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NUTRITION IN RENAL DISEASES

ANATOMY:
2 Kidneys, 2 Ureters , Bladder, Urethra

Physiology:
1. Found along the posterior muscular wall of the abdominal cavity.
2. The left kidney is located slightly more superior than the right kidney
3. Bean shaped
4. EXCRETION OF WASTES
Kidney:
1. Nephron: Working unit of the kidney; Consists of:
1. Glomerulus: works like a sieve
2. Tubules: fluid reabsorbed or sent to bladder
Kidney Functions:
1. Regulates extracellular fluid & osmolarity, electrolyte concentrations, & acid-base balance -
Renin
2. Regulates Blood pressure - Renin
3. Excretes wastes – Urine Formation
4. Produces erythropoietin- RBC production
5. Converts vitamin D to active form
6. Increase calcium absorption - calcitriol
Composition of Urine:
1. A sterile Fluid Composed of:
1. Water (95%)
2. Nitrogen containing waste
1. Urea
2. Uric acid
3. Ammonia
4. creatinine
3. Electrolytes
Glomerular Filtration:
1. Water and Dissolved Substances
1. They move from the vascular system to the glomerulus
2. Then into Bowman’s capsule
2. Glomerular Filtrate is Composed of:
1. Water
2. Electrolytes
3. Waste products
4. Metabolic substrate
3. Glomerular Filtrate Measures Plasma Volume
1. It can be cleared of any given substrate within a certain time frame

4. Glomerular Filtration Rate (GFR)

1. Normal 125 mL/min or 180 L/24 hr filtered

2. Only 1.5 L (1-3 L) of urine excreted in 24 hr


Volume of Glomerular Filtrate Formed:

1. Depends on:
1. Number of glomeruli functioning at a time
2. Volume of blood passing through the glomeruli per minute
3. Effective of glomerular filtration pressure
2. Under normal conditions
1. About 700 mL of plasma flow through the kidneys per minute and 120 mL of fluid are
filtered into Bowman's capsule

Assessment of Renal Function:


1. Glomerular Filtration Rate (GFR)
1. = the volume of water filtered from the plasma per unit of time.
2. Gives a rough measure of the number of functioning nephrons
3. Normal GFR:
1. Men: 130 mL/min./1.73m2
2. Women: 120 mL/min./1.73m2
4. Cannot be measured directly, so we use creatinine and creatinine clearance to
estimate.
2. Creatinine (anhydride of creatine)
1. A naturally occurring amino acid, predominately found in skeletal muscle
2. Freely filtered in the glomerulus, excreted by the kidney and readily measured in the
plasma
3. As plasma creatinine increases, the GFR exponentially decreases.
4. Limitations to estimate GFR:
1. Patients with decrease in muscle mass, liver disease, malnutrition, advanced
age, may have low/normal creatinine despite underlying kidney disease
2. 15-20% of creatinine in the bloodstream is not filtered in glomerulus, but
secreted by renal tubules (giving overestimation of GFR)
3. Medications may artificially elevate creatinine:
1. Trimethroprim (Bactrim)
2. Cimetidine

1. Creatinine Clearance
1. Best way to estimate GFR
2. GFR = (creatinine clearance) x (body surface area in m2/1.73)
3. Ways to measure:
1. 24-hour urine creatinine:
1. Creatinine clearance = (Ucr x Uvol)/ plasma Cr
2. Cockcroft-Gault Equation:
1. (140 - age) x lean body weight [kg]
CrCl (mL/min) = ——————————————— x 0.85 if
Cr [mg/dL] x 72 female
2. Limitations: Based on white men with non-diabetes kidney disease
Kidney failure:
Acute Versus Chronic:
1. Acute
1. sudden onset
2. rapid reduction in urine output
3. Usually reversible
4. Tubular cell death and regeneration
2. Chronic
1. Progressive
2. Not reversible
3. Nephron loss
3. 75% of function can be lost before its noticeable
ACUTE RENAL FAILURE:
1. Function rapidly deteriorates
1. Reduced urine output
2. Build up of nitrogenous wastes
2. Mortality rates are high
3. Urine output in ARF:
4. Oliguria = daily urine output < 400 mL
5. Anuria =No urine production, probably time for dialysis

