بسم الله الرحمن الرحيم. nutrition in kidney diseases
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بسم الله الرحمن الرحيم
Nutrition in Kidney Diseases Nutrition in Kidney Diseases
Functions of KidneyFunctions of Kidney
Excrete waste materialExcrete waste material: end products of : end products of protein metabolism (urea, uric acid, protein metabolism (urea, uric acid, creatinine, ammonia, and sulfates), excess creatinine, ammonia, and sulfates), excess water and nutrients, dead renal cells, and water and nutrients, dead renal cells, and toxic substancestoxic substances
Electrolyte balanceElectrolyte balance
Hormonal regulationHormonal regulation
Blood pressure regulationBlood pressure regulation
Glucose homeostatisGlucose homeostatis
ETIOLOGYETIOLOGY
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.
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Diabetes50%
Hypertension27%
Glomerulonephritis13%
Other10%
Primary Diagnoses for Primary Diagnoses for Patients Who Start DialysisPatients Who Start Dialysis
United States Renal Data System (USRDS) 2000 Annual Data Report • WWW.USRDS.ORG
www.hypertensiononline.org
Chronic Renal FailureChronic Renal FailureDevelops slowly, number of functioning nephrons Develops slowly, number of functioning nephrons constantly diminishing.constantly diminishing.
Uremia is a resultUremia is a result
Symptoms:nausea, headache, coma, convulsions. Symptoms:nausea, headache, coma, convulsions.
Severe renal failure will result in death unless Severe renal failure will result in death unless dialysis used.dialysis used.
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Clinical pathophysioloyClinical pathophysioloy
Metabolic acidosis: result in;Metabolic acidosis: result in;– Muscle breakdown Muscle breakdown – Bone dissolving Bone dissolving
Hyperkalemia Hyperkalemia Hypertension Hypertension Negative N balanceNegative N balance Insulin resistanceInsulin resistance HyperphosphatemiaHyperphosphatemia Anemia Anemia
Progression of chronic renal failureProgression of chronic renal failure
Factors causing progressionFactors causing progression sustaining primary diseasesustaining primary disease systemic hypertensionsystemic hypertension Intraglomerular hypertensionIntraglomerular hypertension ProteinuriaProteinuria NephrocalcinosisNephrocalcinosis DyslipidaemiaDyslipidaemia Imbalance between renal energy demands Imbalance between renal energy demands
and supplyand supply
CRFCRF
Reversible factors in CRFReversible factors in CRF HypertensionHypertension Reduced renal perfusion (renal artery stenosis, Reduced renal perfusion (renal artery stenosis,
hypotension , sodium and water depletion, poor hypotension , sodium and water depletion, poor cardiac function)cardiac function)
Urinary tract obstructionUrinary tract obstruction InfectionInfection Nephrotoxic medicationsNephrotoxic medications Metabolic factors(calcium phosphate products Metabolic factors(calcium phosphate products ))
Slowing the Progression of Chronic Slowing the Progression of Chronic Renal FailureRenal Failure
Control BP to <130 /80Control BP to <130 /80 DietDiet AnaemiaAnaemia Calcium and PhosphateCalcium and Phosphate DyslipidaemiaDyslipidaemia ObesityObesity Smoking CessationSmoking Cessation
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Dietary Treatment of Renal DiseaseDietary Treatment of Renal Disease
Extremely complicated.Extremely complicated.Intended to reduce the amount of excretory work Intended to reduce the amount of excretory work demanded of the kidneys while helping them demanded of the kidneys while helping them maintain fluid, acid-base, and electrolyte balance.maintain fluid, acid-base, and electrolyte balance.In CRF may have protein, sodium, potassium In CRF may have protein, sodium, potassium and phosphorus restricted.and phosphorus restricted.
