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Williams' Basic Nutrition & Diet
Therapy
Chapter 21
Kidney Disease
Copyright © 2013 Mosby, Inc., an imprint of Elsevier In...
Lesson 21.1: Kidney Anatomy,
Physiology, and Disease
 Kidney disease interferes with the normal capacity of
nephrons to f...
Introduction (p. 425)
 100,000 Americans diagnosed with end-stage renal
disease each year
 84,000 die per year
 Reduced...
Basic Structure and Function of
the Kidneys (p. 425)
 Kidneys filter about 1.2 L of fluid per minute
 Structures
 Nephr...
Basic Structure and Function of
the Kidneys (cont’d) (p. 427)
5Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. A...
Tubules (p. 426)
 Proximal tubule: reabsorbs needed nutrients and
returns them to blood
 Loop of Henle: exchanges sodium...
Function (p. 427)
 Excretory and regulatory functions
 Filtration: removes most particles from blood
except proteins and...
Endocrine Functions (p. 428)
 Renin secretion: maintains hormonal control of body
water balance
 Erythropoietin secretio...
Disease Process and Dietary
Considerations (p. 428)
 General causes of kidney disease
 Infection and obstruction: bladde...
General Causes of Kidney
Disease (p. 428)
 Risk factors
 Diabetes, hypertension, CVD
 Older than 60, smoke, obese
 Fam...
Case Study
 Mrs. Hendricks is a 65-year-old female who has poor
glycemic control with her Type 2 diabetes of 32
years, hy...
Case Study (cont’d)
 What are Mrs. Hendrick’s risk factors for chronic
kidney disease (CKD)?
12Copyright © 2013 Mosby, In...
Case Study (cont’d)
 What clinical assessment parameters would be
useful to find out from Mrs. Hendricks?
13Copyright © 2...
Medical Nutrition Therapy in
Kidney Disease (p. 429)
 Based on the nature of the disease process
and individual responses...
Nephron Diseases (p. 429)
 Acute glomerulonephritis or nephritic
syndrome
 Disease process: affects glomeruli
 Clinical...
Nephrotic Syndrome (Nephrosis)
(p. 430)
 Disease process: nephron tissue damage allows
protein to pass into tubule
 Clin...
Nephrotic Syndrome (Nephrosis)
(cont’d) (p. 430)
 Medical nutrition therapy:
 Protein: moderate
 Energy: adequate to su...
Lesson 21.2: Treatment of
Kidney Disease
 The progressive degeneration of chronic kidney
disease requires dialysis treatm...
Kidney Failure (p. 431)
 Acute kidney injury
 Disease process
• Prerenal: inadequate blood flow to kidneys and
subsequen...
Acute Kidney Injury (p. 431)
 Clinical symptoms: RIFLE classification
system assesses severity of:
 Risk
 Injury
 Fail...
Acute Kidney Injury (cont’d)
(p. 431)
 Medical nutrition therapy
 Basic objective: improve or maintain nutrition
status
...
Chronic Kidney Disease (CKD)
(p. 432)
 Disease process:
 Progressive breakdown of kidney tissue
 Most often results fro...
Clinical Symptoms (p. 433)
 Water balance: large amounts of dilute urine
 Electrolyte balance: metabolic acidosis
 Nitr...
General Signs and Symptoms
(p. 433)
 Progressive weakness
 Shortness of breath
 General lethargy
 Fatigue
 Possible t...
Medical Nutrition Therapy
(p. 433)
 Basic objectives: monitor at regular intervals
 Principles
 Protein: generally limi...
Case Study (cont’d)
 Mrs. Hendricks is in what stage of chronic kidney
disease?
26Copyright © 2013 Mosby, Inc., an imprin...
Case Study (cont’d)
 Outline appropriate medical nutrition therapy plan of
care for Mrs. Hendricks.
27Copyright © 2013 Mo...
