Nutritional Management

on Renal Disease

Nurpudji A Taslim,
Nutrition Department
School of Medicine Hasanuddin University
Makassar 2006

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Renal Function
1. WASTE FORMATION & HOMEOSTASIS
- UREA
- REGULATION OF OSMOLALITY AND FLUID
- REGULATION OF Na & K
- REGULATION OF H+
- REGULATION OF Ca & PO4- BALANCED
2. PROTEIN EXCRETION METABOLISM
3. ENDOCRINE
- RENIN SINTHYSIS
- ERYTHROPOETIN SINTHYSIS
- ACTIVATIONI 25 OH CHOLECALCIFEROL
- ADH ACTION
- ALDOSTERON

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DIAGNOSTIC TEST
1. BLOOD
- CREATININE
- BUN (BALANCED URINE NITROGEN)
- CCT (CREATININE CLEARANCE TEST)
2. URINALISIS
- UUN ( Urea Urine Nitrogen)
-PROTEIN ALBUMIN
3. VISUAL
- IVP (intra venous pyelography)
- ARTERIOGRAM
- BIOPSI
- CT-SCAN
-SONOGRAM

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 GOAL
1. MAINTAIN OPTIMAL NUTRITION

2. MINIMIZE DISEASE METABOLISM

3. PREVENT PROGRESSIVITAS OF DISEASE

4. SLOW DIALYSIS OCCURANCE

GNA/GNC
1. GLOMERULUS INFECTION

2. ISPA (STREPTOCOCCUS)

3. ACUT :

THERAPY: ANTI BIOTIC

LOW PROTEIN INTAKE (MILD)

CLINICAL SYMPTOM : DECREASED OF GRF

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 SINDROMA NEPHROTIC

• CLINICAL SYMPTOM:
Oedem, hematuri,
proteinuria, hipoalbuminemia,
azotemia ( NH++ >>),
oligouri ( < 600cc).

• NUTRITION CARE
Energi Range 35 – 60 /kg BB/hr
Protein 0,8 – 1 gr
Fat Moderate
Na+ Moderate
K Monitoring --- Hipokalemia

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 ACUT RENAL FAILURE

Causa : Renal shockdown ----- trauma or bleeding

Clinical symptom:
a. Diuretic Phase : prod urine 450 cc
b. Oligourie phase ( 7-12 hr)
uremia
High level of K, Mg and Phospat
Low level of Na, Calcium
acidosis

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 NUTRITION CARE

NUTRIENT OLIGOURIE DIURETIC

1. ENERGY 40-55 kcal/kg 40-55 kcal/kg

(High in trauma) (high in trauma)
2. CHO 50-70% -
Need supplement -
3. PROTEIN 0,5g/kg 80% HBV 0,8 g/ kg or more
1-1,5 g/kg  dialysis If fasting
4. Fluid + 500 cc increasing as needed
5. Na + 500-1000 mg/d replace losses
6. K+ 1000 mg/d replace losses
7. Fat = dialysis = dialysis

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 CHRONIC RENAL FAILURE

• Causa : Chronic infection

Progressif glomerolus diseases
Chronic Hipertension
Nefrophaty DM
Hidronefrosis Bilateral
Analgesic drug (Phenacetine)

• Symptom : uremia
Acid-base unbalanced
Electrolyte unbalanced

• Clinical : anemia, anxiety, lose weight, pain (bone,

joint), hypertension

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 Standard Nutrition Assessment
on CRF

• Parameter Normal Moderate Severe

Dry weight % RBW 85-95 75-85 < 75

• TSF
men 4-6 <4
Women 8-12 <8
• ACF
men 22-24 <22
Women 18-20 <18
• LAB
Albumin Serum 2,8 –3,3 <2,8
Transferrin 150-180 <150

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 Renal Failure Diet

GOAL
1. Adequate Food, stop decreased Renal Function
2. Decreased Of Ureum & Creatinine Level
3. Minimized Salt Retension

REQUIREMENT
1. HIGH Biologi value of Protein
2. Limitation of Salt ( Heavy HT, >> K, edema, Oligo /anurie)
3. Limitation of K (Glom function or prod urine << 400 cc)
4. Adequate food
5. >> fluid

