Renal diseases .pptx

1. Renal Diseases and Nutrition

2. Renal diseases or kidney diseases are the diseases of the kidneys which result in damaged kidneys or improper functioning of the kidneys. Besides removing wastes and extra fluid from the body, the kidneys also help maintain a healthy balance of water, salts, and minerals in the blood. They remove the acid that the cells of the body produce

3. The functional unit of the kidney is the nephron. Each kidney has about 1 million nephrons. Nephrons contain a filter called glomerulus. Every minute, about 1.3 liters of blood passes through the nephrons. The nephrons remove the waste products and excess water from the bloodstream. The rate of ultrafiltration is referred to as Glomerular Filtration Rate (GFR). GFR varies with age and sex.

4. The filtrate that is formed in the glomerulus passes into the proximal convoluted tubule and then into the loop of Henle. The filtrate finally reaches the collecting ducts through the distal convoluted tubule. The filtrate gets modified during this process to match the needs of the body through reabsorption and secretion. During a renal disease, the excretory function and other functions of the kidney are impaired. Due to this, the serum levels of urea, metabolites, electrolytes, and metabolism of nutrients changes, making the patient symptomatic.

5. Kidney diseases can be caused due to medications, underlying disease conditions such as diabetes, hyperglycemia , improper diet and others. Kidney disorders may be characterized by fatigue, weakness, nausea, vomiting, frequent urination, foamy urine, poor sleep, swelling in the hands or feet and poor appetite. Renal diseases can be acute or chronic in nature. Diagnosis of kidney disorders can often be done by qualitative tests of the urine and blood. Several treatment options are available for kidney diseases. Dialysis and kidney transplantation are some common procedures used to treat chronic renal diseases.

6. Dietary modifications have a crucial role in kidney disease. Appropriate interventions in the intake of fluid, protein, sodium, potassium and phosphate can neutralize the changes caused by the loss of kidney function. Nutritional interventions in kidney disease are used to slow down the progress of the disease to renal failure. Another fundamental role that nutrition plays in kidney disease is the prevention of protein-energy malnutrition (PEM) and cardiovascular disease (CVD), which are most commonly seen in kidney patients. Nutrition in kidney disease is aimed at improving the outcome and survival of the patient.

7. Assessment of Nutritional Status  Clinical examination Dietary intake evaluation Anthropometric evaluation Measurement of indices (biochemical, functional)

8. Measurement of indices Biochemicai –Laboratory tests should ideally be performed before the hemodialysis session or after attaining a state of equilibrium in continuous ambulatory peritoneal dialysis (CAPD). During the interdialytic interval, urea nitrogen can be measured. Levels of serum proteins such as albumin, pre-albumin, transferrin, are measured to identify nutritional changes. Factors including plasma volume, urinary excretion and inflammation can also impact serum protein levels. These factors should be first ruled out as they are non-nutritional and can provide a false assessment report of nutrition. 

9. Creatinine levels should be assessed, but creatinine/height ratio should be excluded as creatinine kinetics is altered in chronic kidney disease. Albumin levels should be assessed. Hyperalbuminemia is strongly associated with higher mortality and risk of cardiac disease. Low levels of transferrin can be a sensitive index of malnutrition. Change in iron status, the presence of infections and inflammation can influence the concentration of the protein. Visceral protein status can be detected by measuring pre-albumin, which has a very short shelf life. As GFR decreases, pre-albumin levels may rise. This change is independent of the patient’s nutritional changes. In dialyzed patients, pre-albumin levels lesser than 30mg/dL is an indication of PEM and often associated with an increased risk of mortality.

10. Declining levels of total serum cholesterol indicate malnutrition. This could also result from the presence of other diseases or inflammation. Total serum cholesterol levels <150 mg/dL are associated with increased risk of mortality.  Increased CRP plasma levels are associated with malnutrition. Functional indices: The most common functional indices include hand grip strength and lymphocyte count. They are used to measure skeletal muscle function and immune response respectively. Measuring functional indices will help in early detection of changes in nutritional status.

