Kharader General Hospital

School Of Nursing
GENERIC BSN, 1ST YEAR,2ND SEMESTER
APPLIED NUTRITION
1-CREDIT HOUR

Rehan Ahmad
(Generic BSN, B.Ed)

Nursing Instructor
Kharadar General Hospital School of Nursing
 UNIT VII: NUTRITIONAL CONSIDERATION IN THE
PREVENTION AND MANAGEMENT OF
RENAL DISEASES
Learning Objectives:
1. Identify nutritional risk factors for nephrolithiasis and renal failure.
2. Discuss the role of a diet in etiology, prevention and management of
nephrolithiasis and renal failure and during dialysis.
3. Describe the nutritional management in nephritic syndrome.
4. Review Iron deficiency anemia and Iron sources (since it is common in
renal patients).
The nutritional care of patients with renal disease involved a highly
selective and complicated process.

In the early stages of chronic renal disease the modification of dietary

intake may be moderate.

As it progress to end stage renal failure, nutrition becomes one of the

most critical components of medical care plan.
• Renal damage and subsequent loss of renal function profoundly affect
metabolism, nutritional requirement, and nutritional status.
• As urine output decereases,fluids and electrolytes accumulate in the body.
• Retention of nitrogenous waste leads to Uremic syndrome.
• Acidosis occur.
• Reabsorption of some nutrients impaired, which causes them to be lost in
the urine.
• Absorption of calcium and iron is impaired.

• Impaired synthesis of renin, erythropoietin and vitamin D.

• Accelerated atherosclerosis increases the risk of congestive heart
failure, myocardial infarction and further renal damage.

• Poor intake related to dietary restrictions,anorexia,alterations in

taste, nausea, vomiting, depression and anxiety is common.

The formulation of renal diet is relatively complex compared to
planning of other modified diets.
6 components must be regulated:
• Proteins
• Sodium
• Potassium
• Phosphorous
• Calcium
• Fluid
 Nutrition Therapy in Renal Diseases
Main goals are:
• Reduce renal workload to delay or prevent
further kidney damage.
• Restore or maintain optimal nutritional
status.
• Control the accumulation of Uremic toxins
such as urea, phosphorous, sodium and
sometimes potassium.
 THE OPTIMAL INTERVENTION NEEDED TO MAINTAIN THESE
OBJECTIVES VARY AMONG INDIVIDUALS AND ACCORDING TO THE
NATURE,SEVERITY,AND STAGE OF THE DISEASE.  
 COMMON RENAL DISORDERS

• Acute Renal failure

• Chronic Renal failure
• End stage renal disease
• Nephrotic Syndrome
• Renal Stones
 ACUTE RENAL FAILURE AND CHRONIC RENAL FAILURE
• Acute Renal Failure: Loss of excretory functions of the kidney within a short
period of time.
• Chronic Renal Failure: Result of progressive; irreversible loss of kidney
function which can develop over days, months or years and progress to
End Stage Renal Disease.
Categories of Renal Failure
• Renal failure is further divided into oliguric,diuretic,and convalescent phases
where by the kidneys try to adapt and compensate in order to maintain renal
function.
 ASSOCIATED NUTRITIONAL PROBLEMS

• As a consequence of lower GFR, clients retains, sodium, nitrogen

metabolites, and other waste products.

• Potassium retention is a problem in acute renal failure (ARF).

• Decreased calcium levels and increased phosphorous levels

• Decreased production of erythropoietin lead to anemia that can

result in fatigue which in turn can effect nutritional intake.
 DIETARY MEASURES USED AS TREATMENT
FOR PREVENTION OF RENAL DISEASES

• Calculation of ideal body weight, actual body weight, and determination

of protein status is necessary in order to establish nutrition goals.

• Early intervention in the form of dialysis may be required.

• To provide enteral or parenteral feeding if the client is incapable of oral

intake.
• Energy: Should be provided in sufficient amounts usually 30-40 kcal/kg to
prevent protein catabolism patients on peritoneal dialysis need to decrease their
calorie intake to compensate for the glucose calories absorbed from the dialysate
(approx 340-688 kcal/d)

• Proteins : In cases where dialysis is not necessary for treatment,0.6g/kg body wt.
(but not less than 40 gms proteins/d) for unstressed patient is recommended.
• Protein requirement may need to be adjusted downward as the disease
progresses.
• When dialysis is used as the treatment protein intake can be liberalized to
1.01.4g/kg.(in either situation protein of high biological value is recommended.)
• Phosphorous : Low phosphorous diets have also shown to delay the
progression of renal disease. Restricting phosphorous is appropriate for all
stages of renal disease.
• Sodium & Potassium: During the oliguric state sodium may be restricted to
1000-2000mg and potassium to 1000mg/day.
• Both potassium and sodium may be lost during diuretic phase or during
dialysis. Therefore losses should be replaced as needed. Replace moderate
sodium losses with a diet containing 4-6 g of salt.
• If patients become hyponatremia (sodium depleted) provide additional
sodium with salty foods.
• Incase of hypernatremia (sodium retention) restrict sodium intake depending
on degree of hypertension and state of hydration.
 Foods high in Potassium