End-Stage Renal Disease
(p. 434)
 Disease process
 Patient, family, physician face life-support
decisions
 Irreversible...
Hemodialysis (p. 434)
 Artificial kidney machine removes toxins and
restores metabolites and nutrients
 Three to six tre...
Peritoneal Dialysis (p. 437)
 About 6% of patients
 Exchange of fluids occurs within the body,
allows mobility
 Medical...
Peritoneal Dialysis (cont’d)
(p. 437)
31Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Transplantation (p. 438)
 Improves quality of life and survival
 More cost effective than maintenance dialysis
 Waiting...
Transplantation (cont’d) (p. 439)
 Transplantation
 Complications: bone disorders, malnutrition,
anemia, hormonal and bl...
Transplantation (cont’d) (p. 439)
 Osteodystrophy
 Bone disease and disorders common with CKD
 Decreased activation of ...
Kidney Stone Disease (p. 442)
 Basic cause is unknown
 Factors relating to urine or urinary tract
environment contribute...
Calcium Stones (p. 442)
 Most common type: 80% of cases
 High levels of urinary oxalate
 Long-term megadosing of vitami...
Struvite Stones (p. 442)
 10% of all stones
 Caused primarily by urinary tract infection
 No diet therapy
 Usually sur...
Uric Acid Stones (p. 443)
 Caused by impairment of purine metabolism
with some diseases
 Account for 9% of stones
 Othe...
Clinical Symptoms and Medical
Nutrition Therapy (p. 443)
 Clinical symptoms
 Severe pain
 Urinary symptoms
 Weakness, ...
Objectives Specific to Type of
Stone (p. 444)
 Calcium stones: reduce dietary intake of stone
constituents, consider fibe...
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  • In one survey, fewer than 6% of individuals with reduced kidney function were aware of their condition.
  • Specific substances are reabsorbed and secreted by the four parts of the tubules.
  • What is the glomerular filtration rate? (The rate at which blood is filtered through the glomerulus)
  • The concentrated urine usually amounts to 1% or less of the filtered fluid.
  • At birth, each person has far more nephrons than are actually needed.
  • Renin initiates the renin-angiotensin-aldosterone system.Parathyroid hormone activates vitamin D.
  • Agents that are toxic to the kidneys are said to be nephrotoxic.
  • Can a person born with only one kidney lead a healthy life without treatment? (Yes. Because of the abundance of nephrons at birth, people born with one kidney often are unaware of their condition and lead full lives.)
  • Mrs. Hendricks is a 65-year-old female who has poor glycemic control with her Type 2 diabetes of 32 years, hypertension, and smokes 1 pack of cigarettes per day.  Her most recent glomerular filtration rate is 22 mL/min.
  • Risk factors for CKD:Older ageRacePoor glycemic control/diabetesHypertensionSmokerDecreased glomerular filtration rate
  • Some clinical symptoms might include:Polyuria/oliguria/anuria, electrolyte imbalances, nitrogen retention, anemia, hypertension, azotemia, weakness, shortness of breath, fatigue, thirst, appetite loss, bleeding, muscular twitching
  • When a patient is being treated with dialysis, working closely with an RD for customized nutrition therapy is especially important.
  • Glomerulonephritis is one of the three most common causes of end-stage renal disease.
  • With nephrosis, both filtration and reabsorption functions of the nephron are disrupted.
  • The primary goals of nutrition therapy are to control major symptoms and replace nutrients lost in the urine.
  • Acute renal failure presents a life-threatening situation.
  • The major sign of acute kidney injury is an increase in serum creatinine and oliguria.
  • Enteral or parenteral nutrition may become necessary.Medical nutrition therapy may vary greatly, depending on the patient.
  • Some risk factors are modifiable, including control of blood pressure and smoking.
  • Anemia results because the kidneys cannot perform their normal function of stimulating RBC production through erythropoietin.
  • Nervous system involvement may cause muscular twitching, burning sensations in the extremities, or convulsions.
