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Nutrition in Kidney Diseases

Krauses Nutrition and diet therapy5

Functions of Kidney Excrete waste material: end products of protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and toxic substances Excrete waste material: end products of protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and toxic substances Electrolyte balance Electrolyte balance Hormonal regulation Hormonal regulation Blood pressure regulation Blood pressure regulation Glucose homeostatis Glucose homeostatis

ETIOLOGY Diabetes mellitus (28%) Diabetes mellitus (28%) Hypertension (25%) Hypertension (25%) Glomerulonephritis (21%) Glomerulonephritis (21%) Polycystic Kidney Diease (4%) Polycystic Kidney Diease (4%) Other (23%): Obstruction, infection, etc. Other (23%): Obstruction, infection, etc.

8 Diabetes 50% Hypertension 27% Glomerulonephritis 13% Other 10% Primary Diagnoses for Patients Who Start Dialysis United States Renal Data System (USRDS) 2000 Annual Data Report

Chronic Renal Failure Develops slowly, number of functioning nephrons constantly diminishing. Uremia is a result Symptoms:nausea, headache, coma, convulsions. Severe renal failure will result in death unless dialysis used. 9

Clinical pathophysioloy Metabolic acidosis: result in; Metabolic acidosis: result in; –Muscle breakdown –Bone dissolving Hyperkalemia Hyperkalemia Hypertension Hypertension Negative N balance Negative N balance Insulin resistance Insulin resistance Hyperphosphatemia Hyperphosphatemia Anemia Anemia

Progression of chronic renal failure Factors causing progression Factors causing progression  sustaining primary disease  systemic hypertension  Intraglomerular hypertension  Proteinuria  Nephrocalcinosis  Dyslipidaemia  Imbalance between renal energy demands and supply

CRF Reversible factors in CRF Hypertension Hypertension Reduced renal perfusion (renal artery stenosis, hypotension, sodium and water depletion, poor cardiac function) Reduced renal perfusion (renal artery stenosis, hypotension, sodium and water depletion, poor cardiac function) Urinary tract obstruction Urinary tract obstruction Infection Infection Nephrotoxic medications Nephrotoxic medications Metabolic factors(calcium phosphate products  ) Metabolic factors(calcium phosphate products  )

Slowing the Progression of Chronic Renal Failure Control BP to <130 /80 Control BP to <130 /80 Diet Diet Anaemia Anaemia Calcium and Phosphate Calcium and Phosphate Dyslipidaemia Dyslipidaemia Obesity Obesity Smoking Cessation Smoking Cessation

14 Dietary Treatment of Renal Disease  Extremely complicated.  Intended to reduce the amount of excretory work demanded of the kidneys while helping them maintain fluid, acid-base, and electrolyte balance.  In CRF may have protein, sodium, potassium and phosphorus restricted.

15 Dietary Treatment of Renal Disease  Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight.  Energy requirements should be fulfilled by carbohydrates and fat.  Protein increases the amount of nitrogen waste the kidneys must handle.  Diet may limit protein to 40 grams( at least 0.5 g/kg ) based on glomerular filtration rate and weight.

CRF Diet therapy Protein restriction ( mg/kg/d) Protein restriction ( mg/kg/d) Adequte intake of calories(30-35kcal/kg/d) Adequte intake of calories(30-35kcal/kg/d) Fluid intake:urine volume +500ml Fluid intake:urine volume +500ml Low phosphate diet( mg/d) Low phosphate diet( mg/d) Supplement of EAA(ketosteril) Supplement of EAA(ketosteril)

Fluid Unrestricted until urine output declines Unrestricted until urine output declines Urine output plus 1000 cc/d Urine output plus 1000 cc/d Evaluate effect on blood pressure and cardiac function

Sodium Sodium Sodium 2-4 g/d (43 mEq = 1 g) 2-4 g/d (43 mEq = 1 g) Variable with urine output and disease etiology Variable with urine output and disease etiology Evaluate effect on hypertension control and cardiac function

Potassium Accumulates in CKD stage 5 Accumulates in CKD stage 5 Hyperkalemia →cardiac danger Hyperkalemia →cardiac danger Restrict to 2-4g/d (26 mEq=1g) Restrict to 2-4g/d (26 mEq=1g)

Hyperkalemia & EKG K > K > Tall, peaked T’s Tall, peaked T’s Wide QRS Wide QRS Prolong PR Prolong PR Diminished P Diminished P Prolonged QT Prolonged QT QRS-T merge – sine wave QRS-T merge – sine wave

