chapter 9 renal disease. 2 elsevier items and derived items © 2010, 2007 by saunders, an imprint of...

Chapter 9Chapter 9

Renal DiseaseRenal Disease

2Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Learning ObjectivesLearning Objectives

Describe the basic functions of the Describe the basic functions of the kidneys.kidneys.

Identify the clinical symptoms and serum Identify the clinical symptoms and serum parameters of renal disease.parameters of renal disease.

Identify risk factors for the development of Identify risk factors for the development of renal disease.renal disease.

Discuss the principles of nutritional Discuss the principles of nutritional management, including the control of management, including the control of disease and promotion of good nutritional disease and promotion of good nutritional status.status.


Functions of KidneysFunctions of Kidneys

Help maintain proper metabolism and Help maintain proper metabolism and hormonal balancehormonal balance Converts the inactive form of vitamin DConverts the inactive form of vitamin D22 into into

the active form Dthe active form D33

Produces the enzyme renin, which affects Produces the enzyme renin, which affects blood pressureblood pressure

Produces erythropoietin, which stimulates red Produces erythropoietin, which stimulates red blood cell production in the bone marrowblood cell production in the bone marrow

Reabsorbing important body constituents, Reabsorbing important body constituents, such as electrolytessuch as electrolytes

Excreting toxins and waste material Excreting toxins and waste material through the 1 million nephronsthrough the 1 million nephrons


Anatomy of a KidneyAnatomy of a Kidney


Main Types of Renal DiseasesMain Types of Renal Diseases

NephropathyNephropathy: any disease of the kidneys: any disease of the kidneys

Chronic Kidney DiseaseChronic Kidney DiseaseGlomerulonephritis, nephritisGlomerulonephritis, nephritis: an inflammatory state of the : an inflammatory state of the glomeruli; can be caused by autoimmune disorders, creatine glomeruli; can be caused by autoimmune disorders, creatine supplements as used by athletessupplements as used by athletes

Glomerulosclerosis, nephrosclerosisGlomerulosclerosis, nephrosclerosis: related to scarring of : related to scarring of the glomeruli; can be caused by diabetes, toxins, HTN, or the glomeruli; can be caused by diabetes, toxins, HTN, or hyperhomocysteinemiahyperhomocysteinemia

Nephrotic syndromeNephrotic syndrome: involves the loss of the glomerular : involves the loss of the glomerular barrier to protein with resulting loss of protein into the urinebarrier to protein with resulting loss of protein into the urine

May lead to May lead to End Stage Renal DiseaseEnd Stage Renal Disease (ESRD) (ESRD)


Factors Related to Increased Factors Related to Increased Risk of NephropathyRisk of Nephropathy

GeneticsGenetics HTN—goal to maintain BP <120/80HTN—goal to maintain BP <120/80 Hyperglycemia—goal to maintain A1c <7%Hyperglycemia—goal to maintain A1c <7% SmokingSmoking Older ageOlder age Male genderMale gender High-protein diet High-protein diet (Ayodele et al., 2004)(Ayodele et al., 2004) UTIs—found with high BG; include cranberry juice in UTIs—found with high BG; include cranberry juice in

moderationmoderation Orlistat with associated fat malabsorptionOrlistat with associated fat malabsorption (Singh et al., 2007)(Singh et al., 2007)

Contrast dyes Contrast dyes (Iyisoy et al., 2008)(Iyisoy et al., 2008) Iga nephropathy—may be due to untreated celiac Iga nephropathy—may be due to untreated celiac (La Villa et al., (La Villa et al.,

2003)2003)


Acute Renal FailureAcute Renal Failure

Occurs with a sudden decrease in Occurs with a sudden decrease in glomerularglomerular filtration rate (GFR)filtration rate (GFR)

May be short-lived with symptoms treatedMay be short-lived with symptoms treated—low potassium diet, low protein—low potassium diet, low protein

May occur due to rhabdomyolysis from May occur due to rhabdomyolysis from medications or undue muscular stress medications or undue muscular stress (trauma), infection, severe dehydration, (trauma), infection, severe dehydration, hypotensionhypotension


UremiaUremia

Noted with elevated serum creatinine Noted with elevated serum creatinine >1.5 mg/dL>1.5 mg/dL

Signs and symptoms:Signs and symptoms: Metallic tasteMetallic taste Nausea and vomitingNausea and vomiting Intense itching of the skinIntense itching of the skin HeadacheHeadache Altered consciousnessAltered consciousness