  • Some recommendations vary depending on whether the patient is receiving dialysis.
  • Mrs. Hendricks is in stage 4: Severely decreased GFR 15 to 29 mL/min. Mrs. Hendrick’s is at 22 mL/min.
  • GoalsReduce protein breakdownAvoid dehydration or excess hydrationCorrect acidosisCorrect electrolyte imbalancesControl fluid and electrolyte lossesMaintain optimal nutritional statusMaintain appetite and moraleControl complications of hypertension, bone pain, nervous system involvementSlow rate of renal failurePrinciplesProvide enough protein therapy to maintain tissue integrity while avoiding excessProvide amino acid supplements for protein supplementation as necessaryReserve protein for tissue synthesis by ensuring adequate carbohydrates and fatsMaintain adequate urine volume with water(Possibly) restrict sodium, phosphate, calcium as necessarySupplement diet with multivitamin as necessary
  • Dialysis is the chief treatment for end-stage renal disease.
  • Medical nutrition therapy involves registered dietitians specializing in renal care.
  • The diet is slightly more liberal for the patient receiving peritoneal dialysis.
  • Continuous ambulatory peritoneal dialysis.
  • Medical nutrition therapy for patients awaiting kidney transplantation is highly individualized.
  • Nutrition support for kidney transplantation patients is highly individualized.
  • Patients with any level of kidney dysfunction should be evaluated for bone disease.
  • Review Box 21-2 for the risk factors for kidney stone development.
  • It is a common error to limit calcium intake in persons who form calcium oxalate stones.
  • These are often called “infection stones.”
  • Uric acid stones may occur with the rapid tissue breakdown during wasting disease or with diarrheal illness, diabetes, obesity and metabolic syndrome.
  • A large fluid intake helps to dilute urine and prevent the accumulation of materials that form stones.
  • All of these approaches include the goal of reducing the intake of the stone constituent.
  • Transcript of "Chapter 021"

    1. 1. Williams' Basic Nutrition & Diet Therapy Chapter 21 Kidney Disease Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 1 14th Edition
    2. 2. Lesson 21.1: Kidney Anatomy, Physiology, and Disease  Kidney disease interferes with the normal capacity of nephrons to filter waste products of metabolism.  Short-term kidney disease requires basic nutrition support for healing rather than dietary restriction. 2Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    3. 3. Introduction (p. 425)  100,000 Americans diagnosed with end-stage renal disease each year  84,000 die per year  Reduced kidney function often undiagnosed  Requires extensive medical nutrition therapy  Dialysis extends lives but carries high costs 3Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    4. 4. Basic Structure and Function of the Kidneys (p. 425)  Kidneys filter about 1.2 L of fluid per minute  Structures  Nephron • Glomurulus: cluster of capillaries filters the blood • Tubules: carries filtered fluid to kidney medulla 4Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    5. 5. Basic Structure and Function of the Kidneys (cont’d) (p. 427) 5Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    6. 6. Tubules (p. 426)  Proximal tubule: reabsorbs needed nutrients and returns them to blood  Loop of Henle: exchanges sodium, chloride, water  Distal tubule: secretes hydrogen ions as needed  Collecting tubule: produces concentrated urine 6Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    7. 7. Function (p. 427)  Excretory and regulatory functions  Filtration: removes most particles from blood except proteins and RBCs  Reabsorption: substances body needs are reabsorbed and returned to blood  Secretion: additional hydrogen ions secreted as needed to maintain acid-base balance  Excretion: waste materials excreted in concentrated urine 7Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    8. 8. Endocrine Functions (p. 428)  Renin secretion: maintains hormonal control of body water balance  Erythropoietin secretion: stimulate RBC production within bone marrow  Vitamin D activation: converts inactive form to final active vitamin D 8Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    9. 9. Disease Process and Dietary Considerations (p. 428)  General causes of kidney disease  Infection and obstruction: bladder infections, kidney stones  Damage from other diseases: diabetes mellitus, hypertension  Toxins: environmental agents, animal venom, certain plants, heavy metals, drugs  Genetic or congenital defects: cystic diseases, congenital abnormalities 9Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    10. 