Hyperkalemia Symptoms Weakness Weakness Lethargy Lethargy Muscle cramps Muscle cramps Paresthesias Paresthesias Hypoactive DTRs Hypoactive DTRs Dysrhythmias Dysrhythmias

Nutrition Implications of ARF ARF causes anorexia, nausea, vomiting, bleeding ARF causes anorexia, nausea, vomiting, bleeding ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism) ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism) ARF causes ↑ gluconeogenesis with insulin resistance ARF causes ↑ gluconeogenesis with insulin resistance Dialysis causes loss of amino acids and protein Dialysis causes loss of amino acids and protein Uremia toxins cause impaired glucose utilization and protein synthesis Uremia toxins cause impaired glucose utilization and protein synthesis

Treatment Goals for Renal Failure Correct electrolytes Correct electrolytes Control acidosis Control acidosis Treat significant hyperphosphatemia Treat significant hyperphosphatemia Treat symptomatic anemia Treat symptomatic anemia Initiate dialysis for hyperkalemia or acidosis not controlled, fluid overload, ↑ in BUN>20 mg/dl/24 hours or BUN>100 mg/dl Initiate dialysis for hyperkalemia or acidosis not controlled, fluid overload, ↑ in BUN>20 mg/dl/24 hours or BUN>100 mg/dl Evaluate drugs for renal effect Evaluate drugs for renal effect Avoid/treat infection Avoid/treat infection

Vitamins in ARF Vitamin A: elevated vitamin A levels are known to occur with RF Vitamin A: elevated vitamin A levels are known to occur with RF Vitamin B – prevent B6 deficiency by giving 10 mg pyridoxine hydrochloride/day Vitamin B – prevent B6 deficiency by giving 10 mg pyridoxine hydrochloride/day Folate and B6: supplement when homocysteine levels are high Folate and B6: supplement when homocysteine levels are high Vitamin C: <200 mg/day to prevent ↑ oxalate Vitamin C: <200 mg/day to prevent ↑ oxalate Activated vitamin D Activated vitamin D Vitamin K: give Vitamin K especially to pts on antibiotics that suppress gut production of K Vitamin K: give Vitamin K especially to pts on antibiotics that suppress gut production of K

Minerals in RF ↑ potassium, magnesium, and phos occur often due to ↓ renal clearance and ↑ protein catabolism ↑ potassium, magnesium, and phos occur often due to ↓ renal clearance and ↑ protein catabolism ↓ potassium, mg and phos can occur with refeeding ↓ potassium, mg and phos can occur with refeeding CRRT pts can have ↓ K+, phos CRRT pts can have ↓ K+, phos Mg deficiency can cause K+ deficiency resistant to supplementation Mg deficiency can cause K+ deficiency resistant to supplementation Vitamin C, copper, chromium lost with CVVH Vitamin C, copper, chromium lost with CVVH

Fluid in ARF Depends on residual renal function, fluid and sodium status, other losses Depends on residual renal function, fluid and sodium status, other losses Usually 500 mL/day + urine output Usually 500 mL/day + urine output

31 Dietary Treatment of Renal Disease Potassium may be restricted in some clients because hyperkalemia tends to occur in end stage renal disease (ESRD). Excess potassium can cause cardiac arrest. Renal clients often have an increased need for vitamins B, C, and D, and supplements are often given. Iron is commonly prescribed.

32 Target Lipid Levels BestBorderline Chol <200 gm/dl LDL< HDL>40 40<40 TG<

33 Dialysis Done be either hemodialysis or peritoneal dialysis. Hemodialysis requires permanent access to the bloodstream through a fistula. Hemodialysis is done 3 times a week for 3-5 hours at a time.

34 Dialysis Peritoneal dialysis makes use of the peritoneal cavity. Less efficient than hemodialysis. Treatments usually last about 10 to 12 hours a day, 3 times a week. Complications include peritonitis, hypotension, weight gain.

35 Diet During Dialysis Dialysis clients may need additional protein. Amount must be carefully controlled. Hemodialysis: 1.0 to 1.2g/kg of protein to make up for losses during dialysis. Peritoneal dialysis: 1.2 to 1.5g/kg protein.

36 Diet During Dialysis 75% of this protein should be high biological value (HBV) protein, found in eggs, meat, fish, poultry, milk, and cheese. Potassium is usually restricted. A typical renal diet could be written as “80-3-3” which means 80g protein, 3g sodium, and 3g potassium daily.

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