Lab Values & Diagnosis of Renal Lab Values & Diagnosis of Renal DiseaseDisease

ProteinuriaProteinuria Elevated blood urea nitrogen (BUN)Elevated blood urea nitrogen (BUN) Elevated serum creatinineElevated serum creatinine——a nitrogen containing a nitrogen containing

compound found in muscle that the kidneys regulatecompound found in muscle that the kidneys regulate Low glomerular filtration rate (GFR)Low glomerular filtration rate (GFR) Hyperkalemia, Hypernatremia, HyperphosphatemiaHyperkalemia, Hypernatremia, Hyperphosphatemia Imbalances of serum calcium (low) & serum Imbalances of serum calcium (low) & serum

phosphate (high)phosphate (high) Anemia—verify form; may be reduced erythropoietin Anemia—verify form; may be reduced erythropoietin

or actual iron deficiency or other cause such as or actual iron deficiency or other cause such as anemia of chronic disease (related to inflammation), anemia of chronic disease (related to inflammation), treat accordingly treat accordingly


Effects of Loss of ProteinEffects of Loss of Protein

Albumin <3.0 mg/dL found with:Albumin <3.0 mg/dL found with:Peripheral edemaPeripheral edemaAscites (abnormal fluid accumulation in the abdominal cavity)Ascites (abnormal fluid accumulation in the abdominal cavity)Anasarca (generalized massive edema)Anasarca (generalized massive edema)

Reduced vitamin D-binding proteins, leading to depletion of Reduced vitamin D-binding proteins, leading to depletion of active vitamin D and osteomalacia (soft bones)active vitamin D and osteomalacia (soft bones)

Hyperlipidemia resulting from loss of lipid-carrying proteins Hyperlipidemia resulting from loss of lipid-carrying proteins

Increased risk of thrombosis because of decreased anticlotting Increased risk of thrombosis because of decreased anticlotting factorsfactors


Treatment of CKDTreatment of CKD

Control glucose in people with DMControl glucose in people with DM HgbAHgbA1c1c <7.2% associated with 50% reduced risk of kidney <7.2% associated with 50% reduced risk of kidney

disease progressiondisease progression Control blood pressure (lifestyle and/or medication)Control blood pressure (lifestyle and/or medication) Slow weight loss as neededSlow weight loss as needed Increased fiber intake helps promote nitrogen Increased fiber intake helps promote nitrogen

excretion through the feceexcretion through the feces s Stop smokingStop smoking Inclusion of omega-3 fats may reduce inflammationInclusion of omega-3 fats may reduce inflammation Decrease homocysteine levels with increased B Decrease homocysteine levels with increased B

vitamins: B2, B6, B12, and folatevitamins: B2, B6, B12, and folate Avoidance of toxins: Certain medications & painkillersAvoidance of toxins: Certain medications & painkillers


Treatment (continued)Treatment (continued)

Potential Restrictions:Potential Restrictions:Provide adequate protein as tolerated Provide adequate protein as tolerated (.8g/kg, reduced protein intake may be (.8g/kg, reduced protein intake may be needed per serum lab values)needed per serum lab values)PotassiumPotassiumPhosphorousPhosphorous

Phosphate bindersPhosphate bindersSodium 2000mgSodium 2000mg

Edema associated with low serum albumin Edema associated with low serum albumin levels should NOT be treated with excess levels should NOT be treated with excess restriction of sodium intakerestriction of sodium intake

Fluid (500-1000mg + urine output)Fluid (500-1000mg + urine output)


Stages of Chronic Stages of Chronic Kidney Disease (CKD)Kidney Disease (CKD)

Stages 1 and 2: GFR normal >60Stages 1 and 2: GFR normal >60 Goal to prevent further damage by controlling BG, BP, aiming Goal to prevent further damage by controlling BG, BP, aiming

for a healthy dietfor a healthy diet Stage 3: GFR 30-59 or creatinine >2 mg/dLStage 3: GFR 30-59 or creatinine >2 mg/dL

Goals include above along w/ maintaining stable weight, Goals include above along w/ maintaining stable weight, restricting potassium as warranted per labs, controlling restricting potassium as warranted per labs, controlling anemia, maintaining or achieving good vitamin D statusanemia, maintaining or achieving good vitamin D status

Stage 4: GFR 15-29Stage 4: GFR 15-29 Goal to delay dialysis via above, protein restriction to 0.6 to Goal to delay dialysis via above, protein restriction to 0.6 to

0.8 g (maximum 1 g) PRO/kg BW, limit phosphorus intake, 0.8 g (maximum 1 g) PRO/kg BW, limit phosphorus intake, monitor serum Ca++ and treat prnmonitor serum Ca++ and treat prn

Stage 5: GFR <15Stage 5: GFR <15 In addition to above, if no dialysis, monitor for need of fluid In addition to above, if no dialysis, monitor for need of fluid

restriction (500-1000 mL plus urine output)restriction (500-1000 mL plus urine output)


