Medical Nutrition Therapy for Renal Disorders Chapter 39
Dec 22, 2015
Medical Nutrition Therapy for Renal Disorders
Medical Nutrition Therapy for Renal Disorders
Chapter 39Chapter 39
© 2004, 2002 Elsevier Inc. All rights reserved.
KidneyKidney
Function
—Maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes
Function
—Maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes
© 2004, 2002 Elsevier Inc. All rights reserved.
The NephronThe Nephron
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Kidney DiseasesKidney Diseases Glomerular diseases
1. Nephrotic syndrome
2. Nephritic syndrome—tubular or interstitial
3. Acute renal failure (ARF)
4. Tubular defects
Other
5. End-stage renal disease (ESRD)
6. Kidney stones
Glomerular diseases
1. Nephrotic syndrome
2. Nephritic syndrome—tubular or interstitial
3. Acute renal failure (ARF)
4. Tubular defects
Other
5. End-stage renal disease (ESRD)
6. Kidney stones
© 2004, 2002 Elsevier Inc. All rights reserved.
Changes in Nephrotic SyndromeChanges in Nephrotic Syndrome
Edema
Proteinuria
Hypoalbuminemia (hypoproteinemia in general)
Hypercholesterolemia
Hypercoagulability
Abnormal bone metabolism
Edema
Proteinuria
Hypoalbuminemia (hypoproteinemia in general)
Hypercholesterolemia
Hypercoagulability
Abnormal bone metabolism
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney DiseasesKidney Diseases
1. Nephrotic syndrome: may be caused by diabetes mellitus (DM), systemic lupus erythematosus (SLE), amyloidosis
Diet: Protein 0.8 to 1 g/kg IBW 80% HBV
Kcal 35 to 40/kg IBW
Phosphorus 8 to 12 mg/kg IBW
Sodium 1to 3 g/day
Potassium unrestricted
Fluid unrestricted
Calcium 1200 to 1400 mg/day
From: National Renal Diet: Professional Guide, 1993
1. Nephrotic syndrome: may be caused by diabetes mellitus (DM), systemic lupus erythematosus (SLE), amyloidosis
Diet: Protein 0.8 to 1 g/kg IBW 80% HBV
Kcal 35 to 40/kg IBW
Phosphorus 8 to 12 mg/kg IBW
Sodium 1to 3 g/day
Potassium unrestricted
Fluid unrestricted
Calcium 1200 to 1400 mg/day
From: National Renal Diet: Professional Guide, 1993
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney Diseases—cont’dKidney Diseases—cont’d
2. Nephritic syndrome: acute glomerulonephritis
Occurs after streptococcus infections
Symptoms:
Hematuria
Hypertension
2. Nephritic syndrome: acute glomerulonephritis
Occurs after streptococcus infections
Symptoms:
Hematuria
Hypertension
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney Diseases—cont’dKidney Diseases—cont’d
3. Nephritic syndrome
—Diet to treat underlying disease
—Restrict diet to control symptoms
—Protein restricted in uremia
—Sodium restrict in hypertension
—Potassium restrict in hyperkalemia
3. Nephritic syndrome
—Diet to treat underlying disease
—Restrict diet to control symptoms
—Protein restricted in uremia
—Sodium restrict in hypertension
—Potassium restrict in hyperkalemia
© 2004, 2002 Elsevier Inc. All rights reserved.
Acute Renal Failure—CauseAcute Renal Failure—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
© 2004, 2002 Elsevier Inc. All rights reserved.
Acute Renal Failure—PathophysiologyAcute Renal Failure—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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Acute Renal Failure—Medical and Nutritional ManagementAcute Renal Failure—Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
TPN, Total parenteral nutrition.
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Sample Calculation of Fluid Requirements in Acute Renal FailureSample Calculation of Fluid Requirements in Acute Renal Failure
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Summary of Medical Nutrition Therapy for Acute Renal FailureSummary of Medical Nutrition Therapy for Acute Renal Failure
GFR, Glomerular filtration rate; HBV, high biologic value; IBW, ideal body weight.
© 2004, 2002 Elsevier Inc. All rights reserved.