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Dietary Treatment of Renal DiseaseDietary Treatment of Renal Disease
Sufficient calories necessary: 25 to 50 kcal per Sufficient calories necessary: 25 to 50 kcal per kilogram of body weight.kilogram of body weight.Energy requirements should be fulfilled by Energy requirements should be fulfilled by carbohydrates and fat.carbohydrates and fat.Protein increases the amount of nitrogen waste Protein increases the amount of nitrogen waste the kidneys must handle.the kidneys must handle.Diet may limit protein to 40 grams( at least 0.5 Diet may limit protein to 40 grams( at least 0.5 g/kgg/kg ) based on glomerular filtration rate and weight.) based on glomerular filtration rate and weight.
CRFCRF
Diet therapyDiet therapy Protein restriction (0.5-0.8mg/kg/d)Protein restriction (0.5-0.8mg/kg/d) Adequte intake of calories(30-35kcal/kg/d)Adequte intake of calories(30-35kcal/kg/d) Fluid intake:urine volume +500mlFluid intake:urine volume +500ml Low phosphate diet(600-1000mg/d)Low phosphate diet(600-1000mg/d) Supplement of EAA(ketosteril)Supplement of EAA(ketosteril)
FluidFluid Unrestricted until urine output declinesUnrestricted until urine output declines Urine output plus 1000 cc/dUrine output plus 1000 cc/d
Evaluate effect on blood pressure andEvaluate effect on blood pressure and
cardiac functioncardiac function
SodiumSodium SodiumSodium 2-4 g/d (43 mEq = 1 g)2-4 g/d (43 mEq = 1 g) Variable with urine output and disease Variable with urine output and disease
etiologyetiology
Evaluate effect on hypertension control and Evaluate effect on hypertension control and cardiac functioncardiac function
PotassiumPotassium
Accumulates in CKD stage 5Accumulates in CKD stage 5 Hyperkalemia →cardiac dangerHyperkalemia →cardiac danger Restrict to 2-4g/d (26 mEq=1g)Restrict to 2-4g/d (26 mEq=1g)
Hyperkalemia & EKGHyperkalemia & EKG K > 5.5 -6K > 5.5 -6 Tall, peaked T’sTall, peaked T’s Wide QRSWide QRS Prolong PRProlong PR Diminished PDiminished P Prolonged QTProlonged QT QRS-T merge – sine QRS-T merge – sine
wavewave
Hyperkalemia SymptomsHyperkalemia Symptoms WeaknessWeakness LethargyLethargy Muscle crampsMuscle cramps ParesthesiasParesthesias Hypoactive DTRsHypoactive DTRs DysrhythmiasDysrhythmias
Nutrition Implications of ARFNutrition Implications of ARF
ARF causes anorexia, nausea, vomiting, ARF causes anorexia, nausea, vomiting, bleedingbleeding
ARF causes rapid nitrogen loss and lean ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism)body mass loss (hypercatabolism)
ARF causes ARF causes ↑ gluconeogenesis with insulin ↑ gluconeogenesis with insulin resistanceresistance
Dialysis causes loss of amino acids and Dialysis causes loss of amino acids and proteinprotein
Uremia toxins cause impaired glucose Uremia toxins cause impaired glucose utilization and protein synthesisutilization and protein synthesis
Treatment Goals for Treatment Goals for Renal Failure Renal Failure
Correct electrolytesCorrect electrolytes Control acidosisControl acidosis Treat significant hyperphosphatemiaTreat significant hyperphosphatemia Treat symptomatic anemiaTreat symptomatic anemia Initiate dialysis for hyperkalemia or acidosis not Initiate dialysis for hyperkalemia or acidosis not
controlled, fluid overload, controlled, fluid overload, ↑ in BUN>20 mg/dl/24 ↑ in BUN>20 mg/dl/24 hours or BUN>100 mg/dlhours or BUN>100 mg/dl
Evaluate drugs for renal effectEvaluate drugs for renal effect Avoid/treat infectionAvoid/treat infection
Vitamins in ARFVitamins in ARF
Vitamin A: elevated vitamin A levels are known Vitamin A: elevated vitamin A levels are known to occur with RFto occur with RF
