NUTRITION FOR URINARY

SYSTEM
 CONTENT
• Nephrolithiasis
• Genitourinary
tuberculosis
• Benign Prostatic
Hyperplasia (BPH)
• Polycystic kidney disease
(PKD)
• Diabetic Kidney
Disease(DKD)
• Pyelonephritis
• Cystitis
• Urethritis
• CRF-on conservative
management and on
dialysis(HD&PD)
• ARF
• Nephritis
• Nephrotic syndrome
 Nephrolithiasis

• Nephrolithiasis or kidney stone, is the

presence of renal calculi caused by a
disruption in the balance between solubility
and precipitation of salts in the urinary tract
and in the kidneys.
 Nephrolithiasis

• Kidney stones develop when urine becomes

"supersaturated" with insoluble compounds
containing calcium, oxalate (CaOx), and
phosphate (CaP), resulting from dehydration
or a genetic predisposition to over-excrete
these ions in the urine.
 Dietary risk factors -Nephrolithiasis

• Sodium

• Potassium
• protein
• Vitamin-C
• Calcium
• Magnesium

• Other dietary factors

 SODIUM
• Dietary sodium restriction decreases urinary calcium

excretion and increases Proximal tubular calcium

reabsorption which decreases the formation of CaOx

stones

• Continues cosumption a high sodium diet, increase the

excretion of calcium and potassium along with citrate,

resulting in a change in the urinary pH that will

eventually increase the risk of stone formation

 POTASSIUM
• Potassium is abundant in most fruits and vegetable

• Diet Approaches to Stop Hypertension (DASH) diet had

decreased risk of stone formation.
• Because DASH diet is high in potassium, magnesium,
and phosphorus, these may increases urine pH and
increases urine volume resulting in decrease formation of
CaOx and uric acid stone

Ref- Taylor EN, Fung TT, Curhan GC. DASH-style diet associates with reduced risk for kidney stones. J Am
Soc Nephrol. 2009;20:2253–2259
 PROTEIN
•  A high protein diet (>2.0 g/kg/d) can reduce urine pH;

therefore, a moderate to low protein diet should be advised

(0.8-1.4 g/kg/d).

• Weight loss diets promote consumption of large amounts of

protein but such a restricted diet is not recommended for the

patients who have a history of kidney stones.

• This high protein diet regimen increases hypercalciuria,

lowers pH of urine and increases uric acid levels, which

increase kidney stone risk

 PROTEIN
• Massey et al, conducted a study to monitor the effect

of stone risk in beef vs. plant protein and concluded

that a moderate amount of protein intake of either

type had the same effects in reducing CaOx stone

risk .The amount of protein seemed to be a more

important factor than the quality.

Ref-  Massey LK, Kynast-Gales SA. Diets with either beef or plant proteins reduce risk of calcium oxalate
precipitation in patients with a history of calcium kidney stones. J Am Diet Assoc. 2001;101:326–331.
 CALCIUM

• Approximately 20% of dietary calcium is

absorbed under normal conditions,high calcium
diet is associated with lower kidney stone
formation, because the higher calcium intake
will bind oxalate in the gut if it is consumed
with meals thereby reducing oxalate absorption
 CALCIUM
• People who consumed a diet with a normal calcium
intake (1,200 mg/d) plus a low animal protein intake
had a 51% lower incidence of recurrent stones than
patients who consumed low (400 mg/d) calcium diets
• Calcium supplement with meals is beneficial because
calcium can bind with oxalate

(Ref-Borghi L, Schianchi T, Meschi T, Guerra A, Allegri F, Maggiore U, Novarini A. Comparison of two diets
for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002;346:77–84.
 MAGNESIUM
• Magnesium forms a complex with oxalate and
decreases caox in the urine, which can reduce the risk
of stone formation

• The DASH diet, which is high in magnesium, showed

a decrease in stone risk by increasing pH and
lowering caox formation

• Magnesium can also bind with oxalate in the

gastrointestinal tract to reduce oxalate absorption
 VITAMIN -C
• Vitamin C is metabolized to dehydro ascorbic acid and then

converted to oxalate which is then excreted in the urine;

• A high vitamin C intake can be a risk for stone formation by

increasing endogenous oxalate

• A recent observational study showed that consumption of

more than 1,000 mg/d vitamin C was associated with a 40%

higher risk of stone formation in men than in those who

consumed the Dietary Reference Intake (DRI)

