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Nutrition for Patients with Kidney Disorders Chapter 21

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutrition for Patients With Kidney Disorders • Kidneys perform many vital functions • Urinary excretion is the primary method by which the body rids itself of: – Excess water – Nitrogenous wastes

– Electrolytes – Sulfates – Organic acids – Toxic substances – Drugs Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutrition for Patients With Kidney Disorders (cont’d) • The kidneys help to regulate acid–base balance by secreting hydrogen ions to increase pH and excreting bicarbonate to lower pH • Involved in blood pressure regulation • Play an important role in maintaining normal metabolism of calcium and phosphorus • Kidney diseases can profoundly impact metabolism, nutritional status, and nutritional requirements Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome • A generic term that refers to a kidney disorder characterized by urinary protein losses greater than 3.0 g/d • Major symptoms:

– Proteinuria – Hypoalbuminemia – Hyperlipidemia – Edema Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont‘d) • Hypoalbuminemia and proteinuria – May lead to protein calorie malnutrition, anemia, increased risk of infection, vitamin D deficiency, and increased clotting • Hyperlipidemia increases the risk of cardiovascular disease and progressive renal damage • Causes of nephrotic syndrome include diabetes, autoimmune diseases (e.g., lupus, IgA nephropathy), infection, and certain chemicals and medications Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont’d) • In some cases, treating the underlying disorder corrects nephrotic syndrome • In others cases, especially diabetes, nephrotic syndrome may be the beginning of chronic kidney disease

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont’d) • Nutrition therapy

– Goals o To minimize edema, proteinuria, and hyperlipidemia

o To replace nutrients lost in the urine o To reduce the risk of progressive renal damage and atherosclerosis Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont’d) • Nutrition therapy (cont’d) – Benefits of minimizing proteinuria o An increase in serum albumin, a decrease in serum lipid levels, a slower progression of kidney disease, and less edema

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont’d) • Sodium and fluid – Sodium restriction begins when fluid retention occurs – For stages 1 to 4 and hemodialysis: o 1,000 to 3,000 mg/day are recommended o Range is 2,000 to 4,000 mg for peritoneal dialysis – Fluid is unrestricted in stages 1 to 4 with normal urine output – For people on hemodialysis, fluid allowance equals the volume of any urine produced plus 1,000 mL Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nephrotic Syndrome (cont’d) • Phosphorus and calcium – As kidney function deteriorates, the conversion of vitamin D to its active form is impaired

– National Kidney Foundation recommends both phosphorus and calcium intake be controlled – In stages 1 to 4, phosphorus allowance is based on lab values and calcium is limited to 1000 to 1,500 mg/day – Phosphate binders must be taken with all meals and snacks Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • Nephrotic syndrome can be caused by what? a. Lupus b. Proteinuria c. Stress d. Hyperlipidemia

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer a. Lupus

Rationale: Causes of nephrotic syndrome include diabetes, autoimmune diseases (e.g., lupus, IgA nephropathy), infection, and certain chemicals and medications.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) • A syndrome of progressive kidney damage and loss of function • Decrease in the number of functioning nephrons overburdens the remaining nephrons, and the kidney’s ability to filter blood deteriorates • Measured by a decrease in glomerular filtration rate (GFR) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • The impact on nutrition – Loss of kidney function produces widespread effects – As urine output decreases, fluid and electrolytes accumulate in the blood, producing symptoms of overhydration such as increased blood pressure, weight gain, edema, shortness of breath, and lung crackles – Uremic syndrome

– Acidosis occurs Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • CKD is associated with premature mortality and decreased quality of life • Progresses slowly and may not be apparent until 50% to 70% of function is lost • In stages 1 to 4, medical and nutrition therapy can potentially delay the progression to stage 5

