Nutrition & Renal Disease

Clinical Nutrition
Chapter 28

Kidney Functions
Nephron
functional unit of the kidney

Glomerulus
located within each nephron
Ball-shaped tuft of capillaries
Serves as gateway through which the
components of blood must pass to form filtrate

Kidney Functions
Bowmans capsule
Surrounds the glomerulus
Functions like a sieve
Retains blood cells and plasma proteins in
blood while allowing fluid and small solutes to
enter the nephrons system of tubules

Kidney Functions
As filtrate passes through the tubules,
The filtrates composition continually changes
Some components are reabsorbed and returned to the
body via capillaries surrounding each tubule

Conducting duct
Where filtrate enters
Shared by several nephrons
Where additional water is reabsorbed to form the final
urine product

Kidney Functions
Ureters
Where the final urine product travels through to
reach the bladder

Bladder
Place where urine is temporarily stored

Kidney Functions
The kidneys
Regulate extracellular fluid volume and osmolarity
Regulate electrolyte concentrations
Regulate acid-base balance
Excrete metabolic waste products like urea and
creatinine and a number of drugs and toxins

Kidney Functions
The kidneys
Help to regulate blood pressure
Produce the hormone erythropoietin, which
stimulates the production of red blood cells in the
bone marrow
Convert vitamin D to its active form plays a
primary role in calcium regulation and bone
formation

The Kidneys and

Urinary Tract

The Nephrotic Syndrome

The Nephrotic Syndrome

Treatment
Protein and energy
Helps minimize losses of muscle tissue
High-protein diets not advised can exacerbate urinary
protein losses
0.8 1.0 grams of protein per kilogram of body weight/day
35 kcalories/kilogram body weight daily sustains weight and
spares protein
Weight loss or infections signal the need for additional
kcalories

The Nephrotic Syndrome

Treatment
Fat
A diet low in saturated fat, cholesterol, and
refined sugars helps to control elevated blood
lipids
May need lipid-lowering medications
prescribed per physician

The Nephrotic Syndrome

Treatment
Sodium
Sodium restriction helps to control edema
Suggested to limit intake to < 2-3 grams daily
If diuretics prescribed for edema potassium wasting
may occur
Encouraged to select foods rich in potassium

The Nephrotic Syndrome

Treatment
Vitamins and minerals
May require vitamin D and calcium
supplementation prevent bone loss and rickets
Multivitamin supplements prevent additional
nutrient deficiencies

Acute Renal Failure

Causes
Consequence of:
Severe illness
Injury
surgery

Acute Renal Failure

Consequences
Kidneys become unable to regulate the levels of
electrolytes, acid, and nitrogenous wastes in in
blood.
Urine may be diminished in quantity or absent.
Diagnosis often a complex task.

Acute Renal Failure

Consequences
Fluid and electrolyte imbalances
Edema early symptom puffiness in face and
hands and swelling of the feet and ankles
Edema may be related to absence of urine or
oliguria (reduced quantity of urine
< 400 ml/day)

Acute Renal Failure

Consequences
Fluid and electrolyte imbalances
Sodium retention contributes to edema
Hyperkalemia elevated potassium can alter heart
rate and lead to heart failure
Hyperphosphatemia elevated phosphate levels - can
increase secretion of parathyroid hormones and
reduce blood calcium levels

Acute Renal Failure

Consequences
Uremia
Accumulation of the bodys nitrogen-containing waste
products blood urea nitrogen (BUN), creatinine, and uric
acid
Catobolic state produces additional nitrogenous wastes
Symptoms fatigue, lethargy, confusion, headache, anorexia,
a metallic taste in the mouth, nausea and vomiting, and
diarrhea rapid pulse, elevated blood pressure, seizures, and
delirium or coma

Acute Renal Failure

Treatment
Primary goal treat the underlying illness
in order to prevent further damage to the
kidneys.

