Nutrition-Dietetics

2016

The Management of
Kidney Disorders

ADELA JAMORABO-RUIZ, MSN, FPAN, FRI(Rs), DPA, PhD, RND

Professor of Nutrition and Food Science
Polytechnic University of the Philippines
Sta. Mesa, Manila
 Review in Kidney
Disorders
Incidence
Kidney Structure and
Functions
Kidney Disorders and
Etiology
Chronic Disease and
Stages of CKD
Management of Renal
Disorders
Kidney Stones
Summary
 Incidence of Renal Disorders
Renal diseases ~10th leading causes of death in RP.
The incidence (new cases) and prevalence (existing cases) of
CKD is growing
CKD has worldwide distribution
CKD is threatening to reach an epidemic
Global annual growth rate of 8%
Two factors impacting growth of CKD:
Ageing of population
Incidence is higher in older adults
Global epidemic of type 2 diabetes
Diabetes prevalence expected to double in next 20 years
 Chronic Kidney Disease (CKD) in the
Philippines

130 million with some stage of CKD

Diabetes
Hypertension
Glomerulonephritis
120,000 new cases each year
23,000 undergoing dialysis

Department of Health 2014

 Mortality and Morbidity of CKD Patients
Hospitalizations
13.7 hospital days per year for dialysis patients
Incident cases included all new
ESRD patients during the
Walking disability reporting year (counted from 1
55.5% of incident patients have a walking disability January to 31 December).
37.2% of prevalent patients have a walking disability
A prevalent case was an ESRD
patient who survived from the
High mortality rate last day of the previous year.
Highest in first year of hemodialysis
The mode of RRT included HD,
20% mortality per year (1 in 5) PD and renal transplantation.
About 50% are cardiac deaths
5.8 expected remaining years for dialysis patients (vs. 25.3 for general population)
5 year survival rate: 1 in 3 dialysis patients
incident patient is one who is receiving regular in-center hemodialysis or any type of peritoneal dialysis
treatments for chronic renal failure at least once weekly for the first time
 Structural details

The human kidneys:

are two bean-shaped organs, one on each side of the backbone.
Represent about 0.5% of the total weight of the body,
but receive 2025% of the total arterial blood pumped by the heart.
Each contains from one to two million nephrons.
 Kidney Functions
What do the kidneys do? What does this do for the body?
Filter the bodys blood of Removes excess sodium, potassium and
wastes urea (waste). They also reabsorb useful
substances for the body.
Maintain fluid balance Removes or reabsorbs water to maintain
hydration (keep the right amount of fluids
in the body).
Excrete acid Filters out acids (e.g. uric acid) to help
maintain the bodys acid and base
balance.
Produce the hormone Erythropoietin helps the bone marrow
erythropoietin make red blood cells. Lack of this
hormone can cause anemia.
Help activate vitamin D Activated vitamin D is needed to help with
calcium balance and bone health. Lack of
vitamin D causes a disease called rickets.
 What happens when kidneys are damaged?
Conditions that damage the kidneys and decrease their
ability to function properly
As kidney disease progresses, wastes can build up to
high levels and cause sickness and complications
High blood pressure, anemia (low blood count), weak
bones, poor nutritional health, and nerve damage
Heart and blood vessel disease
Complications may happen slowly over a long period of
time
When kidney disease progresses, it may eventually lead
to kidney failure, which requires dialysis or a kidney
transplant
National Kidney Foundation
Acute Kidney Injury
formerly Acute Renal Failure

Causes of ARI
 Kidney Disorders and Etiology
Various kinds of kidney problems - most common are:
Urinary tract infection which includes pyelonephritis,
Inflammation e.g. nephritis,
Obstructive uropathy caused by kidney stones referred to as
urolithiasis.
Nephritis is commonly found in younger age group; urinary
infection and stones are most commonly found in middle-aged
group;
Chronic and end-stage disorders are
prevalent in the elderly group.
 Consequences of
Urinary Protein Losses
in Nephrotic Syndrome
 What Causes CKD?
Diabetes (44.4%)
1/3 of people with diabetes will eventually develop CKD

Hypertension (26.8%)
Diabetes and hypertension account for 2/3 of all CKD

Other Causes (11.1%)

