Renal Diseases and Disorders

I. Structure of Kidneys
Nephron approximately one million in each kidney
A. Glomerulus capillaries; Bowmans capsule
B. Proximal convoluted tubule major nutrient reabsorption
C. Loop of Henle water and sodium balance
D. Distal tubule acid-base balance
E. Collecting tubules water reabsorption

II. Hormones
A. Vasopressin (anti-diuretic hormone or ADH)
1. From the pituitary glands
2. Exerts pressor effect; elevates blood pressure
3. Acts on the distal and collecting tubules to reabsorb water

B. Renin
1. Enzyme secreted by the renal cortex
2. Secreted in response to:
a. Decreased sodium intake
b. Sodium loss
c. Hypovolemia or decreased fluid volume
3. Acts on angiotensin (protein substrate from the liver) to form angiotensin I & II

C. Angiotensin II active pressor substance
1. Increases heart beat
2. Retention and reabsorption of Na
3. Excretion of K

D. Aldosterone
1. Acts on distal tubule
2. Retention and reabsorption of Na
3. Excretion of K

E. Erythropoietin stimulates erythropoiesis in the bone marrow
*a hormone secreted by the kidney which acts on stem cells of the bone marrow

F. Activation of vitamin D3 to its active metabolite 1,25 dihydroxycholecalciferol
1. Under the influence of parathyroid hormone (PTH)
2. Absorption of Ca and P for bone mineralization

III. Renal Functions
A. Filtration red blood cells and protein remain in the blood
B. Reabsorption 100% glucose and amino acids; 80-85% water, Na, Cl, K
C. Secretion additional ions to maintain acid-base balance; hormones that control B.P. blood components
D. Excretion wastes, urea, excess ketones, excess water

IV. Renal Solute Load solute excreted in 1L urine
*mainly measures urea (nitrogen) and electrolytes (Na)

V. Laboratory Tests in Renal Diseases
A. Decreased glomerular filtration rate (GFR), creatinine clearance
B. Elevated serum creatinine, BUN

*The manifestations of renal disease are direct consequences of the portions of the urinary tract system that is most
affected. These manifestations include:
1. Glomerular diseases
2. Acute renal failure (ARF)
3. Tubular defects
4. End-stage renal disease (ESRD)
5. Renal stones

Acute Renal Failure sudden shutdown of renal function following metabolic insult or traumatic injury to normal kidneys

Renal failure the inability of kidneys to carry out their many functions such as excretion of more than 200 waste
products, excess fluid and drugs or poisons; regulation of blood pressure; maintenance of acid-base balance and
bone health; and production of the hormone erythropoietin which stimulates red blood cell production

Consequences of Renal Failure:
a. Edema d. Bone disease
b. Uremia e. metabolic acidosis
c. Anemia

I. Characteristics of ARF
- Sudden reduction in glomerular filtration rate (GFR) and an alteration in the ability of the kidney to excrete
metabolic waste excreted daily

II. Etiology: severe injury as in burns, traumatic shock; infections such a peritonitis; toxic agents; obstruction

III. Categories
A. Prerenal (hypoperfused kidney) reversible; nutrition intervention not required
B. Postrenal (obstructed kidney) reversible; nutrition intervention not required
C. Intrinsic renal disease (diseased kidney) damage to glomerular and tubular epithelium
Acute tubular necrosis (ATN) most common form of intrinsic renal disease
Three phases
1. Oliguric
2. Diuretic
3. Convalescent

IV. Symptoms: uremia, metabolic acidosis, fluid and electrolyte imbalance
-often associated with oliguria or anuria, but can occur with normal urine flow

V. Nutritional Care
Aim: to reduce the accumulation of uremic toxins, control electrolyte abnormalities, and correct fluid retention;
maintain nutritional status with or without dialysis treatment


Diet
1. Protein (0.5g/kg BW, high biologic value); increase as GFR returns to normal; should not be severely
restricted with temporary dialysis
For children: protein should never be restricted below 1.0-2.0g/kg BW of high biologic value
2. Kilocalories high
35-45 kcal/kg minimum
50-60 kcal/kg maximum to attain nitrogen balance
For children: 1.5-2 times normal energy expenditure
3. Sodium: 3 g or vary according to fluid retention and hydration status
4. Potassium: 30-50 mEq/day
5. Phosphorus: depends on frequency of dialysis treatment
6. Replace fluid output plus 500 ml