11. GLOMERULONEPHRITIS Is an inflammatory process affecting the glomeruli ,the small blood vessels in the head of the nephron . It is most common in its acute from in children 3 to 10 years of age although it can also occur in adults past age 50. Onset sudden and lasts a short time and procced to either complete recovery or development of chronic nephrotic syndrome.

12. DIETARY MANAGEMENT Dietary management – optimal nutrition support Adequate proteins – unless there is oliguria or anuria - Salt restriction if there edema ,hypertension or oliguria – sodium (500-1000mg/day) Bed rest and antibiotic drug therapy are main treatment Fluid intake – adjusted to output including losses in vomiting or diarrhea -30ml/kg body weight for infants -20ml/kg body weight for older children -10ml /kg body weight for adults

13. Nephrotic syndrome Caused due to progressive glomerulonephritis ,diabetes mellitus,amyloidosis ,quartan malaria,resulting due to drugs ,heavy metals and toxic venom.etc .. PRINCIPLES OF DIET Restricted protein ,high carbohydrates ,salt restricted ,moderate fat with restricted fluid are recommended for nephrotic patient. Vitamin supplements especially vitamin C given Patients with severe and persistant hyperlipidemia should maintain a normal weight for height The diet should be low in fat and cholesterol

14. ACUTE KIDNEY INJURY Sudden shutdown of renal function following metabolic insult or traumatic injury to normal kidneys. There is high mortality and the condition needs a medical emergency in which the nutritionist plays a supporting role. DIETARY MANAGEMENT Energy : A minimum of 600-1000kcal is necessary. A high calorie intake is desired ,mainly from carbohydrates and fats. Proteins : All foods containing protein are stopped if the patient is under conservative treatment and blood urea nitrogen is rising. However ,40gm is allowed during haemodialysis or peritoneal dialysis as it will reduce endogenous protein breakdown. Usually the protein content of the diet varies depending upon the urea content of the blood

15. CARBOHYDRATES : Minimum of 100g/day is essential to minimise tissue protein breakdown. If the patient is not fed by mouth , a nasogastric tube feeding of 700ml of 15 % glucose is administered. If orally given – 700ml of glucose with lime juice can be given. FLUID: The total fluid permitted is 500ml + losses through urine and gastrointestinal tract. With visible perspiration , an additional 500ml may be necessary. SODIUM: sodium loss through urine is measured and replaced. Dilutional hyponatremia occurs due to water retention. Water restriction than salt administration is indicated. Therefore ,sodium restriction is also judged based on sodium loss in the urine

16. POTASSIUM: Potassium intoxication ( hyperkalemia ) occurs with a daily rise of 0.7mEq serum potassium. It has deleterious effects on heart. A bowel wash may remove 100mEq of potassium. Potassium sources like tomato juice,coffee,tea,cocoa and potassium rich vegetables are avoided. Haemodialysis or peritoneal dialysis may be considered when blood urea levels is over 200mg/100ml. The diet may then be raised to 2000-3000kcal and 40g protein,if patient cannot take oral feeds,intravenous fat and amino acid solutions are given FOODS AVOIDED : protein concentrates,pulses,excess consumption of milk ,egg and meat.

17. CHRONIC RENAL FAILURE Its is also known as uraemia as the level of urea in blood is very high.when 90% of functioning renal tissue is destroyed uraemia occurs. DIETARY MANAGEMENT Diet should be palatable ,must have varities,adjusted according to altered biochemistry and physiology ( hyperphosphataemia and hypertension) adequate enough for growth in children. Energy: Adequate kilocalories are mandatory. Carbohydrate and fat must supply sufficient non- protein kilocalories to spare protein for tissue protein synthesis and to supply energy. Patients are encouraged to consume all the carbohydrate and fats they can, since the end products of their metabolism, carbon dioxide and water, do not impose a burden on the progressive renal failure.

