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Chapter 21 Renal Disease Mosby items and derived items © 2006 by Mosby, Inc.
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Chapter 21 Lesson 21.1 Mosby items and derived items © 2006 by Mosby, Inc.
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Key Concepts Renal disease interferes with the normal capacity of nephrons to filter waste products of body metabolism. Short-term renal disease requires basic nutritional support for healing rather than dietary restriction. Mosby items and derived items © 2006 by Mosby, Inc.
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Dual Role of the Kidneys
Kidneys make urine, through which they excrete most of the waste products of metabolism. Kidneys control the concentrations of most constituents of body fluids, especially blood. What are examples of metabolic waste products? How much fluid is filtered through the kidneys on a daily basis? What is a normal output of urine per day? Mosby items and derived items © 2006 by Mosby, Inc.
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Renal Nephrons Basic functional unit of the kidney
Major nephron functions Filtration of materials in blood Reabsorption of needed substances Secretion of hydrogen ions to maintain acid-base balance Excretion of waste materials Additional functions Renin secretion (for body water balance) Erythropoietin secretion (for red cell production) Vitamin D activation What are the key parts of the nephron? How many nephrons are present at birth? Why would anemia be linked to kidney disease? Why are kidneys referred to as “master chemists”? Mosby items and derived items © 2006 by Mosby, Inc.
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Nephron Structures Glomerulus Tubules Cluster of branching capillaries
Cup-shaped membrane at the head of each nephron forms the Bowman’s capsule Filters waste products from blood Glomerular filtration rate (GFR): preferred method of monitoring kidney function Tubules Proximal tubule Loop of Henle Distal tubule Collecting tubule How does osmotic pressure relate to kidney structure and function? What is the GFR, and why is it a useful indicator of kidney function? What is another name for antidiuretic hormone? Who discovered the function of the glomerulus? What doe s the Latin word “glomus” mean? Mosby items and derived items © 2006 by Mosby, Inc.
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Anatomy of the Kidney Identify the parts of the kidney and their functions. Mosby items and derived items © 2006 by Mosby, Inc.
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Causes of Kidney Disease
Inflammatory and degenerative disease Acute glomerulonephritis Nephrotic syndrome Chronic renal failure Damage from other diseases Hypertension, diabetes mellitus Infection and obstruction Damage from other agents Environmental agents Malnutrition Genetic defects What is the number one cause of kidney disease in the U.S.? How does hypertension relate to kidney disease? What are treatments for infection or obstruction of the kidneys? How does malnutrition contribute to kidney disease? Can a person born with only one kidney lead a healthy life without treatment? Mosby items and derived items © 2006 by Mosby, Inc.
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Risk Factors What risk factors can be reduced or prevented with improved education and early diagnosis? What is the role of the nurse in improving quality of life issues in kidney disease? Why is an understanding of kidney function essential for a nurse, regardless of area of specialty? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy Based on the nature of the disease process and individual responses Length of disease Long-term: more specific nutrient modifications Degree of impaired renal function Extensive: extensive nutrition therapy required Individual clinical symptoms How is renal function assessed and monitored? Why is treatment of chronic renal disease so complex and challenging? List other conditions often present with renal disease and their exacerbating effects. Mosby items and derived items © 2006 by Mosby, Inc.
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Glomerulonephritis Clinical symptoms: hematuria, proteinurea, edema, mild hypertension, depressed appetite, possible oliguria or anuria Nutrition therapy Uncomplicated disease: antibiotics and bed rest Advanced disease: Possible restriction of protein, sodium Liberal intake of carbohydrates Potassium intake may be monitored Fluid intake may be restricted Why is dietary therapy less complicated with glomerulonephritis? Why is bed rest required? What are risk factors for glomerulonephritis? Mosby items and derived items © 2006 by Mosby, Inc.
