LALALA - LALAϋ NUTRITIONAL MANAGEMENT OF RENAL DISEASES

DISEASE GOALS ENERGY PROTEIN VITAMINS/MINERALS FATS/FLUIDS Acute

Glomerulonephritis Due to the deposition of immune complexes in the

glomerulus SSx: hematuria, oliguria,

hypertension, edema, proteinuria

1. Reduce

nitrogen levels 2. Reduce

BP/edema 3. Spare CHON

for tissue repair 4. Improve renal

fx and prevent complications

5. Kids: avoid growth retardation

HIGH CALORIE

DIET (35kcal/kg BW) 60% CHO 30% Fat

RESTRICT!

CHON: 0.6g/kgBW

50% in the form

of high biologic value CHONS

Kids: 50% of RNI If with proteinuria:

replace the losses, please

(+) edema/HPN: restrict Na

intake to 2 – 3 g daily

Kids: 500 – 1000mg

(+) potassium retention: restrict K to 1g/day

If needed: Vitamin D3, Ca, Fe, multivitamins

Remember: 2NaK1 (TUNAKI)

2 – 3g Na, K 1g :D

Fluids

If edema is mild, no need for restriction.

Severe cases of edema: give 500ml for insensible losses

Chronic Glomerulonephritis

1. Prevent/treat uremia

2. Prevent/treat edema 3. Maintain

optimal nutrition state

MAINTAIN GOOD NUTRITIONAL STATUS (2000 –

3000kcal/day)

CHON: 40 – 60g/day Impending uremia:

30 – 40g or 0.5g/kgBW (HBV proteins) We don’t restrict CHONs

because in uremia there

is increased breakdown of CHON into glutamine

& glutamate

Protein restriction is NOT recommended

in CHON

malnutrition, neoplasm, &

infections

Kids with uremia: Vitamin D3 is needed

Promote growth &

appetite

Nephrotic Syndrome SSx: Heavy proteinuria

Hypoalbuminemia Anasarca/edema Hyperlipidemia/lipiduria

(low CHON triggers the body to use lipids for energy instead)

Try to remember the sx for each pathology

because it makes it so much easier to memorize the goals :D

1. Provide adequate calories to spare proteins

2. Reduce severity of edema

3. Improve serum albumin and

control malnutrition

4. Control lipidemia

HIGHER than HIGH CALORIE DIET! Adults: 50 –

60kcal/kgBW Kids: 60 – 100kcal/kgBW

Aim for a kcal:nitrogen ratio of

150:1 to prevent N wasting

1.0g/day of HBV CHONs for EACH gram of urinary

CHON loss (easy peasy, 1 is to 1 :D)

Kids: Just give them their RDA

(+) edema: start with a Na restriction of 500mg

When edema is gone: 1500mg/day to 2000 – 3000g/day (tip: same as

acute GN :D) K depletion due to diuretics

& steroids: give high K foods (banana, orange)

Ca chloride: 1 – 2g/day To prevent negative Ca balance, hypoCa, tetanic

convulsions w/ ACTH tx

Replace Zinc, Vit C, folacin

prn

Fat

30% of total calories (same as acute GN

again!) Use linoleic acid

(lowers LDL, raises HDL) and omega 3 fatty acids (lowers

TAGs by inhibiting LDL & HDL synthesis)

Acute Renal Failure Pathology: destruction of tubules which are

responsible for concentrating urine

Ssx: oliguria/anuria, azotemia (recent onset), decreased GFR

1. Maintain optimal nutritional status

2. Reduce accumulation of

uremic toxins 3. Correct fluid

electrolyte imbalance

4. Support tissue healing

5. Control infection

35 – 50kcal/kgABW To provide (+) nitrogen balance

under stress of ARF, to spare proteins

(+) vomiting & diarrhea: parenteral administration of

glucose, essential & NE amino acid solution (Aminosyn) =

reduces CHON catabolism & urea production

Giving CHO alone will only decrease CHON

breakdown by 50%:(

0.5 – 0.6g/kgABW (not less than 40g/day) Increase as GFR normalizes

(+) dialysis: 1 –

1.5g/kgABW/day

(-) dialysis: protein – free diet

Sodium

Anuric – oliguric

phase: 500 -1000mg/day

Diuretic phase:

replace losses based on urinary Na levels, edema and freq of

dialysis Potassium

Tissue destruction can cause K overload

AO phase:

1000mg/day

D phase: same as Na

Phosphorus & Ca: if

needed

Fluid & electrolytes

Intake = net body output

Assess fluid rqmt DAILY

Anuric – oliguric phase: replace output

+ 500ml from previous day

Diuretic phase:

large amounts of fluid

Fat

No modification

LALALA - LALAϋ Chronic Renal Failure Uremia (prolonged

azotemia + constellation of clinical signs & biochemical

abnormalities)

