Cardiovascular disease information with other diseases

Information of diets relating to diseases

1. Cardiovascular Disease

2. Cardiovascular disease (CVD) is a group of interrelated diseases that include coronary heart disease (CHD), atherosclerosis , hypertension , ischemic heart disease, peripheral vascular disease , and heart failure (HF ) . Coronary heart disease (CHD) involves the narrowing of small vessels that oxygenate the heart muscle . Myocardial infarction (MI), or ischemia, in one or more of the coronary arteries with tissue damage, is the main form of heart disease responsible for CVD deaths . Heart disease and stroke cause the most deaths in both sexes of all ethnic groups, increasing with age.

3. Common disorders and complications of Coronary Heart Diseases (CHD) Dyslipidemia Atherosclerosis Abnormal levels of Lipids Angina Pectoris Myocardial Infraction Pain or discomfort An area of necrosis

4. Congestive Cardiac Failure A CLINICAL SYNDROME CAUSED BY CHARACTERISTED BY BREATHLESSNESS, CHEST PAIN AND ABNORMAL SODIUM & WATER RETENTION.

5. ATHEROSCLEROSIS AND CORONARY HEART DISEASE Atherogenesis is the process leading to development of atherosclerosis . It is a chronic, local, inflammatory response to risk factors, such as high levels of low-density lipoprotein (LDL) cholesterol, that are injurious to the arterial wall . Hence lesion formation , progression, and eventual plaque rupture result from the release of inflammatory cytokines . Pro-inflammatory (e.g ., tumor necrosis factor-alpha [TNF- α], interleukin [IL ]-6, and C-reactive protein [CRP]) and anti-inflammatory cytokines (e.g., IL-9, IL-10) are the key proteins that must be balanced to prevent plaque rupture and subsequent clinical events.

6. Pathophysiology Atherosclerotic heart disease (ASHD) involves narrowing and loss of elasticity in the blood vessel wall caused by accumulation of plaque . Plaque forms when inflammation stimulates a response by phagocytic white blood cells (monocytes ). Once in the tissue, monocytes evolve into macrophages that ingest oxidized cholesterol, and become foam cells and then fatty streaks in these vessels. Intracellular microcalcification occurs, forming deposits within the vascular smooth muscle cells of the surrounding muscular layer.

7. Hyperlipidaemia and excess of modified lipoprotein fractions/peroxides/free radicals Endothelial injury or dysfunction In the intima oxidised LDL is formed sticks to the blood vessel Monocytes turn into macrophages promote contraction of the vessel Formation of foam cells Development of lipid pool Smooth muscle cell proliferation wall becomes thickened, hardened narrowing the lumen Fatty streak Transitional plaque Mature Plaque Rupture plaque with thrombus formation.

8. Etiology Hyperlipidemia : Excess circulating fats in blood especially the low density lipoprotein (LDL) and low levels of high density lipoprotein ( FlDL ) can predispose to atherosclerosis. Hypertension: HT can accelerate atherosclerosis and causes complications. Diabetes mellitus: An important risk factor commonly associated with hypertension, due to abnormalities of coagulation, platelet adhesion and aggregation, increased oxidative stress, and abnormalities in vessel vasomotion can be a high risk for atherosclerosis.

9. Obesity: Excessive triglycerides ( hyperglyceridemia ) and LDLc levels ore commonly present in obese and lower HDL levels are a great independent risk factors 'for atherosclerosis. Lifestyle : Low physical activity, cigarette smoking could affect the rate of atherosclerosis, increased CAD risk, On the other hand, regular exercise is seen lo be protective. Factors causing endothelial damage: Elevated blood homocysteine a (genetically determined) and viral infections of lungs could damage the endothelial and cause injury and hence lead to atherosclerosis.

10. Symptoms Excessive weight, hypertension, high levels of cholesterol and triglycerides.

11. Cardiovascular Disease Risk Factors Major Risk Factors Modifiable Cardiovascular Risk Factors Hypertension Age (older than 45 years for men, 55 years for women) Diabetes mellitus Estimated glomerular filtration rate <60 mL/min Microalbuminuria Family history of premature cardiovascular disease (men <55 years of age, or women <65 years of age) Lipoprotein profile • Low-density lipoprotein cholesterol, elevated • Total triglycerides, elevated • High-density lipoprotein (HDL) cholesterol, low Inflammatory markers Fibrinogen C-reactive protein

12. Controllable Risk Factors Hypertension Obesity (body mass index >30 kg/m2) Metabolic syndrome (including reduced HDL, elevatedtriglycerides , abdominal obesity) Lifestyle Risk Factors Tobacco use, particularly cigarettes Physical inactivity Poor diet Stress Insufficient sleep Excessive alcohol consumption

13. Therapeutic Lifestyle Changes The TLC dietary pattern is used for primary and secondary prevention of CHD Nutrient Recommended Intake Total fat 25%-35% of total calories Saturated fat Less than 7% of total calories Trans- fatty acids Zero or as low as possible Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Carbohydrate† 50% to 60% of total calories, Fiber 25-30 g/day Plant sterols 2 g/day Protein Approximately 15% of total calories Cholesterol Less than 200 mg/day Total calories (energy): Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain. Daily energy expenditure should include at least moderate physical activity of approximately200 kcal/day).