18. If energy intake is inadequate, endogenous protein tissue catabolism takes place to supply energy and will futher aggravate the existing uraemia.requirements of calories is similar to the normal requirements Infancy- 100-120Kcal/kg Childhood – 80-110Kcal/kg Adult – 35-50 Kcal/kg

19. PROTEIN: kidney need to be given rest. Protein reduced to 0.5g/kg of body weight per day. There is then a parallel fall in urea production and fall in blood urea and anorexia and vomiting are relieved. This may result from a reduction in the diffusion of urea from the plasma into intestinal lumen, where it is hydrolyzed by bacteria to ammonium carbonate. The ammonium ion is a well-known gastrointestinal irritant and could thus mediate the potentially toxic effects of increased blood urea. The ammonia released in the gut is reabsorbed and taken to the liver by the portal circulation where it is either recycled to urea or used for synthesis of non essential amino acids. This provides an important metabolic pathway which is exploited in the patients on very low protein diets in the treatment of severe chronic renal failure . To prevent endogenous losses protein intake should be 0.25/kg body weight or 15-20g daily in older children and adolescents.

20. Very low protein diets are advised during severe degree of chronic renal failure With these dietetic measures , a patient in whom the GFR has fallen to 2 to 4ml/min can sustain. Otherwise dialysis would be necessary. Below table gives relationship between creatinine clearance and protein intake In chronic renal failure, the protein intake can be adjusted according to the creatinine clearance. If the patient has a creatinine clearance of 40ml/min or higher no protein restriction should be required Creatinine clearance ml/ mn Nitrogen intake g/day Protein intake g/day 10-40 9.6 60 5-20 6.4 40 2-10 2.5-3 20

21. FLUID AND ELECTROLYTES: In patients with less than 5% of the original functioning kidney tissue ,other steps have to be taken in addition to protein restriction to preserve fluid and ionic balance. Oedematic diuresis is secondary to plasma hyper osmolarity. Thirst control fluid intake,increase in fluid often increases the execration of urea If fluid retention occurs the patient should be given diuretics and sodium should be restricted especially if weight increases in the presence of hyponatraemia . If all the above measures fail,dialysis is considered . The usual fluid permitted is,volume of daily urine plus 500ml.

22. SODIUM : Excertion of sodium is more or less constant in chronic renal failure . Ideal intake: 1 to 2 mMol /kg of body weight for infants 40- 60mMol/day for older children. Strict restriction is necessary only if hypertension and oedema are present.0.2mMol/kg body weight /day + diuretics are given until crisis is over In chronic kidney patients ,salt intake is restricted to 2.4g/day POTASSIUM: Potassium execration varies appropriately with intake ,a response that is mediated by a hormone aldosterone and according to plasma potassium concentration. The kidneys are able to maintain near normal levels of potassium exe cration as long as the distal tubule in the kidneys are responsive to aldosterone . Thus dietary restrictions are necessary only in potassium retention status

23. 4g/day potassium intake is recommended in these patients Hypokalemia can occur at any time in chronic renal failure ,it occurs ,small dose of potassium should be given and serum levels monitored. A combination of high potassium ,low calcium and high magnesium have an adverse effect on heart. Guidelines recommend restricting the dietary phosphorous levels to 800-1000mg/day.

24. URINARY CALCULI Kidney stones or the renal calculi are the solid masses made of crystals and mainly originate in the kidneys. Other than the kidney, it can be present along the urinary tract which mainly consist of ureters, bladders and the urethra. These are one of the most painful medical conditions. Prevalence 17% of the whole population will have kidney stones. Affects both males and females. 12% of males and 5% of females are likely to experience kidney stones. Average onset of kidney stones is over the age of 30 years. Those who have previous history of kidney stones are likely to get a second episode of kidney stones.

25. SIGNS AND SYMPTOMS Severe pain in the side or the back that persist. Pain that spreads to the lower abdomen/groin. Painful urination. Pink, red, brown or cloudy colour urine. Nausea and vomiting Persistent urge to urinate Fever and chills. Foul smelling urine.

