL/min

Stage 5• Inadequate to sustain life

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• PathophysiologyAdvanced impairment in control of fluid and electrolyte balance •Uremia, hyperphosphatemia, azotemia, oliguria

•Kidney function < 15 mL/min–Sodium retention, edema,

hypertension–Metabolic acidosis–Hyperkalemia

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• PathophysiologyMicrocytic anemia and iron deficiency• Inadequate erythropoietin

Renal osteodystrophy• d/t impaired intestinal calcium absorption

and secondary hyperparathyroidism

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• TreatmentTreat underlying disease, delay progressionStages 1 & 2 – EPO replacement, vitamin D supplementationStage 5 – renal replacement therapy, nutrition therapy crucial, transplantPost transplant – immunosuppresants

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• Renal Replacement Therapy - Dialysis –removal of excessive and toxic by-products of metabolism from the blood, replacing the filtering function of the kidney

Fluid and electrolyte balance must be maintainedPassing blood across selective membrane exposed to rinsing fluid (dialysate)

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CKD - Renal Replacement Therapy

• Serum creatinine 6 mg/dL for non-diabetics or

• Creatine clearance < 15 mL per minute for diabetics

• Definite indicators:Pericarditis, uncontrolled fluid overload, pulmonary edema, uncontrolled and repeated hyperkalemia, coma, lethargy

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• Hemodialysis (HD) or Peritoneal Dialysis (PD)

Type based on underlying kidney disease and co-morbid factorsSee Box 20.4 - role of health teamBoth require selective, permeable membrane• Allows passage of water and small

molecules• Excludes larger molecules such as protein

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• Hemodialysis (HD)Membrane is manmade dialyzer –“artificial kidney”See Fig. 20.5, 20.7Preferred access site – AVF, AVG Typical regimen• 3 days/week for 4 hrs/treatment

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• Peritoneal dialysis (PD)Lining of patient’s peritoneal wall is the selective membrane – see Fig. 20.6Types• CAPD - continuous ambulatory• CCPD - continuous cycling

Access via catheter into peritoneal cavityRange of dextrose concentrationsDwell time and number of exchanges

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CKD - Stages 1 & 2

• Nutrition TherapyFocus on co-morbid conditions: diabetes, hypertension, hyperlipidemia, progression of CVDK/DOQI guidelines for GFR ≤ 20• SGA every 1–3 mo.• Dietary interviews and food intake, or

nPNA every 3-4 mo.• More frequent if GFR ≤ 15

Protein: .6-.75 g/kgEnergy: 30-35 kcal/kg

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CKD - Stages 3 & 4

• Nutrition TherapySee ADA guidelinesNutrition assessment recommendations – see p. 624Nutrient recommendations – see Table 20.4• Protein (inc), energy, sodium (dec),

potassium, phosphorus, calcium, vitamins, minerals, fluid may need adjustment

Emphasize usual foods

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CKD - Stages 3 & 4

• Outcome measuresClinical• Biochemical – see Table 20.3• Anthropometrics• Clinical signs and symptoms

Behavioral • Meal planning, meeting nutrient needs,

awareness of food/drug interactions, exercise

• See Table 20.6

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CKD - Stage 5

• Nutrition AssessmentOn dialysis – measures not different• Dietary intake• Biochemical: serum albumin• See Table 20.7 for other indicators

Goals: meet nutritional requirements, prevent malnutrition, minimize uremia, minimize complicationsMaintain blood pressure, fluid status

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CKD - Stage 5

• Nutrition InterventionHD – high in protein, control intake of potassium, phosphorus, fluids and sodium• Modifications in fat, cholesterol, TG if

warranted

PD – more liberalized; higher in pro., sodium, potassium and fluid, limit phosphorusSee Table 20.8 – nutrients to monitor

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CKD - Stage 5

• Nutrition InterventionProtein - 1.2 g/kg (HD), at least 50% HBVPD same except during peritonitis –increase protein• Losses increase 50-100% and may

remain elevated

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CKD - Stage 5

• Nutrition InterventionEnergy to prevent catabolism; needs slightly higher; individualizedPD - account for kcal in dialysateCaloric load – PET – Box 20.824-27 kcal/kg/day average intake

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CKD - Stage 5

• Nutrition InterventionAdjusted Edema-Free Body Weightshould be used to calculate body weight for calculating protein and kcal• For those < 95% or > 115% median

standard weight NHANESII• For maintenance in HD and PD pts.• Obtained postdialysis for HD pts., and

after drainage for PD patients

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CKD - Stage 5

• Nutrition InterventionFat - increased risk for CAD and strokeHD typically have normal LDL, HDL, TGPD higher TC, LDL, TGRecommend TLC diet guidelines for both

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CKD - Stage 5

• Nutrition InterventionFluid and Sodium highly individualized based on residual urine output and dialysis modality• Interdialytic weight gain (HD) should not

exceed 5% of body weight• 2 gram sodium diet• Not more than 1 L fluid daily• If urine output > 1 L/day sodium and

fluid can be liberalized to 2-4 g and 2 L

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CKD - Stage 5

• Nutrition InterventionFluid and Sodium • PD – based on ultrafiltration; 2 -2.5 kg

fluid/day• Fluid 2 L• Sodium 2-4 g• Fluid overload: shortness of breath, htn.,

CHF, edema

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CKD - Stage 5

• Nutrition InterventionPhosphorusHyperphospatemia - GFR 20-30 mL/minDietary phosphorus restriction: 800-1000 mg/day, < 17 mg/kg body IBWSee Table 20.12Phosphate binders; calcium saltsLimit calcium intake