Glomerulonephritis
Inherited Diseases, such as Polycystic Kidney Disease
Urologic disease

National Kidney Foundation

USRDS 2008 Annual Data Report
 Phases of Acute Renal Injury

Phases Characteristics
Anuric (14 days) Decreased output to less than 100 mL per day
Oliguric (814 days) Patient excretes 100400 mL daily
Abnormal fluid / electrolyte homeostasis occurs
Dialysis is needed to prevent permanent damage
Polyuric (10days) Patient gradually increases output of urine up to several liters per
day (4004000 mL).
Fluid balance is critical.
Convalescent Patient gradually improves, although some loss of function may
(10days to 3 months be permanent.
or up to 1 year) ARF in acute care may be reversible, but mortality is still 5075%.
 Chronic Kidney Disease
Chronic kidney disease (CKD), MESANGIAL STRUCTURE
defined as glomerular filtration rate
(GFR) of 15-59 mL/minute.
Kidney failure means GFR of less
than 15 mL/minute.
The dreaded consequence of CKD
is end-stage renal disease (ESRD)
requiring dialysis or
transplantation, which inflicts
considerable human and economic
burden on society
ESRD ~ defined as patients who suffered from irreversible damage in renal function due to a
state of uremia and received maintenance dialysis therapy for >1 month
National Kidney Foundation, 2014
KDIGO, 2013
 Classification of CKD
Kidney Disease Improving Global Outcomes GFR categories
GFR category GFR (ml/min/1.73 m2) Terms
G1 >90 Normal or high increased ACR is
G2 6089 Mildly decreased* associated with increased
risk of adverse outcomes
G3a 4559 Mildly to moderately decreased
G3b 3044 Moderately to severely decreased decreased GFR is
G4 1529 Severely decreased associated with increased
G5 <15 Kidney failure risk of adverse outcomes

* Relative to young adult level

Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate
Source: Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) Kidney International (Suppl. 3): 1150

Kidney Disease Improving Global Outcomes ACR categories

ACR category ACR (mg/mmol) Terms increased ACR and
A1 <3 Normal to mildly increased decreased GFR in
A2 330 Moderately increased* combination multiply the
A3 >30 Severely increased** risk of adverse outcomes.
[new 2014]
* Relative to young adult level
** Including nephrotic syndrome (ACR usually >220 mg/mmol)
Abbreviations: ACR, albumin:creatinine ratio; CKD, chronic kidney disease
Source: Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013) Kidney International (Suppl. 3): 1150

National Kidney Foundation, 2014

KDIGO, 2013
Consequences of CKD

CNS = central nervous system

PNS = peripheral nervous system
CVS = cardiovascular system
GIT = gastrointestinal tract
GUS = genitourinary system
 ESRD
There are three options called renal replacement therapy when
treating kidney failure:

1) Hemodialysis
2) Peritoneal dialysis 3) Kidney transplant
 Symptoms of CKD
Most people may not have any severe symptoms until
their CKD is advanced. However, an individual may
notice:
Tiredness and less energy
Trouble concentrating
Poor appetite
Trouble sleeping
Muscle cramping at night
Swollen feet and ankles
Puffiness around eyes, especially in the morning
Dry, itchy skin
Urinating more often, especially at night.
 Traditional CV Risk Factors in CKD
Older age
Male sex
Hypertension
Higher LDL cholesterol
Lower HDL cholesterol
Diabetes mellitus
Smoking
Physical inactivity
Menopause
Family history of cardiovascular
disease
Left ventricular hypertrophy
 Nontraditional Risk Factors in CKD
Albuminuria
Elevated homocysteine
Lipoprotein(a) and apolipoprotein(a) isoforms
Lipoprotein remnants
Anemia
Abnormal calcium/phosphorus metabolism
Extracellular fluid volume overload
Electrolyte imbalance
Oxidative stress
Inflammation (C-reactive protein)
Malnutrition
Thrombogenic factors
Sleep disturbances
Altered nitric oxide/endothelin balance
Focus on Microalbuminuria
Cardiometabolic Risk Factors
 Renal Function

Measurement of renal function is critical in patients especially

those with diabetes, as discovery of asymptomatic renal
insufficiency can prompt treatment to improve the prognosis.