10. General Causes of Kidney Disease (p. 428)  Risk factors  Diabetes, hypertension, CVD  Older than 60, smoke, obese  Family history of kidney disease 10Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    11. 11. Case Study  Mrs. Hendricks is a 65-year-old female who has poor glycemic control with her Type 2 diabetes of 32 years, hypertension, and smokes 1 pack of cigarettes per day. Her most recent glomerular filtration rate is 22 mL/min. 11Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    12. 12. Case Study (cont’d)  What are Mrs. Hendrick’s risk factors for chronic kidney disease (CKD)? 12Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    13. 13. Case Study (cont’d)  What clinical assessment parameters would be useful to find out from Mrs. Hendricks? 13Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    14. 14. Medical Nutrition Therapy in Kidney Disease (p. 429)  Based on the nature of the disease process and individual responses  Length of disease: acute or chronic • Long term: more specific nutrient modifications  Degree of impaired renal function • Extensive: extensive nutrition therapy required  Individual clinical symptoms 14Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    15. 15. Nephron Diseases (p. 429)  Acute glomerulonephritis or nephritic syndrome  Disease process: affects glomeruli  Clinical symptoms: hematuria, proteinuria, possible edema, mild hypertension  Medical nutrition therapy: diet modifications usually not crucial 15Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    16. 16. Nephrotic Syndrome (Nephrosis) (p. 430)  Disease process: nephron tissue damage allows protein to pass into tubule  Clinical symptoms: hypoalbuminemia, edema, ascites, distended abdomen, reduced plasma protein level 16Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    17. 17. Nephrotic Syndrome (Nephrosis) (cont’d) (p. 430)  Medical nutrition therapy:  Protein: moderate  Energy: adequate to support nutrition status  Sodium, potassium: restricted and monitored  Calcium, phosphorus: 1 to 1.5 g/day calcium, maximum 12 mg/day phosphorus  Fluid: restricted according to output and losses 17Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    18. 18. Lesson 21.2: Treatment of Kidney Disease  The progressive degeneration of chronic kidney disease requires dialysis treatment and nutrient modification according to individual disease status.  Current therapy for kidney stones depends more on basic nutrition and health support for medical treatment than on major food and nutrient restrictions. 18Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    19. 19. Kidney Failure (p. 431)  Acute kidney injury  Disease process • Prerenal: inadequate blood flow to kidneys and subsequent reduced GFR • Intrinsic: damage to a part of the kidney • Postrenal obstruction: obstruction of urine flow 19Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    20. 20. Acute Kidney Injury (p. 431)  Clinical symptoms: RIFLE classification system assesses severity of:  Risk  Injury  Failure  Loss  End-stage kidney disease 20Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    21. 21. Acute Kidney Injury (cont’d) (p. 431)  Medical nutrition therapy  Basic objective: improve or maintain nutrition status  Principle: prevent protein catabolism, electrolyte and hydration disturbance, acidosis, uremic toxicity 21Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    22. 22. Chronic Kidney Disease (CKD) (p. 432)  Disease process:  Progressive breakdown of kidney tissue  Most often results from • Primary glomerular disease • Metabolic diseases with kidney involvement • Inherited diseases • Other causes: immune diseases, obstruction, infection, hypertension 22Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    23. 23. Clinical Symptoms (p. 433)  Water balance: large amounts of dilute urine  Electrolyte balance: metabolic acidosis  Nitrogen retention  Anemia  Hypertension  Azotemia 23Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    24. 24. General Signs and Symptoms (p. 433)  Progressive weakness  Shortness of breath  General lethargy  Fatigue  Possible thirst, anorexia, weight loss, diarrhea, vomiting 24Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    25. 