KIDNEY DISORDER:

ACUTE RENAL DISEASE

CHRONIC RENAL DISEASE
Kim Leonard G. dela Luna, RND
College of Public Health
April 13, 2015
 OBJECTIVE

This presentation aims to:

1. Discuss of the overview and brief review of
acute renal disease and chronic renal disease;
2. Present the pathophysiology of the disease;
3. Discuss some nutrition- related concerns and
nutrition management of the disease; and
4. Present current researches regarding
management of the disease.
 OUTLINE

I. Normal Physiology of Kidney and its Function

II. Public Health Significance
III. Pathophysiology
IV. Integrated Role of Nutrients in the Disease
Process
V. Medical Therapy
VI. Drug- Nutrient Interaction
 NORMAL KIDNEY FUNCTION

Production of
ultrafiltrate
FUNCTION OF KIDNEY
PUBLIC HEALTH SIGNIFICANCE
 RENAL DISEASES

- Manifestation of renal disease are direct

consequences of the portions of the urinary
tract system most affected.
- It includes:
 Glomerular disease
Acute Renal Failure
Tubular defects
End stage renal disease
 Renal stones
 GLOBAL PREVALENCE

-Prevalence worldwide is estimated at 6- 8%

- Diabetes Mellitus is the mosty common cause of CKD
-Poorest population is a t risk.
CAUSES OF CHRONIC KIDNEY DISEASE

Cause Incidence (%)

Diabetes 40
Hypertension 27
Glomerulonephritis 13
Interstitial disease 4
Renal cystic disease 3
Tumors 2
Other 10
MAGNITUDE OF THE PROBLEM:
PHILIPPINES
 MAGNITUDE OF THE PROBLEM:
PHILIPPINES

- 1 Filipino in every hour develops Chronic Kidney

Disease
- 120 per million in the population per year or 12000
of new cases of CKS develops yearly
- About 5,000 Filipinos is undergoing dialysis
treatment.
- 60 % of the patients undergoing dialysis is
accounted to Diabetes Mellitus and Hypertens
-Females had a higher prevalence of CKD than males.
-GFR declines by 1 ml/ min/1.73 m2 per year after the age of
30 years in healthy persons.
- Lower CKD prevalence in African Americans as compared to
Caucasians
PATHOPHYSIOLOGY
 RENAL FAILURE

- Implies complete or almost complete

suppression of kidney function. It can be:
Acute Renal Failure (ARF)
Chronic Kidney Disease (CKD)

- Glomerular filtration rate is reduced as renal

failure progresses and greatly dependent on its
severity.
 GLOMERULAR FILTRATION RATE AND RENAL
FUNCTION
STAGES GFR
(ml/min/1.3m2)
Decreased Renal Function
with normal or higher GFR >=90
with mild decreased GFR 60-89

Renal Insufficiency
Moderate decreased GFR 30-59
Severe decreased in GFR 15-29

Renal Failure <15

GLOMERULAR FILTRATION RATE COMPUTATION

GFR (M)= Weight (kg) x 140 - age

72 x serum creatinine (mg/dl)

GFR (W)= Weight (kg) x 140 - age x .85

72 x serum creatinine (mg/dl)
 ACUTE RENAL FAILURE
-Sudden reduction in the glomerular
infiltration rate (GFR) and alteration in the
ability of the kidney to excrete the daily
production of metabolic waste.

-It can be due to:

Inadequate Renal Perfusion (Prerenal)
Diseases within the renal parenchyma (Intrinsic)
Obstruction (Postrenal)
PATHOPHYSIOLOGY
 PRERENAL

- occurs when an underlying condition deprives the

kidney of necessary blood flow, thereby decreasing the
glomerular filtration rate. The decrease in the renal
perfusion can be the result of the following:
i. Volume depletion
ii. Hypotension/ shock
iii. Congestive heart failure
iv. Renal vasoconstriction
v. Renal artery occlusion
 INTRISIC/ INTRARENAL

- part of the kidney such as the tubule the interstitium, the

glomerulus, or the vasculature are damages. Underlying
conditions include the following:
i. Hypertension
ii. Interstitial inflammation from an infection
iii. Acute tubular necrosis
iv. Acute interstitial nephritis
v. Nephrotoxicity
vi. Intrarenal obstruction
 POST RENAL

