Kidney

Function

Maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes

The Nephron

Kidney Diseases

Glomerular diseases

Diseases of the tubules and interstitium

Progressive renal disease

Nephrolithiasis (kidney stones)

Nutrition Therapy:

Primary goal… control HTN, minimize edema, decrease urinary albumin losses, prevent CHON mal’n and
muscle catabolism ( 0.7 – 1 g/kg/day), supply adequate energy (35 kcal/kg/day), and slow the
progression of renal disease

Limit dietary Na

Nutritional Therapy:

Energy ( 30% - 40% kcal/kg )

Fats, oils, simple CHO, low-protein starches should provide non-protein kcal.

0.6 g of CHON/kg BW 9 but not less than 40 g/day can be increased as kidney function improves

Nutritional Therapy:

CHON - 1 – 1.4 g/kg dialysis

Oliguric phase - Na restriction to 1000 – 2000 mg and K to 1000 mg/day

Kidney Stone Formation

Saturation

Supersaturation

Nucleation

Crystal growth or aggregation

Crystal retention

Stone formation

Kidney Stones (Nephrolithiasis)

Calcium stones

Calcium oxalate

Calcium oxalate and calcium phosphate

Calcium phosphate

Uric acid

Struvite

Cystine

Nutrition Therapy for Kidney Stones

Fluid and urine volume

Urine volume 2 to 2.5 L/day

May need to drink 3 L/day, at least 10 cups as water

Cranberry juice acidifies urine: useful for urinary tract infections and struvite stones

Black currant juice (alkalinizing) may prevent uric acid stones

Tea, coffee, beer, and wine increase risk

Dietary contributory factors in Ca stone formation:

animal CHON - makes body more acidic (impedes renal calcium absorption), high in purine (precursor
of uric acid)

Lower urinary pH - increase overall acid load

Alcohol intake - chronic ethanol ingestion creates low serum vit D levels

Dietary contributory factors in Ca stone formation:

Caffeine - increase urinary Ca excretion

Low fluid intake - diminishes urinary volume, increase urine concentration

Potassium - increases renal phosphate absorption

Nutrition Therapy for Calcium Stones

Calcium: no restriction

Oxalate

Animal protein

Citrate

Magnesium
Sodium

Potassium

Vitamins

Vitamin B6

Obesity

Fiber and phytate

Omega 3 fatty acids

Herbal products

Oxalate Stones

Found primarily in foods of plant origin and the end product of ascorbic acid metabolism

Spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, strawberries

Avoid vit. C supplements (500mg/day)

 Accounts for 10% of kidney stones

 The second most common cause of urinary stones

 Acidic urine (hyperuricosuria) - is the primary cause

 <1%

 form in people with hereditary disorder

 Increase fluid intake (> 4L/day)

 Penicillamine - nephrotoxicity, allergic reaction, hematologic abnormalities

 9%-17%

 Caused UTI

 treatment of infection must be done at the same time as removal of infected stones (ESWL)

 women are twice likely to have struvite stones

Nutrition Therapy for Uric Acid, Cystine, and Struvite Stones

Uric acid stones

Restrict dietary purines

Alkaline ash diet

Diet Regimen for Uric Acid Stones

 Promote alkaline urine through k citrate or na carbonate

  Dissolves uric acid stones

 Emphasize milk intake

 helps prevent acidic urine

 Increase consumption of fruits except: Cranberries, plums and prunes

Prevention of Kidney Stones

Drink fluids…. A lot of fluids

Do not restrict dietary calcium

Use fresh or frozen vegetable when possible.

Keep meat( beef and pork) intake to a moderate level

Eat your veggies and fruits.

Limit foods high in oxalates

Increase intake of complex CHO

Avoid Vitamin C supplements

Acute Kidney Injury

Sudden reduction in glomerular filtration rate (GFR)

Associated with either oliguria or normal urine flow

Lasts for a few days to several weeks

Causes: prerenal, intrinsic, and postrenal

Sample Calculation of Fluid Requirements in Acute Renal Failure

Summary of Medical Nutrition Therapy for Acute Renal Failure

Nephritic Syndrome

Acute glomerulonephritis

Occurs after streptococcus infections

Symptoms

Hematuria

Hypertension

Mild loss of renal function

MNT

Maintain good nutritional status

Restrict sodium if hypertension

Changes in Nephrotic Syndrome

Large protein losses in the urine lead to hypoalbuminemia

Edema

Hypercholesterolemia

Hypercoagulability

Abnormal bone metabolism

Nephrotic Syndrome

Causes

Diabetes mellitus

Systemic lupus erythematosus

MNT

Protein: 0.8 g/kg IBW; 50% to 60% HBV

35 kcal/kg IBW (100–150 kcal/kg for children)