Progression to End-Stage Renal Disease (ESRD)Progression to End-Stage Renal Disease (ESRD)
First Decline in glomerular filtration rate (GFR)
Second Adaptations in renal function, i.e., increase in GFR
Third Adaptations work in the short term to improve renal function.
Fourth In the long run a loss of nephron units occurs.
Fifth A slow but progressive decline in renal function
Sixth Eventually this decline leads to renal insufficiency, i.e., ESRD
First Decline in glomerular filtration rate (GFR)
Second Adaptations in renal function, i.e., increase in GFR
Third Adaptations work in the short term to improve renal function.
Fourth In the long run a loss of nephron units occurs.
Fifth A slow but progressive decline in renal function
Sixth Eventually this decline leads to renal insufficiency, i.e., ESRD
© 2004, 2002 Elsevier Inc. All rights reserved.
End-Stage Renal Disease—CauseEnd-Stage Renal Disease—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
© 2004, 2002 Elsevier Inc. All rights reserved.
End-Stage Renal Disease—PathophysiologyEnd-Stage Renal Disease—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
© 2004, 2002 Elsevier Inc. All rights reserved.
End-Stage Renal Disease—Medical and Nutritional ManagementEnd-Stage Renal Disease—Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Katy G. Wilkens, 2002.
© 2004, 2002 Elsevier Inc. All rights reserved.
Comparison of Treatments Pre-ESRD, Hemodialysis, Peritoneal Dialysis
Comparison of Treatments Pre-ESRD, Hemodialysis, Peritoneal Dialysis
Pre-ESRD Hemodialysis CAPD or CCPD
Treatment Diet and medications
Diet and medications Hemodialysis
Diet and medications Peritoneal dialysis
Modality Vascular access Peritoneal membrane
Duration Indefinite 3-5 h 2-3 d/wk
3-5 exchanges 7 d/wk
Concerns Glomerular hyperfiltration: BUN: bone disease: HTN: Glucose control in diabetes
AA loss; interdialytic electrolyte and fluid changes: Bone disease: HTN
Protein loss: glucose absorption: Bone disease: weight gain: hyperlipidemia: glucose control in diabetes
Pre-ESRD Hemodialysis CAPD or CCPD
Treatment Diet and medications
Diet and medications Hemodialysis
Diet and medications Peritoneal dialysis
Modality Vascular access Peritoneal membrane
Duration Indefinite 3-5 h 2-3 d/wk
3-5 exchanges 7 d/wk
Concerns Glomerular hyperfiltration: BUN: bone disease: HTN: Glucose control in diabetes
AA loss; interdialytic electrolyte and fluid changes: Bone disease: HTN
Protein loss: glucose absorption: Bone disease: weight gain: hyperlipidemia: glucose control in diabetes
© 2004, 2002 Elsevier Inc. All rights reserved.
General MNT for Pre-ESRD, Hemodialysis, Peritoneal DialysisGeneral MNT for Pre-ESRD, Hemodialysis, Peritoneal Dialysis
Pre-ESRD Hemodialysis CAPD or CCPD
Protein 0.6-0.8 1.1-1.4 1.2-1.5(g/kg IBW)
Energy 35-40 30-35 25-35
(kcal/kg IBW)
Phosphorus 8-12 <17 <17
(mg/kg IBW)
Sodium 1000-3000 2000-3000 2000-4000
(mg/d)
Potassium Unrestricted ~ 40 Unrestricted
(mg/kg IBW)
Fluid Unrestricted 500-750 + 2000 +
(ml/d) urine output
(1000 if anuric)
Calcium 1200-1600 based on serum based on serum
(mg/d) level level
Use adjusted IBW if obese
Pre-ESRD Hemodialysis CAPD or CCPD
Protein 0.6-0.8 1.1-1.4 1.2-1.5(g/kg IBW)
Energy 35-40 30-35 25-35
(kcal/kg IBW)
Phosphorus 8-12 <17 <17
(mg/kg IBW)
Sodium 1000-3000 2000-3000 2000-4000
(mg/d)
Potassium Unrestricted ~ 40 Unrestricted
(mg/kg IBW)
Fluid Unrestricted 500-750 + 2000 +
(ml/d) urine output
(1000 if anuric)
Calcium 1200-1600 based on serum based on serum
(mg/d) level level
Use adjusted IBW if obese
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Adjusted Body WeightAdjusted Body Weight
Adjusted IBW for obesity
Female
([actual wt – IBW] x 0.32) + IBW
Male
([actual wt – IBW] x 0.38) + IBW
Adjusted IBW for obesity
Female
([actual wt – IBW] x 0.32) + IBW
Male
([actual wt – IBW] x 0.38) + IBW
© 2004, 2002 Elsevier Inc. All rights reserved.
