Download Renal failure Advanced diet therapy

Renal Disorders: nutritional
therapy aspects
A Norouzy
Assistant Professor in Clinical Nutrition
Mashad Medical School
Anatomy of the Kidney
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Creatinine
BUN
Urea
Urine output
Fluid load
Urine analysis (U/A)
GFR
Chronic Renal Failure
A. Definitions
1. Azotemia - elevated blood urea nitrogen (BUN
>28mg/dL) and creatinine (Cr>1.5mg/dL)
2. Uremia - azotemia with symptoms or signs of renal
failure
3. End Stage Renal Disease (ESRD) - uremia requiring
transplantation or dialysis
4. Chronic Renal Failure (CRF) - irreversible kidney
dysfunction with azotemia >3 months
5. Creatinine Clearance (CCr) - the rate of filtration of
creatinine by the kidney (GFR marker)
6. Glomerular Filtration Rate (GFR) - the total rate of
filtration of blood by the kidney
Acute Renal Failure
Acute Renal Failure
Definition
• Acute decrement in GFR/creatinine
• May heal partially or completely or progress
to more severe renal insufficiency, including
end-stage renal disease
Acute Renal Failure
Classification
• Pre-renal (functional)
• Renal (structural)
• Post-renal (obstruction)
Acute Renal Failure
Pre-renal Causes
• Intravascular volume depletion
– Hemorrhage
– Sodium depletion
• Redistribution of ECF
– “Third space” accumulation
– Edematous disorders
• Drugs
Acute Tubular Necrosis
Classification
• Ischemic
• Nephrotoxic
Acute Renal Failure
Nephrotoxic ATN
• Endogenous Toxins
– Heme pigments (myoglobin, hemoglobin)
– Myeloma light chains
• Exogenous Toxins
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Antibiotics (e.g., aminoglycosides, amphotericin B)
Radiocontrast agents
Heavy metals (e.g., cis-platinum, mercury)
Poisons (e.g., ethylene glycol)
Acute Renal Failure
Post-renal Causes
• Intra-renal Obstruction
– Acute uric acid nephropathy
– Drugs (e.g., acyclovir)
• Extra-renal Obstruction
– Renal pelvis or ureter (e.g., stones, clots,
tumors, papillary necrosis, retroperitoneal
fibrosis)
– Bladder (e.g., BPH, neuropathic bladder)
– Urethra (e.g., stricture)
Acute Renal Failure
Urine Volume (1)
• Anuria (< 100 ml/24h)
– Acute bilateral arterial or venous occlusion
– Bilateral cortical necrosis
– Acute necrotizing glomerulonephritis
– Obstruction (complete)
– ATN (very rare)
Acute Renal Failure
Urine Volume (2)
• Oliguria (100-500 ml/24h)
– Pre-renal azotemia
– ATN
• Non-Oliguria (> 500 ml/24h)
– ATN
– Obstruction (partial)
CHRONIC RENAL FAILURE
Etiology
1. Episodes of ARF (usually acute tubular
necrosis) often lead, eventually, to CRF
2. Over time, combinations of acute renal insults
are additive and lead to CRF
3. The definition of CRF requires that at least 3
months of renal failure have occurred
‫نارسايي کليوي قبل از دياليز‬
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‫انرژي‪ 30-35 :‬کيلو کالري به ازاي هر کيلو وزن بدن‬
‫پروتئين‪ 0.6-0.8 :‬کيلو کالري به ازاي هر کيلو وزن‬
‫بدن‬
‫فسفر ‪ 600-900‬ميلي گرم در روز‬
‫سديم‪ 1-3 :‬گرم در روز‬
‫مايعات‪ :‬آزاد‬
End-Stage Renal Disease
• Occurs when patient’s GFR decreases
to 15 ml/min
• Irreversible damage to most nephrons
• Dialysis or transplant are only options
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• Electrolyte Abnormalities
1. Excretion of Na+ is initially increased, probably due to
natriuretic factors
2. As glomerular filtration rate (GFR) falls, Na rises
a. Maintain volume until GFR <10-20mL/min, then
edema
b. Cannot conserve Na+ when GFR <25mL/min, and Na
rises with falling GFR
3. Tubular K+ secretion is decreased
.