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Nephrotic Syndrome Clinical symptoms: massive edema, ascites, proteinurea, distended abdomen, reduced plasma protein level, body tissue wasting Nutrition therapy Protein intake to meet nutritional/growth needs (without excess) Increased caloric intake Possible moderate reduction of sodium No need for potassium restriction Possible need for iron, vitamin supplements What is ascites? Why is the abdomen distended? How is protein intake calculated? How does dietary management of nephrotic syndrome differ with other renal disorders? Mosby items and derived items © 2006 by Mosby, Inc.
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Chapter 21 Lesson 21.2 Mosby items and derived items © 2006 by Mosby, Inc.
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Key Concepts The progressive degeneration of chronic renal failure requires nutrient modification according to individual disease status and dialysis treatment. Current therapy for renal stones depends more on the basic nutrition and health support for medical treatment than on major food and nutrient restrictions. Mosby items and derived items © 2006 by Mosby, Inc.
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Acute Renal Failure Sudden shut-down of kidneys in response to metabolic insult (infectious disease, toxic agents, drug reactions) or traumatic injury Medical emergency Can last from days to weeks Clinical symptoms: oliguria,proteinurea, hematuria, loss of appetite, nausea/vomiting, fatigue, edema, itchy skin Short-term dialysis may be needed May progress to chronic renal failure What are environmental toxins that could cause acute renal failure? What medications might lead to acute renal failure in an allergic person? Why does itchy skin occur? Mosby items and derived items © 2006 by Mosby, Inc.
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Acute Renal Failure: Nutrition Therapy
Goal is to improve or maintain nutritional status Parenteral nutrition therapy may be required Recommendations for protein intake have been debated Individualized therapy based on renal function (indicated by GFR) Are dietary restrictions necessary as with chronic renal failure? What are other differences between acute and chronic renal failure? Is dialysis ever required to treat acute renal failure? Mosby items and derived items © 2006 by Mosby, Inc.
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Chronic Renal Failure Caused by progressive breakdown of renal tissue, which impairs all renal functions Develops slowly No cure (other than kidney transplant) Clinical symptoms: polyuria/oliguria/anurea, electrolyte imbalances, nitrogen retention, anemia, hypertension, azotemia, weakness, shortness of breath, fatigue, thirst, appetite loss, bleeding, muscular twitching Is polyuria a late or early symptom in chronic renal failure? Why? What is meant by azotemia? Why does muscular twitching occur in renal failure? How does uncontrolled hypertension relate to kidney failure? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy Objectives
Reduce protein breakdown Avoid dehydration or excess hydration Correct acidosis Correct electrolyte imbalances Control fluid and electrolyte losses Maintain optimal nutritional status Maintain appetite, morale Control complications of hypertension, bone pain, nervous system involvement Slow rate of renal failure What is a byproduct of protein metabolism? What symptoms does a buildup of urea cause? Why is the kidney unable to retain adequate serum protein in the face of nephron damage? How does pH change in kidney disease? What are nursing interventions for stimulation of appetite? Is depression related to kidney disease? If so, why? Can acute renal failure progress to a more chronic form of the disease? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy Principles
Provide enough protein therapy to maintain tissue integrity while avoiding excess Provide amino acid supplements for protein supplementation Reserve protein for tissue synthesis by ensuring adequate carbohydrates and fats Maintain adequate urine volume with water (Possibly) restrict sodium, phosphate, calcium Supplement diet with multivitamin Why is protein therapy essential in kidney disease? Discuss the importance of individual monitoring of disease based on causes and clinical presentation. How does nutrition therapy vary for short-term and long-term kidney disease? What is the role of the clinical nutritionist in kidney disease management? Mosby items and derived items © 2006 by Mosby, Inc.
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Stages of Chronic Kidney Disease
What are the different grades used to differentiate among chronic kidney disease stages? How is chronic kidney disease defined? What blood abnormalities would be expected in chronic kidney disease? Mosby items and derived items © 2006 by Mosby, Inc.