26. Types All kidney stones are made from different kinds of crystals. Mainly the kidney stones are made up of the following: Calcium Uric acid Struvite Cystine CALCIUM Calcium stones are the most common types of kidney stones and are often formed from calcium oxalate. Eating less oxalate rich foods can reduce the risk of developing the stones

27. URIC ACID They are more common in man than women. They may occur in people who have gout or those who are undergoing chemotherapy. These kinds of stones occurs when the urine is too acidic. Diets rich in purines should be avoided. STRUVITE This is more common in females than in males and are mostly seen in women with urinary tract infection. The size of the stones are large and are formed due to kidney infection. Treating the underlying infection will help in the prevention of such stones.

28. CYSTINE The most rare form of stones in kidney. Occurs in both males and females who have genetic disorder cystinuria. Cystine in the body leaks from the kidney into urine. RISK FACTORS Family history/personal history. Age above 30 years. Male> Females. Dehydration Obesity Diet Digestive diseases History of digestive disorders Rental tubular disorders. Cystinuria Urinary tract infectio

29. Dietary Management: Calcium phosphate: High bran diet leads to a reduction in urinary calcium. Bran consists phytic acid, a substance known to bind calcium & reduce its intestinal absorption. Rice bran be quite effective in preventing recurrent urinary calculus disease. Water: Aim should be 3-litre per 24-h. Soft water is always better than hard water. Hypercalciuria predisposes to stones the urinary calcium should be controlled. Restrict calcium rich intake: Milk & products, custard milk, youhurt. Medications which contain calcium raise urinary calcium. Acidifying the urine.

30. Calcium & Phosphorus Restricted Diet: The maintenance level of calcium & phosphorus. Allowed Restricted Cereals Bajra, barley, millets, parboiled rice, rice flakes, soyabean flour, whole wheat flour, wheat bran, rice bran Corn meal, corn starch, flakes, maize tender, white rice, tapioca, Pulses & legumes Lentil, dried peas, red gram dhal Bengal gram, black gram dhal, field beans, green gram, horse gram, kesari dhal, rajmah, soyabean, dry beans

31. Allowed Restricted Leafy vegetables Asparagus, bottle gourd leaves, brussels, lettuce, mint, mustard leaves, onion top Beet greens, Bengal gram leaves, broccoli, cauliflower greens, celery leaves, colocasia leaves, curry leaves, drumstick leaves, fenugreek, knol-khol greens, neem leaves, radish leaves, parsley, spinach, soyabean sprouts, tamarind leaves, turnip greens, watercress. Roots & tubers Mango, ginger, onion small, potato, radish, sweet potato, turnip, yam Beet roots, carrots, colocasia, onion big Nuts & Oilseeds Cashewnut, groundnut, pistachio nut, walnut, linseed seeds Almonds, coconut, gingelly seeds, mustard seeds, sunflower seeds. Condiments, Spices Cardamom, green chillies, green peppers, garlic, ginger, nutmeg rind, turmeric Hing, dry chillies, cloves, coriander, cumin, fenugreek seeds, omum, tamarind pulp, salt.

32. Oxalate Stones: Patients with hypercalciuria are over-absorbing dietary calcium they will also tend to over-absorb oxalate, especially when on a low calcium diet. Important to advise restriction of the oxalate-rich foods. Rhubarb, spinach, beetroot, beans, tomatoes, cocoa, dried figs, plums, potatoes, tea, strawberries, nuts & chocolates. Large doses of vitamin C are forbidden.

33. Foods With High Oxalic Acid Content: Almonds Amla Beans Beet greens Brinjal Cabbage Cashew nut Celery Chocolate Coriander leaves Curry leaves Drumstick leaves Figs, dried Gingelly seeds Grapefruit Horsegram Khesaridhal Mango, green Mustard leaves Neem leaves Parsley Pepper Plantain flowers Plantain, green Plums Poppy seeds Potatoes Radish Ragi Rhubarb Sesame seeds Soyabean Spinach Tamarind leaves Tapioca Tomatoes