The postrenal stage is caused when crystals,

protein deposits or malignant tumor
infiltration obstruct urine flow.
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY
Anuric and Oliguric Phase:
Kidney Injury Reduction in GFR, destruction in tubular
epithelium and rupture of the basement
membrane of the tubules causing
indiscriminate diffusion of glomerular
Elevated BUN infiltrate into the blood.
(azotemia), acidic
products of CHON
catabolism (phosphate,
sulfate) produce
metabolic acidoses and
hyperkalemia
Polyuric Phase:
The kidney is unable to produce a more
concentrated urine. Patient usually urine
volume reaches 3- 6 liters, it is dilute but
contain large amounts of Na+, K+ and Cl-.
 PHASES OF ACUTE RENAL FAILURE
PHASES CHARACTERISTICS
Anuric Decreased output to less than 100 ml per day
(14 days)
Oliguric Patient excretes 100- 400 ml daily
(8-14 days) Abnormal fluid/ electrolyte homeostasis occurs.
Dialysis is needed to prevent permanent damage
Polyuric Patient gradually increases output of urine to
(10- days) several liters per day (400- 4000ml).
Fluid balance is critical.
Patient gradually improves, although some loss of
function may be permanent care
Convalescent Patient gradually improves, although some loss of
(10 days to 3 months function may be permanent.
or up to 1 year) ARF in acute care may be reversible, but mortality is
stii 50-75%
 CHRONIC KIDNEY DISEASE

-Terminal stage of condition which destroy

renal tissue leaving very few functioning
nephrons to handle the catabolic load.

- Can be caused by diabetes,

glomerulonephritis, long term hypertension,
chronic infection, tubular disease, chronic
hypercalcemia and hyperkalemia.
PATHOPHYSIOLOGY
DIABETES MELLITUS
HYPERTENSION
HYPERTENSION
 GLOMERULONEPHRITIS

- Known to be an immune reaction

mediated by an antigen- antibody
complexes.
- It can be through:
 Immune complex deposition
 Circulating immune complexes
 GLOMERULONEPHRITIS
Immune complex deposition
-Antigen- antibody complex are planted
specifically in the membrane. Immune activity is
targeted at the glomerulus level
 Circulating immune complexes
- Complex was circulating the bloodstream and
eventually reach the glomerulus during filtration.
It can be from other organ or came from foreign
matter in nature.
 STAGES OF CHRONIC KIDNEY DISEASE

STAGES CHARACTERISTIC
Stage 1 Signs of mild kidney disease but with normal or better GFR
(greater than 90% kidney function)
Stage 2 Signs of mild kidney disease with reduced GFR (indicating
60% to 89% kidney function).
Stage 3 Signs of moderate chronic renal insufficiency (where the
GFR indicates 40% to 59% kidney function)
Stage 4 Signs of severe chronic renal insufficiency (where the GFR
indicates 15% to 29% kidney function) PRE- DIALYSIS
Stage 5 Signs of end stage renal failure (where the GFR indicates less
than 15% kidney function).
STAGES OF CHRONIC KIDNEY DISEASE
DIALYSIS
 HEMODIALYSIS

- Loss of essential nutrients is high

- There is a loss of nutrients during hemodialysis.
About 10- 15 g of amino acids and 10- 25 g of
glucose are lost per dialysis treatment using
glucose- free dialysate ; 30- 40% of the amino
acids are essential.
- Loss of water soluble vitamin is also high
- Catabolism and energy expenditure is increased
HEMODIALYSIS: NUTRITION
CONSEQUENCE
HEMODIALYSIS: NUTRITION
CONSEQUENCE
 PERITONEAL DIALYSIS

- As much as 30 g of CHON may be lost per 24

hour treatment; protein loss increases with
peritonitis
- Vitamins and minerals is also high
INTEGRATED ROLE OF NUTRIENTS
IN THE DISEASE PROCESS
INTEGRATED ROLE OF NUTRIENTS AFFECTING
THE DISEASE PROCESS

The following nutrients are being controlled and

has a significant effect on the disease process:
- Protein
- Sodium
- Potassium
- Phosphorus
- Fluids
DIETARY COMPONENTS AND RENAL FAILURE
 PROTEIN
- Major end products of protein metabolism are
non- protein nitrogen such as urea, uric acid
as well as sulfate, creatinine, organic acids,
carbon dioxide and water.
A
C
C
U
M
U
L
Urea, uric acid, sulfate, A
creatinine, organic acids, T
I
carbon dioxide and water. O
N
 PROTEIN
- Protein with High Biological Value is given
emphasis than other source of protein. This is to
supply all essential amino acids to the patient
using a limited amount of protein.