Chronic Renal Failure (CRF) or Chronic Kidney Disease (CKD) this results from the progressive deterioration of
kidneys over a period of months or years, with permanent impairment of renal functions

I. Etiology
a. Glomerulonephritis and other renal vascular and tubular disease
b. Diabetes mellitus
c. Exposure to toxic substances
d. Infections, venereal disease
e. Congenital abnormalities of both kidneys

II. Symptoms: anorexia, weakness, weight loss, nausea, vomiting, anemia, uremia, malnutrition

III. Nutritional Care
Aim: to meet nutritional requirements, minimize uremic complications, maintain acceptable blood chemistry,
blood pressure, and fluid status

Diet
1. Energy for CRF without dialysis
a. Adults below 60 years of age: 35 kcal/kg DBW to meet requirements
b. Adults above 60 years: 30-35 kcal/kg DBW
c. Underweight patient: 40-45 kcal/kg DBW
d. Obese patient: 20-30 kcal/kg DBW
2. No added salt or 2-3 g Na with edema
3. Protein restricted when GFR falls
GFR Grams protein/kg/day
15-20 <1
10-15 0.7
4-10 0.55-0.6
4. Amino acid supplements
a. Essential amino acids (EAA)
b. Keto-analogues of essential amino acids to prevent malnutrition
5. Fluid intake balanced with output
6. Potassium and calcium restriction varies
7. Give supplemental minerals (Ca, P, Fe, if needed with erythropoietin therapy) and vitamins (niacin,
thiamine, riboflavin, pantothenic acid, pyridoxine, biotin, folic acid, vitamin B12, and vitamin C)


Chronic Renal Insufficiency partial or mild kidney failure characterized by less than normal urine excretion
Laboratory findings indicative of early renal damage:
a. Hypoalbuminemia c. a decrease of glomerular filtration rate
b. Albuminuria

Nutrition care
Aim: to slow the progression of kidney disease and possibly delay the need for maintenance dialysis

Diet (Predialysis diet)
1. Protein restricted: 0.6-0.6g/kg IBW, high biologic value depending on creatinine clearance to help preserve
residual renal function
2. Phosphorus restricted: 5-10mg/kg IBW to help retard progression of renal disease
3. Energy
a. Normal weight: 35 kcal/kg IBW
b. Underweight/catabolic: 45 kcal/kg IBW
c. Obese: 20-30 kcal/kg BDW
*adequate kilocalories to maintain somatic and visceral protein stores and body weight
4. Fat: >30% of total kilocalories; PUFA; primary energy source
5. Sodium restricted: 1000-3000 mg
6. Potassium not restricted unless serum K is elevated and urine output <1L/day
7. Calcium is high: 1200-1600 mg/day
8. Fluid: balance intake with urine output if edema or CHF is present

Glomerulonephritis inflammatory disease of the kidneys affecting chiefly the glomeruli

I. Types
a. Acute glomerulonephritis (AGN) common in children 3-10 years old
b. Chronic glomerulonephritis (CGN)

II. Etiology: previous streptococcal infections of the respiratory tract (tonsillitis, sinusitis, pneumonia, influenza)

III. Symptoms: hematuria, proteinuria, edema, hypertension, renal insufficiency, or failure

IV. Nutritional Care
Aim: to provide optimal nutrition support

Diet
1. Protein: controlled (0.5g/kg BW) to minimize nitrogen retention where there is anuria
- protein increased above normal (RDA + amount of protein in the urine) when there is albuminuria
2. Calories: adequate to maintain DBW: reduce catabolism; prevent starvation ketosis
3. Sodium restriction (500-1000 mg/day) due to hypertension and edema
4. Potassium: restricted if there is oliguria
5. Fluids: restricted (intake equals output)

Stages of chronic kidney disease
Stage Creatinine Therapy
1. Early
2. Latent
3. Emergent
4. Imminent
5. ESRD
<1.5 Female; <2.0 Male
1.5-2.5
2.5-3.5
3.5-5.0
>5.0
Reverse progression
Stop progression
Slow progression
Prepare for ESRD
Dialysis/transplant

Nephrotic Syndrome (NS) or Nephrosis
*a group of symptoms characterized by marked proteinuria, hypoalbuminemia, edema, and hyperlipidemia
*characterized by inflammation of the capillary loops of the glomerulus
*the primary manifestation of these diseases is hematuria (blood in the urine) due to the capillary inflammation that
damages the glomerular barrier to blood cells
*presence of hypertension and mild loss of renal function