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 Diet Variation

1. LOW PROTEIN DIET I :

20 gr - CCT 5-20 cc/”, ureum 100 mg

2. LOW PROTEIN DIET II

40 gr - CCT 20 – 30 cc/”, Konservatif

3. LOW PROTEIN DIET III

60 gr - CCT 30-50 cc/”, MILD CRF

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PROTEIN LIMITATION BASED ON GFR

GFR PROTEIN ALLOWANCE

cc/menit g/day g/kgBB/day

>25 no restriction no restriction

20-25 60-90 1.3
15-20 50-70 1.0
10-15 40-55 0.7
5-10 40 u/ pria 0,5-0,6
35 u/ wanita

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 MONITORING PROTEIN HOMEOSTASIS

1. BASED ON RENAL DAMAGED

INDICATOR  HIGHER / LOWER OF MUSCLE MASS LOSS
2. CREATININE CLEARANCE
GFR RENAL DAMAGED– LOW CREATININ CLEARANCE
PADA RENAL FAILURE LEVEL OF CREATINE SERUM --HIGH
3. SUN (SERUM UREA NITROGEN) OR BUN – indicator of renal
function
Stabil  PROTEIN DIET
SUN Increased  Increased PROTEIN INTAKE.
Dehidrasion / catabolic State ( Operasi, Burn, Infection, Fracture
 Drug Catabolic: Steroid
LEVEL 60- 80 mg/dl  ACCEPTABLE
> 80  UREMIA
< 40  MALNUTRISI
4. UREA CLEARANCE  FILTRATION CAPABILITY

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 Progressivitas of Diseases (CRF)

STAGE % LOST GFR (cc/min)

1. Decreased 55% 55-125

renal reserve

2. Renal Insufficiency 80% 30-55

3. Renal Failure 90% 12,5-30

4. Uremia / uremia >90% < 12,5

syndrome (ESRD)

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 OPTIONS- THERAPY
OF ESRD

1. CONSERVATIF MANAGEMENT

2. DIALYSIS
A. HEMODIALISIS
B. PERITONEAL-DIALISIS

3. TRANSPLANTASION

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KONSERVATIF MANAGEMENT

1. LIMITATION SYMPTOM

2. PREVENT IRREVERSIBLE RENAL

DAMAGED

3. MAINTAIN OF HEALTH BEFORE

DIALYSIS OR TRANSPLANTASION

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 TYPE OF DIALYSIS

A. HEMODIALYS
BY MACHINE ( venous )
3-4 hours /d, 3 – 4 x week

B. PERITONEAL DIALYSIS
Intermittent ( IPD)
Continues ambulatory ( CAPD)
Continues Cyclic

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 NUTRITION MANAGEMENT ON
RENAL TRANSPLANTASION

1. ADEQUATE FOOD

2. CHO 40 –50 % FROM TOTAL CALORIES

3. PROTEIN 1.2- 1.5 gr ADJUST TO NORMAL LEVEL (LAB

AND ELECKTROLYT BALANCE)

4. LIMITATION OF Na+ 2 - 4 gr / day

5. K+ AS NEEDED

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 RENAL STONE

Causa:
1. Environment Factor
2. Tractus Urogenitalia
3. Matrix Organik stone

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 A. ENVIRONMENTAL FACTOR

1. CALSIUM ( 96%)
N  eksresi 100 –175 mg
hipersecresion  : high intake Ca, high Vit.D
long imobilisasion, hiperparathyroid
renal tubular asidosis, high calsiurie
idiopatik

2. CYSTEIN ( herediter )

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 B. TRACTUS UROGENITAL

• CHANGED OF URINE PHYSICALLY

• CHANGED OF URINE CONCENTRATION

• CHANGED OF URINE BALANCED

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 C. MATRIX BATU ORGANIK

• RECURRENT INFECTION
• DEFICIENCY OF VITAMIN A
( DESQUAMATION OF CEL EPITHEL)

• DOT CALCIFICATION
RANDALL’S PLAQUE

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 CLINICAL SYMPTOMS
KOLIK, DEMAM, LEMAH

THERAPY
1. High fluid
2. Change pH from acid --- alkalis
3. Elimination food contain nutrient---
contribute to stone development
4. Binding agent – ecretion through feses
e.g. sodium phytate --- for calsium
aluminium gel --- for phosfat
Glycine --- for oksalat

