Nutrition for Patients with
Kidney Disorders
Chapter 21
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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
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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
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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
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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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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Nephrotic Syndrome (cont’d)
• Nutrition therapy
– Goals
o To minimize edema, proteinuria, and
hyperlipidemia
o To replace nutrients lost in the urine
o To reduce the risk of progressive renal
damage and atherosclerosis
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Nephrotic Syndrome (cont’d)
• Nutrition therapy (cont’d)
– Benefits of minimizing proteinuria
o An increase in serum albumin, a decrease
in serum lipid levels, a slower progression
of kidney disease, and less edema
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Nephrotic Syndrome (cont’d)
• Sodium and fluid
– Sodium restriction begins when fluid retention
occurs
– For stages 1 to 4 and hemodialysis:
o 1,000 to 3,000 mg/day are recommended
o 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
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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
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Question
• Nephrotic syndrome can be caused by what?
a. Lupus
b. Proteinuria
c. Stress
d. Hyperlipidemia
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Answer
a. Lupus
Rationale: Causes of nephrotic syndrome include
diabetes, autoimmune diseases (e.g., lupus, IgA
nephropathy), infection, and certain chemicals
and medications.
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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)
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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
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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
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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
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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
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy
– Goals
o Reduce workload on the kidneys
o Restore or maintain optimal nutritional status
o 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
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Protein
o As kidney function declines, the ability to
excrete nitrogenous and other wastes also
declines
o 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%
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Protein (cont’d)
o In stages 1 to 4, the recommended daily
protein intake is 0.6 g/kg to 0.75 g/kg
o Protein allowance may be liberalized to
maintain appropriate body protein stores or
because the severity of restriction is too
difficult to follow
o Protein allowance in stage 5 is 50% higher
than the RDA to account for the loss of serum
proteins
and
acids
the
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© 2010 amino
Wolters Kluwer Health
| Lippincott in
Williams
& Wilkinsdialysate
Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Calories
o 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
o 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
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Calories (cont’d)
o During peritoneal dialysis, a large amount of
calories is absorbed daily through the dialysate
(approximately 340 to 680 cal/day)
o Calories from the dialysate impair the natural
sense of hunger and generally prevent a fall in
blood glucose levels between meals
o Increased intake of pure sugars and pure fats
helps to meet calorie requirements while
keeping
protein intake low
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Sodium and fluid (cont’d)
o Intake is monitored by weight gain
o For many clients on hemodialysis,
fluid restriction is hardest
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Potassium
o Loss of kidney function means potassium
excretion is impaired and hyperkalemia is a risk
o Hypokalemia is a risk for people who receive
continuous ambulatory peritoneal dialysis, take
potassium-wasting diuretics, or who experience
vomiting or diarrhea
o At all CKD stages, potassium allowance is based
on the individual’s serum potassium levels
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Chronic Kidney Disease (CKD) (cont’d)
• Nutrition therapy (cont’d)
– Other vitamins and minerals
o Specially formulated vitamin supplements
o Deficiencies of water-soluble vitamins
o Fat-soluble vitamins A and E have been shown
to accumulate in CKD
o Clients who are undergoing dialysis may
develop a deficiency of zinc
o IV iron for clients receiving hemodialysis
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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
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Chronic Kidney Disease (CKD) (cont’d)
• Diabetic kidney disease
– Formerly known as diabetic nephropathy
– Risk factors for diabetic kidney disease
(DKD)
o Hyperglycemia, hypertension, and altered
lipid levels
– Nutrition therapy seeks to controls these
risks
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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
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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
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Nutrition Recommendation Guidelines for
Diabetic Kidney Disease
• 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
• 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
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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
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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
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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
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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
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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
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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
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Kidney Stones (cont’d)
• Nutrition therapy
– None of the diet recommendations made to
prevent kidney stones are effective when
used alone
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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.
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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.
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