I. Etiology
-progressive glomerulonephritis; associated with diabetes, connective tissue disorder or collagen disease, drug
reactions from exposure to heavy metals; allergic reaction to bee sting

II. Characteristics
1. Massive edema ascites, pedal edema, striae (stretch marks) on the skin of the extremities
2. Massive proteinuria as much as 30 g protein/24 hours lost in the urine
3. Hypoalbuminemia due to excretion of albumin
4. Elevated serum lipids cholesterol >300mg/dL
5. Hematuria and anemia due to RBS and iron losses
6. Sodium retention
7. Fatty liver as a result of malnutrition
8. Loss of appetite or anorexia
9. Vitamin D deficiency

III. Nutritional Care
Aim: to control the major symptoms of edema and malnutrition that result from the massive protein loss

Diet
1. Protein: 0.6 g/kg/day; 80% from high biologic value and 1 gm protein to counteract nitrogen deficits and
replace losses
2. Kilocalories: high (35-50 kcal/kg) to promote positive nitrogen balance; tissue synthesis
3. Sodium: restricted (1-3 g) to reduce edema; to help initiate dialysis
4. Iron and vitamin supplements may be helpful
5. Fluid intake: balance with your fluid output; if less than 1L/day
6. Cholesterol (<300 mg) and PUFA and saturated fat ratio is low (1:1) to reduce elevated serum lipids
7. Fat: 30-35% of total calories
8. Vitamin and mineral supplements: thiamine, riboflavin, niacin, vitamin D, Ca, Zn, Fe

Pyelonephritis or Urinary Tract Infection (UTI) inflammation of both the kidney and its pelvis
*a bacterial infection of the kidney
*in chronic cases, cranberry juice is used to reduce bateriuria; cranberry juice contains concentrated tannins or
proanthocyanidins which inhibit the adherence of Escherichia coli bacteria to the epithelial cells of the urinary tract

I. Predisposing Factors to the Formation of Renal Stones
a. Physical changes in the urine: urine concentrations; change of pH from 5.85 to 6
b. Organic stone matrix: provides the core or nucleus (nidus) which acts as a seed crystal for precipitation
-sources are bacteria from recurrent urinary tract infection (UTI), renal epithelial tissue, calcified plaques
(Randalls plaques)

II. Symptoms: severe pain, general weakness, fever

III. Treatment
a. Urine examination, chemical analysis
b. Change urine pH to increase acidity or alkalinity, depending on stone composition
*an acid-ash diet can increase the acidity of the urine and inhibit bacterial growth

IV. Diet
*high fluid to dilute urine; prevent formation of stones

Renal Calculi (Kidney Stones)
*Kidney stones form when stone constituents become concentrated in the urine and form crystals that grow
*Urolithiasis formation of urinary calculi or insoluble constituents in the urine that precipitate as stones in the
urinary passages
*excessive intakes of sodium, calciu, oxalates, and protein tend to increase the risk for stone formation

Composition of stones
a. Calcium stones characterized by excretion of normal or excessive (hypercalciuria) amounts of
calcium in the urine
b. Uric acid stones this is often associated with gout; uric acid stones form when the urine is persistently
acid and/or contains excessive uric acid
c. Cystine stones this is a consequence of cystinuria (an inhibited disorder of amino acid metabolism);
inability to metabolize the amino acid cysteine
d. Magnesium stones this is associated with recurring urinary tract infections; stones of magnesium
ammonium phosphate (struvite) are formed

Urinary risk factors for stone development
Increased Risk Decreased Risk
Low urine volume
Oxalate
Uric acid
Sodium
Acid pH
Stasis
Calcium
High urine volume and flow
Citrate
Glycoproteins
Magnesium

Dietary factors associated with risk of calcium stones
Increased Risk Decreased Risk
Animal protein
Oxalate
Sodium
Calcium
Potassium
Magnesium
Fluid intake
Fiber
Vitamin B6

I. Factors leading to calculi formation
a. Hyperfunction of the parathyroid gland
b. Vitamin A deficiency
c. Systemic infections
d. Inadequate fluid intake
e. Metabolic distrubances
f. Prolonged bed rest
g. Obstruction in the renal flow, producing stasis of the urine
h. Excessive vitamin C intake can result in oxalate stone formation
II. Treatment
a. Liberal fluid intake to dilute the urine and prevent concentration of stone-forming substances
-ensure a minimum urine output (about 2L/day for women; 2.5L/day for men) by consuming 3L of fluids/day
b. Control urine for acidity or alkalinity based on stone type