Loss of urine diluting and concentrating
abilities
a. Osmotic diuresis due to high solute
concentration for each functioning nephron
b. Reduce urinary output only by reducing
solute excretion
c. Major solutes are salt and protein, so these
should be decreased
Bone Metabolism
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↓GFR leads to ↑ phosphate ↓ calcium + acidosis
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Decreased dihydroxy-vitamin D production
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Low vitamin D causes poor calcium absorption and
hyperparathyroidism (high PTH)
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Increased PTH maintains normal serum Ca2+ and
PO42- until GFR <30mL/min
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Chronic hyperparathyroidism and bone buffering of
acids leads to severe osteoporosis
Other abnormalities
a. Slight hypermagnesemia with inability to
excrete high magnesium loads
b. Uric acid retention occurs with GFR
<40mL/min
c. Vitamin D conversion to dihydroxy-Vitamin
D is severely decreased
d. Erythropoietin (EPO) levels fall and anemia
develops
• Uremic Syndrome
1.Fever, Malaise
2.Anorexia, Nausea
3.Mild neural dysfunction
4.Uremic pruritus
–Anemia
• Due to reduced erythropoietin production by kidney
• Occurs when creatinine rises to >2.5-3mg/dL
• Anemia management: Hct goal @ 33% (Hb 11-13
g/dL)
– Hypertension
a. Blood pressure control is very important to
slowing progression of renal failure
b. About 30% of end-stage renal disease (ESRD)
is related to hypertension
c. Overall risk of CRF with creatinine >2.0mg/dL
is ~2X in five years with HTN
d. Patients with grade IV (severe) HTN have 22X
increased risk vs. normal for CRF
e. Patients with HTN and albuminuria >1gm/day,
blacks, diabetics have higher ESRD risk
–Pre-Dialysis Treatment
• Maintain normal electrolytes
• Potassium, calcium, phosphate are major
electrolytes affected in CRF
• Diuretics (eg. furosemide) may help maintain
potassium in normal range
• Renal diet including high calcium and low
phosphate
Nutrition Therapy Objectives
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Reduce protein breakdown
Avoid dehydration or excess hydration
Correct acidosis
Correct electrolyte imbalances
Control fluid and electrolyte losses
Maintain optimal nutritional status
Maintain appetite, morale
Control complications of hypertension,
bone pain, nervous system involvement
• Slow rate of renal failure
Nutrition Therapy Principles
• Provide enough protein therapy to
maintain tissue integrity while avoiding
excess
• Provide amino acid supplements for
protein supplementation
• Reserve protein for tissue synthesis by
ensuring adequate carbohydrates and fats
• Maintain adequate urine volume with
water
• Supplement diet with multivitamin
Slide 29
Hemodialysis Patient:
Objectives for Diet
• Maintain protein and energy balance
• Prevent dehydration or fluid overload
• Maintain normal serum potassium and
sodium levels
• Maintain acceptable phosphate and
calcium levels
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Hemodialysis Patient:
Other Dietary Concerns
• Avoid protein-energy malnutrition via
careful calculation of protein allowance
• Maintain body mass index within upper
50th percentile via generous amounts of
carbohydrates and some fats
• Fluid intake: 1000 ml/day, plus amount
equal to urine output
• Limit sodium: 1000-3000 mg/day
• Limit potassium: 1500-3000 mg/day
• Supplement of water soluble vitamins
Peritoneal Dialysis
• Performed at home
• Patient introduces dialysate solution