• Apricots
• Bananas
• Raw carrots
• Dried fruits
• Melons
• Oranges/orange juice
• Peanuts (also high in sodium)
• Potatoes
• Spinach
• Tomatoes ,tomato juice, tomato sauce
 Foods high in sodium

• Pickles
• Salted nuts
• Commercial salad dressings
• Chinese salt
• Sauces /soya sauce/ketchup
• Potato chips/popcorns
• Canned meat/canned soups
Commercial beverages
 Foods high in phosphorous

• Animal: protein: fish, poultry,

beef, egg, milk and milk
products.
• Vegetables: almonds, lentils,
peanuts.
• Other sources: carbonated
beverages such as soda, whole
wheat bread.
 Fluids

Usually restricted to patients

output (urine, vomitus, diarrhea)
plus 500ml during the oliguric
phase.
During the diuretic phase, large
amounts of fluids may be needed
to replace losses.
 Vitamins & Minerals

• Diets containing less than 60g proteins/day

may be deficient in niacin, riboflavin,
thiamin, calcium, iron, vitamin B12 and zinc;
and these nutrients may need to be
supplemented during convalescence.
• Less than normal amount of vitamin C are
recommended for people with End stage
renal disease (ESRD) because vitamin C
increases the risk of oxalate stones and many
people with renal failure have high blood
oxalate levels.
 Other Electrolytes

• Dietary phosphate may sometimes have to

be restricted; since a low phosphate diet
may be poorly accepted, phosphate
binding antacids may be used.

• Parenteral iron may be needed to enhance

erythropoiesis if GI absorption is poor.
 CLIENTS RECEIVING DIALYSIS
• It is a treatment used for ARF and CRF.
• In CRF the client usually begins dialysis treatment when GFR is 5-10ml/minute.
• Peritoneal dialysis and Hemodialysis are two types mainly used depending on client’s medical condition.
• Associated Nutritional Problems:
• Chronic hemodialysis is a catabolic process and malnutrition is a continuous problem.
• Intake of calorie nutrients must be sufficient to spare proteins and to maintain body weight.
• Clients may lose proteins during each session, along with an amount of glucose that varies with the glucose
content of the dialysate, for this reason protein restriction may be lessened slightly once dialysis begins.
• Peritoneal dialysis can lead to hyperglycemia because of the glucose content of the dialysate, and the length of
dwell time in the abdomen.
• Sodium and fluid may accumulate between hemodialysis treatments, leading to hypertension, edema and
congestive heart failure.
• Client must maintain accurate intake and output and be aware of sodium, potassium, protein and or fluid
restriction during the course of therapy.
HEMODIALYSIS AND PERITONEAL DIALYSIS
 NUTRITIONAL MONITORING

• Monitor for anemia: transfusions of packed

RBCs at interval may be necessary.
• Monitor blood pressure and body weight
indicator for sodium restriction)
• Monitor micronutrient levels (calcium,
phosphorous , and magnesium).
• Monitor parathyroid hormone level.
 NEPHROTIC SYNDROME
A collection of symptoms that occur
when increased capillary
permeability in the glomeruli allow
serum protein to leak into the urine.

Causes of Nephrotic syndrome

Nephrotic syndrome may be primary
that is because of a disease in the
kidney itself (infection, drug
exposure) or secondary (skin disease,
bone marrow disease).
 Symptoms of Nephrotic syndrome
• Swollen abdomen
• Facial swelling
• Foamy appearance of the urine
• Un intentional weight gain from fluid
retention
• Poor appetite
• High blood pressure
• Reduced urine production, sometimes
down by 20% .
 Nutritional Therapy
Primary goals are :
• To control hypertension
• Minimize edema
• Decrease urinary albumin losses.
• Prevent protein malnutrition and muscle catabolism .
• Supply adequate energy &
• Slow progression of renal disease.
Foods to limit or exclude with nephrotic syndrome
• Salty foods
• Fluids
• High cholesterol foods
• Phosphorous and calcium foods

Foods to include in nephrotic syndrome

• Protein foods
• Low fat foods
Proteins in Nephrotic Syndrome
Patient need to consume adequate amount of proteins and calories to prevent catabolism
of lean body tissues and avoid malnutrition.( about 1.5-2.0 g proteins /day and 35 Kcal
/kg/day.).

Fat & Cholesterol

TLC diet used to prevent CHD is recommended to control elevated lipid levels which is
seen in Nephrotic syndrome.