Vitamin B – prevent B6 deficiency by giving 10 Vitamin B – prevent B6 deficiency by giving 10 mg pyridoxine hydrochloride/daymg pyridoxine hydrochloride/day
Folate and B6: supplement when homocysteine Folate and B6: supplement when homocysteine levels are highlevels are high
Vitamin C: <200 mg/day to prevent Vitamin C: <200 mg/day to prevent ↑ oxalate↑ oxalate Activated vitamin DActivated vitamin D Vitamin K: give Vitamin K especially to pts on Vitamin K: give Vitamin K especially to pts on
antibiotics that suppress gut production of Kantibiotics that suppress gut production of K
Minerals in RFMinerals in RF
↑ ↑ potassium, magnesium, and phos occur potassium, magnesium, and phos occur often due to ↓ renal clearance and ↑ protein often due to ↓ renal clearance and ↑ protein catabolismcatabolism
↓ ↓ potassium, mg and phos can occur with potassium, mg and phos can occur with refeedingrefeeding
CRRT pts can have ↓ K+, phosCRRT pts can have ↓ K+, phos Mg deficiency can cause K+ deficiency Mg deficiency can cause K+ deficiency
resistant to supplementationresistant to supplementation Vitamin C, copper, chromium lost with CVVHVitamin C, copper, chromium lost with CVVH
Fluid in ARFFluid in ARF
Depends on residual renal function, fluid Depends on residual renal function, fluid and sodium status, other lossesand sodium status, other losses
Usually 500 mL/day + urine outputUsually 500 mL/day + urine output
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Target Lipid LevelsTarget Lipid Levels
BestBest BorderlineBorderline
Chol Chol <200 gm/dl<200 gm/dl 200-239200-239
LDLLDL <100<100 100-159100-159
HDLHDL >40>40 <40<40
TGTG <150<150 150-159 150-159
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DialysisDialysis
Done be either hemodialysis or peritoneal dialysis.Done be either hemodialysis or peritoneal dialysis.
Hemodialysis requires permanent access to the Hemodialysis requires permanent access to the bloodstream through a fistula.bloodstream through a fistula.
Hemodialysis is done 3 times a week for 3-5 hours Hemodialysis is done 3 times a week for 3-5 hours at a time.at a time.
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DialysisDialysis
Peritoneal dialysis makes use of the peritoneal Peritoneal dialysis makes use of the peritoneal cavity.cavity.
Less efficient than hemodialysis.Less efficient than hemodialysis.
Treatments usually last about 10 to 12 hours a Treatments usually last about 10 to 12 hours a day, 3 times a week.day, 3 times a week.
Complications include peritonitis, hypotension, Complications include peritonitis, hypotension, weight gain.weight gain.
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Diet During DialysisDiet During Dialysis
Dialysis clients may need additional protein.Dialysis clients may need additional protein.Amount must be carefully controlled.Amount must be carefully controlled.
Hemodialysis: 1.0 to 1.2g/kg of protein to make up Hemodialysis: 1.0 to 1.2g/kg of protein to make up for losses during dialysis.for losses during dialysis. Peritoneal dialysis: 1.2 to 1.5g/kg protein. Peritoneal dialysis: 1.2 to 1.5g/kg protein.
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Diet During DialysisDiet During Dialysis
75% of this protein should be high biological value 75% of this protein should be high biological value (HBV) protein, found in eggs, meat, fish, poultry, (HBV) protein, found in eggs, meat, fish, poultry, milk, and cheese.milk, and cheese.
Potassium is usually restricted.Potassium is usually restricted.
A typical renal diet could be written as “80-3-3” A typical renal diet could be written as “80-3-3” which means 80g protein, 3g sodium, and 3g which means 80g protein, 3g sodium, and 3g potassium daily.potassium daily.
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