Medical Nutrition Therapy In Kidney Disease PDF

# Medical Nutrition Therapy In Kidney Disease ## Dr. Nefisa H. Elbanna - Prof. of Clinical Nutrition - Home Economics Hellwan University - Ph.D. from Univ. of Illinois USA ## The Kidney - The main function of the kidney is to maintain homeostatic balance with respect to fluids, electrolytes, and...

# Medical Nutrition Therapy In Kidney Disease ## Dr. Nefisa H. Elbanna - Prof. of Clinical Nutrition - Home Economics Hellwan University - Ph.D. from Univ. of Illinois USA ## The Kidney - The main function of the kidney is to maintain homeostatic balance with respect to fluids, electrolytes, and organic solutes. - The kidney receives 20% of cardiac output, which allows the filtering of approximately 1600 L/day of blood through active processes of resorbing. Only 1.5 L of urine excreted/day. - Each kidney consists of 1 million nephrons. - The nephron consists of a glomerulus connected with loop of Henle, distal tubule, & collecting duct. - The function of the glomerulus is to filtrate blood & blocks blood cells as well as protein. - The tubules resorb the vast majority of components that compose the ultrafiltrate. - The kidney has ability to regulate water homeostasis. - The majority of the solute load consists of nitrogenous wastes. Urea, uric acid, creatinine, and ammonia. - The ability of the kidney to eliminate nitrogenous waste products is known as renal function; renal failure is the inability to excrete the daily load of these wastes. - The kidney also functions: - A renin-angiotensin mechanism, a major control of blood pressure. - The kidney produces the hormone erythropoietin. - Production of the active form of Vitamin D - 1,25 – (OH)2 D3. ## Kidney Anatomy A diagram showing the anatomy of the kidney can be seen here, which includes the following parts: - Hilum - Renal Vein - Renal Artery - Renal Pelvis - Ureter - Renal Cortex - Renal Medulla - Renal Papilla - Renal Pyramids - Renal Columns - Major Calyx - Minor Calyx - Fibrous Capsule Another diagram showing the anatomy of a nephron can be seen here. This diagram shows: - Cortex - Medulla - Juxtaglomerular Apparatus - Afferent Arteriole - Distal Convoluted Tubule - Descending Limb - Ascending Limb - Loop of Henle - Collecting Duct ## Acute Renal Failure - ARF is characterized by a sudden reduction in glomerular filtration rate (GFR). - Nutritional care in ARF is particularly important the patient has uremia, metabolic acidosis, but also usually suffers from physiologic stress. - In the early stages of ARF, the patient is often unable to eat. Total parenteral nutrition (TPN) and early dialysis positively affect patient survival. ## Chronic Kidney Disease - Chronic kidney diseases (CKD) has recently classified into five stages. - **Stage 1:** Kidney damage with normal, normal or increased GFR (≥90 mL/min/1.73m²) - **Stage 2:** Kidney damage with mild decreased GFR (60-89 mL/min/1.73m²) - **Stage 3:** Moderate decreased GFR (30-59 mL/min/1.73m²) - **Stage 4:** Severe decreased GFR (15-29 mL/min/1.73m²) - **Stage 5:** Kidney failure (<15 mL/min/1.73m²) (or receiving dialysis) therapy. *Chronic kidney disease is defined as kidney damage or a glomerular filtration rate (GFR) <60 mL/min/1.72m² for 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.* ## Kidney Functions - The kidney has 3 primary functions: - Excretory - Endocrine - Metabolic - All these 3 functions may be impaired in renal disease and may affect the patient’s nutritional status and management. ## Goals of Medical Nutrition Therapy in ESRD - To prevent deficiency and maintain good nutritional status through adequate protein energy, vitamins, and minerals. - To control edema and electrolyte imbalance by controlling sodium, potassium, and fluid intake. - To prevent or retard the development of renal osteodystrophy by controlling Ca and vitamin D intake. - To enable the patient to eat a palatable and attractive diet that fits his or her lifestyle. ## Nutritional Needs - Giving carbohydrate (100 g over a 24-hour period) only reduces protein breakdown by 50%. - Protein: From 0.5 to 0.8 g/kg for nondialysis patients to 1 to 2 g/kg for dialyzed patients. - Calorie needs should be estimated at 30 to 40 kilocalories per kilogram. - Large intakes of carbohydrate and fat will prevent the use of protein for energy production. - Even with the development of dialysis methods and transplantation techniques, nutritional care remains essential to enhance dialysis, maintain optimal nutritional status, and prevent complications. ## Dialysis - **Continuous ambulatory peritoneal dialysis:** 20-minute exchanges are given four to five times daily, every day. - **Hemodialysis:** Treatment is usually for 3 to 5 hours, three times per week. <start_of_image> Schematic diagrams showing these two types of dialysis can be seen here. ## Nutrient Requirements For Adults With ESRD On Hemodialysis | Therapy | Energy (kcal/kg IBW) | Protein (g/kg IBW) | Fluid (mL/day +urine output) | Sodium (g/day) | Potassium (g/day or mg/kg IBW) | Phosphorus (g/day or mg/kg IBW) | | -------- | ------------------------ | ----------------- | -------------------------------- | -------------- | ----------------------------------- | -------------------------------- | | Hemodialysis | 35 | 1.2 | 750-1000 | 2-3 | 2-3 or 40 | 1.2-0.8 or 17 | ## Fluid and Sodium Balance - The kidney’s ability to handle sodium and water in ESRD must be assessed frequently through measurement of blood pressure, presence of edema, sodium dietary intake, and serum sodium level. - Dialysis patients with hypertension and edema may need to restrict intake of sodium and fluids. - The recommended intake of sodium for the vast majority of patients is g/day 2-3. - In the patients who is maintained with dialysis, sodium intake, and fluid intake are regulated to allow for a weight gain of 2 to 3 kg from increased fluid between dialysis. - When educating