Nutritional Management on Renal Disease

Nurpudji A Taslim, Nutrition Department School of Medicine Hasanuddin University Makassar 2005

Renal Function
1. WASTE FORMATION & HOMEOSTASIS - UREA - REGULATION OF OSMOLALITY AND FLUID - REGULATION OF Na & K - REGULATION OF H+ - REGULATION OF Ca & PO4- BALANCED 2. PROTEIN EXCRETION METABOLISM 3. ENDOCRINE - RENIN SINTHYSIS - ERYTHROPOETIN SINTHYSIS - ACTIVATIONI 25 OH CHOLECALCIFEROL - ADH ACTION - ALDOSTERON

DIAGNOSTIC TEST
1. BLOOD - CREATININE - BUN (BALANCED URINE NITROGEN) - CCT (CREATININE CLEARANCE TEST) 2. URINALISIS - UUN ( Urea Urine Nitrogen) -PROTEIN ALBUMIN 3. VISUAL - IVP (intra venous pyelography) - ARTERIOGRAM - BIOPSI - CT-SCAN -SONOGRAM
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KLASIFIKASI
Glomerular
Nephritic syndrom Nephrotic syndrom

Tubular & intertitium

ARF Pyelonephritis Others : others tubular or intertitium

Progress nature of renal disease

ESRD Nephrolithiasis

Rheumatoid disorder
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Patofisiologi inflamation
Osteoarthritis Rheumatoid arthritis Sjogren Sistemac Lupus Erythromatosus

NEPHRITIC SYNDROM GNA

GNA --- Inflamasi loop glom kapiler

akut, self limitimg, singkat, hematuria

infeksi sal. Nafas atas GNC --- bila berlanjut menjadi kronis Causa: primer : Primer IgA nepphropathy, hereditary nephritis

sekunder : SLE, Vasculitis, GNA associated endocarditis

Medical nutrition therapy

AKUT : a. Antibiotic b. Maintain nutrition status--- resolve spontaneously

c. Reduced protein and Kalium --- uremia

d. Reduced natrium---- hipertensi

CLINICAL SYMPTOM : DECREASED OF GRF

NEPHROTIC SYNDROM GNC

Patogenesis
Loss of glom barrier to protein Hipoalbuminemia Hiperkolesterolemia Hiperkoaguability Abnormal bone metabolisme

Causa:
DM, SLE, Amyloidosis Peny utama pada ginjal
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SINDROMA NEPHROTIC
CLINICAL 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+ Moderate K Monitoring --- Hipokalemia

GOAL
1. 2. 3. 4. MAINTAIN OPTIMAL NUTRITION MAINTAIN NUTRITIONAL STORES MINIMIZE DISEASE METABOLISM PREVENT PROGRESSIVITAS OF DISEASE

5.

SLOW DIALYSIS OCCURANCE

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

urinary

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ACUT RENAL FAILURE

Causa : 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 cc b. Oligourie phase ( 7-12 hr) uremia High level of K, Mg and Phospat Low level of Na, Calcium acidosis

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Medical nutrition therapy

Manage for:
uremia, metabolic acidosis, imbalanced fluid and electrolyte

Molina (95)
Early nutritional intervention --- positive affect patient survival

Protein
PN --- in case of vomiting and diarrhea CHO--- not effective--- decreased breaking of protein 50% Mixed CHO, lipid and AA --- prevent catabolism of protein Protein --- 0,5 0,8 gr/KgBB/hr Dialysis--- 1-2gr /KgBB

Kalium
Especially---dialyses patients Monitoring K Glucose, insulin, bicarbonate ---- K inside cell
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CHRONIC RENAL FAILURE

Causa : Chronic infection Progressif glomerolus diseases Chronic Hipertension Nefrophaty DM Hidronefrosis Bilateral Analgesic drug (Phenacetine)

Symptom : uremia Acid-base unbalanced Electrolyte unbalanced Clinical : anemia, anxiety, lose weight, pain (bone, joint), hypertension

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Standard Nutrition Assessment on CRF