In evaluating renal function, the estimation of GFR is a more

sensitive and specific tool than serum creatinine levels, which
can be influenced by muscle mass and diet.
 Glomerular Filtration Rate (GFR)
Glomerular filtration is the process by which the kidneys filter the
blood, removing excess wastes and fluids
Glomerular filtration rate (GFR) reflects kidney function
It is the best measure of kidney function and to determine the stage of CKD
The lower the GFR, the worse the kidney function
MDRD GFR Calculator (eGFR): estimates GFR based on serum creatinine,
age, race, and gender
Normal GFR in adults is 120-125 ml/min
GFR declines with age
GFR decreases 10% each decade after age 30
 The Dangers of Procrastination
Half of patients with a plasma
creatinine concentration greater
than 6 mg/dl will require dialysis
within 3 months.

If these patients are not referred

to a nephrologist, their conditions
often worsen until they require
emergent dialysis.
 The Dangers of Procrastination

Edema, myoclonus, lethargy, and pericarditis are signs

that are typically associated with advancing renal
failure; typical symptoms include dyspnea, muscle
cramps, and itching.

On average, three or four signs or symptoms are

present when dialysis is required.
 Malnutrition in CKD
Up to 75% of patients with CKD are malnourished
Risk for malnutrition increases as CKD progresses
Many patients are malnourished by time of dialysis initiation
Malnutrition at the time of dialysis initiation is associated with poor
outcomes
Causes of malnutrition:
Anorexia
Dietary restrictions limit variety of foods
Uremic symptoms cause decreased food intake
Inability to procure and prepare foods
Loss of nutrients during dialysis
Altered metabolism of nutrients
 Malnutrition in CKD
Wasting, malnutrition and inflammation are common and
usually concurrent
Protein-energy wasting = loss of body protein mass and fuel
reserves
Presence of 3 characteristics:
Low serum levels of albumin, transthyretin or cholesterol
Reduced body mass
Reduced muscle mass

Kidney disease wasting = occurrence of protein energy wasting in

CKD or acute kidney injury (AKI) regardless of cause
 Managing Renal Disorders
Drug Therapy
Diet Modification
Renal Replacement Therapy
 Slowing the Progression of CKD
Strategies to slow progression of CKD and reduce the risk of CVD:

Treatment of Hypertension
Lowering blood pressure by any means is important in slowing the progression of CKD
Treatment of hypertension with ACE inhibitors and/or ARBs is most important.
Treatment of Anemia Others
Glycemic Control in Diabetics Control of environmental lead
Control of Dyslipidemia Treatment of hyperhomocysteinemia,
hyperuricemia
Dietary Management Use of antioxidants
Dietary Protein Restriction
Dietary Salt Restriction
Lifestyle Modification
Weight Management
Dietary Control of Phosphate
Smoking Cessation
Stress Management
 Importance of Diet regardless of how much
kidney function left
Meet nutritional needs so that pt wont be malnourished
Cut down the workload on kidneys to help maintain kidney
function that is left
Control the build-up of food wastes like urea
Reduce symptoms like nausea, itching and bad taste in the
mouth
Help maintain a healthy weight and prevent muscle loss
Prevent infection
Give the energy needed to perform daily tasks
Help control high blood sugar if diabetic
 Treatment of Hypertension
Blood Pressure - a low target blood pressure (approx 125/75
mm Hg) slowed progression of kidney disease better than the
usual target blood pressure (< 140/90 mm Hg); the effect of
blood pressure lowering was especially apparent in patients
with proteinuria > 1 g/day.
 Dietary Management for Hypertension
The DASH diet
The blood pressure lowering Dietary Approach to Stop Hypertension or
DASH has been shown to be effective in managing the disease, often
within 14 days of initiation.
This diet includes high quantities of fruits, vegetables, and emphasizes
low-fat dairy products, whole grains, poultry, fish, and nuts.
 Glycemic Control in Diabetics
Sustained control of hyperglycemia by achieving glycated
hemoglobin (Hgb A1C) levels to normal or near-normal levels,
or serum glucose concentration below 200 mg/dL either delay
onset of diabetic nephropathy or slow its progression.