Protein from animal sources is Plant sources of protein generally

considered high biological value do not contain sufficient amounts
protein or a "complete" protein of essential amino acids
HP diets were associated with increased GFR,serum urea,
urinary calcium excretion, and serum concentrations of uric
acid. Moreover, considering the fact that subclinical CKD is
highly prevalent, and that obesity is associated with kidney
disease, weight reduction programs recommending HP diets
especially from animal sources should be handled with
caution.
 POTASSIUM
- Potassium accumulates in the body during
renal failure. Too much potassium will cause
headache and vomiting, bradychardia and
cardiac arrest
FOOD SELECTION GUIDE
FOOD SELECTION GUIDE
FOOD SELECTION GUIDE
 SODIUM
- Hypernatremia may lead to high blood
pressure and edema with consequent
weight gain
- Hyponatremia causes low blood pressure
depletion of extracellular fluid volume.
 CALCIUM AND PHOSPHORUS

- Phosphate retention occurs with a decline

in renal function, serum calcium goes
down.
- A lowered serum calcium concentration
stimulates an increase in the secretion of
the parathyroid hormone which results to
the withdrawal of calcium from the bones.
FOOD SELECTION GUIDE
MEDICAL NUTRITION THERAPY
 ACUTE RENAL FAILURE

MANAGEMENT

MEDICAL MANAGEMENT NUTRITION MANAGEMENT

MILD  Parenteral administration

(Drug Toxicity) of glucose, lipids and EAA/
Withdraw Drug NEAA
SEVERE High intake of carbohydrate
(Ischemia Acute Tubular Necrosis) and fat to spare protein
High caloric, low proetin
TPN diet and sodium restriction
Electrolyte Replacement
 MEDICAL NUTRITION THERAPY

The diet for ARF aims to:

- Reduce the accumulation of the uremic toxins
- Control electrolyte abnormalities
- Correct fluid retention
- Maintain or improve the nutritional status of
the patient
 NUTRITION MANAGEMENT AND RATIONALE
DIETARY MODIFICATION RATIONALE
Low Protein Diet Limit the toxic waste end product
of protein metabolism
50-60% of the CHON requirement Supply all the essential amino
must come from to High Biologic acids even the protein is
Value restricted.
High carbohydrate and high fat diet Use to spare protein as energy
source
Vitamin B12 and Iron Vitamin B12 and Iron most
Supplementation must be done absorbable form can be found in
meat sources.
Serve fried or braised foods from To increase caloric intake through
time to time the use of fat and carbohydrate
as energy source
 NUTRITION MANAGEMENT AND
RATIONALE
DIETARY MODIFICATION RATIONALE
Calcium supplementation may be Phosphorus and Calcium are
needed frequently constantly occurring is
same type of food and restricting
Phosphorus also lowers calcium-
rich foods
For Dialyzed Patients:
Supplementation particularly with Due to high nutrient loss during
Vitamin C, folic acid, pyridoxine, dialysis
Vitamin D and iron
SPECIFIC DIETARY RECOMMENDATIONS
Dietary Factor Recommendation
Protein 0.5- 0.6 g/ kg present body weight (but not less
than 40g/d; increase as GFR returns to normal;
with dialysis, allow 1.0-1.5 g/kg of present
weight/d.
Energy 35-50 kcal/g present body weight ; energy must
take into consideration the stress accompanying
ARF
Phosphorus Individualize according to laboratory values
Sodium Anuric- oliguric phase: 500-1000 mg/d
Diuretic Phase: Replace losses on urinary
sodium levels, edema and frequency of dialysis.
SPECIFIC DIETARY RECOMMENDATIONS
Dietary Factor Recommendation
Potassium Anuric- Oliguric Phase: 1000 mg/d
Diuretic Phase: Replace losses as indicated by
urinary volume, serum and urinary potassium
levels, frequency of dialysis and drug therapy.
Fluid Assess on a daily basis
Anuric- Oliguric Phase: Replace output
(urine, vomitus, and diarrhea) plus 500 ml from
the previous day.
Calcium Individualize based on laboratory values
Fat No modification indicated during ARF
SPECIFIC DIETARY RECOMMENDATIONS
Dietary Factor Recommendation
Potassium Anuric- Oliguric Phase: 1000 mg/d
Diuretic Phase: Replace losses as indicated by
urinary volume, serum and urinary potassium
levels, frequency of dialysis and drug therapy.
Fluid Assess on a daily basis
Anuric- Oliguric Phase: Replace output
(urine, vomitus, and diarrhea) plus 500 ml from
the previous day.
Calcium Individualize based on laboratory values
Fat No modification indicated during ARF
 FOOD SELECTION GUIDE
FOOD ITEM ALLOW AVOID OR RESTRICT
Vegetables All fresh in allowed Legumes, pickled vegetables,
amounts salt fermented vegetables like
burong mustasa, sauerkraut,
kimchi, canned and frozen
vegetable if sodium is
restricted
Fruit All except on avoided list, Maraschino cherries,
in allowed amounts
Milk Evaporated, whole in In excess of allowance:
allowed amounts Commercial foods made with
milk, condensed milk, malted
milk, milk mixes, sherbet,
chocolate, cocoa
 FOOD SELECTION GUIDE
FOOD ITEM ALLOW AVOID OR RESTRICT
Rice Rice, breads, bihon, macaroni,Commercially prepared desserts,
spaghetti, corn, all of these mixes and pretzels, mixes and
and their products in allowed pastries; potato chips, pretzels,
amounts snack chips, cereals or crackers
containing baking powder,
baking soda, salt or other
sodium compounds; bran
cereals, boxed frozen or canned
meals, whole wheat/ grain
breads and cereals, mami, miki,
miswa, instant noodles; cookies
and sweets made with nuts
Meat or substitute All except nuts; seeds, beans In excess of allowance; nuts
in allowed amounts seeds and beans
 FOOD SELECTION GUIDE
FOOD ITEM ALLOW AVOID OR RESTRICT
Fat Cooking fats , butter, Coconuts, other nuts in
margarine, salad oils and allowed amounts
dressings
Sugar and All Except those with
sweets chocolate and nuts
Dessert Made with allowed foods Those with milk, eggs and
only; low protein desserts as cereals in allowed amounts
plain arrowroot or cornstarch such as ice cream, custard,
and puddings, nata de coco, puddings; cakes, cookies,
matamis na bao, puffed rice
bibingka, etc. cocoa,
only, kondol, rimas, sago or
chocolate and nuts.
kaong with syrup.
HYPOTHETICAL CASE AND ESTIMATING
ENERGY ALLOWANCE
CPF DISTRIBUTION AND DIET RX
RENAL EXCHANGE LIST
SAMPLE MENU PLAN
SAMPLE MENU PLAN
Both higher dietary phosphorus intake and a greater dietary
phosphorus to protein ratio are associated with increased
death risk in Hemodialysis patients, even after adjustments
for serum phosphorus, type of phosphate binder used, and
dietary protein, energy, and potassium intake.
 CHRONIC KIDNEY DISEASE

MANAGEMENT

NUTRITION MANAGEMENT

 Prevent deficiencies
MEDICAL MANAGEMENT
Dialysis Control edema and serum
Kidney Transplantation electrolytes
Immunosuppresant Drug Prevent Renal
Psychologic Support Osteodystrophy
Provide a palatable and
attractive diet
 MEDICAL AND NUTRITIONAL
MANAGEMENT
STAGE MEDICAL AND NUTRITION THERAPY
OBJECTIVE
Stage 1 Reverse Progression
Stage 2 Stop Progression
Stage 3 Slow Progression
Stage 4 Prepare for ESRD
Stage 5 Dialysis/ Transplant
MEDICAL AND NUTRITIONAL
MANAGEMENT
 MEDICAL NUTRITION THERAPY PLAN
(WITHOUT DIALYSIS)

The diet for CKD is plan to:

- Meet nutritional requirements
- Minimize uremic complications
- Maintain acceptable blood chemistries, blood
pressure and the fluid status of patients
- Promote well- being
NUTRITION MANAGEMENT AND RATIONALE
(WITHOUT DIALYSIS)
NUTRITION MANAGEMENT AND RATIONALE
(WITHOUT DIALYSIS)
 MEDICAL NUTRITION THERAPY PLAN
(WITH DIALYSIS)