14. Saturated Fatty Acids. The predominant sources of SFAs in the American diet are animal foods (meat and dairy ). SFAs are restricted because they have the most potent effect on LDL cholesterol, which rises in a dose response fashion when increasing levels of SFAs are consumed . Trans-fatty Acids. Trans-fatty acids (stereoisomers of the naturally occurring cis -linoleic acid) are produced in the hydrogenation process used in the food industry to increase shelf life of foods and to make margarines, made from oil, firmer . Most trans -fatty acids intake comes from partially hydrogenated vegetable oils. These fatty acids are limited because they raise LDL cholesterol ( Basu et al., 2006 ). No more than 1% of calories (approximately 1-3 g/day) should come from trans -fatty acids

15. Monounsaturated Fatty Acids. Oleic acid ( C18:1) is the most prevalent MUFA Substituting oleic acid for carbohydrate has almost no appreciable effect on blood lipids. However, replacing SFAs with MUFAs (as would happen when substituting olive oil for butter) lowers serum cholesterol levels, LDL cholesterol levels , and triglyceride levels to about the same extent as PUFAs. The effects of MUFAs on HDL cholesterol depend on the total fat content of the diet. When intakes of both MUFA (>15% of total kilocalories) and total fat (>35% of kilocalories) are high, HDL cholesterol does not change or increases slightly compared with levels with a lower-fat diet. Oleic acid as part of the Mediterranean diet has been shown to have anti-inflammatory effects.

16. Mediterranean-type A Mediterranean-type step I diet may reduce recurrent CVD by 50% to 70% and has been shown to positively affect lipoprotein levels in high-risk populations. This diet emphasizes fruits , root vegetables (carrots, turnips, potatoes, onions , radishes), leafy green vegetables, breads and cereals, fish , foods high in α-linolenic acid (flax, canola oil), vegetable oil products (salad dressing and other products made with nonhydrogenated oils), and nuts and seeds (walnuts and flaxseed). Red wine is considered a key part of the Mediterranean diet . Resveratrol, a polyphenolic compound, is found in the skin of red grapes. Resveratrol in large quantities appears to lower blood pressure by increasing nitric oxide levels. Its role in smaller quantities found in the 1-2 glasses of red wine recommended in the Mediterranean diet is not yet clear. Grape juice is another good source of resveratrol .

17. Polyunsaturated Fatty Acids. The essential fatty acid linoleic acid (LA) is the predominant PUFA consumed in the American diet; its effect depends on the total fatty acid profile of the diet. When added to study diets, large amounts of LA diminish HDL serum cholesterol levels. High intakes of ω-6 PUFAs may exert adverse effects on the function of vascular endothelium or stimulate production of proinflammatory cytokines . Thus a low ratio of ω-6:ω-3 PUFAs is recommended Replacing PUFAs for carbohydrate in the diet results in a decline in serum LDL cholesterol. When SFAs are replaced with PUFAs in a low-fat diet, LDL and HDL cholesterol levels are lowered. Overall, eliminating SFAs is twice as effective in lowering serum cholesterol levels as increasing PUFAs .

18. Omega-3 Fatty Acids. The main ω-3 fatty acids ( eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA ]) are high in fish oils, fish oil capsules, and ocean fish. Many studies have shown that eating fish is associated with a decreased CVD risk. The recommendation for the general population for fish consumption is to eat fish high in ω-3 fatty acids (salmon, tuna, mackerel, sardines) at least twice a week.

19. Total Fat. Total fat intakes are related to obesity, which affects many of the major risk factors for atherosclerosis. Also, high-fat diets increase postprandial lipemia and chylomicron remnants , both of which are associated with increased risk of CHD. When fat is reduced in the diet and carbohydrate is the replacement source of calories, triglycerides and HDL levels are affected. Low-fat diets (<25% of total kilocalories from fat) raise triglyceride levels and lower HDL cholesterol levels . Dietary Cholesterol. Dietary cholesterol raises total cholesterol and LDL cholesterol but to a lesser extent than SFAs . The AHA and TLC dietary patterns contain no more than 200 mg of cholesterol each day. There is a threshold beyond which addition of cholesterol to the diet has minimal effects .