34. Foods Containing Traces Or No Oxalic Acid: Apple Apricots Ashgourd Asparagus Bajra Banana Bengal gram Bitter gourd Blackberries Butter Buttermilk Carrots Cauliflower Celery Cherries Corn Cream Eggs Gooseberries Eggs Grapes Green chillies Guavas Jack fruit Ladies fingers Leeks Lemon peel Lentil Lettuce Litchi Maize Mango, ripe Meat Melons Milk Mint Mushrooms Onions Oranges Pears Peppers Pickels Pineapple Potatoes Rasberries Rice Sitaphal Snake gourd Starches Strawberries Sugars Turnips Wheat cabbage

35. Uric Acid Stones: Increasing urinary volume Reducing dietary purine intake Potato diet Low purine diet: Coffee & tea contain methylated purines. Intake of protein may be restricted to maintenance level, i.e to 1g.per kg of body weight. Vegetables, fruits, fruit juices, milk, buttermilk, skim milk, cheese, curd, eggs, cereals, nuts. Avoid: Meat, fish, poultry, seafoods, lentils & pulses, spinach, asparagus, cauliflower, mushrooms, alcohol, fats.

36. High Acid Diet: When the calculi consists of phosphate the urine should be kept acid. Urine can be changed from alkaline to acid reaction. Milk can be used not more than half liter. A liberal fluid intake is important. Salt may be used in moderation. Fruits & vegetables so selected should not contribute more than 25ml of base daily.

37. Allowed Avoid Vegetables Cauliflower, knol-khol, brussels sprouts, cabbage, broad beans, asparagus, pumpkins, turnips, tomatoes, mushrooms, fresh or canned corn, cranberries Carrots, tapioca, spinach, beet greens, fenugreek, kale, kohlrabi, potatoes Pulses & Legumes Bengal gram, dried peas, khesari dhal Bengal gram whole, moong, urad dhal, koolthi Cereals Whole grains Ragi

38. High Alkaline Diet: In case of oxalate & uric acid stones urine has to be kept alkaline. Alkaline producing foods such as fruits, vegetables & milk, while acid producing foods like meat, eggs & cereals are restricted. Allowed Avoid Vegetables Carrots, tapioca, beet greens, chard, kale, kohlrabi, potatoes, sweet potatoes. Cauliflower, knol-khol, brussel-sprouts, cabbage, broad beans, parwal, asparagus, pumpkins, corn, lentils, turnips, tomatoes, mushrooms Pulses & Legumes Soyabean, koolthi, chana, urad Bengal gram dhal, masor dhal, dried peas, khesari dhal. Cereals Ragi, any other whole grain, not more than half cup Rice Fruits Citrus fruits, bananas, apples, muskmelons, cantaloupe. Cranberries, plums, prunes.

39. Foods Rich In Calcium, Phosphates, Oxalates & Purines: Calcium Phosphates Oxalates Purines Leafy vegetables, milk & milk products, small fish, prawns, crabs, ragi Whole cereals, bran, legumes, nuts, oilseeds, banana, carrot, meat, fish, egg, milk products, cheese, organ meat, soft drinks Leafy vegetables, grapes, tea, chocolates, cocoa, coffee, cola drinks, beef, cashewnuts, beetroot, yam. Meat, fish, animal tissues & organs(kidney, liver, brain, heart)

40. Fluids: Water is rightly called the “life savior” Drinking adequate water is the best & most natural way to flush out stones from the body. Water also help body to stay fit & hydrated. Adequate fluids like water-3liters, in order to ensure the passage of 2000ml of urine per day. Dilute urine avoids concentration of solids & also tend to make the urine neutral. Simplest guide to see that the urine when voided is very light in colour.

41. Barley Water: It can create required bladder pressure and make the kidney stone elimination process easier. Helps in maintaining the pH balance in our body by making it alkaline. It eventually restricts the production of kidney stones. It plays a key role in nourishing our kidneys and keeping them healthy. Helps in cleansing the kidneys by flushing all sorts of toxic materials out of the body through urine. Rich in dietary fiber, which is required for reducing the excretion of calcium in our urine.

