1. Chapter 9 Renal Disease

2. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Learning Objectives  Describe the basic functions of the kidneys.  Identify the clinical symptoms and serum parameters of renal disease.  Identify risk factors for the development of renal disease.  Discuss the principles of nutritional management, including the control of disease and promotion of good nutritional status.

3. 3 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Functions of Kidneys  Help maintain proper metabolism and hormonal balance  Converts the inactive form of vitamin D 2 into the active form D 3  Produces the enzyme renin, which affects blood pressure  Produces erythropoietin, which stimulates red blood cell production in the bone marrow  Reabsorbing important body constituents, such as electrolytes  Excreting toxins and waste material through the 1 million nephrons

4. 4 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Anatomy of a Kidney

5. 5 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Main Types of Renal Diseases Nephropathy: any disease of the kidneys Chronic Kidney Disease  Glomerulonephritis, nephritis: an inflammatory state of the glomeruli; can be caused by autoimmune disorders, creatine supplements as used by athletes  Glomerulosclerosis, nephrosclerosis: related to scarring of the glomeruli; can be caused by diabetes, toxins, HTN, or hyperhomocysteinemia  Nephrotic syndrome: involves the loss of the glomerular barrier to protein with resulting loss of protein into the urine May lead to End Stage Renal Disease (ESRD)

6. 6 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Factors Related to Increased Risk of Nephropathy  Genetics  HTN—goal to maintain BP <120/80  Hyperglycemia—goal to maintain A1c <7%  Smoking  Older age  Male gender  High-protein diet (Ayodele et al., 2004)  UTIs—found with high BG; include cranberry juice in moderation  Orlistat with associated fat malabsorption (Singh et al., 2007)  Contrast dyes (Iyisoy et al., 2008)  Iga nephropathy—may be due to untreated celiac (La Villa et al., 2003)

7. 7 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Acute Renal Failure  Occurs with a sudden decrease in glomerular filtration rate (GFR)  May be short-lived with symptoms treated—low potassium diet, low protein  May occur due to rhabdomyolysis from medications or undue muscular stress (trauma), infection, severe dehydration, hypotension

8. 8 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Uremia  Noted with elevated serum creatinine >1.5 mg/dL  Signs and symptoms:  Metallic taste  Nausea and vomiting  Intense itching of the skin  Headache  Altered consciousness

9. 9 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Lab Values & Diagnosis of Renal Disease  Proteinuria  Elevated blood urea nitrogen (BUN)  Elevated serum creatinine—a nitrogen containing compound found in muscle that the kidneys regulate  Low glomerular filtration rate (GFR)  Hyperkalemia, Hypernatremia, Hyperphosphatemia  Imbalances of serum calcium (low) & serum phosphate (high)  Anemia—verify form; may be reduced erythropoietin or actual iron deficiency or other cause such as anemia of chronic disease (related to inflammation), treat accordingly

10. 10 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Effects of Loss of Protein Albumin <3.0 mg/dL found with:  Peripheral edema  Ascites (abnormal fluid accumulation in the abdominal cavity)  Anasarca (generalized massive edema)  Reduced vitamin D-binding proteins, leading to depletion of active vitamin D and osteomalacia (soft bones)  Hyperlipidemia resulting from loss of lipid-carrying proteins  Increased risk of thrombosis because of decreased anticlotting factors

11. 11 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Treatment of CKD  Control glucose in people with DM  HgbA 1c <7.2% associated with 50% reduced risk of kidney disease progression  Control blood pressure (lifestyle and/or medication)  Slow weight loss as needed  Increased fiber intake helps promote nitrogen excretion through the fece s  Stop smoking  Inclusion of omega-3 fats may reduce inflammation  Decrease homocysteine levels with increased B vitamins: B2, B6, B12, and folate  Avoidance of toxins: Certain medications & painkillers