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Modifiable risk factors

– Smoking cessation, an increase in physical activity, and controlling blood lipid levels – Stage 5 requires dialysis or kidney transplant for survival – Diabetes is the leading cause of CKD – Other risk factors include cardiovascular disease, hypertension, and obesity Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • The impact on nutrition – Reabsorption of some nutrients is impaired – GI absorption of some minerals, such as calcium and iron, is impaired – Impaired synthesis of rennin, erythropoietin, and the active form of vitamin D can lead to high blood pressure, anemia, and bone demineralization – Accelerated atherosclerosis increases the risk of coronary heart disease, myocardial infarction, and further renal damage Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy – Goals o Reduce workload on the kidneys

o Restore or maintain optimal nutritional status o Control the accumulation of uremic toxins – Diet modifications are made in response to symptoms and laboratory values and require frequent monitoring and adjustment – Diet is both complex and dynamic Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Protein o As kidney function declines, the ability to excrete nitrogenous and other wastes also declines o Modification of Diet in Renal Disease (MDRD) study showed that tight control of blood pressure and a restricted protein intake of 0.6 g/kg/day helped delay the progression of kidney disease by 41% Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Protein (cont’d) o In stages 1 to 4, the recommended daily protein intake is 0.6 g/kg to 0.75 g/kg o Protein allowance may be liberalized to maintain appropriate body protein stores or because the severity of restriction is too difficult to follow o Protein allowance in stage 5 is 50% higher than the RDA to account for the loss of serum proteins and acids the Copyright © 2010 amino Wolters Kluwer Health | Lippincott in Williams & Wilkinsdialysate

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Calories o When protein intake is restricted, it is vital to consume adequate calories to spare protein from being used for energy, enabling it to be used for protein synthesis o For all stages of CKD:

 Calorie recommendations are 35 cal/kg for adults under 60 years of age  30 to 35 cal/kg for those who are older Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Calories (cont’d) o During peritoneal dialysis, a large amount of calories is absorbed daily through the dialysate (approximately 340 to 680 cal/day) o Calories from the dialysate impair the natural sense of hunger and generally prevent a fall in blood glucose levels between meals o Increased intake of pure sugars and pure fats helps to meet calorie requirements while keeping protein intake low Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Sodium and fluid (cont’d) o Intake is monitored by weight gain o For many clients on hemodialysis, fluid restriction is hardest Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d)

– Potassium o Loss of kidney function means potassium excretion is impaired and hyperkalemia is a risk o Hypokalemia is a risk for people who receive continuous ambulatory peritoneal dialysis, take potassium-wasting diuretics, or who experience vomiting or diarrhea o At all CKD stages, potassium allowance is based on the individual’s serum potassium levels Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Nutrition therapy (cont’d) – Other vitamins and minerals o Specially formulated vitamin supplements o Deficiencies of water-soluble vitamins o Fat-soluble vitamins A and E have been shown to accumulate in CKD o Clients who are undergoing dialysis may develop a deficiency of zinc o IV iron for clients receiving hemodialysis Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Translating recommendations into meals – Diet for CKD is complex – “Choice” system, similar to the diabetic exchange system, may be used to help clients implement dietary restrictions

– Individualized meal plan – Selections can be severely limited Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Kidney Disease (CKD) (cont’d) • Diabetic kidney disease – Formerly known as diabetic nephropathy

– Risk factors for diabetic kidney disease (DKD) o Hyperglycemia, hypertension, and altered lipid levels – Nutrition therapy seeks to controls these risks Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question • What are the calorie recommendations for patients with chronic kidney disease? a. 40 cal/kg for adults under 60 years; 35 to 40 cal/ kg for those who are older b. 35 to 40 cal/kg for all adults c. 35 to 40 cal/kg for adults under 60 years; 30 to 35 cal/kg for those who are older d. 35 cal/kg for adults under 60 years; 30 cal/kg for those who are older Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer d. 35 cal/kg for adults under 60 years; 30 cal/kg for those who are older

Rationale: Calorie recommendations are: 35 cal/kg for adults under 60 years of age;

30 to 35 cal/kg for those who are older

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutrition Recommendation Guidelines for Diabetic Kidney Disease • Protein 0.8 g/kg • Sodium 2,300 mg/d • Lipids ≤30% calories from fat,