III. Types of Stones and Diet
1. Calcium stones: calcium oxalate, calcium phosphate
Diet: Low calcium (400mg), low oxalate (40-50mg/day)
Limit calcium sources if stones are caused by excess calcium: omit milk, cheese, sardines, shellfish,
calcium-rich vegetables
Limit oxalate sources: fruits (berries, grapes, figs, rhubarb, tangerines); (beans, beets, celery, greens,
okra, spinach, peepers, sweet potatoes, tomatoes); beverages (cocoa, tea, beer); nuts (almonds,
cashews, peanuts, nut butters); and grains ( (wheat germ, soy products including tofu, grits)

2. Uric acid stones
Diet: Low purine; alkaline-ash vegetable, milk, fruits

3. Cystine stones
Diet: Low methionine omit milk, eggs, fish and cheese; strictly limit meat; alkaline-ash

Hemodialysis the removal of toxic materials from metabolism from the blood and body fluids by mechanical means; uses
an artificial kidney and extracorporeal dialysis method

I. Characteristics
A. Minimal protein losses into the dialysate
B. Loss of amino acids 5 to 8 g/day
C. Loss of water-soluble vitamins

II. Nutritional Care
Aim:
A. To provide sufficient protein to replace amino acids and nitrogen lost during dialysis, to maintain nitrogen
balance, and to prevent excessive accumulation of waste products
B. Provide adequate kilocalories to prevent weight loss
C. Limit Na, K, P and fluids

Diet dietary recommendations are based on the frequency of dialysis, renal function, and size of the patient
1. Protein 1-1.2g/kg BW, adjusted according to dialysis treatment
2. Kilocalories: adequate to maintain weight, mostly supplied by non-protein kcals from fats, oils, and simple sugar
3. Sodium: 60-120 mEq to control HPN and edema
4. Potassium: 60-70 mEq to control hyperkalemia
5. Fluid limited to an amount equal to urine output plus 1000mL (sources include beverages and foods that are
liquid at room temperature, water content of non-liquid foods, water from oxidation of food)
6. Phosphorus: restricted to prevent hyperphosphatemia; use of calcium carbonate or calcium acteate (taken with
meals) as phosphate binders
7. Calcium supplements if with hypocalcemia
8. Cholesterol- and fat-controlled, preferably MUFA and PUFA to control hypercholesterolemia and/or
hypertriglyceridemia

III. Supplementary Management
A. Intradialytic Parenteral Nutrition (IDPN) for continued weight loss and decline in albumin levels
B. Human recombinant erythropoietin (EPO) a drug recently introduced for the treatment of anemia in ESRD

Peritoneal Dialysis the removal of toxic materials from metabolism from the blood and body fluids by mechanical means,
and uses the peritoneal membrane

I. Characteristics
1. Protein losses (9g/day)
2. Loss of amino acids (2-4 g/day)
3. Loss of water-soluble vitamins

II. Types
1. Continuous Ambulatory Peritoneal Dialysis (CAPD)
a. Self-dialysis technique: machine not required
b. Patient performs exchanges of dialysate into the peritoneal cavity 4 to 5 times
c. Advantage: mobility; liberalized diet; increased sense of well-being
d. Disadvantage: risk of peritonitis with hospitalization

2. Continuous Cyclic Peritoneal Dialysis (CCPD)
a. Home dialysis technique; requires an automated machine to maintain nitrogen balance
b. Patient performs five to six 2L exchanges (1.5 hours duration) at night; one 1L exchange
c. Advantage: less risk of peritonitis

III. Nutritional Care
1. Provide sufficient protein to replace large losses in the dialysate and to maintain nitrogen balance
2. Prevent excessive weight gain
3. Control hyperlipidemia, hypertension, edema, hyperphosphatemia, and renal osteodystrophy

Diet
1. Protein: 1.2-1.5g/kg BW to replace losses, maintain nitrogen balance
2. Kilocalories computed as:
a. Dietary kcal = TER kcal from dialysate
b. Kcal from dialysate = Glucose concenteration (g/L) x 3.7 kcal/g x 0.8 x volume (L)
3. Sodium: 90-120mEq for CAPD; not restricted in CCPD
4. Potassium: 60-70mEq if serum P is elevated; not restricted in CCPD
5. Calcium supplement as needed
6. Simple CHO restricted if with hypertriglyceridemia and overweight
7. Cholesterol and saturated fat low if with hypercholesterolemia
8. Fluid restriction not necessary; up to 2L may be tolerated