Chapter 39
Medical Nutrition
Therapy for
Renal Disorders
Kidney

Function
—Maintain homeostatic balance with
respect to fluids, electrolytes, and organic
solutes
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The Nephron
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Kidney Diseases

Glomerular diseases
1. Nephrotic syndrome
2. Nephritic syndrome—tubular or interstitial
3. Acute renal failure (ARF)
4. Tubular defects

Other
5. End-stage renal disease (ESRD)
6. Kidney stones
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Changes in Nephrotic Syndrome

Edema

Proteinuria

Hypoalbuminemia
(hypoproteinemia in general)

Hypercholesterolemia

Hypercoagulability

Abnormal bone metabolism
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Kidney Diseases
1. Nephrotic syndrome: may be caused by diabetes mellitus
(DM), systemic lupus erythematosus (SLE), amyloidosis
Diet: Protein 0.8 to 1 g/kg IBW 80% HBV
Kcal 35 to 40/kg IBW
Phosphorus 8 to 12 mg/kg IBW
Sodium 1to 3 g/day
Potassium unrestricted
Fluid unrestricted
Calcium 1200 to 1400 mg/day
From: National Renal Diet: Professional Guide, 1993
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Kidney Diseases—cont’d
2. Nephritic syndrome: acute
glomerulonephritis
Occurs after streptococcus infections
Symptoms:
Hematuria
Hypertension
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Kidney Diseases—cont’d
3. Nephritic syndrome
—Diet to treat underlying disease
—Restrict diet to control symptoms
—Protein restricted in uremia
—Sodium restrict in hypertension
—Potassium restrict in hyperkalemia
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Acute Renal Failure—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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Acute Renal Failure—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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Acute Renal Failure—Medical and Nutritional
Management
TPN, Total parenteral nutrition.
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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Sample Calculation of Fluid Requirements in
Acute Renal Failure
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Summary of Medical Nutrition Therapy for
Acute Renal Failure
GFR, Glomerular filtration rate; HBV, high biologic value; IBW, ideal body weight.
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Progression to End-Stage Renal
Disease (ESRD)
First
Decline in glomerular filtration rate (GFR)
Second
Adaptations in renal function, i.e.,
increase in GFR
Third
Adaptations work in the short term to
improve renal function.
Fourth
In the long run a loss of nephron units
occurs.
Fifth
A slow but progressive decline in renal
function
Sixth
Eventually this decline leads to renal
insufficiency, i.e., ESRD
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End-Stage Renal Disease—Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
© 2004, 2002 Elsevier Inc. All rights reserved.
End-Stage Renal Disease—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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End-Stage Renal Disease—Medical and
Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Katy G. Wilkens, 2002.
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Comparison of Treatments
Pre-ESRD, Hemodialysis, Peritoneal Dialysis
Treatment
Pre-ESRD
Hemodialysis
CAPD or CCPD
Diet and
medications
Diet and medications
Hemodialysis
Vascular access
Diet and
medications
Peritoneal
dialysis
Peritoneal membrane
Modality
Duration
Indefinite
3-5 h
2-3 d/wk
3-5 exchanges
7 d/wk
Concerns
Glomerular
hyperfiltration:
BUN:
bone disease:
HTN:
Glucose control in
diabetes
AA loss;
interdialytic
electrolyte and
fluid changes:
Bone disease:
HTN
Protein loss:
glucose absorption:
Bone disease:
weight gain:
hyperlipidemia:
glucose control in diabetes
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General MNT for Pre-ESRD,
Hemodialysis, Peritoneal Dialysis
Pre-ESRD
Hemodialysis
CAPD or CCPD
Protein
(g/kg IBW)
0.6-0.8
1.1-1.4
1.2-1.5
Energy
35-40
30-35
25-35
<17
<17
1000-3000
2000-3000
2000-4000
Unrestricted
~ 40
Unrestricted
Unrestricted
500-750 +
2000 +
(kcal/kg IBW)
Phosphorus8-12
(mg/kg IBW)
Sodium
(mg/d)
Potassium
(mg/kg IBW)
Fluid
(ml/d)
urine output
(1000 if anuric)
Calcium
1200-1600
(mg/d)
Use adjusted IBW if obese
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based on serum
based on serum
level
level
Adjusted Body Weight