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 THERAPY

Susunan Kimia Modifikasi zat Gizi Diet Ash

1. Calsium low calsium acid ash
Phospat low phospat
Oxalat low oxalat

2. As. Urat low purine alkaline ash

3. Cystine low methionine alkaline ash

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 VARIATION DIET

1. LOW CALCIUM HIGH ASH CAID

2. HIGH DIET ASH ALKALIS

3. LOW PURINE DIET

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 LOW CALCIUM DIET HIGH ASH ACID

• FLUID > 2500 cc/day

• Low calcium
• Limitation food intake contains:
PROTEIN : milk, cheese, schrimp, crab, rilis, salt fish, sarden,
animal brain, ren, liver, cor
CHO : potatoes, sweet potatoes, cassava, biscuit, cake
contain milk
VEGETABLE : Spinach, mangkok leaf, melinjo leaf, papaya
leaf, lamtoro leaf, cassava leaf, talas (taro) leaf,
d.katuk leaf, kelor leaf, jtg pisang, melinjo, sawi,
leunca
FRUITS : All Fermented Fruits
OTHERS : SOFT DRINK contains soda, alcohol, coclate, yeast

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 HIGH DIET ASH ALKALIS

Especially for Cystein and Uric acid stone

1. Fluid > 2500 cc/day

2. Low AA (contain Sulfur)

3. Vegetables < 300 gr/day

4. Fruit < 300 gr/day

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 LOW PURINE DIET

LIMIT FOOD SOURCES OF URIC

ACID

LOST WEIGHT TO IDEAL BODY

WEIGHT

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GOUT

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 Gout

Acut disease of joint, characterized only

for foot thumb

causa increased level of uric acid

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CLASIFICATION
- Primary Gout  disturbance metabolism of uric
acid

- Secundary Gout  impact from other disease

- Most on Men, menopouse women, obesity, high

consumption of protein

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THERAPY

• Medicamentosa

• Diet

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 Low Purin Diet
*
Goal :

1. Eliminate uric acid development

2. Lost weight ----obese or maintain ideal
body weight or normal weight

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Requirement

1. Low purin contain 120-150 mg

2. Adequate calorie, protein, mineral and
vitamin
3. High carbohydrate
4. Mild fat
5. High fluid

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 FOOD PROHIBITION

Food contains Un-prohibition Prohibition

CHO sources all -
source of Animal meat,poultry,tuna Sardin, clamp,
protein ,tenggiri,egg,milk, jantung, hati, limpa,
cheese 50gr/day paru, otak, ekstrak
daging/kaldu,bebek,
angsa, burung
source of protein Nuts or tofu/tempeh -
Nabati 50gr/hr

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Gol.Bhn.Mkn. Mkn.yang.boleh Mkn.yg.tdk.boleh

Sumber Lemak Minyak dalam jumlah -

terbatas
Sayuran Semua sayuran -
sekehendak kecuali
asparagus,kacang
polong,buncis,kemban
g kol,bayam jamur
maksimum.50 gr/hr
Buah Semua macam buah -
Minuman Teh,kopi,soda alkohol
Bumbu dll. Semua bumbu ragi
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NUTRITIONAL
ASSESMENT
Nurpudji A Taslim

NUTRITION DEPARTMENT
SCHOOL OF MEDICINE
HASANUDDIN UNIVERSITY
@ 2005

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PERHITUNGAN KALORI

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• Define :
The interpretation of information obtained form
dietary, biochemical anthropometric and clinical
studies
• Form :
• Surveys (Cross Sectional Survey)
• Surveillance (Monitoring of Nutritional Status)
• Screening (Determined Risk Level)

• Methods Used in Nitritional Assesment :

• Dietary Methods
• Laboratory Methods
• Anthropometric Methods
• Clinical Methods
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Evaluasi Status Gizi
Perempuan 42 tahun
TB 150 cm, BB 59 kg
Lingkar pinggang 91 cm
LILA 27cm
Serum Albumin 2.2
GFR 15/menit
Status Gizi ?
Kemungkinan menderita penyakit?
Pertanyaan lain untuk menetapkan
diagnosa?
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• Pertanyaan tambahan:
Rawat jalan atau rawat inap?
Keluhan utama ?
Sudah berapa lama ?
Berobat atau tidak sebelumnya?
Penting!!!
Hasil pengukuran Lab
darah/urine/rutin
Antropometrik
Assessment
Plan
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• Status gizi : kurang/ baik/ lebih ?
• Diagnosa : hiperlipidemia?
Overweight/ obese?
Ginjal akut/kronik ?
• Status protein tubuh
positif/ negatif?
degradasi protein otot?
Rumus kebutuhan energi
IMT
Harris-Benedict?
Rencana Terapi?