about fluid balance, the health care provider must teach the patient how to deal with thirst without drinking. ## Potassium - Potassium (K+) usually requires restriction depending on the individual’s body size, the serum K+ level, urine output, and the frequency of dialysis. - The daily intake of K+ is about 3-5 g and is usually reduced in ESRD to (2-3 g). ## Protein - Dialysis is a drain on body protein, and the daily intake should be increased. - Patients who received hemodialysis, intake of protein is 1.2 g/kg body weight, at least 50% should be high biological value protein. - A recent trend in evaluating the efficacy of dialysis relies on measuring the removal of urea from patient’s blood. - The patient is well dialyzed when a 65% or greater reduction in serum urea occurs. - Patients who are poorly dialyzed tend to have lower albumin levels. - Hypoalbuminemia is multifactorial and related to poor nutrition. ## Energy - Energy intake must be adequate to spare protein for tissue protein synthesis and to prevent its metabolism for energy. - Depending on the patient’s nutritional status and degree of stress, between 25 and 40 kcal/kg body weight should be provided. ## Calcium, Phosphorus, & Vitamin D - A major complication of ESRD is metabolic bone disease, or renal osteodystrophy. - As the GFR decreases, phosphorus, the level of which is controlled by renal excretion, is retained in the plasma. The serum calcium level declines for several reasons. - In essence, calcium and phosphorus intake must be controlled to as great a degree as possible to avoid aggravation of the delicate situation posed by hyperparathyroidism, phosphate retention, and hypocalcemia in renal failure. - In practical terms, calcium intake is kept high and phosphorus intake is kept low, this is a problem concerning food. ## Vitamins - Water-soluble vitamins are lost during dialysis. - Levels of the fat-soluble vitamins do not usually change as much as levels of the water-soluble vitamins in renal disease. - Vitamin K supplements are usually avoided because of the large number of patients who take anticoagulants. ## Carbohydrate - Glucose intolerance with both hyperglycemia and hypoglycemia commonly is observed in patients with ESRD. ## Lipid - Atherosclerotic cardiovascular disease is the most common cause of death among patients maintained on long-term hemodialysis. - Treatment of hyperlipidemia with diet or pharmacologic agents remains controversial. - Improvement of the plasma lipid profile in ESRD may result from supplementation with the amino acid L-carnitine. ## Anemia in Chronic Kidney Disease - Anemia is a significant cause of morbidity and mortality in patients with CKD and ESRD. - The WHO has defined anemia as a Hb level of less than 13 g/dL in men and postmenopausal women, and less than 12 g/dL in premenopausal women. - Anemia arises as an early complication of (CKD), often as (GFR) falls below about 60 mL/min/1.73m². - The prevalence and severity of anemia in CKD patients increase with worsening kidney function. - Anemia is present in as many as 90% of patients with stages 4 and 5 CKD and is almost universally present when patients reach the need for dialysis. - It is now recommended that Hb testing should be carried out at least annually in all patients with CKD. ## Erythropoietin and Anemia - Anemia in patients with CKD is multifactorial, but it is caused primarily by insufficient production of erythrocytes by the bone marrow due to a deficiency of erythropoietin. - Erythropoietin-producing renal cells sense decreased oxygen delivery as a result of anemia or hypoxia. ## Contributing Factors To Anemia of CKD - **Iron deficiency:** Besides erythropoietin deficiency, iron deficiency is the next most common factor contributing to the anemia of CKD. - Absolute iron deficiency is a state where circulating iron and the body’s total iron stores are depleted. - This is often defined in patients with CKD by a TSAT less than 20% & a serum ferritin of less than 100 ng/dl. - **Folic acid and Vitamin B12 Deficiency:** Deficiency of either folic acid or vitamin B12 can result in the development of macrocytic anemia. Hemodialysis can result in the loss of folic acid into the dialysate. ## Treatment - With Epoetin and Darbepoetin, the ability to treat anemia in dialysis patients and subsequently CKD patients not on dialysis was dramatically improved. - Current guidelines recommend that in patients with CKD, the Hb target should generally be in the range of 11.0 to 12.0 g/dL and that the Hb target should not be greater than 13.0 g/dL. - Above Hb levels of 13 g/dL, there has been concern about adverse effects, including HD access thrombosis and cardiovascular morbidity, and mortality. ## Iron Therapy - An adequate supply of iron is necessary for normal erythropoiesis. - Iron supplementation guidelines recommend iron treatment as needed to maintain TSAT greater than 20% and serum ferritin above 200 ng/dL in hemodialysis patients. ## Simple Menu Plan For Dialysis Patient - **Limit dairy products to one serving per day.** - **Cold or hot cereal with milk, nondairy creamer or alternative, or egg.** - **Toast, muffin, or bagel.** - **Fruit or fruit juice.** - **Sandwich - roast beef, turkey, tuna, chicken, or egg salad.** - **Fruit.** - **Cookie.** - **Beverage.** - **Beef, fish, pork, chicken, turkey, or seafood.** - **Fresh or frozen vegetables.** - **Potato, rice, or pasta.** - **Bread or roll.** - **Fruit, cookie, sherbet, or other desert.** - **Beverage.** - **Snacks:** Sandwich, cookie, fruit, or low-salt crackers. Appropriate high-calorie supplement if needed. - **Limit fruits, vegetables, and juices to six servings total per day** - **Limit water and other fluids as needed to prevent water gains of more than 2.0 kg (4.5 lb) between treatments** *A simple menu plan for a patient on dialysis. The diet should allow for no more than 5% weight gain* ## Thanks