Parameter Dry weight % RBW TSF men Women ACF men Women LAB Albumin Serum Transferrin 2,8 3,3 150-180 <2,8 <150 22-24 18-20 <22 <18 4-6 8-12 <4 <8 Normal 85-95 Moderate 75-85 Severe < 75

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Renal Failure Diet

GOAL

1. ADEQUATE FOOD, NOT MAKE HEAVIER RENAL FUNCTION 2. DECREASED OF UREUM & CREATININ LEVEL 3. MINIMIZED SALT RETENSION
REQUIREMENT 1. HIGH Biologi value of Protein 2. Limitation of Salt ( Heavy HT, >> K, edema, Oligo /anurie) 3. Limitation of K (Glom function or prod urine << 400 cc) 4. Adequate food 5. >> fluid

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Others Tubular & Intertitial disease

1. Chronic Intertitial Nephritis
Cause :
Analgesic abuse, Sickle cel anemia, DM, Vesico urethral reflux

Therapy

Increased fluid intake

2. Fanconis Syndrom
In ability to re-absorbsi proper amount of glucose, AA, phospate, bicarbonate in proximal tubulus

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GEJALA KLINIK

ANAK
Polyurie Ricketts Growth retardation vomiting Acidosis Hipokalemia Polyurie Osteomalacia
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GEJALA

PYELONEPHRITIS
Infection bacteria at the kidney Avorn et al (94) & Hovell et al (98)
Therapy cranberry or blueberry juice will decreased bacteria

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SJOGRENS SYNDROM
Tabara & vara-Cristo,2000, Chronic inflammatory disorder, characterized by poly-glandular tissue destructions leading to:
Keratoconjunctivitis Diminished prod of tears and saliva Xerostomia xeropthalmia

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Dietary Management
Relief of symptoms and eating discomfort Lack of appetite, weight loss, fatigue, difficulty chewing and swallowing Ready-to-eat food Sweetened lemon drops Iron, B12 and folate as well balance diet
(Lundstom and Lindstom,2001)

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

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Medical Management
Disease is rogessive and current treatment produces are cure Side effects may results as discussion above

Medical Nutrition Therapy

Dysphagia Malabs of lactose, vit, FA, minerals Need high Energy, high protein through NGF as a supplement PN diarre persistent
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SYSTEMIC LUPUS ERTHEMATOSUS (SLE) Etiologi tdk jelas A genetic predisposition

Genetic marker HLA Human leukocyte Ag Presence of anti-DNA ab Environmental factors viral infection

Prevalence women and childbearing age in

Americans and Caucasians 1954 survival rate 50%, today 97%
25% DEVELOPS SJOGRENS SYNDROM

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MEDICAL MANAGEMENT
SLE 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 DRUGTHERAPY
Corticosteroid alter of protein, Na, fluid, calcium need Plaquenil ( antimalaria) effective in clearing upskin lessions ( SE nausea,cramping abd, diarrhea) Immunosuppresantazathioprine---in the event of brain or renal involment, but GIT effects may occur

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MEDICAL NUTRITION THERAPY

No specific dietary guidelines Diet based on individual need Prioritiessequelae of disease and pharmacologic effects on organ function and nutrition metabolism Restricted---sodium and fluids intake Limitationsfat intake Leiba 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
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Diet Variation
1. LOW 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 III 60 gr - CCT 30-50 cc/, MILD CRF

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PROTEIN LIMITATION BASED ON GFR

GFR cc/menit >25 20-25 15-20 10-15 5-10

PROTEIN ALLOWANCE g/day g/kgBB/day no restriction 60-90 50-70 40-55 40 u/ pria 35 u/ wanita no restriction 1.3 1.0 0.7 0,5-0,6

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MONITORING PROTEIN HOMEOSTASIS

1.