20. Fiber. High intake levels of dietary fiber are associated with significantly lower prevalence of CHD and stroke. The AHA, TLC, and DASH dietary patterns emphasize fruits, vegetables, legumes, and whole grains , so they contain adequate fiber to lower LDL cholesterol. In particular, the soluble fibers in pectins , gums, mucilages , algal polysaccharides, and some hemicelluloses lower LDL cholesterol. The quantity of fiber needed to produce the lipid-lowering effect varies by food source; higher quantities of legumes are needed than of pectin or gums .

21. Antioxidants. Two dietary components that affect the oxidation potential of LDL cholesterol are the level of LA in the particle and the availability of antioxidants. Vitamins C, E, and β-carotene at physiologic levels have antioxidant roles in the body. Vitamin E is the most concentrated antioxidant carried on LDLs, the amount being 20 to 300 times greater than any other antioxidant. A major function of vitamin E is to prevent oxidation of PUFAs in the cell membrane.

22. Hypertension Hypertension is persistently high arterial blood pressure, the force exerted per unit area on the walls of arteries. To be defined as hypertension, the systolic blood pressure (SBP ), the blood pressure during the contraction phase of the cardiac cycle, has to be 120 mm Hg or higher; or the diastolic blood pressure (DBP), the pressure during the relaxation phase of the cardiac cycle, has to be 80 mm Hg or higher ; this is reported as more than 120/80 mm Hg . If an individual has a blood pressure of 120 mm Hg and a DBP of 80 mm Hg, this is read as a blood pressure of 120/80 .

23. Types Of those persons with high blood pressure, 90% to 95% have E ssential hypertension (hypertension of unknown cause ) or primary hypertension . The cause involves a complex interaction between poor lifestyle choices and gene expression . Lifestyle factors that have been implicated include poor diet (i.e., high sodium, low fruit and vegetable intake ), smoking, physical inactivity, stress, and obesity.

24. Hypertension that arises as the result of another disease, usually endocrine, is referred to as secondary hypertension . Depending on the extent of the underlying disease, secondary hypertension can be cured . Common causes include specific renal diseases such as polycystic kidney disease; adrenal gland tumors/disorders; congenital defects of blood vessels; certain medications; renal artery stenosis; and hyperparathyroidism

25. Risk Factors Black race Youth Male gender Persistent diastolic pressure >115 mm Hg Smoking Diabetes mellitus Hypercholesterolemia Obesity Excessive alcohol intake Evidence of end organ damage

26. Adverse Prognosis in Hypertension Cardiac Eyes Renal Nervous system Cardiac enlargement Electrocardiographic signs of ischemia or left ventricular strain Myocardial infarction Heart failure Retinal exudates and hemorrhages Papilledema Impaired Renal functions CVA

27. Pathophysiology Blood pressure is a function of cardiac output multiplied by peripheral resistance (the resistance in the blood vessels to the flow of blood). Thus the diameter of the blood vessel markedly affects blood flow. When the diameter is decreased (as in atherosclerosis) resistance and blood pressure increase. Conversely, when the diameter is increased (as with vasodilator drug therapy), resistance decreases and blood pressure is lowered.

28. Treatment Primary prevention can improve quality of life and the associated costs. One strategy is to reduce blood pressure in those with prehypertension (above 120/80) but below the cutoff points for stage 1 hypertension. A downward shift of 3 mm Hg in SBP would decrease the mortality from stroke by 8% and from CHD by 5%. Persons at highest risk should be strongly encouraged to adopt healthier lifestyles . Changing lifestyle factors have documented efficacy in the primary prevention and control of hypertension.

29. Goals and Objectives To lower blood pressure and maintain it at desirable level. To control sodium intake to manage htn in sodium sensitive persons and to promote the loss of excess fluids or expanded ECF. Control of body weight at desirable level. To prevent long term complications of HTN.

30. DASH Diet. Several dietary patterns have been shown to lower blood pressure . Vegetarian dietary patterns have been associated with lower SBP in observational studies and clinical trials. Average SBP reductions of 5 to 6 mm Hg have been reported . Specifically , the Dietary Approaches to Stop Hypertension (DASH) Diet Study shows that this low-fat dietary pattern (including lean meats and nuts and emphasizing fruits , vegetables, and nonfat dairy products) decreased SBP . The DASH diet is found to be more effective than just adding fruits and vegetables to a low-fat dietary pattern