Acute Renal Failure

Treatment
Drug therapy
May require lower doses of certain medications
Avoid drugs that are nephrotoxic or that reduce blood
flow to the kidneys
Diuretics may be used to mobilize fluids
furosemide (lasix)

Acute Renal Failure

Treatment
Drug therapy
Hyperkalemia treated with
potassium exchange resins
insulin causes temporary shift of extracellular potassium
into cells must be given with glucose

Acidosis treated with bicarbonate orally or

intravenously

Acute Renal Failure

Treatment
Protein and energy
Due to catobolic condition associated with
hypermetabolism and muscle wasting sufficient
protein and energy needed to preserve bodys protein
content
35 kcalories/kilogram body weight/day
Protein usually restricted to about 0.6 0.8
grams/kilogram body weight/day
With dialysis protein restricted to 1.2 1.3
grams/kilogram daily

Acute Renal Failure

Treatment
Fluids
Monitor weight fluctuations, blood pressure, pulse
rates, appearance of skin and mucous membranes
Measure serum sodium concentrations
Low sodium level indicates excessive fluid intake
High sodium level suggests inadequate intake

Acute Renal Failure

Treatment
Fluids
Daily fluid needs determined by measuring urine
output and adding
500 mL to replace the water lost through skin, lungs
and perspiration

Individuals with fever, vomiting, or diarrhea

requires additional fluid
If on dialysis more liberal fluid intake allowed
1.5-2 liters/day

Acute Renal Failure

Treatment
Electrolytes
With oliguria sodium intakes limited to 2-3 grams
daily
Serum electrolyte levels monitored closely
If on dialysis generally can consume electrolytes
more freely
Oliguric patients who experience diuresis may need
electrolyte replacement to compensate for urinary
losses

Acute Renal Failure

Treatment
Enteral and parenteral nutrition
Some patients need enteral or parenteral nutrition
support to obtain adequate energy
Renal formulas more kcalorically dense and have
lower concentrations of protein and electrolytes

Acute Renal Failure

Treatment
Enteral and parenteral nutrition
Enteral support (tube feeding) generally preferred
over parenteral nutrition because it is less likely to
cause infection and sepsis
Total parenteral nutrition used only if patients are
severely malnourished or cannot consume food for
more than 14 days

Chronic Renal Failure

Consequences
Generally progresses over many years without
causing symptoms
Typically diagnosed late in the course of illness,
after most kidney function has been lost
Most common causes :
Diabetes mellitus (43%)
Hypertension (26%)

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Chronic Renal Failure

Consequences

Chronic Renal Failure

Consequences
Altered electrolytes and hormones
Usually develop during the final stage of renal failure
Hormonal adaptations occur to help regulate
electrolyte levels may cause complications too
Increased aldosterone secretion helps to maintain
serum potassium levels contributes to the
development of hypertension
Increased secretion of parathyroid hormone keeps
serum phosphate levels normal, but contributes to
bone loss renal osteodystrophy

Chronic Renal Failure

Consequences
Altered electrolytes and hormones
Electrolyte imbalances may develop when GFR
becomes extremely low:
< 5 mL/minute

Uremic syndrome
Develops during the final stages of CRF
GFR < 15 mL/per minute
BUN > 60 mg/dL

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Chronic Renal Failure

Consequences
Uremic syndrome
Complications
Subtle mental dysfunctions
Neuromuscular changes muscle cramping, twitching,
restless leg syndrome
Impaired hormone synthesis erythropoietin anemia
Bleeding abnormalities defects in platelet function and
clotting factors

Chronic Renal Failure

Consequences
Uremic syndrome
Complications
Cardiovascular disease risk hypertension,
increased insulin resistance, and abnormal blood
lipids elevated parathyroid hormone levels lead to
calcification of blood vessels and heart tissue
Reduced immunity poor immune responses
develop infections, a frequent cause of death

Chronic Renal Failure

Consequences
Uremic syndrome
Protein-energy malnutrition
Anorexia believed to be a primary cause of poor
food intake secondary to nausea and vomiting,
restrictive diets, uremia and medications
Nutrient losses consequence of vomiting, diarrhea,
gastrointestinal bleeding, concurrent catabolic
disease and dialysis

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Drug therapy

Diuretics
ACE inhibitors
Angiotensin receptor blockers
Calcium channel blockers
And others
Erythropoietin (epoetin)