Role of ExerciseRole of Exercise

Helps lower insulin resistance and control Helps lower insulin resistance and control BG and BPBG and BP

Helps reduce cardiovascular disease Helps reduce cardiovascular disease associated with CKDassociated with CKD

Helps maintain quality of lifeHelps maintain quality of life Improves variety of health outcomes Improves variety of health outcomes

associated with CKD associated with CKD (Chan et al., 2007)(Chan et al., 2007)


End-Stage Renal Disease (ESRD)End-Stage Renal Disease (ESRD)or Chronic Renal Failureor Chronic Renal Failure

Associated with severe loss in the Associated with severe loss in the glomerular filtration rate and may be glomerular filtration rate and may be associated with oliguria (severe reduction associated with oliguria (severe reduction in urine production) or anuria (no urine in urine production) or anuria (no urine output)output)

Fluid restriction required with reduced Fluid restriction required with reduced urine outputurine output

Dialysis or renal transplant is warranted at Dialysis or renal transplant is warranted at this stage of renal disease this stage of renal disease


Dialysis IssuesDialysis Issues

PRO goal PRO goal ≥1.2 g/kg BW≥1.2 g/kg BW Aim for dry weight stabilization (weight after Aim for dry weight stabilization (weight after

dialysis when BP normal), between dialysis dialysis when BP normal), between dialysis sessions (interdialytic weight gain) with fluid sessions (interdialytic weight gain) with fluid restriction as neededrestriction as needed

Supplement with water-soluble vitaminsSupplement with water-soluble vitamins Supplement with CaSupplement with Ca++ ++ (when phosphate normal) (when phosphate normal)

and active form of vitamin D (Dand active form of vitamin D (D33)) Consider zinc and magnesium supplementsConsider zinc and magnesium supplements Undertake iron studies to rule out need for FeSoUndertake iron studies to rule out need for FeSo44

Consult a dietitian: multiple restrictions result in a Consult a dietitian: multiple restrictions result in a complicated diet that is difficulty to follow and complicated diet that is difficulty to follow and malnutrition is commonmalnutrition is common


Nephrolithiasis (Kidney Stones)Nephrolithiasis (Kidney Stones)

Increasing in frequency, believed due to Increasing in frequency, believed due to rise in obesity ratesrise in obesity rates

Increase in fluid intake (water) is most Increase in fluid intake (water) is most useful to keep urine diluteuseful to keep urine dilute

Dietary restrictions must be based on the Dietary restrictions must be based on the type of kidney stonetype of kidney stone


Calcium Oxalate Stones Calcium Oxalate Stones (Most Common Form)(Most Common Form)

Increased frequency found among persons with Increased frequency found among persons with Roux-en-Y bariatric weight loss procedureRoux-en-Y bariatric weight loss procedure

Increased frequency found with use of Orlistat Increased frequency found with use of Orlistat and fat malabsorptionand fat malabsorption

Increase fluid intakeIncrease fluid intake Decrease oxalate intakeDecrease oxalate intake

Avoid excess vitamin C because it results in oxalate Avoid excess vitamin C because it results in oxalate formation; increase magnesium (milk; fatty fish also formation; increase magnesium (milk; fatty fish also beneficial and rich in magnesium)beneficial and rich in magnesium)

Legumes, nuts, dark-green leafy vegetables, berries, Legumes, nuts, dark-green leafy vegetables, berries, citrus fruitscitrus fruits

800 to 1200 mg calcium (2.5 to 4 cups milk or 800 to 1200 mg calcium (2.5 to 4 cups milk or equivalent milk products)equivalent milk products)

Mild sodium restrictionMild sodium restriction


Uric Acid Stones Uric Acid Stones (Second Most Common Form)(Second Most Common Form)

Often found with type 2 diabetesOften found with type 2 diabetes Goal to reduce urine acidityGoal to reduce urine acidity

With potassium citrate or calcium carbonateWith potassium citrate or calcium carbonate Moderate PRO intake (50g/day)Moderate PRO intake (50g/day)

Decrease intake of meat, eggs, legumes, Decrease intake of meat, eggs, legumes, whole grainswhole grains

Increase intake of milk and milk productsIncrease intake of milk and milk products Increase fruit & vegetable intakeIncrease fruit & vegetable intake

Except cranberries and plums/prunesExcept cranberries and plums/prunes


Study GuideStudy Guide


Study Guide (continued)Study Guide (continued)

Function of the kidneys Risk factors for nephropathy Signs & symptoms of CKD Nutritional treatment of CKD and ESRD Nutrition management of Calcium oxalate

stones and uric acid stones Role of exercise

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