31. Individuals should adopt the DASH dietary pattern, which is rich in fruits, vegetables , low-fat dairy, and nuts; low in sodium, total fat, and saturated fat; and adequate in calories for weight management. Approximate SBP reduction range 8-14 mm Hg . Fruits and vegetables : Fruits and vegetables should be recommended at a level of five to ten servings per day for significant BP reduction. Sodium: Sodium intake should be limited to no more than 2300 mg/day; if adherent to this recommendation and BP target not achieved, a further reduction in dietary sodium to 1600 mg/day should be encouraged in combination with a DASH dietary pattern . Approximate SBP reduction range 2-8 mm Hg . Lipids: Current recommendations for lipid composition of the diet are recommended to help control weight and decrease the risk of CVD

32. Physical activity: Individuals should be encouraged to engage in aerobic physical activity for at least 30 minutes per day on most days of the week, as it reduces SBP. Approximate SBP reduction range 4-9 mm Hg . Weight management : Optimal body weight should be achieved and maintained (BMI 18.5-24.9) to reduce BP . Approximate SBP reduction range 5-20 mm Hg/10 kg. Alcohol: For individuals who can safely consume alcohol, consumption should be limited to no more than two drinks per day in most men and to no more than one drink per day in women. Approximate SBP reduction range 2-4 mm Hg.

33. Calcium : Higher dairy versus supplemental calcium is associated with lower risk of hypertension. Mechanistically, a low calcium intake increases intracellular calcium concentration. This in turn increases 1,25-vitamin D3 and parathyroid hormone levels, causing calcium influx into v ascular smooth muscle cells and greater vascular resistance . Alternatively , peptides derived from milk proteins, especially fermented milk products, may function as ACEs, thereby lowering blood pressure . Magnesium: Magnesium is a potent inhibitor of vascular smooth-muscle contraction and may play a role in blood pressure regulation as a vasodilator . Potassium : Studies support a modest relationship between increasing intake of potassium and a lower sodium-potassium ratio with lowered blood pressure .

34. HEART FAILURE

35. Normally the heart pumps adequate blood to perfuse tissues and meet metabolic needs. In heart failure (HF ), formerly called congestive heart failure, the heart cannot provide adequate blood flow to the rest of the body, causing symptoms of fatigue, shortness of breath (dyspnea), and fluid retention . HF can be right-sided , left-sided, or can affect both sides of the heart . It is further categorized as systolic failure when the heart cannot pump, or eject, blood efficiently out of the heart or diastolic failure, meaning the heart cannot fill with blood as it should .

36. Causes Valve disease HTN DM Coronary Heart Disease Obesity Atherosclerosis Chronic Obstructive Pulmonary Disease. Dyslipidemia

37. In HF the heart can compensate for poor cardiac output by increasing the force of contraction, ( 2) increasing in size , ( 3) pumping more often, and ( 4) stimulating the kidneys to conserve sodium and water. . Three symptoms—fatigue, shortness of breath, and fluid retention—are the hallmarks of HF. Shortness of breath on exertion , or effort intolerance, is the earliest symptom .

38. Dietary Management Goals To reduce the cardiac workload, breathlessness and edema of the extremities. To assist drug therapy in treatment of Congestive heart failure and in management of Cardiac cachexia .

39. Dietary Modification depend on individual signs of edema , breathlessness and overall nutritional status. Energy Requirement is 20-30% higher than the basal requirement, based on Harris Benedicts equation, due to increased cardiac and pulmonary workload. Needs may be adjusted for catabolic state. Protein needs vary from 1.1 g/kg for well nourished patients to 1.4g/kg for those undernourished, in order to preserve body composition and limit effect of hypercatabolism . Sodium Intake should be to less than 2000mg per day, depending on the severity of the disease. The restriction may be as low as 1000mg Na in hospital settings, if warranted. High Potassium may be required for patients on potassium-wasting diuretics

40. Adequate folate consumption through supplement or food o folate with B6and B12 is beneficial. Thiamine Status and Mg should be evaluated and ensured that atleast the DRI is consumed. In Obese individual, weight loss may give relief to breathlessness. Fluid intake should be 1.4L to 1.9L per day depending on clinical symptoms. Caffeine intake should be limited due to possible increase in heart rate and dysrhythmia. Small frequent meals may reduce the workload of the heart while meeting full requirements. Consistency of the diet may vary from normal to soft depending on need and stage of CHF. Alcohol: Upto two standard drinks for men and one for women has not been found to be harmful in pts of CHF. d

41. Stroke

42. A stroke can occur when blood flow to the brain is blocked or there is sudden bleeding in the brain. There are two types of strokes. A stroke that occurs because blood flow to the brain is blocked is called an ischemic stroke . The brain cannot get oxygen and nutrients from the blood. Without oxygen and nutrients, brain cells begin to die within minutes. A stroke that occurs because of sudden bleeding in the brain is called a hemorrhagic stroke. The leaked blood results in pressure on brain cells, damaging them. Just under 90% of strokes involve blocked blood vessels (ischemic), and the rest involve internal bleeding (hemorrhagic). Strokes are further classified based on where in the brain the blockage or bleeding occurs. A stroke is a medical emergency. A stroke can cause lasting brain damage, long-term disability, or even death.