1. Maintain optimal NS &

stimulate px well – being

2. Provide adequate energy intake

3. Regulate CHON intake to

minimize uremic toxicity, prevent CHON

catabolism, provide for growth of kids, retard

progression of RF 4. Regulate fluid

intake to balance fluid output (regulate Na and

K) 5. Provide vitamin

& mineral supp

Adequate to maintain or achieve DBW and

prevent CHON catab = 35kcal/kgBW/day (if you’ll notice, it’s almost the same as energy rqmt in acute GN and ARF:D)

Kids: 100kcal/kgBW (ideal); 80kcal/kg

(realistic) HIGHLY

INDIVIDUALIZED! Stage 1 CRF:

No diet restrictions yet

but if w/ HPN – limit Na and caloric intake

Stage 2 CRF:

CHON & calorie,

Na, K, P restrictions – NOT necessary

Stage 3 CRF:

STRICT diet

modifications

Stage 4 CRF:

Nutrients strictly

monitored

Urea & nitrogen in blood: gauge of

severity of renal damage

RESTRICT! CHON: 0.55 – 0.60g/kgBW/day May slow down progression of CRF

Level of daily CHON intake may also be based on residual

renal function (creatinine clearance) * see box below

Kids: DO NOT reduce CHON below 1 –

1.3g/kgBW/day; at least 75% must be HBV

Advanced renal failure:

Na = 1 – 3g (40 – 130meq) + 1500 – 3000ml of fluids to maintain Na/water

balance If with severe Na wasting, increase intake to 6 – 8

g/day

K = should not exceed

70mEq (2730mg)/day Supplement water soluble

vitamins, include biotin

Cofactor in

carboxylation reactions

Calcitriol supp also

needed due to kidney failure

Increase Ca to 1 – 3

g/day

Restrict phosphorus

from 45 – 65mEq (700 – 1000mg/day)

Fluid & electrolytes

Optimal intake: 1500

– 2000ml/day Satisfactory: 500 – 700ml (2 – 3 cups)

Nephrolithiasis Characterized by renal

colic, hematuria, stone formation

1. Prevent recurrence in

calculi – prone px 2. Identify

predominant components and modify diet based

on it 3. Increase

secretion of salts, dilute urine -> increase fluid

volume to at elast 2L per 24 hours

Acid ash diet

Found in

cranberries, plums, prunes,

meat, bread Alkaline ash

Milk, fruit, veggies

Choice between the two will depend on stone composition

Ca oxalate stones:

Restrict Ca to

<1000mg

Normal Na intake (not

high); with thiazides

Fewer dairy products,

nuts, fish, green leafy veggies, peanut butter

More fiber (source of phytic acid)

Less vitamin D

Cystine stones:

Low cystine, methionine, cysteine

diet

CHON lessened, not

restricted too much

Usually hereditary

Alkalinize urine w/ D – penicillamine

Uric acid stones:

Result from purine

metab

Reduce high purine

foods (sardines)

Alkalinize urine with

citrate or bicarbonate

HIGH FLUID INTAKE! (8OZ

hourly while awake)

Patients on Dialysis 1. Prevent deficiency and

maintain good nutritional status

2. Control edema & electrolyte imbalance

K restriction HD:

30 – 35 kcal/kg DBW/day (weight maintenance).

25 – 30 (weight reduction),

40 – 50 (weight gain)

Assess ability to handle Na and

water frequently

Hemodialysis (HD)

Na: 2000 – 3000mg/day Fluid: 500 –

*Creatinine clearance & CHON intake 5 – 10ml/min = 15 – 25g of HBV CHON

10 – 15ml/min = 30g 15 – 20ml/min = 40g 20 – 30ml/min = 50g

LALALA - LALAϋ 3. Prevent/retard dev’t of renal

osteodystrophy 4. Enable px to

eat a palatable attractive diet

PD:

25 –

35kcal/kgDBW/day (maintenance)

30 – 50 kcal/kgDBW/day

(repletion)

20 – 25 (reduction)

35 if (+) DM

Ca, Phosphorus, Vitamin

D

Control intake to

avoid aggravation of disease (hypoparathyroidism,

phosphate retention, hypocalcemia)

Start supplementation

of Ca early to prevent hyperparathyroidism

Phosphate intake

lowered (use of PO4 binding resins –

Amphogel Calcium

HD: 1000 – 1800mg/day PD: same as for hemodialysis

Phosphorus HD: <17 mEq or 800 –

1200mg/day; keep serum level at max of 4 – 6mg/100ml

PD: < less than hemodialysis; ~1200mg/day

Keep serum level at max of 6mg/100ml

Vitamin D Give when hypocalemia is

severe or causing osteomalacia

Phosphate binders:

impt during admin of large doses of Vit D

Routine drug is available as calcitriol (Rocaltrol)

Give vitamin supplements!

750ml/day + daily urine output (~ 750

– 1500ml/day) Peritioneal dialysis

(PD) Na: individualized based on BP &

weight Fluid: ~ 2000 – 3000ml/day for

continuous dialysis; if intermittent: same as for hemodialysis