directly into peritoneal cavity 4-5
times/day
• Surgical insertion of permanent catheter
is required
• Disposable bag containing dialysate
solution is attached to catheter
• Diet is more liberal than with
hemodialysis
Peritoneal Dialysis:
Nutritional Therapy
• Increase protein intake to 1.2-1.5 g/kg
body weight
• Limit phosphorus to 1200-1500 mg/day
• Increase potassium via wide variety of
fruits and vegetables
• Encourage liberal fluid intake
• Avoid sweets and fats
• Maintain lean body weight
Slide 33
‫حمايتهای تغذيه ای در بيماران دياليزی‬
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‫نگهداری سطح پتاسيم درحد طبيعی‪ 3.5-4.5 :‬ميلی‬
‫گرم‬
‫نگهداری سطح سديم درحد طبيعی‪ 135-145 :‬ميلی‬
‫اکيواالن‬
‫نگهداری سطح فسفر درحد طبيعی‪ 3.3-5.5 :‬ميلی گرم‬
‫نگهداری سطح پتاسيم درحد طبيعی‪ :‬زير ‪ 200‬ميلی‬
‫گرم‬
‫شروع کار!‬
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‫دوری کردن از مصرف غذاهای آماده‪ ،‬گوشتهای‬
‫پروسس شده‪ ،‬انواع پنير و فست فودها‬
‫کاهش دريافت پروتئين مهم است‪.‬‬
‫کالری مصرفی بايد در طول روز تقسيم شود‪.‬‬
‫مصرف مايعات محدود به ‪ 950‬ميلی ليتر در روز‬
‫شود‪.‬‬
‫• هدف اصلی‪:‬‬
‫– بهبود کيفيت زندگی فرد‬
‫– برگشت سريعتر به زندگی طبيعی‬
‫– برگشته به کار‬
‫بيماران همودياليزي‬
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‫پيشگيري از سوء تغذيه‬
‫انرژي به ميزان ‪ 30-35‬کيلوکالري به ازاي هر کيلوگرم در‬
‫روز‬
‫پروتئين به ميزان ‪ 1.1-1.4‬گرم به ازاي هر کيلوگرم در روز‬
‫تنظيم ميزان فسفر و کلسيم رژيم بر اساس سطح پالسمايي آنها‬
‫آب ‪ 1000‬ميلي ليتر در روز به اضافه ادرار‬
‫سديم ‪ 1-3‬گرم در روز (نمک ‪3-5‬گرم در روز)‬
‫پتاسيم ‪ 1500-3000‬ميلي گرم در روز‬
‫چگونه فسفر را در رژيم غذايی محدود کنيم؟‬
‫• يک وعده لبنيات در روز‪:‬‬
‫– شير ‪ 200‬ميلی لير‬
‫– پنير ‪ 60‬گرم‬
‫– ماست کم چرب ‪ 200‬گرم‬
‫– بستنی ليوانی متوسط‬
‫چگونه فسفر را در رژيم غذايی محدود کنيم؟‬
‫• مغزها‪ :‬نصف ليوان در روز‬
‫• جايگزينی شير سويا با شير معمولی‬
‫• مصرف پاپ کورن به جای مغزها‬
‫• عالئم فسفر باال‪:‬‬
‫– دردهای استخوانی‬
‫– زخم اندامها‬
‫– اختالل جريان خون در اندامها‬
‫چگونه پتاسيم را در رژيم غذايی محدود کنيم؟‬
‫• محدود کردن غذاهای پر پتاسيم به يک وعده در روز‪:‬‬
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‫موز‪ :‬يک عدد‬
‫شليل‪ :‬يک عدد‬
‫پرتقال‪ :‬يک عدد‬
‫کيوی‪ :‬يک عدد‬
‫طالبی‪ :‬يک چهارم‬
‫سيب زمينی‪ 10 :‬عدد سيب زمينی سرخ شده‬
‫اسفناج‪ :‬نصف ليوان پخته‬
‫گوجه فرنگی‪ 80 :‬گرم‬
‫چگونه پتاسيم را در رژيم غذايی محدود کنيم؟‬
‫• محدود کردن غذاهای با پتاسيم متوسط به ‪2‬وعده در روز‪:‬‬
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‫سيب‪ 2 :‬عدد‬
‫هلو‪ 2 :‬عدد‬
‫گيالس‪ :‬نصف ليوان در روز‬
‫گالبی‪ 2 :‬عدد‬
‫آلو‪4 :‬عدد‬
‫مغزها‪ 50 :‬گرم‬
‫قارچ‪ :‬يک ليوان‬
‫باميه‪ :‬يک ليوان‬
‫چگونه پتاسيم را در رژيم غذايی محدود کنيم؟‬
‫• محدود کردن غذاهای با پتاسيم کم به ‪ 3‬وعده در روز‪:‬‬
‫– انگور‪ :‬يک خوشه متوسط‬
‫– توت فرنگی‪ 150 :‬گرم‬
‫– نارنگی‪ 3 :‬عدد‬
‫– کاهو‪ 3 :‬ليوان‬
‫– کلم‪ 1.5 :‬ليوان‬
‫– پياز‪ 1.5 :‬ليوان‬
‫چگونه پتاسيم را در رژيم غذايی محدود کنيم؟‬
‫• غذاهای پر پتاسيم که بهتر است مصرف نشود‪:‬‬
‫– موز‬
‫– کيوی‬
‫– ميوه های خشک شده‪ :‬زردآلو‪ ،‬آلبالو خشک‪ ،‬هلوی خشک‪،‬‬
‫توت خشک‬
‫– شکالت‬
‫مصرف سديم‬
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‫محدود کردن به ‪ 5‬گرم در روز‬
‫اهميت در فشارخون و پيشگيری از بيماريهای عروقی‬
‫مغزی و قلبی‬
‫نمک مخفی در غذاها‬
‫جايگزين کردن بی ضرر سديم با فلفل و ساير ادويه‬
‫جات‬
‫نمکهای کم سديم‪ :‬مشکل پتاسيم باال‬
‫مصرف پروتئين‬
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‫از دست دادن پروتئين در دياليت‬
‫اهميت آن در کاهش وزن خود به خودی وزن‬
‫محدوديت مصرف غذاهای پرپروتئين (پروتئين گياهی‬
‫و حيوانی) به ‪ 240-300‬گرم در روز‬