43. Symptoms of stroke include the following sudden changes: Numbness ( paresthesia ) or weakness (paresis) of the face, arm, or leg, usually on one side of the body Confusion, difficulty speaking ( dysarthria or aphasia) or understanding Visual disturbances, which may include partial or complete vision loss Dizziness and/or ataxia Severe headache with no known cause—particularly with hemorrhagic strokes

44. Risk Factors Age . The risk of stroke doubles every 10 years beyond age 55. Gender . Women have a slightly higher incidence of stroke compared with men, and case-fatality rates due to stroke are also higher in women. Hypertension . As the most important modifiable risk factor, especially for hemorrhagic stroke, both systolic hypertension and diastolic hypertension are associated with an increased risk. Smoking . Overweight . Excess body weight is associated with increased ischemic stroke risk. Diabetes . According to the American Diabetes Association, people with diabetes have a 1.5-times-greater risk of having a stroke. High blood glucose levels are associated with worse outcomes and higher rates of mortality, especially after an ischemic stroke. Dyslipidemia . Sedentary lifestyle . Higher levels of occupational or leisure-time physical activity protect against stroke. 

45. Poor nutrition . High-fat, high-sodium diets and a lack of key nutrients such as folic acid have been associated with increased risk for stroke Carotid stenosis . Both symptomatic and asymptomatic stenoses of the internal carotid arteries are associated with increased risk for ischemic stroke. Alcohol abuse . Drug abuse . Use of cocaine and amphetamines may result in ischemic or hemorrhagic strokes.

46. Dietary Management of Stroke A healthy dietary pattern . Healthy dietary patterns are defined by the relative absence of foods that are energy-dense, high in saturated fats (e.g., meat and full-fat dairy products), fried, processed, or high in glycemic load. This should be accompanied by the presence of higher amounts of fruits, vegetables, soy foods and other legumes, nuts, unsaturated fats, and foods that are low in energy density and high in fiber, among other characteristics.

47. Fish intake . Reviews have concluded that fish consumption and the intake of long-chain omega-3 fatty acids is inversely associated with cerebrovascular disease risk, and that higher compared with lower intakes significantly reduce the risk for ischemic stroke in both men and women, and total stroke risk in women.

48. Diets rich in fruits, vegetables, and dietary fiber and low in refined carbohydrate s. Higher intakes of fruits and vegetables are inversely associated with the risk for stroke.  Consuming less sodium and more potassium . Maintenance of healthy body weight .   Limiting alcohol consumption . Adequate vitamin D status . Compared with individuals with the highest blood level of vitamin D, those with the lowest level have a 64% greater risk for stroke. Tea and coffee Caution with vitamin E and calcium supplements . 

49. ACUTE AND CHRONIC NEPHRITIS

50. Nephritis refers to the inflammatory disease of the nephrons due to infection, degenerative processes or vascular disease. In most cases, the inflammatory process affects the capillaries of the glomeruli , this disorder is termed as glomerulonephritis (GN). There may be damage to the tubules also. Etiology Acute form of glomerulonephritis is commonly seen in 3-10 year old children, although in 5% or more cases the initial attack occurs in adults past the age of 50 years. Previous streptococcal infection, 7-20 days prior to onset, is a common cause of this disease and antigen-antibody reaction is mostly the basis of damage of nephrons .

51. Clinical and Metabolic Manifestations The clinical manifestations include Fever i.e. elevation of body temperature above 98.4o F or 37oC. Uremia: accumulation of nitrogenous waste products and other urinary constituents in blood, particularly haematuria and proteinurea Oedema : fluid and electrolyte retention in tissues Hypertension: Systolic and Diastolic blood pressure above 120/80 mm Hg Oliguria and anuria because of reduced GFR.

52. Dietary Management Calories: A high-energy diet is recommended to spare the proteins for tissue repair rather than being used for energy. Adults may need 30-40 Kcal / kg dry weight and children about 100 Kcal /kg dry weight or more, based on age. Increased energy requirements are also recommended since elevation of body temperature i.e. fevers may be present in patients with glomerulonephritis . Elevation of body temperature results in increase in basal metabolic rate (BMR) and hence the energy intake may be increased to about 10%. Proteins: Blood urea nitrogen (BUN) and oliguria determine the restriction of protein in the diet. Initially, 0.6 to 0.8 g protein/kg Ideal Body Weight (IBW) is provided using principally high quality protein. Normal levels of protein (1 g/kg IBW) may be provided if BUN levels remain within the normal range.