Sustained tight control of diabetes has also been shown to

reduce or delay many other vascular and systemic
complications of diabetes
 Control of Dyslipidemia
There are no randomized controlled studies
demonstrating that lipid control slows progression of
CKD. But there are numerous studies demonstrating that
lipid control with use of HMG-CoA reductase inhibitors
(statins) reduce cardiovascular complications both in the
general population and in patients with CKD.

Analyses of some of these trials for secondary outcomes

suggest that lipid control may also slow progression of
CKD. In the MDRD study, low HDL was an independent
predictor of progression of CKD.
 Recommended Blood Lipid Concentrations

Total LDL HDL

Cholesterol Cholesterol Cholesterol Triglyceride
mg/dl mg/dl mg/dl mg/dl

Desirable Less than Less than Greater Less than

200 130 than 60 200

Borderline 200 to 239 130 to 159 35 to 59 200 to 399

High Greater Greater Less than Greater

than 240 than 160 35 than 400
Dyslipidemia
Dietary Management

High blood cholesterol can be treated by diet and drugs.

The first step is by dietary means through a prudent diet that is low in
total fat, low in saturated fat, and low in cholesterol. This is followed for
six months.
If after 6 months and goal is not achieved, drug therapy should be
commenced.
The US recommends a TLC dietary approach.
(formerly Step 1 & Step 2 Diets)
 Visit 1 Visit 2 Visit 3 Visit N
6 wk Evaluate LDL 6 wk Evaluate LDL Q 4-6 mo
Begin response Response Monitor
lifestyle If LDL goal not If LDL goal not adherence
therapies achieved, intensify achieved, consider to TLC
LDL-lowering Rx Adding drug Rx
Emphasize reduction Reinforce reduction
in saturated fat and in saturated fat and
cholesterol cholesterol Initiate Rx for
Encourage moderate Consider adding metabolic
physical activity plant stanols/ sterols syndrome
Consider referral to Consider referral to Intensify weight
a dietitian a dietitian management and
physical activity
Consider referral
to a dietitian

Steps In Therapeutic Lifestyle Changes

Dietary Management in Chronic Kidney
Disease

Adequate Energy (kcal)

Protein Restriction
Salt Restriction
Control of Phosphate
Other nutrients
 Dietary Management in CKD
Energy
Energy expenditure similar to normal healthy individuals
60 yrs 35 kcal/kg*/day
> 60 yrs 30-35 kcal/kg*/day
Protein Malnutrition
Intake must meet nutritional needs and compensate for any
losses.
Excessive protein enhances production of nitrogenous toxins
Inadequate protein promote malnutrition
Majority of published studies demonstrate a beneficial effect
of restriction of dietary protein intake to 0.6 g/kg ideal body
weight/day.
 Dietary Management in CKD
Protein
During hemodialysis (HD) or peritoneal dialysis (PD)
Clinically stable maintenance HD = 1.2 g/kg/day; at least 50%
HBVP

Clinically stable chronic PD = 1.2-1.3 g/kg/day; at least 50%

HBVP.
 Dietary Management in CKD
Protein Restriction
Dietary protein both contributes to uremic symptoms and
promotes the progressive loss of renal function in chronic
renal failure.

Patients with CRF spontaneously reduce their intake of

dietary protein as they lose renal function.

When the GFR is less than 20 ml/min, aversion to meat is

not uncommon; at that level of renal function, the
spontaneous intake of dietary protein may be 0.8 g/kg/day
or lower.
 Dietary Management in CKD
Protein Restriction
Adherence to a low-protein diet is difficult, and there is
controversy as to whether restricting the intake of daily
protein to less than 1 g/kg/day slows the progression of
CRF.

However, studies demonstrate that this antiproteinuric

strategy is nutritionally safe.