‫حداقل ‪ %50‬از پروتئين با کيفيت‬
‫استفاده از مکملهای پروتئينی يا آمينوپالسمال در‬
‫بيماران با الغری شديد‬
‫• مصرف حداقل ‪ %50‬پروتئين مورد نياز روزانه‬
‫بالفاصله بعد از دياليز‬
‫• اهميت ورزش و فعاليت بدنی‬
‫ويتامين د‬
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‫کاهش توليد ويتامين د‬
‫فرم فعال ويتامين د در کليه ها ساخته می شود‪.‬‬
‫اهميت ويتامين د در جذب کلسيم از روده ها‬
‫مصرف فرم ارگوکلسيفرول ‪vitamin D2‬‬
‫چربيها‬
‫• محدوديت مصرف انواع روغن های بويژه روغن زرد‬
‫• افزايش مصرف فيبر غذايی به ‪ 20‬گرم در روز‬
‫مکملهای ويتامينی‬
‫• محدوديت مصرف ويتامين ث به ‪ 60-100‬گرم در‬
‫روز‬
‫• احتمال سنگ سازی با مکملهای زياد ويتامينی‬
‫• مصرف روی و کلسيم و ويتامين د ممانعتی ندارد‪.‬‬
‫آنمی و کمبود آهن‬
‫• اهميت نوع آهن‬
‫• آهن تزريقی يا خوراکی‬
‫غذاهايی که بايد دوری کرد؟‬
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‫موز‬
‫پنير‬
‫شکالت‬
‫نارگيل‬
‫ميوه های خشک‬
‫شير‬
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‫کنترل تغذيه ای ديابت‬
‫کنترل وزن‬
‫کنترل فشارخون‬
‫بررسی وضعيت ويتامين ها و ساير مواد معدنی‬
Kidney Stones
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Calcium Stones
• 70%-80% of kidney stones are composed of
calcium oxalate
• Almost half result from genetic predisposition
• Other causes:
– Excess calcium in blood (hypercalcemia) or urine
(hypercalciuria)
– Excess oxalate in urine (hyperoxaluria)
– Low levels of citrate in urine (hypocitraturia)
– Infection
Examples of Food Sources of
Oxalates
• Fruits: berries, currants, figs, fruit cocktail,
plums, rhubarb, tangerines
• Vegetables: baked/green/wax beans,
beet/collard greens, beets, celery, eggplant,
endive, kale, okra, green peppers, spinach,
sweet potatoes, tomatoes
• Nuts: almonds, cashews, peanuts/peanut butter
• Beverages: cocoa, draft beer, tea
• Other: tofu, wheat germ
Struvite Stones
• Composed of magnesium ammonium
phosphate
• Mainly caused by urinary tract infections
rather than specific nutrient
• No diet therapy is involved
• Usually removed surgically
Other Stones
• Cystine stones
– Caused by genetic metabolic defect
– Occur rarely
• Xanthine stones
– Associated with treatment for gout and
family history of gout
– Occur rarely
Kidney Stones: Symptoms and
Treatment
• Clinical symptoms: severe pain, other urinary
symptoms, general weakness, and fever
• Several considerations for treatment
– Fluid intake to prevent accumulation of materials
– Dietary control of stone constituents
– Achievement of desired pH of urine via medication
– Use of binding agents to prevent absorption of
stone elements
– Drug therapy in combination with diet therapy
Nutrition Therapy: Calcium Stones
• Low-calcium diet (approx. 400 mg/day)
recommended for those with supersaturation of
calcium in the urine and who are not at risk for
bone loss
• If stone is calcium phosphate, sources of
phosphorus (meats, legumes, nuts) are
controlled
• Fluid intake increased
• Sodium intake decreased
• Fiber foods high in phytates increased
Low-Calcium Diet
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Nutrition Therapy:
Uric Acid Stones
• Low-purine diet sometimes
recommended
• Avoid:
– Organ meats
– Alcohol
– Anchovies, sardines
– Yeast
– Legumes, mushrooms, spinach,
asparagus, cauliflower
– Poultry
Nutrition Therapy:
Cystine Stones
• Low-methionine diet (essentially a lowprotein diet) sometimes recommended
• In children, a regular diet to support
growth is recommended
• Medical drug therapy is used to control
infection or produce more alkaline urine
General Dietary Principles:
Kidney Stones
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