12. 12 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Treatment (continued) Potential Restrictions:  Provide adequate protein as tolerated (.8g/kg, reduced protein intake may be needed per serum lab values)  Potassium  Phosphorous  Phosphate binders  Sodium 2000mg  Edema associated with low serum albumin levels should NOT be treated with excess restriction of sodium intake  Fluid (500-1000mg + urine output)

13. 13 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Stages of Chronic Kidney Disease (CKD)  Stages 1 and 2: GFR normal >60  Goal to prevent further damage by controlling BG, BP, aiming for a healthy diet  Stage 3: GFR 30-59 or creatinine >2 mg/dL  Goals include above along w/ maintaining stable weight, restricting potassium as warranted per labs, controlling anemia, maintaining or achieving good vitamin D status  Stage 4: GFR 15-29  Goal to delay dialysis via above, protein restriction to 0.6 to 0.8 g (maximum 1 g) PRO/kg BW, limit phosphorus intake, monitor serum Ca++ and treat prn  Stage 5: GFR <15  In addition to above, if no dialysis, monitor for need of fluid restriction (500-1000 mL plus urine output)

14. 14 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Role of Exercise  Helps lower insulin resistance and control BG and BP  Helps reduce cardiovascular disease associated with CKD  Helps maintain quality of life  Improves variety of health outcomes associated with CKD (Chan et al., 2007)

15. 15 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. End-Stage Renal Disease (ESRD) or Chronic Renal Failure  Associated with severe loss in the glomerular filtration rate and may be associated with oliguria (severe reduction in urine production) or anuria (no urine output)  Fluid restriction required with reduced urine output  Dialysis or renal transplant is warranted at this stage of renal disease

16. 16 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Dialysis Issues  PRO goal ≥1.2 g/kg BW  Aim for dry weight stabilization (weight after dialysis when BP normal), between dialysis sessions (interdialytic weight gain) with fluid restriction as needed  Supplement with water-soluble vitamins  Supplement with Ca ++ (when phosphate normal) and active form of vitamin D (D 3 )  Consider zinc and magnesium supplements  Undertake iron studies to rule out need for FeSo 4  Consult a dietitian: multiple restrictions result in a complicated diet that is difficulty to follow and malnutrition is common

17. 17 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Nephrolithiasis (Kidney Stones)  Increasing in frequency, believed due to rise in obesity rates  Increase in fluid intake (water) is most useful to keep urine dilute  Dietary restrictions must be based on the type of kidney stone

18. 18 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Calcium Oxalate Stones (Most Common Form)  Increased frequency found among persons with Roux-en-Y bariatric weight loss procedure  Increased frequency found with use of Orlistat and fat malabsorption  Increase fluid intake  Decrease oxalate intake  Avoid excess vitamin C because it results in oxalate formation; increase magnesium (milk; fatty fish also beneficial and rich in magnesium)  Legumes, nuts, dark-green leafy vegetables, berries, citrus fruits  800 to 1200 mg calcium (2.5 to 4 cups milk or equivalent milk products)  Mild sodium restriction

19. 19 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Uric Acid Stones (Second Most Common Form)  Often found with type 2 diabetes  Goal to reduce urine acidity  With potassium citrate or calcium carbonate  Moderate PRO intake (50g/day)  Decrease intake of meat, eggs, legumes, whole grains  Increase intake of milk and milk products  Increase fruit & vegetable intake  Except cranberries and plums/prunes

20. 20 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Study Guide   Vocabulary   Nephropathy   Nephritis   Nephrotic Syndrome   Nephrosclerosis   Nephrolithiasis   Blood Urea Nitrogen   Creatinine   Hyperkalemia   Hypernatremia   Uremia   Oliguria   Anuria

21. 21 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Study Guide (continued)   Function of the kidneys   Risk factors for nephropathy   Signs & symptoms of CKD   Nutritional treatment of CKD and ESRD   Nutrition management of Calcium oxalate stones and uric acid stones   Role of exercise