53. Carbohydrates: Liberal carbohydrate intake is important for protein sparing action, for reducing catabolism of protein, as well as, for preventing starvation ketosis. Both simple carbohydrates such as sugar, as well as, complex form such as starches can be included in the diet. Fats: Based on tolerance levels, fat is included to provide non-protein calories for energy needs. Being energy dense, fat reduces the bulk of the diet and makes the diet more palatable. It can varies from 30-35% of total calories. Sodium: The restriction of sodium is dependent on the degree of oliguria and hence sodium retention. If renal function is impaired, sodium may be restricted to 500 to 1000 mg/day. With recovery, the intake may be increased

54. Potassium: In case of oliguria , renal clearance of potassium is impaired resulting in hyperkalemia (increased level of potassium in blood). In the initial stages, therefore potassium may have to be restricted to 1200-1500 mg/day. In addition, fruit, fruit juices, nuts and coconut water may be restricted or avoided, as they are rich in potassium. Fluid: Intake of fluids needs to be restricted in case of reduced GRF and oliguria to 500-700 ml/day plus the volume of urine output in previous 24 hours. Without oliguria fluid intake may be normal.

55. Definition Nephrotic syndrome is an immune mediated disease in which nephrons of the kidney are damaged, allowing plasma proteins to leak into the urine in large amounts. With resultant hypoproteinemia , some of the fluid leaks out the bloodstream into the tissues, causing fluid retention and edema.

56. Symptoms Nephrotic syndrome or nephrosis is defined by presence of nephrotic range proteinuria, edema, hyperlipidemia and hyperalbuminemia . Nephrotic range of proteinuria can be 3.5g or more per day. The edema is noticeable in the legs and around the eyes when one gets up in the morning. Eventually, it may occur in other parts of the body. The Urine foams more than usual because of the amount of protein in it.

57. Dietary Management Protein : The primary objective of dietary treatment in nephrotic treatment is to replace the proteins that are lost from the plasma into the urine. The dietary protein intake for patients with NS remains controversial. Historically, a high protein diet ( upto 1.5g/kg/day) was given in an attempt to increase the protein levels and prevent malnutrition.however it was seen that by giving these diets serum protein levels do not increase , whereas the loss of protein in urine increased. Studies have shown that a protein intake of 0.8g/kg/day with 50% of HBV. 1g for 1g of protein lost in urine.

58. Nutrients Recommendation Calories Adequate to maintain edema free ideal body weight. For adults – 35-40 Kcal/kg/IBW and children 100 Kcal/kg. Sufficient calories provide for optimum utilization of proteins for tissue synthesis Fats Limit to 30% energy from fat and < 300 mg cholesterol, especially if the patient has hyperlipoproteinemia and hypercholesterolemia. Carbohydrates High intake due to its protein sparing action, Remaining calories from complex carbohydrates. Salt A low salt diet is prescribed to prevent edema. (1-4g/ perday ) Calcium 800mg/day due to abnormal bone metabolism.

59. Sodium 2-3 g/day and diuretics in order to reduce oedema . Potassium Required in adequate amounts as its losses may occur due to tissue protein breakdown and diuretic use Fluid Normal – unless GFR is reduced

60. Acute kidney injury (AKI), formerly acute renal failure (ARF ), is characterized by a sudden reduction in glomerular filtration rate (GFR), the amount of filtrate per unit in the nephrons , and altered ability of the kidney to excrete the daily production of metabolic waste . AKI can occur in association with oliguria (decreased output of urine) or normal urine flow, but it typically occurs in previously healthy kidneys . Duration varies from a few days to several weeks.

61. Acute renal failure (ARF) is a rapid loss bf renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney. Depending on the severity and duration of the renal dysfunction, this accumulation is accompanied by metabolic disturbances, such as metabolic acidosis (acidification of the blood) and hyperkalaemia ( eIevated potassium levels), changes in body fluid balance, and effects on many other organ systems. It can be characterized by oliguria or anuria (decrease or cessation of urine production), although ~non oliguric ARF may occur. It is a serious disease and treated as a medical emergency.