Chronic Renal Failure

Treatment of Chronic Renal Failure
Drug therapy
Phosphate binders (with meals) to reduce
phosphorus levels
Sodium bicarbonate to reverse acidosis
Cholesterol-lowering medications
Vitamin D or Calcitrol supplements to raise
calcium and reduce parathyroid hormone levels

Chronic Renal Failure

Treatment of Chronic Renal Failure
Dialysis
Hemodialysis blood is circulated through a dialyzer
(artificial kidney), where it is bathed by dialysate, a
solution that selectively removes fluid and wastes
Peritoneal dialysis dialysate is infused into a
persons peritoneal cavity, and blood is filtered by the
peritoneum (the membrane that surrounds the
abdominal cavity) after several hours, the dialysate
is drained, removing unneeded fluid and wastes

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Energy
Foods and beverages of high nutrient density
Encouraged to consume high-kcalorie foods and
condiments
Malnourished patients may require oral formulas or
tube feedings to maintain weight

Chronic Renal Failure

Treatment of Chronic Renal Failure
Energy
Peritoneal dialysis can contribute a substantial
amount of glucose from the dialysate may
contribute as many as 800 kcalories daily weight
gain is sometimes a problem

Chronic Renal Failure

Treatment of Chronic Renal Failure
Protein
Predialysis - - 0.6 to 0.75 grams/kilogram body
weight/day
Low-protein diets produce fewer nitrogenous wastes
reduce risk of uremia
Low-protein diets supply less phosphorus reducing risks
associated with hyperphosphatemia
Care taken to provide enough protein to meet needs and
prevent wasting
50% of the protein should be from high-quality sources

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Protein
Predialysis - - 0.6 to 0.75 grams/kilogram body
weight/day
Low-protein breads, pastas, and other grain-based products
available to help renal patients improve energy intake

Once dialysis begun protein restrictions relaxed

Dialysis removes nitrogenous wastes
Some amino acids lost during the procedure

Chronic Renal Failure

Treatment of Chronic Renal Failure
Lipids
Some renal patients at risk for coronary heart
disease restrict saturated fat and cholesterol
Renal diets include high-fat foods to increase
calories encourage patients to select foods
providing mostly monounsaturated fats nuts,
seeds, salad dressings, mayonnaise, avocados
and soybean products

Chronic Renal Failure

Treatment of Chronic Renal Failure
Fluids and sodium
Excrete less urine as CRF progresses cant handle
normal sodium and fluid intake
Monitor total urine output, changes in body weight
and blood pressure and serum sodium levels
Fluids - not restricted until urine output decreases

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Fluids and sodium
Fluid intake should match the daily urine output
Once on dialysis sodium and fluid intakes
controlled so that water weight gain is 2 pounds
between dialysis treatments

Chronic Renal Failure

Treatment of Chronic Renal Failure
Potassium
Predialysis can handle typical intakes of potassium
People with diabetic nephropathy at high risk for
hyperkalemia may need to limit potassium during
early stages of disease
Supplementation may be needed for patients using
potassium-wasting diuretics

Chronic Renal Failure

Treatment of Chronic Renal Failure
Potassium
Dialysis patients should control potassium intakes to
prevent hyperkalemia and in some cases hypokalemia
Patients are taught
foods that contain
levels of potassium
acceptable for renal
diets

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Calcium, phosphorus and vitamin D
Elevation of serum phosphorus indicates need for
phosphate binders taken with meals
Foods high in phosphorus avoided protein-restricted
diets
After dialysis begun calcium and vitamin D
supplementation standard therapyprotein intakes
are liberalized

Chronic Renal Failure

Treatment of Chronic Renal Failure
Vitamins and minerals
Folate 1 mg/day
Vitamin B6 10 mg/day
Vitamin C < 100 mg/day
Vitamins A and E not recommended accumulate in
renal failure
Intravenous administration of iron with
erythropoietin therapy

Chronic Renal Failure

Treatment of Chronic Renal Failure
Enteral and parenteral nutrition
Intradialytic parenteral nutrition infusion of
nutrients during hemodialysis, often providing amino
acids, dextrose, lipids, and some trace minerals
Volume of fluid infused can be simultaneously removed
Successful for increasing weight gain, muscle mass and
body fat in malnourished hemodialysis patients