Recommendations for Dietary Protein IntakeRecommendations for Dietary Protein Intake
A. GFR >55 ml/min B. 25< GFR <55 ml/min
0.8 mg/day 0.6 mg/day
A. GFR >55 ml/min B. 25< GFR <55 ml/min
0.8 mg/day 0.6 mg/day
In Patients with Progressive Renal DiseaseIn Patients with Progressive Renal Disease
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Glucose Kcal from DialysateGlucose Kcal from Dialysate
Glucose in dialysate
1.5% = 15 g/L
2.5% = 25 g/L
4.25% = 43 g/L
1. L of % solution x g/L glucose = g glucose
2. Repeat for each glucose concentration used
3. Total g glucose for all exchanges
4. 0.80 x total g glucose = g glucose absorbed
5. g glucose absorbed x 3.7 kcal/g = kcal
Glucose in dialysate
1.5% = 15 g/L
2.5% = 25 g/L
4.25% = 43 g/L
1. L of % solution x g/L glucose = g glucose
2. Repeat for each glucose concentration used
3. Total g glucose for all exchanges
4. 0.80 x total g glucose = g glucose absorbed
5. g glucose absorbed x 3.7 kcal/g = kcal
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Monitor Patient StatusMonitor Patient Status
1. BP >140/90
2. Edema
3. Weight changes
4. Urine output
5. Urine analysis:
—Albumin
—Protein
1. BP >140/90
2. Edema
3. Weight changes
4. Urine output
5. Urine analysis:
—Albumin
—Protein
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Monitor Patient Status—cont’dMonitor Patient Status—cont’d
6. Kidney function
Creatinine clearance
Glomerular filtration rate (GFR)
7. Blood values
BUN 10 to 20 mg/dl (<100 mg/dl)
Creatinine 0.7 to 1.5 mg/dl (10-15 mg/dl)
Potassium 3.5 to 5.5 mEq/L
Phosphorus 3.0 to 4.5 mg/dl
Albumin 3.5-5.5 g/dl
Calcium 9-11 mg/dl
6. Kidney function
Creatinine clearance
Glomerular filtration rate (GFR)
7. Blood values
BUN 10 to 20 mg/dl (<100 mg/dl)
Creatinine 0.7 to 1.5 mg/dl (10-15 mg/dl)
Potassium 3.5 to 5.5 mEq/L
Phosphorus 3.0 to 4.5 mg/dl
Albumin 3.5-5.5 g/dl
Calcium 9-11 mg/dl
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Uremia, a Clinical Syndrome—Signs and SymptomsUremia, a Clinical Syndrome—Signs and Symptoms
Malaise
Weakness
Nausea and vomiting
Muscle cramps
Itching
Metallic taste (mouth)
Neurologic impairment
Malaise
Weakness
Nausea and vomiting
Muscle cramps
Itching
Metallic taste (mouth)
Neurologic impairment
© 2004, 2002 Elsevier Inc. All rights reserved.
Skeletal Effects of Chronic Renal FailureSkeletal Effects of Chronic Renal Failure
Hyperphosphatemia
Hypocalcemia
Hyperparathyroidism
Low bone mass and density
Osteitis fibrosa cystica—hyperplastic demineralized bone
Hyperphosphatemia
Hypocalcemia
Hyperparathyroidism
Low bone mass and density
Osteitis fibrosa cystica—hyperplastic demineralized bone
© 2004, 2002 Elsevier Inc. All rights reserved.
