Transcript Excrete waste material

‫بسم هللا الرحمن الرحيم‬
Nutrition in Kidney Diseases
Functions of Kidney
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Excrete waste material: end products of
protein metabolism (urea, uric acid,
creatinine, ammonia, and sulfates), excess
water and nutrients, dead renal cells, and
toxic substances
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Electrolyte balance
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Hormonal regulation
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Blood pressure regulation
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Glucose homeostatis
ETIOLOGY
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Diabetes mellitus (28%)
Hypertension (25%)
Glomerulonephritis (21%)
Polycystic Kidney Diease (4%)
Other (23%): Obstruction, infection, etc.
Primary Diagnoses for
Patients Who Start Dialysis
Other
10%
Diabetes
Glomerulonephritis
50%
13%
Hypertension
27%
United States Renal Data System
(USRDS) 2000 Annual Data Report •
WWW.USRDS.ORG
www.hypertensiononline.org 8
Chronic Renal Failure
Develops slowly, number of functioning nephrons
constantly diminishing.
Uremia is a result
Symptoms:nausea, headache, coma, convulsions.
Severe renal failure will result in death unless
dialysis used.
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Clinical pathophysioloy
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Metabolic acidosis: result in;
– Muscle breakdown
– Bone dissolving
Hyperkalemia
Hypertension
Negative N balance
Insulin resistance
Hyperphosphatemia
Anemia
Progression of chronic renal failure
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Factors causing progression
 sustaining primary disease
 systemic hypertension
 Intraglomerular hypertension
 Proteinuria
 Nephrocalcinosis
 Dyslipidaemia
 Imbalance between renal energy demands
and supply
CRF
Reversible factors in CRF
 Hypertension
 Reduced renal perfusion (renal artery stenosis,
hypotension , sodium and water depletion, poor
cardiac function)
 Urinary tract obstruction
 Infection
 Nephrotoxic medications
 Metabolic factors(calcium phosphate products )
Slowing the Progression of Chronic
Renal Failure
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Control BP to <130 /80
Diet
Anaemia
Calcium and Phosphate
Dyslipidaemia
Obesity
Smoking Cessation
Dietary Treatment of Renal
Disease
Extremely
complicated.
Intended to reduce the amount of excretory work
demanded of the kidneys while helping them
maintain fluid, acid-base, and electrolyte balance.
In CRF may have protein, sodium, potassium
and phosphorus restricted.
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Dietary Treatment of Renal
Disease
Sufficient
calories necessary: 25 to 50 kcal per
kilogram of body weight.
Energy requirements should be fulfilled by
carbohydrates and fat.
Protein increases the amount of nitrogen waste
the kidneys must handle.
Diet may limit protein to 40 grams( at least 0.5 g/kg
) based on glomerular filtration rate and weight.
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CRF
Diet therapy
 Protein restriction (0.5-0.8mg/kg/d)
 Adequte intake of calories(30-35kcal/kg/d)
 Fluid intake:urine volume +500ml
 Low phosphate diet(600-1000mg/d)
 Supplement of EAA(ketosteril)
Fluid
Unrestricted until urine output declines
 Urine output plus 1000 cc/d
Evaluate effect on blood pressure and
cardiac function
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Sodium
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Sodium
 2-4 g/d (43 mEq = 1 g)
 Variable with urine output and disease
etiology
Evaluate effect on hypertension control and
cardiac function
Potassium
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Accumulates in CKD stage 5
 Hyperkalemia →cardiac danger
 Restrict to 2-4g/d (26 mEq=1g)
Hyperkalemia & EKG
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K > 5.5 -6
 Tall, peaked T’s
 Wide QRS
 Prolong PR
 Diminished P
 Prolonged QT
 QRS-T merge – sine
wave
Hyperkalemia Symptoms
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Weakness
 Lethargy
 Muscle cramps
 Paresthesias
 Hypoactive DTRs
 Dysrhythmias
Nutrition Implications of ARF
ARF causes anorexia, nausea, vomiting,
bleeding
 ARF causes rapid nitrogen loss and lean
body mass loss (hypercatabolism)
 ARF causes ↑ gluconeogenesis with
insulin resistance
 Dialysis causes loss of amino acids and
protein
 Uremia toxins cause impaired glucose
utilization and protein synthesis
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Treatment Goals for
Renal Failure
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Correct electrolytes
Control acidosis
Treat significant hyperphosphatemia
Treat symptomatic anemia
Initiate dialysis for hyperkalemia or acidosis not
controlled, fluid overload, ↑ in BUN>20 mg/dl/24
hours or BUN>100 mg/dl
Evaluate drugs for renal effect
Avoid/treat infection
Vitamins in ARF
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Vitamin A: elevated vitamin A levels are known
to occur with RF
Vitamin B – prevent B6 deficiency by giving 10
mg pyridoxine hydrochloride/day
Folate and B6: supplement when homocysteine
levels are high
Vitamin C: <200 mg/day to prevent ↑ oxalate
Activated vitamin D
Vitamin K: give Vitamin K especially to pts on
antibiotics that suppress gut production of K
Minerals in RF
↑ potassium, magnesium, and phos occur
often due to ↓ renal clearance and ↑
protein catabolism
 ↓ potassium, mg and phos can occur with
refeeding
 CRRT pts can have ↓ K+, phos
 Mg deficiency can cause K+ deficiency
resistant to supplementation
 Vitamin C, copper, chromium lost with
CVVH
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Fluid in ARF
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Depends on residual renal function, fluid
and sodium status, other losses
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Usually 500 mL/day + urine output
Target Lipid Levels
Chol
LDL
HDL
TG
Best
<200 gm/dl
<100
>40
<150
Borderline
200-239
100-159
<40
150-159
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Dialysis
Done be either hemodialysis or peritoneal dialysis.
Hemodialysis requires permanent access to the
bloodstream through a fistula.
Hemodialysis is done 3 times a week for 3-5 hours
at a time.
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Dialysis
Peritoneal dialysis makes use of the peritoneal
cavity.
Less efficient than hemodialysis.
Treatments usually last about 10 to 12 hours a
day, 3 times a week.
Complications include peritonitis, hypotension,
weight gain.
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Diet During Dialysis
Dialysis clients may need additional protein.
Amount must be carefully controlled.
Hemodialysis: 1.0 to 1.2g/kg of protein to make up
for losses during dialysis.
Peritoneal dialysis: 1.2 to 1.5g/kg protein.
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Diet During Dialysis
75% of this protein should be high biological value
(HBV) protein, found in eggs, meat, fish, poultry,
milk, and cheese.
Potassium is usually restricted.
A typical renal diet could be written as “80-3-3”
which means 80g protein, 3g sodium, and 3g
potassium daily.
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