Nutrition in renal dosorders

NUTRITION IN RENAL DISORDERS

Zia Imran 2015 year 1

© 2007 Thomson - Wadsworth

Kidneys

• Nephron

I. Working unit of the kidney

II. Consists of

• Glomerulus: works like a sieve

• Tubules: fluid reabsorbed or sent to bladder

FUNCTIONS OF THE KIDNEY

(Produces erythropoietin)

(conversion of vitamin D to its active form).

(secretes rennin)

Renal damage and subsequent loss of renal function profoundly affect metabolism, nutritional requirement, and nutritional status.

• As urine output decereases,fluids and electrolytes

accumulate in the body.

• Retention of nitrogenous waste leads to Uremic syndrome.

• Acidosis occur

• Reabsorption of some nutrients impaired, which causes them to be lost in the urine.

• Absorption of calcium and iron is impaired.

• Impaired synthesis of renin,erythropoietin and vitamin D.

• Certain peptide hormones such as insulin,glucagon,and parathyroid hormone are not adequately inactivated.

• Poor intake related to dietary restrictions,anorexia,alterations in taste,nausea,vomitting,depression and anxiety is common.

COMMON RENAL DISORDERS:

Acute Renal failure

Chronic Renal failure

End stage renal disease

Nephrotic Syndrome

Renal Stones


Acute Renal Failure

• Function rapidly deteriorates

– Reduced urine output

– Build up of nitrogenous wastes

• Mortality rates are high


Consequences

Oliguria < than 400 mL urine/day

Sodium retention

Elevated potassium, phosphate, & magnesium

Edema

Uremia

– BUN, creatinine & uric acid accumulate in blood

– Fatigue, lethargy, confusion, headache, anorexia, metallic taste, ,diarrhea


Treatment

Drug therapy

Protein – Depends on kidney

function, degree of catabolism, use of dialysis

Fluids

Measure output and add 500 mL

Can increase if on dialysis

Electrolytes

– Restrict potassium, phosphorus, sodium


Chronic Renal Failure

• Is a gradual & irreversible deterioration

• Usually not diagnosed until 75% of function is lost

• Causes

– Diabetes mellitus 43%

– Hypertension 26%

– Inflammatory, immunological, or hereditary diseases

– May follow acute failure


Consequences

• Nephrons enlarge to compensate

• Overburdened nephrons degenerate

• End-stage renal disease occurs

• Evaluation

– Glomerular filtration rate (GFR)

– Rate at which kidneys form filtrate( GFR is the amount of

filtrate formed per minute based on total surface area available for filtration(number of functioning glomeruli).



Consequences

• Electrolyte imbalances occur when – GFR becomes extremely low

– Hormonal adaptations are inadequate

– Intake of water & electrolytes are very restrictive or excessive

• Renal osteodystrophy – Increased parathyroid

hormone contributes to bone loss

• Acidosis may develop

• Uremic syndrome – Mental dysfunctions

– Neuromuscular changes

– Muscle cramping, twitching, restless leg syndrome

• Protein energy malnutrition


Treatment

Goal – Slow disease progression – Prevent or alleviate symptoms

Medical Nutrition therapy

• 6 components must be regulated:

1. Protein 2. Sodium 3. Potassium 4. Phosphorous 5. Calcium 6. fluid

Drugs – Erythropoietin

– Phosphate binders

– Sodium bicarbonate

– Cholesterol-lowering medications

– Active vitamin D supplements


Dialysis

• Removes excess fluid & wastes from blood

• Blood is circulated though a dialyzer

• Blood is bathed by dialysate

• Hemodialysis & peritoneal dialysis


Medical Nutrition Therapy

• Energy – Enough to maintain healthy

weight & prevent wasting(30-40 kcal/kg)

• Low-protein diet o in case of where no dialysis is

needed not less than 40 gms /d. o *Can increase when on dialysis o In either situation protein of

high biological value is recommended.

• Lipids – Restrict saturated fat &

cholesterol

• Fluids – Not restricted until output

decreases

• Sodium and potassium individualized according to lab results

_sodium may need to restrict in oliguric state to

1000mg-2000mg/d) – Mild restriction – If hyponatremia( provide

additional salt) – If hypernatremia (restrict

sodium) – Replace moderate sodium losses

with 4-6 gms of salt.

• Potassium – May need to restrict high-potassium

foods(during oilguric state)about 1000mg/d.

• The potassium content of vegetables can be lowered by :

slicing and rinsing them in running water.

Placing them in water bath at 50-60⁰c for 2 hours and again rinsing in water.

Double boiling and draining off excess water.

cont proteins

*

Clients may lose proteins during each session of dialysis, along with an amount of glucose that varies with the glucose content of the dialysate,for this reason protein restriction may be lessened slightly once dialysis begins.

For hemodialysis----protein requirement is 1.0—1.5 g/kg body wt/day.

For peritoneal dialysis----protein requirement is 1.5---2g/kgbodywt/day.


Medical Nutrition Therapy

• Calcium & vitamin D needs increase

• May need phosphorus restrictions

– Restrict protein

– Restrict milk & milk products

• Dietary supplements

– Generous folate and B6

– Recommended amounts of water-soluble vitamins except vitamin C

– IV iron administration

• parenteral nutrition

• Phosphorous :(normal 3.5-5.5 mg/dl)

• As renal function decreases,phosphorous accumulates in the blood.

