medical nutrition therapy for renal disorders chapter 39

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

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

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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