Ref-Grases F, March JG, Prieto RM, Simonet BM, Costa-Bauzá A, García-Raja A, Conte A. Urinary phytate in
calcium oxalate stone formers and healthy people-dietary effects on phytate excretion. Scand J Urol
Nephrol. 2000;34:162–164.
 OTHER DIETARY FACTORS
Citrate
• Citrate can increase urine pH, and also increases citrate
concentration in the urine. Citrate also inhibit
crystallization of CaOx

Phytate
• Phytate are present in whole grains and legumes and they
can inhibit CaOx stone formation.
 Alkaline-Ash Diet

• Increases alkalinity of urine (contains sodium,

potassium, calcium, and magnesium)
• Fruits and vegetables emphasized (exceptions are
corn, lentils, cranberries, plums, prunes)
• Meats and grains limited
 Acid-Ash Diet

• Increases acidity of urine (contains chloride,

phosphorus, and sulfur)
• Meats, cheese, grains emphasized
• Fruits and vegetables limited (exceptions are corn,
lentils, cranberries, plums, prunes)
 TYPES OF STONES

• Calcium oxalate-70-80%

• Calcium phosphate 

• Uric acid-10%
• Struvite (Mg ammonium phosphate)-10%
• Drug related stones-(cystine)-<1%
 CALCIUM OXALATE
Type of stone
•CaOx concentration is 7 to 11 times
higher than normal solubility
• Low urine volume and presence of high
calcium, high oxalate
•Hypercalciuria (hyperparathyroidism,
malignancy, sarcoidosis and vitamin D
excess )
•Low citrate concentration in urine
• More Dietary oxalate intake
•High dose of vitamin-C
•IBD,Post Bariatric surgery
•Severe Diarrhoea-Bicarbonate loss in the
stool causes low urinary PH
Dietary management
Oxalate is a naturally occurring substance
found in a wide variety of foods.
Green leafy vegetables,
Ladiesfinger ,carrot ,beets ,brinjal,
greenchillies ,sweet potatoes baked
potatoes,berries,amla,,blue grapes ,figs
bajra,jowar,popcorn,whole wheat flour
Whole black gram dhal, cow pea,
horse gram ,kesaridhal
kidneybeans,peas ,redgramdhal,
soya beans,nuts-all nuts, oilseeds like
sesame,poppy,pumpkin,chocolate,cocoa
powder,cinnamon,tea
 URIC ACID STONE
Type of stone
•Uric acid calculi are tend to form in
individuals with hyperuricosuria.
•15-20% of patients with uric acid
stones have a history of gout
• A diet rich in animal protein, which
is in high purine content, produces
uric acid in its catabolism, may
increase the risk of uric acid stone
formation .
• Urinary pH of less than 5.5 -risk of
uric acid stone is higher.
•A high protein diet (>2.0 g/kg) can
cause a decrease in urine pH
therefore moderate amount of protein
(0.8-1.4 g/kg/day) is recommended
Dietary management
High-purine foods: Limit or avoid
foods high in purine
Anchovies, sardines, mackrel,
scallops, mussels, Tuna, herring, and
haddock,
Red meats,Organ meats, such as
brains, heart, kidney, liver
Gravies and sauces made with meat
Medium-purine food- Limit
Vegetables:cauliflower,spinach,
mushroom,green peas,brinjal,beans,
oats, wheatgerms and wheatbrans
 CYSTEINE STONE
Type of stone Dietary management
•These stones tend to form only in There is no specific diet
patients with cystinuria (large recommendations for cysteine
amounts of urinary cystine stones except increasing fluid
excretion) -an autosomal recessive intake.
disorder .
• Cystinuria occurs equally in Low animal protein diet can lower
males and females, although males the stone risk by lowering
are more severely affected. Stones methionine which is precursor of
begin to form in the 1st to 4th cysteine.
decades of life and tend to be large
and multiple
•When stone recurrence happens
(every 1-4 years) Urinary tract
infection and obstruction are
possible
 STRUVITE STONE
Type of stone Dietary management
•Struvite stones are also called The preferred treatment of struvite
triple phosphate stones stones is surgical removal because
(magnesium ammonium they are large.
phosphate ) or infection stones.
• They form in the presence upper Antibiotic therapy is important
urinary tract infections –Bacterial and may slow stone growth.
urease which leads to an elevation