Beneficial effects of dietary protein restriction have been observed in

both diabetic and nondiabetic nephropathies.
 Dietary Management in CKD
Potassium
Dietary intake not restricted unless there is K retention and
need to prescribe potassium-retaining medications or both
conditions are present.
Individual metabolic abnormalities related to hormonal
imbalances or glucose metabolism could result in
hyperkalemia.
Recommendation: Stages 1 2 = 2-4 g K+/day
Stages 3 4 = 3-4 g K+/day
Dietary Management in CKD
Sodium
Salt restriction is an important component of blood pressure
control.
Salt restriction may be renoprotective beyond blood pressure
control in that it may enhance the antiproteinuric effect of
angiotensin blockade.
Restriction of dietary NaCl intake to 80-100 mmol/day
appears realistic and adequate for optimum benefit. (2.4 to 4
g Na+/day)
Individualized modification for patients with sodium-wasting
disease or is prescribed with medications that cause sodium
loss.
 Dietary Management in CKD
Phosphorus
Serum levels controlled by diet modification & meds.
Measures for lowering plasma phosphate levels include the
restriction of dietary phosphorus, by itself or in conjunction with
the use of phosphate binders (e.g., calcium carbonate or
aluminum hydroxide) to reduce the absorption of ingested
phosphorus.
Phosphate binders are taken during a meal or within 15 minutes of
eating (either before or after)
Precaution: if binder is calcium-based watch out because excessive Ca+
can exacerbate vascular and extraskeletal calcification. So maintain
total Ca+ within RENI (800 mg) or up to 1200 mg Ca+ (US RDA)
 Dietary Management in CKD
Control of Phosphate
Phosphate restriction arrests progression of kidney disease
independent of protein intake.
Hyperphosphatemia plays a major role in the development of the
secondary hyperparathyroidism seen in CRF.
Measures for lowering plasma phosphate levels include the
restriction of dietary phosphorus, by itself or in conjunction with
the use of phosphate binders (e.g., calcium carbonate or
aluminum hydroxide) to reduce the absorption of ingested
phosphorus.
 Dietary Considerations in CKD
Vitamin D
Calcitriol, which is the active form of vitamin D, may be deficient in patients
with CRF because of reduction in functional kidney parenchyma and,
consequently, diminished 1-hydroxylation of vitamin D.

In modest doses (0.25 to 1 mg daily), calcitriol may reduce secondary

hyperparathyroidism and improve bone histology.

Incautious use of calcitriol may cause hypercalcemia, which can worsen

kidney function. On balance, use of calcitriol should be undertaken only with
appropriate monitoring and an awareness of the potential hazards.
 Other Interventions
Control of environmental lead
Treatment of hyperhomocysteinemia,
hyperuricemia
Use of antioxidants
 Lifestyle Modifications
Weight Management
Smoking Cessation
Stress Management
 Interventions to delay progression of CKD and/or
prevent development of CVD

These include: Other interventions, such as

low-protein diets; the administration of lipid-
correction of calcium- lowering agents,
phosphate disorders and anti-inflammatory drugs,
anemia; anti-oxidant agents are
blood pressure and emerging as particularly
proteinuria control; and promising therapeutic
smoking cessation. approaches
Patient-Centered Management of CKD
SUMMARY

Intervention in the conservative phase of CKD is

likely to be more effective if performed as early as
possible in the course of the disease, since it has
been widely demonstrated that early treatment is
associated with decreased morbidity and mortality.
 Dietary Guidelines Following Kidney Transplant
Protein and energy requirements increase after surgery due to stress and the catabolic effects
of drug therapy.
 Kidney Stones

Common disorders that affect

the kidneys and urinary tract.
Develop when stones
constituents become
concentrated in the urine and
form crystals that grow.

Characterized by frequent occurrences between the ages 30 to 50, predominance

in males (3x more often).
The risk doubles with a family history of kidney stones.
 Kinds of kidney stones

Calcium stones - formation is unclear

people with hypercalciuria are either more
efficient at absorbing calcium from the intestine
or more wasteful in their excretion of calcium
than most calcium
 Kinds of kidney
stones

Uric acid stones

- frequently associated with gout;
- Uric acid stones form when urine is supersaturated with
undissolved uric acid, which occurs at urinary pH less
than 5.5.
- Alkalinize urine with citrate or bicarbonate.
 Dietary Management for Kidney Stones
Diets restricted in purine
is prescribed to prevent
uric acid stones.

