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LALALA - LALA

NUTRITIONAL MANAGEMENT OF RENAL DISEASES


DISEASE

GOALS

Acute
Glomerulonephritis
Due to the deposition of
immune complexes in the
glomerulus

1. Reduce
nitrogen levels

SSx: hematuria, oliguria,


hypertension, edema,
proteinuria

3. Spare CHON
for tissue repair

2. Reduce
BP/edema

ENERGY
HIGH CALORIE
DIET (35kcal/kg BW)
60% CHO
30% Fat

Chronic
Glomerulonephritis

2. Prevent/treat
edema

If with proteinuria:
replace the losses,
please

MAINTAIN GOOD
NUTRITIONAL
STATUS (2000
3000kcal/day)

Try to remember the sx


for each pathology
because it makes it so
much easier to memorize
the goals :D

1. Provide
adequate calories
to spare proteins
2. Reduce
severity of edema
3. Improve serum
albumin and
control
malnutrition

FATS/FLUIDS
Fluids
If edema is mild, no
need for restriction.

(+) potassium retention:


restrict K to 1g/day

Severe cases of
edema: give 500ml
for insensible losses

CHON: 40 60g/day
Impending uremia:
30 40g or
0.5g/kgBW (HBV
proteins)

If needed: Vitamin D3, Ca,


Fe, multivitamins
Remember: 2NaK1
(TUNAKI)
2 3g Na, K 1g :D

Kids with uremia:


Vitamin D3 is needed

Promote growth &


appetite

We dont restrict CHONs


because in uremia there
is increased breakdown
of CHON into glutamine
& glutamate

3. Maintain
optimal nutrition
state

Nephrotic Syndrome
SSx:
Heavy proteinuria
Hypoalbuminemia
Anasarca/edema
Hyperlipidemia/lipiduria
(low CHON triggers the
body to use lipids for
energy instead)

VITAMINS/MINERALS
(+) edema/HPN: restrict Na
intake to 2 3 g daily

Kids: 500 1000mg

Kids: 50% of RNI

4. Improve renal
fx and prevent
complications
5. Kids: avoid
growth retardation
1. Prevent/treat
uremia

PROTEIN
RESTRICT!
CHON: 0.6g/kgBW

50% in the form


of high biologic
value CHONS

HIGHER than HIGH


CALORIE DIET!
Adults: 50
60kcal/kgBW
Kids: 60
100kcal/kgBW
Aim for a
kcal:nitrogen ratio of
150:1 to prevent N
wasting

Protein restriction is
NOT recommended
in CHON
malnutrition,
neoplasm, &
infections
1.0g/day of HBV
CHONs for EACH
gram of urinary
CHON loss (easy
peasy, 1 is to 1 :D)
Kids: Just give them
their RDA

(+) edema: start with a Na


restriction of 500mg
When edema is gone:
1500mg/day to 2000
3000g/day (tip: same as
acute GN :D)
K depletion due to diuretics
& steroids: give high K
foods (banana, orange)

Fat
30% of total calories
(same as acute GN
again!)
Use linoleic acid
(lowers LDL, raises
HDL) and omega 3
fatty acids (lowers
TAGs by inhibiting
LDL & HDL
synthesis)

Ca chloride: 1 2g/day
To prevent negative Ca
balance, hypoCa, tetanic
convulsions w/ ACTH tx

4. Control
lipidemia

Replace Zinc, Vit C, folacin


prn

Acute Renal Failure


Pathology: destruction of
tubules which are
responsible for
concentrating urine
Ssx: oliguria/anuria,
azotemia (recent onset),
decreased GFR

1. Maintain
optimal nutritional
status
2. Reduce
accumulation of
uremic toxins
3. Correct fluid
electrolyte
imbalance
4. Support tissue
healing
5. Control
infection

35 50kcal/kgABW
To provide (+)
nitrogen balance
under stress of ARF,
to spare proteins

0.5 0.6g/kgABW
(not less than
40g/day)
Increase as GFR
normalizes

(+) vomiting &


diarrhea: parenteral
administration of
glucose, essential &
NE amino acid
solution (Aminosyn) =
reduces CHON
catabolism & urea
production

(+) dialysis: 1
1.5g/kgABW/day

Giving CHO alone will


only decrease CHON
breakdown by 50%:(

(-) dialysis: protein


free diet

Sodium

Anuric oliguric
phase: 500 1000mg/day

Diuretic phase:
replace losses based
on urinary Na levels,
edema and freq of
dialysis
Potassium
Tissue destruction can
cause K overload

AO phase:
1000mg/day

D phase: same as Na
Phosphorus & Ca: if
needed

Fluid & electrolytes


Intake = net body
output
Assess fluid rqmt
DAILY

Anuric
oliguric phase:
replace output
+ 500ml from
previous day

Diuretic phase:
large amounts
of fluid
Fat
No modification

LALALA - LALA
Chronic Renal Failure
Uremia (prolonged
azotemia + constellation
of clinical signs &
biochemical
abnormalities)