62. Causes Condition Prerenal inadequate renal perfusion Severe dehydration Circulatory collapse Intrinsic diseases within the renal parenchyma Acute tubular necrosis: • trauma, surgery, septicemia Ischemic acute tubular necrosis: Nephrotoxicity • antibiotics, contrast agents, and other drugs Local reaction to drugs Vascular disorders Postrenal urinary tract obstruction Carcinoma of the bladder or prostate

63. Dietary Management In AKI the common nutritional problems include: (1) Poor appetite, (2) Inability to take food/or fluids orally due to intubation , and (3) Hypercatabolism (increased metabolism) due to underlying illnesses such as infection, postoperative healing. Diet therapy in Acute Kidney Injury (AKI), therefore, focuses on: reestablishment of fluid electrolyte balance, maintenance of acceptable levels of blood urea and creatinine while supporting tissue healing and making up catabolic losses, and preventing infection

64. Nutrients Recommendations Protein 0.8-1 g/kg IBW increasing as GFR returns to normal; 60% should be HBV protein Energy 30-40 kcal/kg of body weight Potassium 30-50 mEq /day in oliguric phase (depending on urinary output, dialysis, and serum K+ level); replace losses in diuretic phase Sodium 20-40 mEq /day in oliguric phase (depending on urinary output, edema, dialysis, and serum Na+ level); replace losses in diuretic phase Fluid Replace output from the previous day (vomitus, diarrhea, urine) plus 500 mL Phosphorus Limit as necessary

65. CHRONIC KIDNEY DISEASE A wide range of kidney lesions are characterized by a slow, steady decline in renal function. A number of the diseases discussed earlier lead to renal failure in some patients, whereas other patients have a benign course without loss of renal function. It is unclear why some patients remain stable with chronic kidney disease (CKD) for many months to years while others progress rapidly to renal failure and dialysis .

66. Etiology A number of diseases that involves the nephrons may result in CRF like primary glomerular diseases such as: immune complex glomerulonephritis , a metabolic disease with renal involvement such as diabetes mellitus, especially IDDM, e hypertension, exposure to toxic substances, kidney stones and inIections , renal vascular diseases, renal tubular diseases, chronic pyelonephritis , and congenital abiiormalities of both kidneys. These conditions call cause extensive changes in kidney structure and function

67. Progressive loss of nephrons with a decreased renal blood flow and glomerular filtration results in a marked impairment of not only excretory but also metabolic and endocrine functions of the kidney. There is a decreased ability of the kidneys lo maintain body water balance, concentrate solutes in body fluid ( osmolality ) and electrolyte and acid-base balance, Other clinical manifestations that develop ,may relate to almost every system of the body due to an overall pervasive metabolic derangement of the body.

68. Dietary Management Feeding is a challenge in CRF as anorexia and taste changes reduce food intake. The main focus of dietary management is on protein, sodium, potassium, phosphate, water and adequate non-protein calories. Individual modifications are required based on clinical profile, treatment and response of the patient. Protein . Protein needs to be restricted. However, enough has to be provided to minimize tissue catabolism. About 0.5 gkg /day is recommended but has to be regulated depending on declining renal function. A protein intake of 35-40 g /day (60-70% of high biological value protein) with liberal calorie intake can maintain the nitrogen equilibrium for long periods while reducing azotemia . If BUN rises, the protein intake inay need to be restricted to 20 glday . High biological value proteins from milk and eggs are recommended to provide all the essential amino acids. To reduce the nitrogen load, in advanced cases, mixture of essential amino acids or nitrogen free precursors of the essential amino acids like a keto or a hydroxy analogs may be recommended.

69. Energy. Energy: About 2000-2500 Kcallday are recommended or 30-40 Kcal/kg/day for adults and about 100-150 Kcalkglday for children. If the calorie intake is inadequate, endogenous protein catabolism and gluconeogenesis occur to supply energy and further aggravate uremia. Therefore, 300-400 g of carbohydrates are recommended. Sodium. Edema, the most clinically apparent manifestation, indicates total body sodium overload. Additionally, because of low oncotic pressure from hypoalbuminemia, the volume of circulating blood may be reduced. Sodium intake will vary between 500 mg to 2.0 g/day. Weight loss and decreasing urine volume usually indicate a need for additional sodium, whereas if hypertension and oedema are present, the sodium intake needs to be restricted.

70. Potassium : The failing kidney cannot excrete potassium adequately and therefore intake is kept at about 1500 mg/day (35 to 40 mEq /day). The potassium intake has to be adjusted to maintain normal levels in blood. In severe vomiting and diarrhoea , significant losses of potassium can occur and in these conditions, careful potassium supplementation may be needed. Potassium content of various vegetables and the methods of leaching potassium are given.

71. Lipids. The important consequence of dyslipidemia is cardiovascular disease . Vitamins. CKD patients are routinely recommended a water-soluble renal customized vitamin supplement, because restrictions may cause the diet to be inadequate . Fluid : Intake is dependent on urine output and water balance. Fluid intake should be adequate to stimulate urine output for excretion of wastes but should avoid excess fluid retention at the same time.

72. END STAGE RENAL DISEASE (ESRD) The condition when kidneys have lost all or most of their ability to function with GFR < 5 ml/minute is called end stage renal disease (ESRD). Today, there are new and better treatments for ESRD that replace the work of healthy kidneys. The treatment of choice includes dialysis - haemodialysis (HD) and peritoneal dialysis (PD) - and kidney transplantation.