Sodium: 3 g/day

High risk for premature atherosclerosis; cholesterol-lowering diet

Pyelonephritis

Bacterial infection of the kidney

In chronic cases, cranberry juice and blueberry juice are beneficial

Chronic Kidney Disease

Progressive loss of function

When 1/4 to 2/3 of function lost, regardless of underlying disease, kidney failure ensues

The kidney adapts to decreasing GFR

Stages of Chronic Kidney Disease

Medical Nutrition Therapy for Progressive Renal Disease

Role of dietary protein restriction

National Kidney Foundation’s Kidney Dialysis Outcome Quality Initiative (KDOQI)

0.6 g/kg/day (50% high BV) and 35 kcal/kg/day for GFR <25 mL/min without dialysis

If unable to maintain adequate kcal intake, increase protein to 0.75 g/kg/day

Control hypertension

Uremia: Signs and Symptoms

BUN >100 mg/dL and creatinine 10 to 12 mg/dL

Malaise

Weakness

Nausea and vomiting

Muscle cramps

Itching

Metallic taste (mouth)

Neurologic impairment

End-Stage Renal Disease

Types of Dialysis

Hemodialysis

Peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD)

Continuous cyclical peritoneal dialysis (CCPD)

General MNT for Pre-ESRD, Hemodialysis, Peritoneal Dialysis

Pre-ESRD Hemodialysis CAPD or CCPD

Protein (g/kg IBW*) 0.6–1.0 1.2 1.2–1.5

Energy (kcal/kg IBW*) 30–35 35 30–35

Phosphorus 8–12 <17 <17

(mg/kg IBW*)

Sodium (g/d) 2–3 2–3 2–4

Potassium (g/day) Unrestricted 2–3 3–4

Fluid (mL/d) Unrestricted 750–1000 + 2000 +

urine output urine output

*Use adjusted IBW if obese.

Goals of Medical Nutrition Therapy for End-Stage Renal Disease

Prevent deficiency and maintain good nutritional status

Control edema and electrolyte imbalance

Prevent or retard renal osteodystrophy

Palatable attractive diet that fits lifestyle

Fluid and Sodium Balance in End-Stage Renal Disease

Measure blood pressure, edema, fluid weight gain, serum sodium, and dietary intake

Modify sodium and fluid intake accordingly

Most dialysis patients need to restrict sodium

Allow weight gain of 4 to 5 lb between dialyses

Potassium in End-Stage Renal Disease

Usually requires restriction

Monitor laboratory values, content of dialysate, and laboratory values

Potassium in foods

Potassium in salt substitutes

Protein and Energy in End-Stage Renal Disease

Dialysis drains body protein

Require higher protein intakes and >50% high BV

Energy intake must be adequate to spare protein

Calcium, Phosphorus, and Vitamin D in End-Stage Renal Disease

Metabolic bone disease or renal osteodystrophy

Osteomalacia (bone demineralization)

Osteitis fibrosa cystica (hyperparathyroidism)

Metastatic calcification of joints and soft tissues

Low turnover bone disease restrict dietary phosphate to <1200 mg/day

Restrict dietary phosphate to <1200 mg/day

Phosphate binders

Calcium supplements

Active vitamin D (calcitriol)

Iron in End-Stage Renal Disease

Hypoproliferative, normochromic anemia of chronic renal failure

Fatigue

Inability of kidney to produce erythropoietin (EPO)

Recombinant human erythropoietin (rHuEPO)

Oral iron: do not take with phosphate binders; avoid high doses of vitamin C

Monitor iron status using serum ferritin

Vitamins in End-Stage Renal Disease

Water-soluble vitamins lost during dialysis

Dietary restrictions may decrease vitamin intake

Require active form of vitamin D

Specific formulations for renal patients

Lipids in End-Stage Renal Disease

Atherosclerosis is common

Typically have elevated triglycerides with or without elevated cholesterol

Treat using dietary and pharmacologic treatment

Enteral and Parenteral Nutrition in End-Stage Renal Disease

Standard vs. specialty enteral formulas

Parenteral nutrition on if too ill to maintain adequate oral intake and GI complications

Parenteral vitamin and mineral requirements may differ from other patients

Intradialytic parenteral nutrition for malnourished patients

Special Considerations in End-Stage Renal Disease

40% to 50% of patients starting dialysis have diabetes

Specialized diet therapy

Specific complications

Education: patient is responsible for own diet

Educational tools

Children: aggressive monitoring and encouragement