2. Renal Disease  Kidney functions  The nephrotic syndrome  Acute Renal Disease  Chronic Renal Failure  Kidney Stones

3. Kidney Functions Regulate extracellular fluid volume and osmolarity Regulate electrolyte concentrations Regulate acid-base balance Excrete metabolic waste products like urea and creatinine and a number of drugs and toxins Help to regulate blood pressure Produce the hormone erythropoietin, which stimulates the production of red blood cells in the bone marrow Convert vitamin D to its active form – plays a primary role in calcium regulation and bone formation

4. The Nephrotic Syndrome: Treatment Protein and energy – Helps minimize losses of muscle tissue – High-protein diets not advised – can exacerbate urinary protein losses – 0.8 – 1.0 grams of protein per kilogram of body weight/day – 35 kcalories/kilogram body weight daily – sustains weight and spares protein – Weight loss or infections–signal the need for additional kcalories

8. The Nephrotic Syndrome: Treatment Fat – A diet low in saturated fat, cholesterol, and refined sugars helps to control elevated blood lipids – May need lipid-lowering medications prescribed per physician

9. The Nephrotic Syndrome: Treatment Sodium – Sodium restriction helps to control edema – Suggested to limit intake to < 2-3 grams daily – If diuretics prescribed for edema – potassium wasting may occur – Encouraged to select foods rich in potassium

10. The Nephrotic Syndrome: Treatment Vitamins and minerals – May require vitamin D and calcium supplementation – prevent bone loss and rickets – Multivitamin supplements – prevent additional nutrient deficiencies

11. Acute Renal Disease: Consequences Kidneys become unable to regulate the levels of electrolytes, acid, and nitrogenous wastes in in blood. Urine may be diminished in quantity or absent. Diagnosis – often a complex task. Fluid and electrolyte imbalances

12. Acute Renal Disease Goals of nutritional therapy for ARF patients: debilitated: – Minimize uremia (accum. of bld nitrogenwaste “urea”) and maintain the body’s regular chemical composition – Preserve the body’s protein stores – Maintain fluid, electrolyte, and acid-base homeostasis

13. Nutritional therapy for ARF patients Protein –  Due to catobolic condition associated with hypermetabolism and muscle wasting – sufficient protein and energy needed to preserve body’s protein content  0.6g/kg/day in non-dialyzed, non-hypercatabolic patient.  With dialysis – protein restricted to 1.2 – 1.3 Calories – 35 kcal/kg of BW/day.

14. Nutritional therapy for ARF patients Fluids. – Needed to monitor weight fluctuations, blood pressure, pulse rates, appearance of skin and mucous membranes – Daily fluid intake should equal urine output, plus approximately 500ml to replace insensible losses ( the water lost through skin, lungs and perspiration) – Individuals with fever, vomiting, or diarrhea requires additional fluid – If on dialysis more liberal fluid intake allowed –1.5-2 liters/day

15. Nutritional therapy for ARF patients Vitamins/Minerals –  Electrolytes must be closely monitored. Potassium and phosphate levels may be elevated. There may also be salt and water imbalances.  With oliguria (abnl production of urine) – sodium intakes limited to 2-3 grams daily  If on dialysis-generally can consume electrolytes more freely  Oliguric patients who experience diuresis may need electrolyte replacement to compensate for urinary losses  Some patients need enteral or parenteral nutrition support to obtain adequate energy (high Kcal Low ptn and electrolytes)

16. Chronic Renal Failure: Consequences Generally progresses over many years without causing symptoms Typically diagnosed late in the course of illness, after most kidney function has been lost Most common causes : Diabetes mellitus (43%) Hypertension (26%) Altered electrolytes and hormones Uremic syndrome

17. Chronic Renal Failure Goals of nutritional therapy. – Prevent symptoms of uremia while restoring biochemical balance. – Retard progression of the disease. – Provide adequate calories to maintain or achieve ideal body weight.

18. Nutritional therapy for chronic renal failure Protein –  Protein should be restricted to 0.6g/kg/day, with sufficient essential amino acids.  Once dialysis begun – protein restrictions relaxed Dialysis removes nitrogenous wastes Some amino acids –lost during the procedure. Calories –  Calorie intake should be about 35 kcal/kg to maintain body weight.  Foods and beverages of high nutrient density  Malnourished patients may require oral formulas or tube feedings to maintain weight

19. Nutritional therapy for chronic renal failure Fat –  Restrict saturated fat and cholesterol levels, some renal patients at risk for coronary heart.  Renal diets include high-fat foods to increase calories – encourage patients to select foods providing mostly monounsaturated fats.

20. Nutritional therapy for chronic renal failure Fluids and Sodium –  Fluid intake should be based on the patient’s ability to eliminate fluid  Fluid intake should match the daily urine output,if urine output decreases Fluids – should be restricted  Excrete less urine as CRF progresses – can’t handle normal sodium and fluid intake  Monitor total urine output, changes in body weight and blood pressure and serum sodium levels  2-3 gm/d.adeq., but 1gm/d if the renal failure is severe.  Once on dialysis – sodium and fluid intakes controlled so that water weight gain is 2 pounds between dialysis treatments

21. Nutritional therapy for chronic renal failure Potassium –  2 to 3 gms/day should be initiated. Calcium and Phosphate –  supplement calcium and restrict phosphate to 8-12 mg/kg/day. Vitamins and Mineral-  Supplementing folic acid, B 6, B-complex, Vitamin D, Vitamin C necessary. Vitamin A and E not recommended because it may accumulate with renal failure.

22. Kidney Transplants Immunosuppressive Drug Therapy – Side effects of nausea, vomiting, diarrhea, glucose intolerance, altered blood lipids, fluid retention, hypertension and infection – Increases risk of food borne infection – food safety guidelines discussed with patients and caregivers – Dietary interventions

23. Kidney Transplants Energy: 30-35kcal/kg/d. adjust to maintain reasonable weight. Protein: 1.3-1.5 g/kg/d,reduced to 1g/kg/d after 6-8 weeks Carbohydrate: consistent CHO intake/d. increase fiber. Fat: Limited saturated fat and cholesterol to help control serum lipids. Sodium: Restricted (to 2-4g/d ) if fluid retention and hypertension are present. Potassium: adjust according to serum potassium levels. Calcium: 1000 to 1500 mg to minimize bone loss associated with drug therapy. Phosphorus: 1200-1500 mg: supplement needed if serum phosphorus is low. Fluid: No restriction

24. Kidney Stones Kidney stone – crystalline mass that forms within the urinary tract. Stone passage can cause severe pain or block the urinary tract. Formation of kidney stones- 75% of kidney stones – made up primarily of calcium oxalate Factors that predispose to stone formation: Dehydration or low urine volume Renal disease Urine acidity Metabolic factors Calcium oxalate stones Uric acid stones Cystine stones Struvite stones (could be initiated by bacteria forming from ph)

25. Kidney Stones: Consequences Consequences of kidney stones – Renal colic – Urinary tract complications

26. Kidney Stones: Prevention and treatment of kidney stones – Diet containing 800 – 1000 mg of calcium per day is recommended because calcium combines with oxalate in the intestines, reducing its absorption and helping to control hyperoxaluria – Moderate protein and sodium restriction advised High fluid intakes recommended

29. hemodialysis

32. peritoneal dialysis

33. Thank you!