NUTRITION IN RENAL DISORDERS

• Each kidney is composed of one million functional units

called nephrons. Each nephron consists of glomerulus which
is tuft of capillaries, invaginated in to a epithelial sac called
Bowman's capsule from which arises a tubule.blood flow
through the kidney is large, amounting 130 ml/min
• Functions of kidney-
• Excreation1Excretory organ, removes waste products of
nitrogen metabolism urea creatinine ,hydrogen ions and
sulphates .
• They also secrete surplus quantities of water, sodium,
potassium ,calcium phosphate and magnesium.
• Regulatory Function Regulate the amount of water , sodium
and hydrogen ions in the body by modifying composition of
urine , maintain volume of body fluids ,their electrolytic
composition in narrow limits.
• Endocrine Function a)Exclusive site for production of
1,25 dihydroxy cholecalciferol-active form of vit D.
Kidney function failure may lead to bone diseases
• b)Kidneys also produce erythropoietin which is
essential for the synthesis RBC
• c) Renin is enzyme released by kidneys in response to
low B.P directly and also stimulates production of
aldosterone-
• d)Parathyroid hormone ,calcitonin, insulin and gastrin
are degraded by the kidneys
• Metabolic Function-Nitrogen metabolism and
gluconeogenesis especially during starvation
• kidney failure may cause acidosis ,hypertension or
hyperkalemia
• Renal function Dignostic Tests
• 1 Plasma/serum concentration of urea,creatinine and uric acid
creatinine clearance -increased.
• 2 GFR-Glomerular filteration rate is measured by creatinine
clearance.GFR< 30ml/min in kidney failure.
• 3 Serum electrolyte-Sodium,Potassium,chloride,inorganic phosphorus
biocarbonaten concentration may increase or decrease.
• 4 Alkaline phosphate level in blood.-altered
• 5 Blood haemoglobin-depending upon erytropitin synthesis it reduces.
• 6 Volume of urine and ECF-Increase or decrease based on excreatory
capacity
• 7 Urine analysis-clarity,colour, microscopic examination,pH,specific
gravity ,osmolality, presence of abnormal urinary constituents-
blood ,protein
• 8 Urine electrolytes-Sodium potassium, magnesium-especially in
tubular disorders.
 RENAL DISORDERS
• Glomerulonephritis
• Nephrotic syndrome(Nephrosis)
• Acute Renal failure
• Chronic Renal failure
• Dialysis-Haemodialysis , Peritoneal dialysis
• Renal Transplant
• Urolithiasis OR urinary calculi
 GENERALPRINCILPES OF DIETARY MANAGEMENT IN RENAL DISEASES
• Reduce excretory work of kidneys
• -normal fluid, acid base, and electrolyte balance.
• Satisfactory nutritional status
• Prevent progression of renal damage and dev. of uremia
• Dietary modification-proteins, Electrolytes especially sodium and potassium,
fluids
• Energy –simple diet low in proteins, mod to high in CHO and unsaturated fats
• Proteins- Amount depending upon GFR Enough proteins to prevent muscle
wasting and malnutrition, and to avoid accumulation of nitrogenous wastes in
blood and uremia Good quality proteins from eggs and milk are advised.
• Electrolytes-Sodium restriction to avoid oedema, hypertension, CCF-observe is it
retained in body or lost through urine
• Vitamins and minerals calcium and vit D is required, Phosphate restriction, Iron
supplements are needed, Vit B and Vit C needed due to increased requirements
• Fluid Restriction due to reduced GFR in most of the patients, In poly
urea fluid requirement may increase.
 Glomerulonephritis
• Inflammatory disease of nephrons due to infection,degenerative
processes or vascular disease.In most CASES IT AFFECTS CAPILLARIES OF THE
GLOMERULI SO TERMED AS GLOMERULONEPHRITIS. THERE MAY BE DAMAGE TO THE
TUBULES. ALSO
• Symptoms- Fever
• Uremia,Haematuria and proteinuria.
• Oedema
• Hypertension
• Oliguria and anuria due to reduced GFR
• Etiology-common in 3-10 yrs old children,5% in adults ageing >50
yrs
• Streptococcal infection,antigen antibody reaction is mostly basis of
damage of nephrons
• Energy-High energy diet 30-40kcal/kg for adults, 100Kcal /kg for
children dry wt or 10% more calories of RDA
• Proteins-BUN and oliguria decides protein restriction Initially 0.5-
to 0.6 gm/Kg IBW-High biological value proteins .If BUN is normal
1gm/kg protein can be given
• CHO-Liberal amount to avoid protein sparing for reducing
catabolism of proteins. prevent starvation ketosis Both simple
and complex CHO can be given
• Fats Based upon tolerance level to provide non protein calorie for
energy needs ,gives Low bulk in diet and are more palatable
• Sodium-sodium is restricted to 500-1000 mg/day-oliguria desides
sodium restriction.With recovery amount can be increased
• Potassium-1200-1500 mg/day
• Fluids-500-700ml/day plus volume of urine output in previous 24
hrs.Wthout oluguria fluid intake may be normal
 Nephrotic syndrome/Nephrosis
• Nephrotic syndrome is an immune mediated disease in which nephrons
of the kidney are damaged ,allowing plasma proteins to leak in to the
urine in large amounts. This reduces the blood and protein in the blood.