73. Dialysis So what does the process of dialysis involve? Yes, the process of dialysis involves cleansing the blood of metabolic wastes, based on the principle of osmosis and diffusion. A semi permeable porous membrane is used in dialysis to separate the patient blood carrying excess fluid and metabolic wastes and the hypotonic "dialysis fluid" called dialysate . Through osmosis and diffusion, the metabolic waste and excess water move into the dialysate . The pores of the semi permeable membrane do not permit large particles like protein and RBC to pass through, but smaller water-soluble molecules can pass.

74. Haemodialysis (HD) - In this, patient's blood circulates outside the body through what is commonly referred to as an "artificial kidney machine". An opening is created to connect an artery and a vein. Blood leaves the body via the artery, into dialyses and after cleansing, flow back to the body. Peritoneal dialysis (PD) - In this, the patient's peritoneal is used as the semi permeable membrane and excess water and metabolic wastes are removal by injecting the dialysis fluid into the peritoneal cavity. After same time, the fluid with the metabolic waste is drained out from the peritoneum. Peritoneal dialysis is less effective than haemodiaIysis and can result in loss of intact large molecular proteins also.

75. Renal Calculi Renal calculi or stones may be formed in the kidney, pelvis or ureter , when the concentration of compoilents in the urine reaches a level in which crystallization is possible. The process of stone formation is also called nephrolithiasis or urolithiasis . A kidney stone is a solid mass that consists of a collection of tiny crystals. There can be one or more stones present at the same time in the kidney or in the ureter . They generally are composed of calcium salt, uric acid, cystic or struvite (triple salt of ammonium, magnesium and phosphorus). Crystals of these substances interspersed in an organic matrix or base can form stones of varying size.

76. Etiology

77. Cancer

78. Cancer is considered to be one of the leading causes of morbidity and mortality worldwide. Cancer arises due to uncontrolled cellular growth. The development of cancer is multistep process that occurs in three stages : Initiation Promotion Propagation Causes : no. of exogenous factors are known to cause cancer Tobacco use Infectious agent Radiation Medication Chemical exposures.

79. Dietary Management Goals and Objectives Achieve and maintain healthy body weight Prevent or reduce nutrient deficiencies Preserve lean body mass and maintain strength and energy Minimize the effect of nutrition related side effects and complications Improve tolerance to treatment Reduce the risk of cancer recurrence, the development of another cancer and other chronic diseases such as heart disease, Type 2 diabetes and osteoporosis. Maximize quality of life Be physically active To meet these goals, a diet that is high protein, high calorie with optimum vitamins, minerals and antioxidants intake is the general recommendation

80. Energy Norm metabolic patients: 25-30 Kcal/kg/day Hypermetabolic or weight lose: 30-35 Kcal/kg/day Obese patients: 21-25 Kcal/kg/day (when weight maintenance is the goal; energy needs may be increased when nutritional status deteriorating ). Protein Adequate protein intake is important to prevent or reduce negative nitrogen balance and to meet the increase demands for protein synthesis during and following antineoplastic interventions. Guidelines for protein requirements are as follows; Non stresses 1.0-1.2 g/kg/day Undergoing treatment 1.2-1.5g/kg/day Hypermetabolism or protein losing conditions: 1.5-2.0g/kg/day

81. Fat Fat can be given as per moderate requirement- usually up to 30% of total energy from appropriate sources. Carbohydrate s Remaining calories come from appropriate carbohydrates preferably complex- about 50-55% of the energy requirement. Avoid giving sugar, sugary foods and refined carbohydrates . Vitamins and minerals Deficiencies of vitamins (vitamin D, vitamin B12, vitamin C and retinol) and mineral (calcium, magnesium, zinc, copper and iron) can occur as a result of direct effects of the tumor , effects of cytokines, infectious processes, maldigestion and malabsorption , chemotherapy, radiation or inadequate food intake.

82. Fluid Dehydration is prevalent in many cancer patients, especially those who receive chemotherapy and/or radiation therapy. Chemotherapy agents can damage the GI mucosa and cause diarrhea. Also , patients undergoing radiation for head and neck cancer prone to dehydration owing to their inability to take adequate oral fluids secondary to xerostomia , mucositis , dysgeusia , dysphagia . High-risk patients should be closely monitored for signs and symptoms of dehydration such as dark, concentrated urine, decreased urine output, dry mouth, acute weight loss and fatigue. The fluid needs of cancer patients are similar to those of other patients populations without renal disease (30-35ml/kg/day) , although fluid needs may also be greater in the face of increased fluid losses that may occur as a result of vomiting diarrhea and fistulas.