• Phosphorous triggers release of” PTH(parathyroid hormone)” that releases calcium from bone.

• Phosphate binders(drugs) prevent phosphorous from being absorbed in the gut;form insoluble compound so phosphorous is excreted in stool.

• Low phosphorous diets have also shown to delay the progression of renal disease. Restricting phosphorous is appropriate for all stages of renal disease.

Foods high in Potassium

Apricots

Bananas

Cantaloupe

Raw carrots

Dried fruits

Melons

Oranges/orange juice

Peanuts (also high in sodium)

Potatoes

Spinach

Tomatoes ,tomato juice,tomato sauce

Foods high in sodium:

Pickles

Salted nuts

Commercial salad dressings

Chinese salt

Sauces /soya sauce/ketchup

Potato chips/popcorns

Canned meat/canned soups

Commercial beverages

Foods high in phosphorous Animal: protein:fish,poultry,beef,egg, milk and milk products. Vegetables:almonds,lentils, peanuts. Other sources: carbonated beverages such as soda,wholewheat bread.


Kidney Stones

• Affects 12% of men & 5% of women

• Crystalline mass in urinary tract

– Severe pain

– Can obstruct tract

• Formation is promoted by:

– Reduced urine volume

– Blocked urine flow

– Increased concentrations of stone-forming substances

Urinary Risk Factors For Stone Development:

Increased Risk ↑ Decreased Risk ↓

Low urine volume High urine volume

& flow.(increased fluid

intake).

Oxalate Citrate

Uric acid Magnesium

Sodium Calcium

Potassium

Acid PH

Increase intake

Of vitamin C


Types of Stones

• Calcium oxalate stones

– Most common

(70-80%)

– Reduce intake of oxalate

– Avoid vitamin C supplements(as it is a precursor of oxalate production)

• Uric acid stones

– Abnormally acidic urine

– Associated with gout

– Low-purine diet

• Cystine stones

– Inherited disorder cystinuria

• Struvite stones

– Form in alkaline urine


Calcium Oxalate Stone


Consequences

• Renal colic

– Severe, continuous pain

– Begins in the back & travels toward bladder

– Nausea & vomiting

• Urinary tract complications

– Urgency

– Frequency

– Inability to urinate

– Obstruction

– Infection


Prevention & Treatment

• Increase Fluids • Drink 12-16 cups of

fluids/day. • No cola beverages

or grapefruit juice • Orange juice is

beneficial in uric acid stone formers with low citrate levels.


Other Dietary Measures

• Consume enough calcium to control oxalate absorption

• Restrict dietary oxalate & purine

• Moderate protein intake

• Sodium restriction

Oxalate rich foods:

Beets (chukandar) Strawberries Spinach Egg plant(beigan) Black tea Coffee Chocolate

High purine foods include: Red meats especially organ meat(liver,kiney,brain) Roe(fisheggs),mackerel,herring. Duck Mince meat/broth/gravies/meat extracts Chikoo Custard apple.


Nephrotic Syndrome

• Any kidney disorder that results in proteinuria exceeding 3.5 g/day

• Cause

– Any damage to glomeruli increasing their permeability to plasma proteins

NEPHROTIC SYNDROME

A collection of symptoms that occur when increased capillary permeability in the glomerli allow serum protein to leak into the urine.


Nephrotic Syndrome

• Possible causes

– Infections

– Chemical damage

– Immunological & hereditary disorders

– Diabetes mellitus

• Clinical findings

– Proteinuria

– Low serum albumin

– Edema

– Elevated blood lipids

– Blood coagulation disorders

Symptoms of Nephrotic syndrome;


Consequences

• Disturbances in protein metabolism

• Edema – Loss of albumin

– Sodium retention

• Risk of CVD – Elevated LDL, VLDL &

lipoprotein(a)

– Loss of blood clotting proteins

• Decreased vitamin D-binding protein

– Lower D & calcium levels

• Protein energy malnutrition (PEM)


Consequences of Protein Loss


Treatment

• Medications

• Protein & energy

– A high protein diet is advised .1.5 -2.0 grams/day to prevent catabolism of lean body tissues and avoid malnutrition.

– 35 kcalories/kg

• Fat

– Low saturated fat, cholesterol, & refined sugars

• Sodium

– 2-3 g/day

• Vitamin D & calcium

• Multivitamin

SAMPLE MENU FOR A 9 YEAR OLD CHILD WITH NEPHROTIC SYNDROME:

• Breakfast Porridge with skimmed milk 1 cup and sugar 2 teaspoon. Egg 1 poached or boiled Toast 1

• Mid morning Banana and ½ cup skimmed milk

• Lunch chicken pattie 3 ounce Burger bun 1 Mashed potato ½ cup Jelly

• 4 pm Chicken sandwich and juice I small pkt(frooto)

• Dinner Roast chicken/chicken tikka 3 ounce Dal ½ cup Chappatti 1 Vegetable salad Mixed Fruit chat

SAMPLE MENU OF CHRONIC RENAL FAILURE

Breakfast Hard boiled egg 1 Toast 2 Butter/jam Tea Mid morning snack Fruit juice 1 cup Lunch Chicken curry with 1 ounce chicken cucumber salad Chappatti 1 Apple 7.up 4 pm Tea Biscuits 2 Dinner Vegetable pulao Yogurt ½ cup Potato cutlet Fruit salad THANK YOU

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Nutrition in renal dosorders