Causes:
1. Pre renal
1. Heart failure
2. Shock
3. Blood loss
2. Intra renal
1. Infections
2. Toxins
3. Drugs
4. Direct trauma
3. Post renal
1. Factors preventing excretion of urine
2. Urinary tract obstructions
4. Pre-renal =
1. vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure
2. cardiac failure, liver dysfunction, or septic shock
5. Intrinsic
1. Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins
6. Post-renal =
1. prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders
2. neurogenic bladder
3. bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and
fungus
Consequences:
1. Oliguria < than 400 mL urine/day
2. Sodium retention
3. Elevated potassium, phosphate, & magnesium
4. Edema
5. Uremia
1. BUN, creatinine & uric acid accumulate in blood
2. Fatigue, lethargy, confusion, headache, anorexia, metallic taste, Nausea & Vomiting,
diarrhea
Treatment of Acute Renal Failure
Goals for treatment:
1. To Treat underlying cause

2. To improve urine output

3. To correct electrolyte imbalance

Treat underlying cause


1. Blood pressure
2. Infections
3. Stop inciting medications
4. Nephrostomy tubes/ureteral stents if obstruction
5. Treat scleroderma renal crisis with ACE inhibitor
4. Hydration
5. Diuresis (Lasix)
6. Dialysis
7. Renal Transplant
Drug therapy for ARF:
1. Diuretics
2. Potassium exchange resins
3. Insulin, glucose
4. Bicarbonate
CHRONIC RENAL FAILURE:
1. Is a gradual & irreversible deterioration
2. Usually not diagnosed until 75% of function is lost
Causes:
3. Diabetic Nephropathy
4. Hypertension
5. Glomerulonephritis
6. HIV nephropathy
7. Reflux nephropathy in children
8. Polycystic kidney disease
9. Kidney infections & obstructions

CRF Symptoms:
1. Weakness 10. Peptic ulceration
2. Fatigue
3. Neuropathy 11. Diverticulosis
4. CHF
12. Anemia
5. Anorexia
6. Nausea 13. Jaundice
7. Vomiting
8. Seizure 14. Abnormal hemostasis

9. Constipation
Consequences of CKD:

1. Nephrons enlarge to compensate

2. Overburdened nephrons degenerate

3. End-stage renal disease occurs

4. Evaluation

1. Glomerular filtration rate (GFR)

2. Rate at which kidneys form filtrate


Electrolyte imbalances occur when
3. GFR becomes extremely low

4. Hormonal adaptations are inadequate

5. Intake of water & electrolytes are very restrictive or excessive

Renal osteodystrophy

6. Increased parathyroid hormone contributes to bone loss

Acidosis may develop

Uremic syndrome

7. Mental dysfunctions
8. Neuromuscular changes

9. Muscle cramping, twitching, restless leg syndrome

Protein energy malnutrition

Complications of Uremic Syndrome:

1. Impaired hormone synthesis

2. Impaired hormone degradation

3. Bleeding abnormalities

4. Increased cardiovascular disease risk

5. Reduced immunity

GOALS FOR TREATMENT FOR CKD:


1. Slow disease progression

2. Prevent symptoms

3. Correct electrolyte imbalances


DRUG THERAPY:

4. DIURETICS 8. SODIUM BICARBONATE

5. ANTI HYPERTENSIVES 9. CHOLESTEROL-LOWERING


MEDICATIONS
6. ERYTHROPOIETIN
10. ACTIVE VITAMIN D SUPPLEMENTS
7. PHOSPHATE BINDERS

11.
DIALYSIS:
1. Removes excess fluid & wastes from blood

2. Blood is circulated though a dialyzer

3. Blood is bathed by dialysate

4. Two types: Hemodialysis & peritoneal dialysis

Principle of dialysis:
1. Employs diffusion, osmosis, & ultrafiltration

2. If a substance is lower in dialysate, substance will diffuse out of the blood

3. If substance is higher in the dialysate, substance will diffuse into the blood

4. Ultrafiltration removes fluid from the blood


HEMODIALYSIS:
1. Lasts 3-4 hours

2. 3 times/week

3. Complications

1. Infections

2. Blood clotting

3. Hypotension

4. Muscle cramping

5. Headaches, weakness

6. Nausea & vomiting

7. Agitation

PERITONEAL DIALYSIS:

4. Vascular access not required

5. Fewer dietary restrictions


6. Can be scheduled when convenient

5. Acute failure

1. Continuous renal replacement therapy (CRRT)

TYPES OF ACCESS:
1. Temporary site

2. AV fistula

1. Surgeon constructs by combining an artery and a vein

2. 3 to 6 months to mature

3. AV graft

1. Man-made tube inserted by a surgeon to connect artery and vein

2. 2 to 6 weeks to mature

AV FISTULA & GRAFT


PERITONEAL DIALYSIS

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