The diet for dialysis patient is aim to:

- Prevent the deficiency and maintain good
nutritional status through adequate macro- and
micronutrients
- Control edema and electrolyte imbalance
- Prevent o retard the progression of renal
osteodystrophy
- Enable the patient to eat a palatable, attractive
diet.
NUTRITION MANAGEMENT AND RATIONALE
(WITH DIALYSIS)

1.1- 1.4 g/ BW
1.1- 1.5 g/ BW
 DIETARY RECOMMENDATIONS

Dietary Factor Without Dialysis

Protein .6- 1.0 k/kg/day
Energy (kcal/kg IBW) 35 for maintenance
40-45 for repletion
20-30 for reduction
Potassium 2700 mg/day
Sodium No edema: 1 to 3 g/ day
With Edema: Restricted to 1.5 to 2.0 g/
day
Phosphorus 750 mg/ day
Fluid 500- 700 ml + urine output
DIETARY RECOMMENDATIONS
 DIETARY RECOMMENDATIONS
Dietary Factor Hemodialysis Peritoneal Dialysis
Protein 1.1 - 1.4; at least 60% high 1.1-1.5
biological value 1.2-1.3 for maintenance
1.5 for repletion
1.2 for reduction if with
diabetes
Energy (kcal/kg 30-35 for weight 25-35 for maintenance
IBW) maintenance 35-50 for repletion
24-30 for weight reduction 20-25 for reduction
40-50 for weight gain 35 if with diabetes
Phosphorus <1 mEq or approximately < or approximately 1200
800- 1200 mg/d. (Keep mg/d. (Keep serum level at
serum level at maximum maximum of 6 mg/ 100 ml)
of 4-6 mg/ 1000 ml)
 DIETARY RECOMMENDATIONS
Dietary Factor Hemodialysis Peritoneal Dialysis
Potassium 40 mg/kg IBW or Generally, unrestricted CAPD
approximately 50-80 and CCPD.
mEq/d (1250- 2000 mg/d) For IPD: 2000- 3000 mg/d
Fluid 500- 750 ml/d plus urine In CAP and CCPD,
output or approximately approximately 2000- 3000 ml/
750 – 1500 ml/d day based on daily weight
fluctuations and blood
pressure; IPD, same as for
hemodialysis
Calcium Approximately 1000- Same as for hemodialysis
8000 mg/ d; supplement as
needed depending on
serum level
 DIETARY RECOMMENDATIONS

Dietary Factor Hemodialysis Peritoneal Dialysis

Fat Limit cholesterol to less Same as for hemodialysis
than 3000 mg/d;
emphasize unsaturated
fats
Fiber 20-25 g/d Same as for hemodialysis
HYPOTHETICAL CASE AND CALORIC
DISTRIBUTION
RENAL EXCHANGE LIST
SAMPLE MENU PLAN
SAMPLE MENU PLAN
NUTRIENT- DRUG INTERACTION
DRUG- TO- DRUG INTERACTION
NUTRIENT- DRUG INTERACTION
NUTRIENT- DRUG INTERACTION
NUTRIENT- DRUG INTERACTION
Allopurinol treatment decreases inflammation and slows the
progression of renal disease in patients with moderate CKD.
In addition, allopurinol reduces cardiovascular and
hospitalization risk.
 REFERENCES
Hanbook for Nutritional Management of Renal Diseases. 1995. Food and
Research Institute. Taguig: Philippines.

Jamorabo- Ruiz A, Claudio VS and de Castro EE. 2008. Medical Nutrition

Therapy for Filipinos. Manila, RP: Merriam and Webster Bookstore, Inc.

Mahan LK and Escott- Stump S. (Editors). 2008. Krause’s Food and Nutrition
Therapy. 12th ed. St, Louis, Missouri: Elsevier.

Rolfes SR, Pinna K and Whitney E. 2009. Understanding Normal and Clinical
Nutrition. 8th Edition. Belmont, CA: Thompson/ Brooks/Cole.

Shils ME, Shike M, Ross AC, Caballero B and Cousins RJ (Editors). 2006.
Modern Nutrition in Health and Disease. 10 th Ed. New York: Lippincott,
William and Wilkins
THANK YOU!