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Medical Nutrition Therapy for Renal Disorders

Chapter 39. Medical Nutrition Therapy for Renal Disorders. Kidney. Function —Maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes. The Nephron. Kidney Diseases. Glomerular diseases 1. Nephrotic syndrome 2. Nephritic syndrome—tubular or interstitial

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Medical Nutrition Therapy for Renal Disorders

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  1. Chapter 39 Medical Nutrition Therapy for Renal Disorders

  2. Kidney • Function —Maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes

  3. The Nephron

  4. Kidney 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

  5. Changes in Nephrotic Syndrome • Edema • Proteinuria • Hypoalbuminemia (hypoproteinemia in general) • Hypercholesterolemia • Hypercoagulability • Abnormal bone metabolism

  6. Kidney 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

  7. Kidney Diseases—cont’d 2. Nephritic syndrome: acute glomerulonephritis Occurs after streptococcus infections Symptoms: Hematuria Hypertension

  8. Kidney 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

  9. Acute Renal Failure—Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

  10. Acute Renal Failure—Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

  11. Acute Renal Failure—Medical and Nutritional Management TPN, Total parenteral nutrition. Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

  12. Sample Calculation of Fluid Requirements in Acute Renal Failure

  13. Summary of Medical Nutrition Therapy for Acute Renal Failure GFR, Glomerular filtration rate; HBV, high biologic value; IBW, ideal body weight.

  14. 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

  15. End-Stage Renal Disease—Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

  16. End-Stage Renal Disease—Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

  17. End-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.

  18. Comparison of TreatmentsPre-ESRD, Hemodialysis, Peritoneal Dialysis

  19. General 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

  20. Adjusted Body Weight • Adjusted IBW for obesity Female ([actual wt – IBW] x 0.32) + IBW Male ([actual wt – IBW] x 0.38) + IBW

  21. Recommendations for Dietary Protein Intake In Patients with Progressive Renal Disease A. GFR >55 ml/min B. 25< GFR <55 ml/min 0.8 mg/day 0.6 mg/day

  22. Glucose 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

  23. Monitor Patient Status 1. BP >140/90 2. Edema 3. Weight changes 4. Urine output 5. Urine analysis: • Albumin • Protein

  24. Monitor 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

  25. Uremia, a Clinical Syndrome—Signs and Symptoms • Malaise • Weakness • Nausea and vomiting • Muscle cramps • Itching • Metallic taste (mouth) • Neurologic impairment

  26. Skeletal Effects of Chronic Renal Failure • Hyperphosphatemia • Hypocalcemia • Hyperparathyroidism • Low bone mass and density • Osteitis fibrosa cystica—hyperplastic demineralized bone

  27. Regimen 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.

  28. Regimen 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.

  29. Kidney 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

  30. Kidney 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

  31. Kidney 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

  32. Acid-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)

  33. Alkaline-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

  34. Summary • Renal diseases—delicate balance of nutrients • Regular monitoring of lab values, with altered dietary interventions accordingly

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