42. Provides enough vitamin B6 to our body, which breaks down the calcium oxalate masses formed inside our kidneys. Contains lots of magnesium, which speeds up the dissolution of calcium oxalate crystals. Evidence: In 2012 Shah J G concludes that ethanolic extract of Hordeum vulgare seeds as an  antiurolithiatic and antioxidant agent.

43. Limit Salt: High sodium levels in the body, can promote calcium buildup in urine.

44. Plantain Pith Juice: In Ayurveda, it has been stated that the banana stem juice is good for passing or dissolving kidney stones. Banana stem juice has diuretic properties and reduces the size of the kidney stones. Evidence: V. Kalpana Devi concludes that reduction in urinary oxalate by Musa stem kernel extract in rat lithogenesis and are likely to contribute to the antilithic action of the herbal plant. Poonguzhali states that banana stem extract family may be a useful agent in the treatment of patients with hyperoxaluric urolihiasis.

45. Coconut Water: Drinking a lot of coconut water will increase the body’s urine output. Apart from this, the potassium present in this refreshing drink will alkalinize the acidic urine and also dissolve the stones.

46. Ashgourd Juice: Helpful in frequent urinary tract infections and suffer with symptoms like burning micturition or difficulty in urine & in renal calculi According to Ayurveda, ash gourd or Kushmand balances pitta dosha (heating factor) in body and provides cooling effects. This helps to break down the stone and remove it out easily. It allows easy passage of urine.

47. Wheatgrass Juice: Help to expel minerals & salts from the urinary tract, preventing them from crystalizing. It contains compounds that increase urine production.

48. Citrus Fruits: Citrus fruits are very helpful in breaking down kidney stones. Citric acid binds with calcium in the urine, thus preventing the formation of calcium oxalate which leads to oxalate kidney stone formation. Citrus fruits such as lemons should be a part of daily diet.

49. Apple Cider Vinegar: The chemical composition of apple cider vinegar helps to soften and dissolve the kidney stones. The acids present in ACV will prevent stones from forming.

50. Grapes: They contain a high quantity of water and potassium – a vital ingredient for dissolving the stones in the kidneys. These fruits are also considered best during such a time because they contain low quantities of sodium chloride and albumin.

51. Watermelon: Watermelon contains the highest amount of water. It will help in flushing out the stones easily without causing much pain. The potassium content of this fruit will fasten the process of eliminating even small stones. Watermelon seeds: They are strong detoxifiers, especially for the renal system. All the accumulated waste is flushed out from the body along with the kidney stones.

52. Dandelion Root: The potassium present in it is mainly responsible for dissolving the kidney stones. Dandelion root is also a natural diuretic. Dandelion root can interact with blood pressure and diabetes medication. Sanskrit name: Dugdhapheni .

53. Kidney Bean: Excellent remedy for flushing out kidney stones from the body. Craneberry Activity: Diuretic Indications: Bladder infections, Nephrosis, Pyelonephrosis Dosage: 90ml fruit juice/day. Evidence: Acoording to McHarg T in 2003 Craneberry juice has antilithogenic properties & deserves consideration as a conservative therapeutic protocol in managing calcium oxalate urolithiasis.

54. Blackberry Lily(Belamcanda chinensis) Activities: Diuretic Indications: Dysuria Dosages: 2.5-9g root in decoction

55. Prevention Of Renal Calculi: Reduce the body weight to ideal body weight. Advise patients to drink enough water to bring the urinary volume up to at least 2 liters /day. Limit animal protein intake, the total of proteins deriving from meat, fish, chicken, eggs, milk and cheese should not exceed 50-60 g/day. Avoid excessive carbohydrates. Refined ones, in particular, should not exceed 20 g per day. Advise patients to avoid excess of saturated fats. Advise patients to limit sodium chloride consumption to no more than 6 g/day.

56. 7. Consume milk, yogurt and cheese regularly, but not excessively. 8. Consume fruit and vegetables daily, taking care to avoid foods containing very high quantities of oxalate. 9. Do not give patients vitamin D supplements; allow, if requested, vitamin C supplements of not more than 1500 mg/day, avoid vitamin B6 deficiencies. 10. Use fresh or frozen products, not prepacked or precooked foods.