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Chronic Renal Failure

Treatment of Chronic Renal Failure
Dietary compliance
Often requires extensive counseling
Because the diets have so many restrictions, patient
compliance is often a problem

Kidney Transplants
Immunosuppressive Drug Therapy
Side effects of nausea, vomiting, diarrhea,
glucose intolerance, altered blood lipids, fluid
retention, hypertension and infection
Increases risk of food borne infection food
safety guidelines discussed with patients and
caregivers

Kidney Transplants
Immunosuppressive Drug Therapy
Dietary interventions

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Kidney Stones
Most common disorder affecting the kidneys
and urinary tract -- > 400,000 people in the
United States treated yearly.
Kidney stone crystalline mass that forms
within the urinary tract . Stone passage can
cause severe pain or block the urinary tract.

Kidney Stones
Formation of kidney stones
75% of kidney stones made up primarily of
calcium oxalate
Factors that predispose to stone formation:
Dehydration or low urine volume
Obstruction
Renal disease
Urine acidity
Metabolic factors

Kidney Stones
Calcium oxalate stones
Commonly associated with hypercalciuria
excessive calcium in urine may result from:
Excessive calcium absorption
Impaired reabsorption of calcium in kidney tubules
Elevated serum levels of parathyroid hormone or vitamin D

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Kidney Stones
Calcium oxalate stones
Excessive urinary oxalate hyperoxaluria promotes
the formation of calcium oxalate crystals
Avoid supplementation with vitamin C degrades to
oxalate
Vitamin B6 can also increase oxalate production in
the body

Kidney Stones
Uric acid stones
Develop when urine is abnormally acidic, contains
excessive uric acid or both
Frequently associated with gout
Purine-rich diet contributes to high uric acid levels

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Kidney Stones
Cystine stones
Consequence of inherited disorder of amino acid
metabolism cystinuria
Renal tubules unable to reabsorb cystine normally
Stones occur when cystine concentration is excessive

Kidney Stones
Struvite stones
Composed of magnesium ammonium phosphate
Form when infectious bacteria degrade urea to
ammonia and elevate urinary pH to a level that favors
struvite formation
Occur most frequently in patients who have chronic
urinary infections or disorders that interfere with
urinary flow

Kidney Stones
Consequences of kidney stones
Renal colic
Stabbing pain produced when a stone passes through
the ureter
Pain begins suddenly in the back and intensifies as the
stone follow the ureters course down to the abdomen
toward the groin
Pain may be severe causing nausea and vomiting

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Kidney Stones
Consequences of kidney stones
Urinary tract complications
Blood may appear in urine hematuria
May cause damage to the kidney or ureter
lining
May cause urinary tract obstruction or infection

Kidney Stones
Prevention and treatment of kidney stones
Calcium oxalate stones
Thiazide diuretics reduce urinary calcium by
enhancing calcium reabsorption by the kidney tubules
Cholestyramine reduces oxalate absorption

Kidney Stones
Prevention and treatment of kidney stones
Calcium oxalate stones
Allopurinol reduces uric acid production in the
body
Potassium citrate inhibits formation and growth of
crystals may cause stomach upset and diarrhea

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Kidney Stones
Prevention and treatment of kidney stones
Calcium oxalate stones
Diet containing 800 1000 mg of calcium per day is
recommended because calcium combines with
oxalate in the intestines, reducing its absorption and
helping to control hyperoxaluria
Moderate protein and sodium restriction advised

Kidney Stones
Prevention and treatment of kidney stones
Uric acid stones
Allopurinol reduce urinary uric acid
Potassium citrate reduce urine acidity
Benefits to purine restriction - unknown

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Kidney Stones
Prevention and treatment of kidney stones
Cystine and struvite stones
High fluid intakes
Penicillamine and tiopronin reduce cystine levels
Potassium citrate reduce urine acidity
Prevent urinary tract infections may require
antibiotic therapy to prevent further stone formation

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