The body synthesizes cystine, NEAA from

methionine; therefore patient with cystine stones
needs just enough methionine from the diet, and
reduction of urine acidity is beneficial.
 Foods High in Uric Acid

For uric acid stones (avoid)

Organ Meats
Anchovies
Sardines
Meat-based broth
Gravy
 Oxalate
Hyperoxaluria plays an important role in calcium
stone formation. The normal oxalate content is in
the range of 80 to 100 mg/day & absorption does
not usually exceed 10% to 20% of the amount in
food.
Oxalate cannot be metabolized in the body and the
renal route is the only mode of excretion.
 Foods High in Oxalate
Spinach ~ 600-970 mg oxalate/100g
Soy burger patty ~ 870 mg oxalate/100g
Almond ~ 383 mg oxalate/100g
Tofu ~ 140-280 mg oxalate/100g
Pecans ~ 202 mg oxalate/100g
Peanuts ~ 187 mg oxalate/100g
Okra 146 ~ mg oxalate/100g
Chocolate ~ 117 mg oxalate/100g
Sweet Potato ~ 56 mg oxalate/100g
 Foods Low In Oxalate
Animal foods
Avocado
Cantaloupe
Cauliflower
Cucumber
Lemon juice
Melon
Radish
Squash
 Acid-Ash & Alkaline-Ash Diets

Dietary intake can influence the acidity or alkalinity of

the urine. The acid-forming potential contributed by
chloride, phosphorus & sulfur (anions) and the base-
forming potential by sodium, potassium, calcium and
magnesium (cations)

Before the use of medication to acidify or alkalinize

the urine, dietary changes were commonly used.
 Acid-Ash & Alkaline-Ash Diets

Milk contributes to both categories.

However, because factors of digestion, absorption,
use of salt or medications, hormonal status and
homeostatic mechanisms all affect renal excretion
and urine production, urine pH cannot be predicted
by calculation of intake.
Potentially Acid or Acid-Ash Foods

Meat: meat, fish, fowl, shellfish, eggs, all types

of cheese, peanuts
Fat: bacon, nuts (Brazil nuts, walnuts), peanut
butter
Starch: all types of bread (especially whole-
wheat), cereal, crackers, macaroni, spaghetti,
noodles, rice
Vegetables: corn, lentils
Fruits: cranberries, plums, prunes
Desserts: plain cakes, cookies.
Potentially Basic or Alkaline-Ash Foods

Milk: milk and milk products, cream, buttermilk

Fat: nuts (almonds, chestnuts), coconut
Vegetables: all types (except corn, lentils),
especially beets, beet greens, Swiss chard,
dandelion greens, kale, mustard greens,
spinach, turnip greens
Fruits: all types (except cranberries, prunes,
plums)
Sweets: molasses
 If a person has a tendency to form renal stones, he/she
should try to change eating habits in the following ways:
1. Eat plenty of cereal fiber with each meal. This can be
done by eating foods in their natural unrefined form.
2. Cut down on animal protein, particularly meat.
3. Avoid refined foods, e.g., sugar and sugary foods. Cut
out sugar in drinks. Avoid sweets, chocolates, soft
drinks, tinned fruits, sweet cakes and biscuits.
4. Drink liberal amounts of fluid, 10 glasses per day at least.
Remember, clean water is better than sweetened drinks.
If you have been advised to avoid high oxalate foods,
avoid excessive consumption of tea especially strong
tea and coffee. Avoid chocolate, peanuts, and spinach.
The advice given is not a special diet. Many nutritionist-
dietitians agree that it is a very healthy eating pattern and is
therefore suitable for the whole family.
 The only person you are destined to
become is the person you decide to be.
Ralph Waldo Emerson

ADELA JAMORABO-RUIZ, RND, MSN, DPA, PhD

One of 10 Past and Present Leaders in Nutrition & Dietetics 2015
(award given every 10 years)
PRC Most Outstanding Professional Awardee in the field of Nutrition
and Dietetics, 2006
NDAP Nutritionist of the Year Awardee, 1998
PAN Fellow in Nutrition Education, 1997
NDAP Most Outstanding ND in Education, 1995
First PRC ND Licensure Exam Topnotcher, 1978
NDAPs Most Outstanding Dietetic Intern Scholar, 1977-78