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End-Stage Renal Disease
Occurs when patient’s GFR decreases to 15 ml/min Irreversible damage to most nephrons Dialysis or transplant are only options Why is the GFR used to assess kidney function? Why should patients in end-stage renal disease have an advanced directive? What ethnic groups are at risk for end-stage renal disease? How can controlling diabetes prevent end-stage renal disease? Is treatment for end-stage renal disease costly? How is quality of life affected? Mosby items and derived items © 2006 by Mosby, Inc.
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Hemodialysis Uses an artificial kidney machine to remove toxic substances from blood, restore nutrients and metabolites 2-3 treatments/week typically required Patient’s blood makes several “round trips” through machine Dialysis solution (dialysate) removes excess waste material Where is hemodialysis provided? Can LPNs/LVNs supervise hemodialysis treatments? What does an A/V fistula look like? What are complications of hemodialysis? Mosby items and derived items © 2006 by Mosby, Inc.
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Hemodialysis Patient: Objectives for Diet
Maintain protein and energy balance Prevent dehydration or fluid overload Maintain normal serum potassium and sodium levels Maintain acceptable phosphate and calcium levels Are the dietary objectives similar for hemodialysis and peritoneal dialysis patients? Why is individualized dietary monitoring important? What other health conditions may be present in patients receiving hemodialysis? How does that affect their organ function? Mosby items and derived items © 2006 by Mosby, Inc.
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Hemodialysis Patient: Other Dietary Concerns
Avoid protein-energy malnutrition via careful calculation of protein allowance Maintain body mass index within upper 50th percentile via generous amounts of carbohydrates and some fats Fluid intake: 1000 ml/day, plus amount equal to urine output Limit sodium: mg/day Limit potassium: mg/day Supplement of water-soluble vitamins (e.g., B complex, C) How can intake and output be monitored? What are dietary sources of sodium? Why should vitamins be supplemented for hemodialysis patients? How is protein allowance calculated? Mosby items and derived items © 2006 by Mosby, Inc.
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Peritoneal Dialysis Performed at home
Patient introduces dialysate solution directly into peritoneal cavity 4-5 times/day Surgical insertion of permanent catheter is required Disposable bag containing dialysate solution is attached to catheter Diet is more liberal than with hemodialysis What is an advantage of peritoneal dialysis in comparison to hemodialysis? What does the dialysate solution look like? How is it disposed of? Is infection a risk? What are some quality-of-life considerations for patients on dialysis? Mosby items and derived items © 2006 by Mosby, Inc.
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Peritoneal Dialysis: Nutritional Therapy
Increase protein intake to g/kg body weight Limit phosphorus to mg/day Increase potassium via wide variety of fruits and vegetables Encourage liberal fluid intake Avoid sweets and fats Maintain lean body weight Why does protein loss occur with kidney disease? What are foods high in phosphorus? What are dietary sources of potassium? How are phosphorus and postassium levels monitored? Why is dehydration a risk with peritoneal dialysis? Mosby items and derived items © 2006 by Mosby, Inc.
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Comorbid Conditions Osteodystrophy Neuropathy
Bone disease resulting from defective bone formation Found in about 40% of patients suffering from decreased kidney function and 100% of patients with kidney failure Neuropathy Central and peripheral neurologic disorders Found in up to 65% of patients at the initiation of dialysis How is osteodystrophy managed? Why is neuropathy related to diabetes as well as kidney disease? What nursing interventions can be used for neuropathy? Why is pain management important? Mosby items and derived items © 2006 by Mosby, Inc.
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Kidney Stones Basic cause is unknown
Factors relating to urine or urinary tract environment contribute to formation Present in 5% of U.S. women and 12% of U.S. men Major stones are formed from one of three substances: Calcium Struvite Uric acid (Cont’d…) Why are men more predisposed to stone formation? How does genetics relate to creation of kidney stones? Mosby items and derived items © 2006 by Mosby, Inc.
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Kidney Stones (…Cont’d)
Compare and contrast the different appearances of the stones. Why is pain a primary manifestation with kidney stones? What parts of the kidney may have stones present? Mosby items and derived items © 2006 by Mosby, Inc.
