1. Nutrition for Patients with Kidney Disorders Chapter 21

2. Nutrition for Patients With Kidney Disorders
Kidneys perform many vital functions
Urinary excretion is the primary method by which the body rids itself of:
Excess water
Nitrogenous wastes
Electrolytes
Sulfates
Organic acids
Toxic substances
Drugs

3. Nutrition for Patients With Kidney Disorders (cont’d)
The kidneys help to regulate acid–base balance by secreting hydrogen ions to increase pH and excreting bicarbonate to lower pH
Involved in blood pressure regulation
Play an important role in maintaining normal metabolism of calcium and phosphorus
Kidney diseases can profoundly impact metabolism, nutritional status, and nutritional requirements

4. Nephrotic Syndrome
A generic term that refers to a kidney disorder characterized by urinary protein losses greater than 3.0 g/d
Major symptoms:
Proteinuria
Hypoalbuminemia
Hyperlipidemia
Edema

5. Nephrotic Syndrome (cont‘d)
Hypoalbuminemia and proteinuria
May lead to protein calorie malnutrition, anemia, increased risk of infection, vitamin D deficiency, and increased clotting
Hyperlipidemia increases the risk of cardiovascular disease and progressive renal damage
Causes of nephrotic syndrome include diabetes, autoimmune diseases (e.g., lupus, IgA nephropathy), infection, and certain chemicals and medications

6. Nephrotic Syndrome (cont’d)
In some cases, treating the underlying disorder corrects nephrotic syndrome
In others cases, especially diabetes, nephrotic syndrome may be the beginning of chronic kidney disease

7. Nephrotic Syndrome (cont’d)
Nutrition therapy
Goals
To minimize edema, proteinuria, and hyperlipidemia
To replace nutrients lost in the urine
To reduce the risk of progressive renal damage and atherosclerosis

8. Nephrotic Syndrome (cont’d)
Nutrition therapy (cont’d)
Benefits of minimizing proteinuria
An increase in serum albumin, a decrease in serum lipid levels, a slower progression of kidney disease, and less edema

9. Nephrotic Syndrome (cont’d)
Sodium and fluid
Sodium restriction begins when fluid retention occurs
For stages 1 to 4 and hemodialysis:
1,000 to 3,000 mg/day are recommended
Range is 2,000 to 4,000 mg for peritoneal dialysis
Fluid is unrestricted in stages 1 to 4 with normal urine output
For people on hemodialysis, fluid allowance equals the volume of any urine produced plus 1,000 mL

10. Nephrotic Syndrome (cont’d)
Phosphorus and calcium
As kidney function deteriorates, the conversion of vitamin D to its active form is impaired
National Kidney Foundation recommends both phosphorus and calcium intake be controlled
In stages 1 to 4, phosphorus allowance is based on lab values and calcium is limited to 1000 to 1,500 mg/day
Phosphate binders must be taken with all meals and snacks

11. Question Nephrotic syndrome can be caused by what? a. Lupus
b. Proteinuria
c. Stress
d. Hyperlipidemia

12. Answer
a. Lupus Rationale: Causes of nephrotic syndrome include diabetes, autoimmune diseases (e.g., lupus, IgA nephropathy), infection, and certain chemicals and medications.

13. Chronic Kidney Disease (CKD)
A syndrome of progressive kidney damage and loss of function
Decrease in the number of functioning nephrons overburdens the remaining nephrons, and the kidney’s ability to filter blood deteriorates
Measured by a decrease in glomerular filtration rate (GFR)

14. Chronic Kidney Disease (CKD) (cont’d)
The impact on nutrition
Loss of kidney function produces widespread effects
As urine output decreases, fluid and electrolytes accumulate in the blood, producing symptoms of overhydration such as increased blood pressure, weight gain, edema, shortness of breath, and lung crackles
Uremic syndrome
Acidosis occurs

15. Chronic Kidney Disease (CKD) (cont’d)
CKD is associated with premature mortality and decreased quality of life
Progresses slowly and may not be apparent until 50% to 70% of function is lost
In stages 1 to 4, medical and nutrition therapy can potentially delay the progression to stage 5

16. Chronic Kidney Disease (CKD) (cont’d)
Modifiable risk factors
Smoking cessation, an increase in physical activity, and controlling blood lipid levels
Stage 5 requires dialysis or kidney transplant for survival
Diabetes is the leading cause of CKD
Other risk factors include cardiovascular disease, hypertension, and obesity

17. Chronic Kidney Disease (CKD) (cont’d)
The impact on nutrition
Reabsorption of some nutrients is impaired
GI absorption of some minerals, such as calcium and iron, is impaired
Impaired synthesis of rennin, erythropoietin, and the active form of vitamin D can lead to high blood pressure, anemia, and bone demineralization
Accelerated atherosclerosis increases the risk of coronary heart disease, myocardial infarction, and further renal damage

18. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy
Goals
Reduce workload on the kidneys
Restore or maintain optimal nutritional status
Control the accumulation of uremic toxins
Diet modifications are made in response to symptoms and laboratory values and require frequent monitoring and adjustment
Diet is both complex and dynamic

19. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Protein
As kidney function declines, the ability to excrete nitrogenous and other wastes also declines
Modification of Diet in Renal Disease (MDRD) study showed that tight control of blood pressure and a restricted protein intake of 0.6 g/kg/day helped delay the progression of kidney disease by 41%

20. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Protein (cont’d)
In stages 1 to 4, the recommended daily protein intake is 0.6 g/kg to 0.75 g/kg
Protein allowance may be liberalized to maintain appropriate body protein stores or because the severity of restriction is too difficult to follow
Protein allowance in stage 5 is 50% higher than the RDA to account for the loss of serum proteins and amino acids in the dialysate

21. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Calories
When protein intake is restricted, it is vital to consume adequate calories to spare protein from being used for energy, enabling it to be used for protein synthesis
For all stages of CKD:
Calorie recommendations are 35 cal/kg for adults under 60 years of age
30 to 35 cal/kg for those who are older

22. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Calories (cont’d)
During peritoneal dialysis, a large amount of calories is absorbed daily through the dialysate (approximately 340 to 680 cal/day)
Calories from the dialysate impair the natural sense of hunger and generally prevent a fall in blood glucose levels between meals
Increased intake of pure sugars and pure fats helps to meet calorie requirements while keeping protein intake low

23. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Sodium and fluid (cont’d)
Intake is monitored by weight gain
For many clients on hemodialysis, fluid restriction is hardest

24. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Potassium
Loss of kidney function means potassium excretion is impaired and hyperkalemia is a risk
Hypokalemia is a risk for people who receive continuous ambulatory peritoneal dialysis, take potassium-wasting diuretics, or who experience vomiting or diarrhea
At all CKD stages, potassium allowance is based on the individual’s serum potassium levels

25. Chronic Kidney Disease (CKD) (cont’d)
Nutrition therapy (cont’d)
Other vitamins and minerals
Specially formulated vitamin supplements
Deficiencies of water-soluble vitamins
Fat-soluble vitamins A and E have been shown to accumulate in CKD
Clients who are undergoing dialysis may develop a deficiency of zinc
IV iron for clients receiving hemodialysis

26. Chronic Kidney Disease (CKD) (cont’d)
Translating recommendations into meals
Diet for CKD is complex
“Choice” system, similar to the diabetic exchange system, may be used to help clients implement dietary restrictions
Individualized meal plan
Selections can be severely limited

27. Chronic Kidney Disease (CKD) (cont’d)
Diabetic kidney disease
Formerly known as diabetic nephropathy
Risk factors for diabetic kidney disease (DKD)
Hyperglycemia, hypertension, and altered lipid levels
Nutrition therapy seeks to controls these risks

28. Question
What are the calorie recommendations for patients with chronic kidney disease?
a. 40 cal/kg for adults under 60 years; 35 to 40 cal/ kg for those who are older
b. 35 to 40 cal/kg for all adults
c. 35 to 40 cal/kg for adults under 60 years; 30 to 35 cal/kg for those who are older
d. 35 cal/kg for adults under 60 years; 30 cal/kg for those who are older

29. Answer
d. 35 cal/kg for adults under 60 years; 30 cal/kg for those who are older Rationale: Calorie recommendations are: 35 cal/kg for adults under 60 years of age; 30 to 35 cal/kg for those who are older

30. Nutrition Recommendation Guidelines for Diabetic Kidney Disease
Phosphorus 1,700 mg/d for stages 1 and 2
800 to 1000 mg/d for stages 3 and 4
Potassium <4,000 mg/d for stages 1 and 2
2,400 mg/d for stages 3 and 4
Protein 0.8 g/kg
Sodium 2,300 mg/d
Lipids ≤30% calories from fat, <10% calories from saturated fat, 200 mg cholesterol/d
Carbohydrates 50% to 60% of total calories

31. Chronic Kidney Disease (CKD) (cont’d)
Kidney transplantation
A treatment option for people with stage 5 CKD
Immediate postoperative diet is high in protein and calories to promote healing
Most dietary parameters are removed when the new kidney functions normally
Lifelong commitment to “healthy” eating is important

32. Acute Renal Failure
Acute renal failure (ARF) is the sudden loss of renal function characterized by an acute increase in serum creatinine and decrease in urine output
Can develop over a period of hours or days
Can range from mild to severe
Causes: shock, severe infection, trauma, medications, and obstruction
Primary focus of treatment is to correct the underlying disorder

33. Acute Renal Failure (cont’d)
Nutrition therapy
It has not been proven that nutrition therapy for ARF promotes recovery of kidney function or improves survival
Goal is to provide adequate amounts of calories, protein, and other nutrients to prevent or minimize malnutrition
It is difficult to achieve nutritional goals with oral, enteral, or parenteral nutrition

34. Acute Renal Failure (cont’d)
Nutrition therapy (cont’d)
One approach is to strictly limit fluid, electrolytes, and protein
For patients who are malnourished and hypercatabolic, the approach may be to give ample amounts of protein and nutrients and provide dialysis as needed
Oral, enteral, or parenteral nutrition is given

35. Kidney Stones Form when insoluble crystals precipitate out of urine
75% of kidney stones are made of calcium oxalate
Risk factors:
Dehydration or low urine volume, urinary tract obstruction, gout, chronic inflammation of the bowel, and intestinal bypass or ostomy surgery
High fluid intake dilutes the urine

36. Kidney Stones (cont’d)
Oxalate
Normally only 6% to 14% consumed is absorbed
Calcium
Binds with dietary oxalate in the intestines, forming an insoluble compound that the body cannot absorb
Protein
High intakes of animal protein increase urinary excretion of calcium, oxalate, and uric acid and reduce urinary pH
Sodium
A high sodium intake promotes urinary calcium excretion by decreasing calcium reabsorption by the kidneys

37. Kidney Stones (cont’d)
Nutrition therapy
None of the diet recommendations made to prevent kidney stones are effective when used alone

38. Question Is the following statement true or false?
The goal of nutrition therapy for acute renal failure (ARF) is to provide an adequate amount of calories, protein, and other nutrients to prevent or minimize malnutrition. This is easy to achieve with either oral, enteral, or parenteral nutrition.

39. Answer
False. Rationale: Goal is to provide adequate amounts of calories, protein, and other nutrients to prevent or minimize malnutrition. It is difficult to achieve nutritional goals with oral, enteral or parenteral nutrition.