25. Medical Nutrition Therapy (p. 433)  Basic objectives: monitor at regular intervals  Principles  Protein: generally limited to .0 to 0.8 g/kg body weight  Energy: 35 kcal/day for those under 60 with GFR less than 25 ml/min  Sodium/potassium: may be restricted  Phosphorus/calcium: phosphorus may be restricted, calcium 1.0 to 1.5 g/day  Vitamins/minerals: help patients meet needs for B-complex vitamins and vitamin C  Fluid: intake balanced with output 25Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    26. 26. Case Study (cont’d)  Mrs. Hendricks is in what stage of chronic kidney disease? 26Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    27. 27. Case Study (cont’d)  Outline appropriate medical nutrition therapy plan of care for Mrs. Hendricks. 27Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    28. 28. End-Stage Renal Disease (p. 434)  Disease process  Patient, family, physician face life-support decisions  Irreversible damage to majority of nephrons  Options are long-term dialysis for kidney transplant 28Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    29. 29. Hemodialysis (p. 434)  Artificial kidney machine removes toxins and restores metabolites and nutrients  Three to six treatments per week  Medical nutrition therapy  Protein: major concern of patients on dialysis  Energy: 35 kcal/day for patients <60 years  Sodium/potassium: may be restricted  Phosphorus/calcium: monitored and limited  Vitamins/minerals: achieve the DRI 29Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    30. 30. Peritoneal Dialysis (p. 437)  About 6% of patients  Exchange of fluids occurs within the body, allows mobility  Medical nutrition therapy  Protein: increased slightly  Energy: maintain lean body weight  Sodium/potassium: intake slightly more liberal  Phosphorus/calcium, vitamins/minerals: same as for hemodialysis 30Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    31. 31. Peritoneal Dialysis (cont’d) (p. 437) 31Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    32. 32. Transplantation (p. 438)  Improves quality of life and survival  More cost effective than maintenance dialysis  Waiting lists can be long  Donor matches difficult to find 32Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    33. 33. Transplantation (cont’d) (p. 439)  Transplantation  Complications: bone disorders, malnutrition, anemia, hormonal and blood pressure imbalances, depression, reduced quality of life  Nutrition support: enteral or parenteral feedings customized to dialysis 33Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    34. 34. Transplantation (cont’d) (p. 439)  Osteodystrophy  Bone disease and disorders common with CKD  Decreased activation of vitamin D has cascade effect  Neuropathy  Central and peripheral disturbances common at initiation of dialysis  Patients should be periodically assessed 34Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    35. 35. Kidney Stone Disease (p. 442)  Basic cause is unknown  Factors relating to urine or urinary tract environment contribute to formation  Present in 5% of U.S. women and 12% of U.S. men  Major stones are formed from one of three substances:  Calcium  Struvite  Uric acid 35Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    36. 36. Calcium Stones (p. 442)  Most common type: 80% of cases  High levels of urinary oxalate  Long-term megadosing of vitamin C  Dietary calcium intake inversely related to stones 36Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    37. 37. Struvite Stones (p. 442)  10% of all stones  Caused primarily by urinary tract infection  No diet therapy  Usually surgically removed 37Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    38. 38. Uric Acid Stones (p. 443)  Caused by impairment of purine metabolism with some diseases  Account for 9% of stones  Other stones  Due to inherited disorders or complications of medications 38Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    39. 39. Clinical Symptoms and Medical Nutrition Therapy (p. 443)  Clinical symptoms  Severe pain  Urinary symptoms  Weakness, fever  Medical nutrition therapy  Protein: no more than DRI  Calcium: normal calcium intake  Sodium: no more than 2300 to 3450 mg/day  Oxalates: avoid  Vitamins/minerals: limit to DRI  Fluid: high intake 39Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    40. 40. Objectives Specific to Type of Stone (p. 444)  Calcium stones: reduce dietary intake of stone constituents, consider fiber intake  Uric acid stones: raise urinary pH, maintain healthy weight, limit animal protein  Cystine stones: reduce intake of cystine and dilute urine 40Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
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