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Risk Factors What is the relationship between malnutrition and kidney stone formation? Why might certain medications contribute to stone formation? Mosby items and derived items © 2006 by Mosby, Inc.
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Calcium Stones 70%-80% of kidney stones are composed of calcium oxalate Almost half result from genetic predisposition Other causes: Excess calcium in blood (hypercalcemia) or urine (hypercalciuria) Excess oxalate in urine (hyperoxaluria) Low levels of citrate in urine (hypocitraturia) Infection What risk factors can be minimized by the patient? What does a calcium stone look like? Mosby items and derived items © 2006 by Mosby, Inc.
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Examples of Food Sources of Oxalates
Fruits: berries, Concord grapes, currants, figs, fruit cocktail, plums, rhubarb, tangerines Vegetables: baked/green/wax beans, beet/collard greens, beets, celery, Swiss chard, chives, eggplant, endive, kale, okra, green peppers, spinach, sweet potatoes, tomatoes Nuts: almonds, cashews, peanuts/peanut butter Beverages: cocoa, draft beer, tea Other: grits, tofu, wheat germ What types of kidney stones are related to oxalates? Should wine be avoided? Mosby items and derived items © 2006 by Mosby, Inc.
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Struvite Stones Composed of magnesium ammonium phosphate
Mainly caused by urinary tract infections rather than specific nutrient No diet therapy is involved Usually removed surgically Why isn’t diet therapy indicated? What are symptoms of a urinary tract infection? Why is surgery required? Mosby items and derived items © 2006 by Mosby, Inc.
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Other Stones Cystine stones Xanthine stones
Caused by genetic metabolic defect Occur rarely Xanthine stones Associated with treatment for gout and family history of gout What is gout? Mosby items and derived items © 2006 by Mosby, Inc.
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Kidney Stones: Symptoms and Treatment
Clinical symptoms: severe pain, other urinary symptoms, general weakness, and fever Several considerations for treatment Fluid intake to prevent accumulation of materials Dietary control of stone constituents Achievement of desired pH of urine via medication Use of binding agents to prevent absorption of stone elements Drug therapy in combination with diet therapy What type of pain is it often likened to? (labor pain/cramps) What are pain management strategies for kidney stones? How is stone composition determined? What are binding agents? What types of medications are used in treatment? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy: Calcium Stones
Low-calcium diet (approx. 400 mg/day) recommended for those with supersaturation of calcium in the urine and who are not at risk for bone loss If stone is calcium phosphate, sources of phosphorus (meats, legumes, nuts) are controlled Fluid intake increased Sodium intake decreased Fiber foods high in phytates increased What types of patients are at risk for bone loss? Why should fluid intake be increased? Should soda intake be reduced? What are food sources high in sodium? What are examples of high-fiber foods? Mosby items and derived items © 2006 by Mosby, Inc.
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Low-Calcium Diet Provide an example of a low-calcium diet for a 24-hour period. Note what the total daily calcium intake should be. Why would distilled water be indicated? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy: Uric Acid Stones
Low-purine diet sometimes recommended Avoid: Organ meats Alcohol Anchovies, sardines Yeast Legumes, mushrooms, spinach, asparagus, cauliflower Poultry How does this type of stone relate to gout? Provide examples of organ meats. What are examples of protein sources that are acceptable with this type of kidney stone? Mosby items and derived items © 2006 by Mosby, Inc.
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Nutrition Therapy: Cystine Stones
Low-methionine diet (essentially a low-protein diet) sometimes recommended In children, a regular diet to support growth is recommended Medical drug therapy is used to control infection or produce more alkaline urine Is this type of stone caused by a genetic disorder? Why does age determine dietary treatment? What are the different metabolic needs of children compared to adults? What is methionine? What medications are used as treatments and why? Mosby items and derived items © 2006 by Mosby, Inc.
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General Dietary Principles: Kidney Stones
How do the different stone compositions affect nutrition therapy? What is an example of a low-calcium diet? What foods are high in purines? What is the acid/alkaline concept? Mosby items and derived items © 2006 by Mosby, Inc.
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