Regimen for Total Parenteral Nutrition by Subclavian Vein for Dialysis PatientsRegimen for Total Parenteral Nutrition by Subclavian Vein for Dialysis Patients
Developed by Katy Wilkens, RD, Northwest Kidney Center; Seattle, Wash.* Additional volume may include insulin and vitamins.
© 2004, 2002 Elsevier Inc. All rights reserved.
Regimen for Intermittent Parenteral Nutrition Administered During Hemodialysis TherapyRegimen for Intermittent Parenteral Nutrition Administered During Hemodialysis Therapy
Developed by Katy Wilkens, RD, Northwest Kidney Center; Seattle, Wash.* Additional volume may include insulin and vitamins.
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney TransplantKidney Transplant
1. Types: related donor or cadaver
2. Posttransplant management:
Corticosteroids
Cyclosporine
3. Diet while on high-dose steroids:
1.3 to 2 g/kg BW protein
30 to 35 kcal/kg BW energy
80 to 100 mEq Na
4. Diet after steroids:
1 g/kg BW protein
Kcal to achieve IBW
Individualize Na level
1. Types: related donor or cadaver
2. Posttransplant management:
Corticosteroids
Cyclosporine
3. Diet while on high-dose steroids:
1.3 to 2 g/kg BW protein
30 to 35 kcal/kg BW energy
80 to 100 mEq Na
4. Diet after steroids:
1 g/kg BW protein
Kcal to achieve IBW
Individualize Na level
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney StonesKidney Stones
1. Particulate matter crystallizes
Ca salts (Ca oxalate or Ca phosphate)
Uric acid
Cystine
Struvite (NH4, magnesium and phosphate)
2. Ca salts in stones—Rx: high fluid; evaluate calcium from diet; may need more!
3. Treat metabolic problem; low-oxalate diet may be needed; acid-ash diet is sometimes useful but not proven totally effective
1. Particulate matter crystallizes
Ca salts (Ca oxalate or Ca phosphate)
Uric acid
Cystine
Struvite (NH4, magnesium and phosphate)
2. Ca salts in stones—Rx: high fluid; evaluate calcium from diet; may need more!
3. Treat metabolic problem; low-oxalate diet may be needed; acid-ash diet is sometimes useful but not proven totally effective
© 2004, 2002 Elsevier Inc. All rights reserved.
Kidney Stones—cont’dKidney Stones—cont’d
4. Uric acid stones
Alter pH of urine to more alkaline
Use high-alkaline-ash diet
Food list in Krause text
5. Cystine stones (rare)
6. Struvite antibiotics and/or surgery
4. Uric acid stones
Alter pH of urine to more alkaline
Use high-alkaline-ash diet
Food list in Krause text
5. Cystine stones (rare)
6. Struvite antibiotics and/or surgery
© 2004, 2002 Elsevier Inc. All rights reserved.
Acid-Ash DietAcid-Ash Diet
Increases acidity of urine (contains chloride, phosphorus, and sulfur)
Meats, cheese, grains emphasized
Fruits and vegetables limited (exceptions are corn, lentils, cranberries, plums, prunes)
Increases acidity of urine (contains chloride, phosphorus, and sulfur)
Meats, cheese, grains emphasized
Fruits and vegetables limited (exceptions are corn, lentils, cranberries, plums, prunes)
© 2004, 2002 Elsevier Inc. All rights reserved.
Alkaline-Ash DietAlkaline-Ash Diet
Increases alkalinity of urine (contains sodium, potassium, calcium, and magnesium)
Fruits and vegetables emphasized (exceptions are corn, lentils, cranberries, plums, prunes)
Meats and grains limited
Increases alkalinity of urine (contains sodium, potassium, calcium, and magnesium)
Fruits and vegetables emphasized (exceptions are corn, lentils, cranberries, plums, prunes)
Meats and grains limited
© 2004, 2002 Elsevier Inc. All rights reserved.
SummarySummary
Renal diseases—delicate balance of nutrients
Regular monitoring of lab values, with altered dietary interventions accordingly
Renal diseases—delicate balance of nutrients
Regular monitoring of lab values, with altered dietary interventions accordingly