Sodium & Fluid

A low sodium diet is needed to control HTN and edema. Generally 2 gm Na restriction is
recommended but a more severe restriction is necessary depending on the patients
response to diuretics.
Daily weight are used to assess fluid status.
 KIDNEY STONES

• Also known as renal calculi, vary from a size of a grain of sand to a

large stag horn calculus that fills the entire pelvis of the kidneys.

• Reduced urine flow, increased excretion of calcium and potassium

and changes in PH may increase the tendency of calculi information.
• In addition calculi may form due to crystallization of organic material in the
urine.
• Metabolic disease that can cause calculi formation include cystinuria, gout
hyperoxaluria, hyperparathyroidism, some bone disease, excessive amount
of vitamin D,renal tubular acidosis, and idiopathic hypercalciuria.
• Calculi may form as a complication of GI disorder.
• Genetics may play role in the formulation of kidney stones.
 Urinary Risk Factors For Stone Development

Increased Risk Decreased Risk

• Low urine volume
• Oxalate
• High urine volume & flow.
• Citrate
(increased fluid intake).
• Uric acid
• Potassium
• Magnesium
• Sodium
• Calcium
• Acid PH
• Increase intake Of vitamin C
Causes & Composition of Renal Stones
Pathogenic causes Composition of stone

Hypercalciuria

Hypocitraturia
Acid urine PH Uric acid

Real tubular acidosis

Alkaline urine PH Ca po4

• PH of urine Stone
PH < 5.5 Uric acid stone
5.5----7.5 Ca oxalate stone

7.5 Ca phosphate
stone
 STONE FORMATION

• 75 %Contain Calcium
• 70-80% calcium oxalate
• calcium phosphate
• 15% are Struvite
• 8% are Uric Acid
• 3% are Cystine
Associated nutritional problems

• Nausea, vomiting abdominal distension,

constipation.

• If the client is experiencing pain flank

pain) dietary intake may be altered.
 Dietary Measures Used as Treatment

• The most effective nutrition intervention for the

treatment and prevention of renal calculi is to
“increase fluids” and thereby dilute the urine.

• Most calculi are passed spontaneously others may

eventually be removed by surgery or ultrasound,
increasing water intake to 2-4 liters/d is
recommended.
 Fluid Intake

• Patient should drink 10 glasses of water per day.

• High urine flow rate will tend to wash out any formed crystals. To achieve
dilution, the goal for a urine volume should be 2.0 to 2.5 l/d;250 ml of
fluid at each meal, at bed time and when arising.

• Hydration during sleep hours is important to break the cycle of a “most

concentrated” morning urine.
• Mild salt restriction may be helpful.
• For most clients, calcium intake should not be restricted severely unless intake is
significantly higher than normal, since calcium restriction increases oxalate
absorption from the intestine and thus increases the need for oxalate excretion.
• Restrict calcium 600 mg/day for clients with absorptive hypercalciuria or who
have not formed many stones.
• Limit ascorbic acid(vit C) to less than 4 gm/d,as it is a precursor of oxalate
production, doses of greater than 4gm/d increase oxalate excretion and
tendency to form oxalate calculi.
• For oxalate stones reduce intake of foods high in oxalate.
• For uric acid stone low purine diet is recommended.
• For cystine calculi, low protein diets are proposed.
• Lemonade made with lemon juice (4 oz) diluted to 2
liters with water should be encouraged in patients with
low urinary citrates.

• Orange juice is beneficial in uric acid stone formers with

low citrate levels.

• Cola beverages and grapefruit juices increase the risk of

stone formation and should be avoided.
 Uric Acid Stone
• Uric acid stone results from a problem metabolizing purines. They may
form in a condition such as gout.
• Recommendations for client with uric acid stones are as follows:
• Consume protein in moderation.
• Limit alcohol
• Limit high Purine food
• High purine foods include:
• Red meats especially organ meat(liver, kiney,brain) Roe(fish
eggs),mackerel, herring.
• Duck
• Mince meat/broth/gravies Chikoo Custard apple.
Struvite Stones
• Composed of magnesium ammonium phosphate
• Mainly caused by urinary tract infections rather than specific nutrient
• No diet therapy is involved
• Usually removed surgically
Medical Nutrition Therapy
• Cystine Stones
Low-methionine diet (essentially a lowprotein diet) sometimes
recommended
• In children, a regular diet to support growth is recommended
• Medical drug therapy is used to control infection or produce more
alkaline urine
 References

1. Ruth A. Roth (2011).Nutrition and Diet Therapy (10th edition): Maxwell

drive Clifton park USA.
2. S.R. Mudambi, M.V. Raja Gopal (2006). Fundamental of Food, Nutrition
and Diet Therapy (fifth edition): New age international Publisher India.