Based on renal damaged indicator higher / lower of muscle mass loss

2. Creatinine clearance Gfr renal damaged low creatinin clearance pada renal failure level of creatine serum high 3. SUN (SERUM UREA NITROGEN) OR BUN indicator of renal function Stabil PROTEIN DIET SUN increased increased PROTEIN INTAKE. Dehidrasion / catabolic state ( operasi, burn, infection, fracture drug catabolic: steroid LEVEL 60- 80 mg/dl ACCEPTABLE > 80 uremia < 40 malnutrisi 4. Urea clearance filtration capability

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NUTRITION CARE
NUTRIENT 1. ENERGY 2. CHO 3. PROTEIN 4. 5. 6. 7. Fluid Na + K+ Fat OLIGOURIE 40-55 kcal/kg
(High in trauma)

DIURETIC 40-55 kcal/kg

(high in trauma)

50-70%
Need supplement

0,5g/kg 80% HBV 0,8 g/ kg or more 1-1,5 g/kg dialysis If fasting + 500 cc increasing as needed 500-1000 mg/d replace losses 1000 mg/d replace losses = dialysis = dialysis
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Progresivitas of Diseases (CRF)

STAGE 1. Decreased renal reserve 2. Renal Insuficiency 3. Renal Failure 4. Uremia / uremia syndrome (ESRD) % LOST 55% GFR (cc/min) 55-125

80% 90% >90%

30-55 12,5-30 < 12,5

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OPTIONS- THERAPY OF ESRD

1. 2. CONSERVATIF MANAGEMENT DIALYSIS A. HEMODIALISIS B. PERITONEAL-DIALISIS TRANSPLANTASION

3.

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KONSERVATIF MANAGEMENT

1. 2.

LIMITATION SYMPTOM PREVENT IRREVERSIBLE RENAL DAMAGED MAINTAIN OF HEALTH BEFORE DIALYSIS OR TRANSPLANTASION

3.

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TYPE OF DIALYSIS
A. HEMODIALYS BY MACHINE ( venous ) 3-4 hours /d, 3 4 x week B. PERITONEAL DIALYSIS Intermittent ( IPD) Continous ambulatory ( CAPD) Continous Cyclic

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NUTRITION MANAGEMENT ON RENAL TRANSPLANTASION

1. ADEQUATE FOOD 2. CHO 40 50 % FROM TOTAL CALORIES

3. PROTEIN 1.2- 1.5 gr ADJUST TO NORMAL LEVEL (LAB

AND ELECKTROLYT BALANCE) 4. LIMITATION OF Na+ 2 - 4 gr / day 5. K+ AS NEEDED
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RENAL STONE Causa: 1. Environment Factor 2. Tractus Urogenitalia 3. Matrix Organik stone

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A. ENVIRONMENTAL FACTOR

1. CALSIUM ( 96%) N eksresi 100 175 mg hipersecresion : high intake Ca, high Vit.D long imobilisasion, hiperparathyroid renal tubular asidosis, high calsiurie idiopatik 2. CYSTEIN ( herediter )

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B. TRACTUS UROGENITAL

CHANGED OF URINE PHYSICALLY CHANGED OF URINE CONCENTRATION CHANGED OF URINE BALANCED

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C. MATRIX BATU ORGANIK

RECURRENT INFECTION
DEFICIENCY OF VITAMIN A
( DESQUAMATION OF CEL EPITHEL)

DOT CALCIFICATION
RANDALLS PLAQUE

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CLINICAL SYMPTOMS
KOLIK, DEMAM, LEMAH

THERAPY 1. High fluid 2. Change pH from acid --- alkalis 3. Elimination food contain nutrient--contribute to stone development 4. Binding agent ecretion through feses e.g. sodium phytate --- for calsium aluminium gel --- for phosfat Glycine --- for oksalat
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THERAPY
Susunan Kimia
1. Calsium Phospat Oxalat 2. As. Urat

Modifikasi zat Gizi

low calsium low phospat low oxalat low purine

Diet Ash
acid ash

alkaline ash

3. Cystine

low methionine

alkaline ash
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VARIATION DIET

1. LOW CALCIUM HIGH ASH CAID

2. HIGH DIET ASH ALKALIS 3. LOW PURINE DIET

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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

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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

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