Adjusted IBW for obesity
Female
([actual wt – IBW] x 0.32) + IBW
Male
([actual wt – IBW] x 0.38) + IBW
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Recommendations for Dietary
Protein Intake
In Patients with Progressive Renal Disease
A. GFR >55 ml/min
B. 25< GFR <55 ml/min
0.8 mg/day
0.6 mg/day
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Glucose Kcal from Dialysate

Glucose in dialysate
1.5% = 15 g/L
2.5% = 25 g/L
4.25% = 43 g/L
1. L of % solution x g/L glucose = g glucose
2. Repeat for each glucose concentration used
3. Total g glucose for all exchanges
4. 0.80 x total g glucose = g glucose absorbed
5. g glucose absorbed x 3.7 kcal/g = kcal
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Monitor Patient Status
1. BP >140/90
2. Edema
3. Weight changes
4. Urine output
5. Urine analysis:
—Albumin
—Protein
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Monitor Patient Status—cont’d
6. Kidney function
Creatinine clearance
Glomerular filtration rate (GFR)
7. Blood values
BUN 10 to 20 mg/dl (<100 mg/dl)
Creatinine 0.7 to 1.5 mg/dl (10-15 mg/dl)
Potassium 3.5 to 5.5 mEq/L
Phosphorus 3.0 to 4.5 mg/dl
Albumin 3.5-5.5 g/dl
Calcium 9-11 mg/dl
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Uremia, a Clinical Syndrome—
Signs and Symptoms

Malaise

Weakness

Nausea and vomiting

Muscle cramps

Itching

Metallic taste (mouth)

Neurologic impairment
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Skeletal Effects of Chronic
Renal Failure

Hyperphosphatemia

Hypocalcemia

Hyperparathyroidism

Low bone mass and density

Osteitis fibrosa cystica—hyperplastic
demineralized bone
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Regimen for Total Parenteral Nutrition by
Subclavian Vein for Dialysis Patients
Developed by Katy Wilkens, RD, Northwest Kidney Center; Seattle, Wash.
* Additional volume may include insulin and vitamins.
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Regimen for Intermittent Parenteral Nutrition
Administered During Hemodialysis Therapy
Developed by Katy Wilkens, RD, Northwest Kidney Center; Seattle, Wash.
* Additional volume may include insulin and vitamins.
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Kidney Transplant
1. Types: related donor or cadaver
2. Posttransplant management:
Corticosteroids
Cyclosporine
3. Diet while on high-dose steroids:
1.3 to 2 g/kg BW protein
30 to 35 kcal/kg BW energy
80 to 100 mEq Na
4. Diet after steroids:
1 g/kg BW protein
Kcal to achieve IBW
Individualize Na level
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Kidney Stones
1. Particulate matter crystallizes
Ca salts (Ca oxalate or Ca phosphate)
Uric acid
Cystine
Struvite (NH4, magnesium and phosphate)
2. Ca salts in stones—Rx: high fluid; evaluate
calcium from diet; may need more!
3. Treat metabolic problem; low-oxalate diet
may be needed; acid-ash diet is sometimes
useful but not proven totally effective
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Kidney Stones—cont’d
4. Uric acid stones
Alter pH of urine to more alkaline
Use high-alkaline-ash diet
Food list in Krause text
5. Cystine stones (rare)
6. Struvite antibiotics and/or surgery
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Acid-Ash Diet

Increases acidity of urine (contains
chloride, phosphorus, and sulfur)

Meats, cheese, grains emphasized

Fruits and vegetables limited (exceptions
are corn, lentils, cranberries, plums,
prunes)
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Alkaline-Ash Diet

Increases alkalinity of urine (contains
sodium, potassium, calcium, and
magnesium)

Fruits and vegetables emphasized
(exceptions are corn, lentils, cranberries,
plums, prunes)

Meats and grains limited
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Summary

Renal diseases—delicate balance of
nutrients

Regular monitoring of lab values, with
altered dietary interventions accordingly
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