in ammonium, carbonate and Low sodium diet can help
combines with phospate and forms prevention of struvite stone
magnesium ammonium phosphate
(struvite) and calcium carbonate-
apatite.
 Dietary recommendation to
prevent kidney stones
• Nutrients Recommendation
• Ca 800-1,200 mg/d
• Na 2,000-3,000 mg/d
• Protein 0.8-1.4 g/kg/d
• Fluid >2.5 L/d
• Vitamin D Low dose if vitamin D insufficiency or
deficiency (1,000 IU/d)
• Vitamin C -Dietary Reference Intake
 Tips for Kidney Stone
1. Increase fluid intake
2. Maintain a low salt/low sodium diet
3. Eat more fresh, non-processed foods, like fruits
and vegetables
4. Limit intake of meat
5. Maintain a normal dietary calcium intake
6. Increase intake of citrus fruits and juices
 Genitourinary tuberculosis (GUTB)
Disease
•Genitourinary tuberculosis
(GUTB) involving the kidneys,
prostate and testis
•The infection manifests as
pyelonephritis, renal colic, kidney
stones, sepsis, or even renal
failure.
Dietary management
Healthy balanced diet
Avoid-
•Alcohol as it increases the risk of
drug toxicity
•Carbonated drinks
•Excess of tea and coffee, or their
intake with food
•Tobacco and tobacco products
•Excess of spices & salt.
 Benign Prostatic Hyperplasia
(BPH)
Disease
•Benign prostatic hyperplasia
(BPH) is a non-cancerous
enlargement of the prostate.
•This enlargement obstructs
the flow of urine and causes
weak urine stream, straining
to urinate, incomplete bladder
emptying, sudden
uncontrollable urges to
urinate and increased urinary
frequency.
Dietary management
•Red meat
•Foods rich in saturated fats& trans fatty acids
•Caffeine and carbonated beverages-Caffeine
has a diuretic effect, which increases urge to
urinate.
•Spicy Foods-Spicy and acidic foods can
irritate the bladder and prostate causing
urinary symptoms
•Alcohol- It acts as an irritant .It is a diuretic
increases the amount of urine .
•Sodium: A high salt intake may increase the
urinary tract symptoms
• Balanced healthier diet with more of
antioxidant could be the key to maintain better
prostate health.
 Polycystic kidney disease (PKD)
Disease
•Polycystic kidney disease causes
numerous cysts to grow in the
kidneys
• These cysts are filled with fluid.
If too many cysts grow or if they
get too big, the kidneys can
become damaged and leads to
kidney failure
Dietary management
•To control  blood pressure limit
sodium intake
•Right amount of fluid may help
slow PKD’s progress toward
kidney failure.
• High-quality protein and
restricted protein also can help
protect the kidneys.
• If kidneys become more
damaged -may need to restrict
 phosphorus and potassium in the
diet
 Diet for Diabetic Kidney
Disease(DKD
Disease
•Diabetic kidney disease is also
called DKD, chronic kidney
disease CKD, kidney disease of
diabetes, or diabetic nephropathy.
•Diabetes is the leading cause of
kidney disease
•Kidney damage caused by
diabetes usually occurs slowly,
over many years
Dietary management
•Diet should be designed to delay
the progression of kidney disease
•Need to restrict sodium, protein,
and potassium if uremia ,
hypertension, edema,
hyperkalemia, hyperlipidemia
present
• Personalized diet plan and
continuous monitoring are
required
 Pyelonephritis
Disease Dietary management
• Kidney infection is a type of • Well balanced diet
urinary tract infection (UTI)
that commonly begins in • Drinking lots of liquids helps to
bladder and moves upstream to flush bacteria from urinary tract
one or both of kidneys.

• In rare cases, kidney infections

can lead to serious health
problems, but quick treatment
prevents most complications.
 Cystitis
Disease
Cystitis is inflammation of the
bladder, usually caused by a
bladder infection.
Dietary management
•Some foods or drinks like
•Coffee, soda, alcohol,
tomatoes, hot and spicy foods,
chocolate, caffeinated
beverages, citrus juices and
drinks, MSG, and high-acid
food, artificial sweeteners
might trigger or worsen the
symptoms.
 Urethritis
Disease Dietary management