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 Hitung Nitrogen Balance
•NB= Protein intake - (UUN+4)
6,25

Asupan protein=56 gram

UUN 550 mg dalam 2000 ml urine
NITROGEN BALANCE?

Apa arti positif atau negatif???

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• UUN = (550)(2000) = 11.000MG=11 gr
100

NB = 56 – (11+4) = ?
6,25

Hasil (+) = NB positif, protein cukup

(-) = NB negatif, sudah terjadi
pemecahan protein otot
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 Soal
•Laki-laki 35 tahun, TSF 8 mm
•Standard TSF normal 12.5 mm
–% TSF= 8/12.5=64%
–Bandingkan nilai standar 12.5mm
–N range 51-90%
•HASIL
–Observasi 64% nilai Standar
–Nilai status gizi: <90%
–Arti: mild defisit, rentan terhadap kekurangan
gizi
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 Pasien dengan NGF
• Tentukan:
kalori = (cc formula/24 jam) x (kal/cc)
Prot = (cc formula/24 jam) x (prot/g/lt)
Soal;
Q; Prot dalam 2000 cc formula.
Density 1 kal/cc, 15% terdiri dari prot
A; (0.15) (2000)=300/4=75 gr prot
75gr prot/6.25= 12 g N
N prot kal:N = 2000-300=1700 kal
NP kal:N= 1700kal/12 g N =140:1
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 TPN
Dextrose = 3.4 kal/gr
Protein = 4 kal/gr
• LIPID
Q ?? = 10% ---1.1 kal/cc 20% ---- 2,0 kal
D10W +5 %AA 120 cc/r + 3 btl 20% fat/minggu (
1 btl=500cc)

• D10w=(.10)(1000cc)=100g dextrose
= 3.4x100=340 kalori
5%AA=(0.05)(1120cc)=56 prot
= 4x 56=224 kalori
Lemak= 3(500)(2)=3000cc/7 hr
=430kal
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• Total cairan
(10cc/24 jam)(24)=2880=3000 cc
CHO=(3000cc)(0.10)(3.4)= 1020/4=255g
Prot=(3000cc)(0.05)(4)= 600/4=150g
Fat = (1500cc)(2)=3000/7
hr=430/9=30.7g

Total kalori= 1020+600+430=2050 kal

Total Kal :N= 2050:150/6.25=2050/24

= 85:1
NP cal=1450:150/6.25=1450/24
= 60:1 48
 Soal
• 500 cc D50w + 500 cc 8,5%AA
• Menghasilkan kalori???

• Mixed=D25w dan 4.25AA

= (0.25)(1000)+(0.0425)(1000)(4)
=250x3.4 + 4.25x4
= 850 + 170
= 1020 kalori
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Cara menghitung apakah kebutuhan
penderita adekuat atau tidak, dapat
dilihat dari contoh dibawah ini :
Contoh :
Kebutuhan energi Ms.Susi 1900 kcal,
tapi dalam perawatan ia
mendapatkan ensure personde 100
cc / 2 jam tanpa tambahan lainnya, bila
kalori densitynya 1.06. berapa kalori
yang diperolehnya dalam sehari ?

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Jawab :
Kalori yang dikonsumsi
= 24 jam/2 jam x 100 cc/hari x
kalori density
= 1200 cc x 1.06
= 1272 kcal

Dari hasil di atas ditemukan bahwa

asupan kalori Ms. Susi tidak adekuat

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Konversi mg --- ke m Eq atau m.Eq ke-- mg

(m.eq) (at.wt)
= ------------------- = …. mg
valence

1. Valensi Na+ = 23; K+ =36

bila ditemukan Na + = 85 meg
Q = berapa mg kandungan Na
A = (85)(23) = 1955 mg
1
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2. Q???
kandungan Na pada NaCl ? ½ tsp -- Na ?
NaCl = (23 + 35) = 58

Na = 23/58 x 100% = 40%

A : 1 tsp = 5 g = 5000 mg
½ tsp = 2,5 g = 2500 mg
= 2500 mg x 0,4 = 1000 mg Na
= 2500 mg x 23/58 = 991 mg Na
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