Due to hypo proteinemia, some of the fluid leaks out of the bloodstream
in to the tissues ,causing fluid retention and edema
Clinical features-
• Nephrotic –range proteinuria –Leakage of proteins from glomeruli
exceeds the reabsorptive capacity of the renal tubules,large urinary
losses of plasma proteins and and albumin leads to tissue wastage,fatty
liver,malnutrition, and increased succeptability to infection.
• Hyperlipidemia -Lipoproteins and other proteins such as fibrinogen and
other coagulation factors are increased while antithrombin 3 is lost in
urine.This may account for increased incidence of atherosclerosis and
thrombosis in patients with nephrotic syndrome.Plasma cholesterol is
increased in them .300mg/dl
.
Nephrotic syndrome/NEPHROSIS
• In adults protein execration 3.5 g or more per day ,in
children 40mg/sq m.Urine protein/ creatinine of 2-3 mg
protein/mg creatinine or greater
• The urine foams more than usual because of the amount
of protein in it
Massive Edema-Protineuria leads to edema most
noticeable in the legs and around eyes when one gets up in
the morning eventually it may occur in other parts of the
body ,facial puffiness is also seen(4-10g/day protein loss)
• Hypo albumiemia.-Plasma albumin is in small molecules
and escape most readily through a leak in the glomerular
membrane,Globulins have high molecular weight
• Classification of Nephrotic syndrome
• 1 Primary-When kidney is the only organ involved
• 2 Secondary-When kidney is involved as part of multisystem
involvement e.g.DM, SLE, hepatitis B or E, use of non steroidal
inflammatory drugs, amyloidosis , Multiple myeloma, HIV, Preeclampsia
• Diagnosis-Urine analysis, urine protein quantification(in 24 hour urine
or by doing urine protein to creatinine ratio in spot urine sample),serum
albumin, lipid profile
• Other tests to determine primary or secondary- CBC, Metabolic panel-
Electrolytes,calcium,phosphorus,BUN,creatinine.,HIV test, Hepatitis B
and C3,C4,ANA Antinuclear antibody, Anti double stranded DNA
antibody, Genetic studies, kidney ultra sonography, Kidney biopsy in
selected patients
• Medical management-If DM-Treatment for good glycemic control, Good
BP control-ACE i( angiotensin converting enzyme inhibitors),If immune
mediated disease-Treatment for immunosuppression(Steroids),ARBs,
Diuretics for edema
 MNT
• Proteins-0.8 g/kg/Day Out of which 50% proteins of high
biological value. Additional protein is prescribed to match
urinary losses i.e. 1 g for 1g protein lost in urine.
• Low quality proteins-pulses should be mixed with cereals or
milk to improve quality of proteins
• Energy- 35-40 Kcal /kg/day is recommended. Adequate to
maintain edema free ideal body weight. Appetite is poor. Use
complex carbohydrates
• Fats- 30% of total calories, Diet should be low in SFA,
Cholesterol,Refined sugars 300 mg of cholesterol per day
• Sodium-Low salt diet to prevent edema.1-4 g salt per day
depending upon patients acceptance and degree of edema
• Potassium- Supplemented if patient is on diuretics. Diuretics
unless protein sparing , increase potassium loss
• Vitamins and Minerals-Vit C supplements are essential ,vit D if
required
calcium At least 800 mg/day As vit D binding globulin and 25-
hydroxy vit D3 is lost in the urine, calcium absorption is less and
may cause Tetany.
Hypocalcaemia in nephrotic syndrome is due to reduction in
protein bound calcium secondary to hypoalbuminaemia.
Fluids-Fluid restriction if oliguria is present ,urine output is
less than 25ml/kg/24 hrs and when kidney is affected in its
functions accompanied by oedema
• Diet has to be soft ,patient should maintain normal weight for
height
• Schwartz Estimate Equation(used at bedside)
GFR = 0.413XHt(cm)/S Cr (mg/dl)
Term infants to 1 year Multiply by 0.45
Cockcroft- Gault formula
Cr.Cl(ml/min)=(140-age)X Wt in kg(present wt)
/72XS.Cr
(above value multiplied by 0.85 for female)
GFR=UV/P U= Creatinine concentration in urine, V=
Volume of urine excreted in one minute
P= creatinine concentration in plasma
Normal GFR is about 100-125 ml/mn/1.73 sq m
 ACUTE KIDNEY INJURY
• AKI is the abrupt loss of kidney
function ,resulting in the retention of urea and
other nitrogenous waste products and in
impairment of fluid ,electrolytes and acid base
balance.
• There is high mortality and the condition
needs a medical emergency in which
nutritionist plays a supporting role
• Causes-1Metabolic insult or traumatic injury to
normal kidneys
• Causes- 1. Metabolic insult or traumatic injury to normal
kidneys.
• 2. Loss of blood.during RTA ,accidents ,ulcers,internal
haemorrhage,or at the time of delivery
• 3. Loss of plasma –Burns,crush injuries
• 4.Loss of fluid –Diarrhoea,vomitting,diabetic coma(excessive
urination,sweating)
• 5.Serious infection produce shock and reduce renal blood
• 6.Nephrotoxins-paracetomol,some variety of mushrooms
• 7 General anesthesia and surgical operation reduce renal
blood flow and may precipitate renal failure.
• 7Acute haemolytic disorders(RBC are destroyed due to some
diseases
• 8Nephritis and nephrosis can also result in ARF