•Urethritis is inflammation of • Alkaline foods –most of the

the urethra. Painful urination is fruits and vegetables,
the main symptom of urethritis. especially potatoes (white
Urethritis is commonly due to and sweet), spinach, bananas,
infection by bacteria and raisins may be helpful
 The Most Common Kidney
Diseases
• Acute Renal Failure - Sudden kidney failure caused by
blood loss, drugs or poisons.  If the kidneys are not
seriously damaged, acute renal failure may be reversed.
• Chronic Renal Failure - Gradual loss of kidney
function is called Chronic Renal Failure or Chronic
Renal Disease.
• End-Stage Renal Disease - The condition of total or
nearly total and permanent kidney failure. 
The Most Common Kidney
Diseases
Glomerular diseases
– Nephrotic syndrome
– Nephritic syndrome—tubular or
interstitial
 MNT for Adult ARF
• Energy: 25-35 kcal/kg
• Protein: 0.8-1 g/kg without dialysis
• 1.2-1.5 g/kg initiation of dialysis

• Fluid: 24 hour urine output + 500 ml (750-1500 ml)

• Sodium: 2.0-3.0 grams
• Potassium: 2.0-3.0 grams

• Phosphorus: 8-15 mg/kg; may need binders; needs may

increase with dialysis, return of kidney function.
Medical nutrition therapy recommendation
(stages 3 to 5)
Calories 30-35 kcals/kg IBW
Protein 0.6-0.8 gm/kg IBW
Sodium 1000-4000mg
Fluids Evaluate need to restrict
Potassium Evaluate need to restrict
Calcium <2000mg
Phosphorus 800-1000mg
Vitamins Individualized
 Energy requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Energy
30-35 30-35 30-35
Kcal/kg

Foods that are high in Energy and nil protein are:

• Sago arrow root
• Butter
• Oil
• Sugar
• Potatoes
 Protein requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Protein
0.6-1.0 1.1-1.4 1.2-1.5
g/kg/day

Foods that are rich in protein –HBV;

• All animal foods like –
• Fish
• Chicken
• Meat
• Egg
• Milk and milk product like –
• Curd
• Paneer
• Cheese
 Phosphorus requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Phosphorus
8-12 <=17 <=17
mg/kg

Phosphorus can be found naturally in foods (organic

phosphorus) and is naturally found in protein-rich
foods such as
• Meats , poultry, fish, nuts, beans and dairy
products.
Phosphorus found in animal foods is absorbed more
easily than phosphorus found in plant foods.
 Sodium requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Sodium
1000-3000 2000-3000 3000-4000
mg/d

•Salt •Popcorn
•Baking powder •Salted biscuits
•Baking soda •Papads
•Canned foods •Pickles
•Bacon •Sauces
•Ham •Aerated drinks
•Sausages, •Commercial soups
•Meat •Ajinomoto
•Meat extracts •Dried fish
•Salted chips •Dried fruits
•Nuts
 Potassium requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Potassium
Individualized 40 Individualized
mg/kg

Foods that are rich in Potassium rich food

potassium are all fruits • Tender coconut
except • Water
• Apple • Tea
• Pine apple • Coffee
• Pappaya • Lemon
• Guava • Cocoa
• Pears • Chocolate
• Tamarind
 Fluid requirements
NUTRIENT CKD CKD ON HD CKD ON CAPD
Fluid 500-750+ urine output
Unrestricted Individualized
ml/d (1000 if anuric)

Fluid should be counted including

the following
• Water
• Milk
• Soup
• Gravies
• Curd
 Fluid allowance- Tips

• Pre measure meal time liquids

• Drink very hot or very cold beverages

• Drink from smaller cups

• Use spray bottles to mist mouth
• Freeze juice in ice trays and eat like popsicles
 Nephrotic Syndrome

• Albuminuria

• Hypoalbuminemia

• Hypertension
• Hyperlipidemia
• Edema
 MNT in Nephrotic Syndrome
• Protein 0.8 to 1 g/kg IBW 80% HBV
• Sodium based on fluid status
• Potassium and other minerals (calcium,
phosphorus) monitored and individualized
• Fluid unrestricted
• Diet therapy probably not effective for
hyperlipidemia; may require medication
Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney disease.ADA, 2004
 Nephritic syndrome
• Acute glomerulonephritis (inflammation of
the glomerulus) sudden onset, often after
streptococcus infections
• Symptoms include hematuria, hypertension
• Usually resolve on their own or advance to
nephrotic syndrome or ESRD
 MNT in Nephritic syndrome
• Diet to treat underlying disease

• Restrict diet if necessary to control symptoms

• Protein restriction in uremia

• Sodium restriction in hypertension

• Potassium restriction in hyperkalemia

PROTEIN SUPPLEMENTS
FOR RENAL PATIENTS
PROTEIN SUPPLEMENTS
FOR RENAL PATIENTS
PROTEIN SUPPLEMENTS
FOR RENAL PATIENTS