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CKD - Stage 5

• Nutrition InterventionCalcium requirements higher in CKDRestrict foods high in calciumTake supplements on empty stomachLimit to 2000 mg/day from all sources

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CKD - Stage 5

• Nutrition InterventionVitamin SupplementationWater-soluble vitaminsDaily requirements – Table 20.14“Renal” vitamins include B12, folic acid, vitamin CAvoid high doses of vitamins A & CMay need vitamin K if on antibiotics

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CKD - Stage 5

• Nutrition InterventionMineral supplementationAvoid Mg-containing phosphate binders, antacids, and supplementsIronZinc

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Comorbid Conditions -Nutrition Therapy

• Cardiovascular Disease - more likely to die from CVD than progress to Stage 4 CKD

• Heart failure, LVH, atherosclerosis• Accelerated atherogenesis• Other “non-traditional” risk factors• Elevated CRP

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• Secondary Hyperparathyroidism (SHPT)• Can progress to severe, intractable forms

of bone disease• Prolonged PTH exposure – osteitis fibrosa• More prone to fracture• Restrict dietary phosphorus• Supplementation of vitamin D

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• Anemia d/t low Hgb from inadequate endogenous erythropoietin

• Treatment with rHuEPO and iron

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Medicare Coverage for MNT

• Part B Medicare, renal disease • dg of GFR 13-50 mL/min or kidney

transplant qualify• Dialysis patients excluded

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Post Transplant

• Nutrition therapy differs between: Acute phase – up to 8 weeksChronic phase – after 9 weeks

• See Table 20.17 for summary

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Post Transplant

• Protein and Energy Increased for up to 6–8 weeksAfter 8 weeks: RDA for protein and low in saturated fat

• CarbohydrateGlucose intolerance common; insulin or OHA may be warrantedEmphasize dietary fiber

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Post Transplant

• FatLow-fat diet

• SodiumHypertension common; restrict sodium

• PotassiumPotassium restriction in acute period

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Post Transplant

• ImmunosuppressantsUsed to prevent acute rejectionAvoid grapefruit and grapefruit juice

• Cardiovascular DiseaseTLCLipid-lowering agents

• HypomagnesemiaSupplementation of Mg to lower LDL and apolipoprotein B

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Post Transplant

• ObesityWeight gain common; may complicate hyperlipidemia and glucose intoleranceEmphasize diet, behavior modification, exercise

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Post Transplant

• Calcium, Phosphorus, Altered Bone Metabolism

Osteoporosis and altered vitamin DHypercalcuria from corticosteroids Supplement with calcium, vitamin D, anti-resorptive agentsIncrease phosphorusMonitor serum potassium

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Acute Renal Failure

• ARF - when kidneys suddenly stop functioning and abrupt cessation or reduction in GFR and accumulation of nitrogenous wastes occurs

Stress or injury induced hypercatabolicstateStatus declines rapidly, loss in lean body mass, toxicity-related symptoms

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Acute Renal Failure

• Clinical manifestationsFluid and electrolyte disorders, azotemia, wastingElectrolytes – increases or decreases in potassium, Mg, phosphorus; monitor frequentlyBUN and creatinine elevated even if ratio is normal; maintain BUN 80-100 mg/dL

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Acute Renal Failure

• Treatment Treat underlying causeNutrition therapy depends on type of dialysis or CRRT

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Acute Renal Failure

• Nutrition ImplicationsTrace Minerals and Vitamins• May develop trace mineral toxicity• Daily infusion not recommended• Vitamins A, D, K and C may need to be

adjusted

Triglycerides• May need lipid-free formula

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Acute Renal Failure

• Nutrition InterventionsEnergy and protein May need enteral nutritionProtein .6 to 1.4 g/kg/d; essential and nonessential amino acidsKcal 30-35 kcal/kg/d60% CHO, 20-35% fatTPN > 5 days; 50-100 g lipids as emulsion

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Acute Renal Failure

• Nutrition InterventionsFluid status should be monitored Supplementation of minerals, electrolytes, and trace elements• Monitor serum and urine levels• Vitamin A not recommended• Vitamin K recommended• B12; 10 mg pyridoxine• Limit ascorbic acid to 60-100 mg/d

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Nephrolithiasis

• Kidney stones form when calcium, oxalate or uric acid in urine in higher than normal amounts

• Can become lodged in urinary tract and obstruct urine flow

• Typically consist of calcium salts, cystine, uric acid or struvite

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Nephrolithiasis

• Risk factors: family hx, hypercalciuria, hyperuricosuria, hyperoxaluria and low urine volume

• Other causes: gout, excess intake of vitamin D, UTIs, and urinary tract blockages

• Asymptomatic until blockage occurs• Acute pain, hematuria, nausea, vomiting,

pain with urination, urgency to urinate

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Nephrolithiasis

• Treatment/Nutrition TherapyMost can pass with plenty of fluid and pain medicationsMedical procedures if unable to pass• ESWL most common

Increase fluid intake by 3 L/day in divided dosesAvoid calcium supplementation, dairy OK

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Nephrolithiasis

• Treatment/Nutrition TherapyLimit oxalate intake to 50-60 mg/dAvoid foods that increase urinary oxalate…beets, chocolate, cola, coffee/tea, nuts, berries, wheat bran, spinach, rhubarb

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Diseases of the Renal System - Cengage fileDiseases of the Renal System ... 1.2 million in each kidney 9Glomerulus within Bowman’s capsule •Afferent arteriole – carries blood