1. Maintain
optimal NS &
stimulate px well
being
2. Provide
adequate energy
intake
3. Regulate
CHON intake to
minimize uremic
toxicity, prevent
CHON
catabolism,
provide for growth
of kids, retard
progression of RF
4. Regulate fluid
intake to balance
fluid output
(regulate Na and
K)
5. Provide vitamin
& mineral supp

Adequate to maintain
or achieve DBW and
prevent CHON catab
= 35kcal/kgBW/day
(if youll notice, its
almost the same as
energy rqmt in acute GN
and ARF:D)

Kids: 100kcal/kgBW
(ideal); 80kcal/kg
(realistic)
HIGHLY
INDIVIDUALIZED!
Stage 1 CRF:

No diet
restrictions yet
but if w/ HPN
limit Na and
caloric intake
Stage 2 CRF:

CHON & calorie,


Na, K, P
restrictions
NOT necessary
Stage 3 CRF:

STRICT diet
modifications

Nephrolithiasis
Characterized by renal
colic, hematuria, stone
formation

1. Prevent
recurrence in
calculi prone px
2. Identify
predominant
components and
modify diet based
on it
3. Increase
secretion of salts,
dilute urine ->
increase fluid
volume to at elast
2L per 24 hours

Stage 4 CRF:

Nutrients strictly
monitored
Acid ash diet

Found in
cranberries,
plums, prunes,
meat, bread
Alkaline ash

Milk, fruit,
veggies
Choice between the
two will depend on
stone composition

Urea & nitrogen in


blood: gauge of
severity of renal
damage
RESTRICT!
CHON: 0.55
0.60g/kgBW/day
May slow down
progression of CRF
Level of daily CHON
intake may also be
based on residual
renal function
(creatinine clearance)
* see box below

*Creatinine clearance &


CHON intake
5 10ml/min = 15 25g of
HBV CHON
10 15ml/min = 30g
15 20ml/min = 40g
20 30ml/min = 50g

Advanced renal failure:


Na = 1 3g (40 130meq)
+ 1500 3000ml of fluids
to maintain Na/water
balance
If with severe Na wasting,
increase intake to 6 8
g/day
K = should not exceed
70mEq (2730mg)/day
Supplement water soluble
vitamins, include biotin

Cofactor in
carboxylation
reactions

Calcitriol supp also


needed due to kidney
failure

Increase Ca to 1 3
g/day

Restrict phosphorus
from 45 65mEq
(700 1000mg/day)

Kids: DO NOT reduce


CHON below 1
1.3g/kgBW/day; at
least 75% must be
HBV

Ca oxalate stones:

Restrict Ca to
<1000mg

Normal Na intake (not


high); with thiazides

Fewer dairy products,


nuts, fish, green leafy
veggies, peanut
butter

More fiber (source of


phytic acid)

Less vitamin D

1. Prevent
deficiency and
maintain good
nutritional status
2. Control edema
& electrolyte
imbalance

HIGH FLUID
INTAKE! (8OZ
hourly while awake)

Cystine stones:

Low cystine,
methionine, cysteine
diet

CHON lessened, not


restricted too much

Usually hereditary

Alkalinize urine w/ D
penicillamine

Patients on Dialysis

Fluid & electrolytes


Optimal intake: 1500
2000ml/day
Satisfactory: 500
700ml (2 3 cups)

Uric acid stones:


Result from purine
metab
Reduce high purine
foods (sardines)
Alkalinize urine with
citrate or bicarbonate

K restriction
HD:

30 35 kcal/kg
DBW/day (weight
maintenance).

25 30 (weight
reduction),

40 50 (weight gain)

Assess ability to
handle Na and
water frequently
Hemodialysis (HD)
Na: 2000
3000mg/day
Fluid: 500

LALALA - LALA
3. Prevent/retard
devt of renal
osteodystrophy
4. Enable px to
eat a palatable
attractive diet

PD:

25
35kcal/kgDBW/day
(maintenance)

30 50
kcal/kgDBW/day
(repletion)

20 25 (reduction)

35 if (+) DM
Ca, Phosphorus, Vitamin
D

Control intake to
avoid aggravation of
disease
(hypoparathyroidism,
phosphate retention,
hypocalcemia)

Start supplementation
of Ca early to prevent
hyperparathyroidism

Phosphate intake
lowered (use of PO4
binding resins
Amphogel
Calcium
HD: 1000 1800mg/day
PD: same as for
hemodialysis
Phosphorus
HD: <17 mEq or 800
1200mg/day; keep serum
level at max of 4
6mg/100ml
PD: < less than
hemodialysis;
~1200mg/day
Keep serum level at max of
6mg/100ml

Vitamin D
Give when hypocalemia is
severe or causing
osteomalacia

Phosphate binders:
impt during admin of
large doses of Vit D

Routine drug is
available as calcitriol
(Rocaltrol)
Give vitamin supplements!

750ml/day + daily
urine output (~ 750
1500ml/day)
Peritioneal dialysis
(PD)
Na: individualized
based on BP &
weight
Fluid: ~ 2000
3000ml/day for
continuous dialysis;
if intermittent: same
as for hemodialysis