Module I.

Nutritional Management in Kidney Diseases

 Glomerulonephritis, Nephrotic syndrome and its dietary management
 Acute renal failure, Chronic renal failure
 Dialysis, types
 Urolithiasis or urinary calculi
Kidney:
• The kidneys are among the most important organs.
• The kidneys are a pair of bean-shaped organs present in all vertebrates.
• They remove waste products from the body, maintain balanced electrolyte levels, and
regulate blood pressure.

Structure:
• The kidneys are at the back of the abdominal cavity, with one sitting on each side of
the spine.
• The right kidney is generally slightly smaller and lower than the left, to make space
for the liver.
• Each kidney weighs 125–170 grams (g) in males and 115–155 g in females.
• A tough, fibrous renal capsule surrounds each kidney. Beyond that, two layers of fat
serve as protection.
• The adrenal glands lay on top of the kidneys.
• Inside the kidneys are a number of pyramid-shaped lobes.
• Each consists of an outer renal cortex and an inner renal medulla.
• Nephrons flow between these sections. These are the urine-producing structures of the
kidneys.
• Blood enters the kidneys through the renal arteries and leaves through the renal veins.
• The kidneys are relatively small organs but receive 20–25 percent of the heart's
output.
 • Each kidney excretes urine through a tube called the ureter that leads to the bladder.

Functions of kidney
• Waste excretion.
• Reabsorption of nutrients
• Maintaining pH
• Osmolality regulation
• Regulating blood pressure
• Secretion of active compounds
Diseases of the renal system:
• Kidney disease also known as Nephropathy, means damage to or disease of a kidney.
• Nephrosis is non-inflammatory nephropathy.
• Nephritis is an inflammatory kidney disease.
• Nephrotic syndrome is a kidney disorder that causes our body to pass too much
protein in our urine. Nephrotic syndrome is usually caused by damage to the clusters
of small blood vessels in our kidneys that filter waste and excess water from our
blood.
1. Glomerulonephritis (Bright's Disease):
What is glomerulonephritis?
• Glomerulonephritis (GN) is the inflammation of the glomeruli, that are made up of
tiny blood vessels.
• These knots of vessels help filter blood and remove excess fluids.
• If glomeruli are damaged, kidneys will stop working properly, and leads to kidney
failure.
• Sometimes called nephritis, GN is a serious illness that can be life-threatening and
requires immediate treatment.
• GN can be both acute, or sudden, and chronic, or long-term.
• This condition used to be known as Bright's disease.

What are the causes of GN?

The causes of GN depend on whether it’s acute or chronic.
1. Acute GN:
 • Acute GN can be a response to an infection such as strep throat or an abscessed tooth.
• It may be due to problems in immune system overreacting to the infection.
 Certain illnesses are known to trigger acute GN, including:
a) Systemic lupus erythematosus, which is also called lupus (body's immune system
attacks your own tissues and organs).
b) Goodpasture syndrome, a rare autoimmune disease in which antibodies attack own
kidneys and lungs.
 Amyloidosis, which occurs when abnormal proteins that can cause harm build up in
our organs and tissues.
 Granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), a
rare disease that causes inflammation of the blood vessels.
 Polyarteritis nodosa, a disease in which cells attack arteries.
 Heavy use of non-steroidal anti-inflammatory drugs, such as ibuprofen (Advil) and
naproxen (Aleve), may also be a risk factor.

2. Chronic GN:
• The chronic form of GN can develop over several years with no or very few
symptoms.
• This can cause irreversible damage to the kidneys and ultimately lead to
complete kidney failure.
• Chronic GN doesn’t always have a clear cause.
• A genetic disease can sometimes cause chronic GN. Hereditary nephritis occurs in
young men with poor vision and poor hearing.
• Other possible causes include:
1. Certain immune diseases
2. A history of cancer
3. Exposure to some hydrocarbon solvents
4. Having the acute form of GN
What are the symptoms of GN?
It depends on what form of GN the patient have as well as how severe it is.
1. Acute GN:
Early symptoms of acute GN include:
• Puffiness of face
 • Urinating less often
• Blood in the urine, which turns urine to a dark rust color
• Extra fluid in lungs, causing coughing
• High blood pressure
2. Chronic GN:
• The chronic form of GN can creep up without any symptoms.
• There may be slow development of symptoms similar to the acute form.
• Some symptoms include:
1. Blood or excess protein in urine,
2. High blood pressure
3. Swelling in ankles and face
4. Frequent night-time urination
5. Bubbly or foamy urine, from excess protein
6. Abdominal pain
7. Frequent nosebleeds

What are the complications associated with GN?

• GN can lead to nephrotic syndrome, which causes to lose large amounts of protein in
urine.
• This leads to a lot of fluid and salt retention in body.
• Development of high blood pressure, high cholesterol, and swelling throughout body.
• Eventually, nephrotic syndrome will lead to end-stage renal disease if it doesn’t come
under control.

The following conditions can also occur due to GN:

 Acute kidney failure
 Chronic kidney disease
 Electrolyte imbalances, such as high levels of sodium or potassium
 Chronic urinary tract infections
 Congestive heart failure due to retained fluid or fluid overload
 Pulmonary edema due to retained fluid or fluid overload
  High blood pressure
 Malignant hypertension, which is rapidly increasing high blood pressure
 Increased risk of infections.

Dietary management:
Aim should be to maintain fluid balance and to provide non-protein calories either oral or
parenteral to minimize the catabolism of tissue proteins.
1. ENERGY:
• Adequate calories should be provided acc. to age, height, weight, sex and disease
condition.
• 10% additional allowance is provided for infections.
• 1800-2000 Kcals.
• Provide calories without increasing the protein content.
• Honey, sugar, glucose, sago, rice, fats, oils and starchy foods can be given.
2. Protein:
• It should be restricted in presence of oliguria or renal failure.
• A diet not exceeding 40gms/day of protein can be given initially.
• 50% protein should be of good quality protein sources e.g. eggs and milk.
• Protein intakes should be increased by amount of protein lost in urine.
• 0.5 g/kg body wt.- Older children
• 1 g/kg body wt to 1.5g/kg body wt. – younger children
• A low protein diet is advised to provide rest to the kidneys while proteins are
completely stopped if anuria occurs.
• Protein sources rich in Na and K should be restricted.
3. Sodium:
• Na management depends on the degree of oliguria and hypertension.
• Na restriction is followed in presence of edema and hypertension.
• 500 – 1000 mg of Na is recommended.
• Na should be restricted if there is danger of heart failure and pulmonary edema.
• Following needs to be controlled or avoided: table salt, processed food, dried foods,
chemical preservatives, ready to eat foods, packed beverages, etc.
4. Potassium:
 • K should be restricted as during malfunctioning of kidney, there is buildup of K in the
body which causes unrythmical beating of the heart and eventually stops beating.
• K is also restricted in case of reduction in urine formation.
• K is present in almost all foods especially, fruits, vegetables and meats.
• Vegetables should be boiled in excess water, then water should be discarded to
remove excess minerals.
• Spices and condiments should be used sparingly as they are rich in K.

5. Fluids:
• In presence of oliguria, fluids are restricted to prevent edema.
• Fluids intake depends on the output of the previous day.
• Daily weighing and monitoring of overall fluid balance is must.
• 500 to 1000 ml more fluids than lost in the previous day is allowed.
• 500 ml/day plus the volume excreted is administered taking into account the
insensible water loss.
• Insensible water loss:
 Infants – 30 ml/kg body wt.
 Older children- 20 ml/kg body wt.
 Adults - 10 ml/kg body wt.

II. NEPHROSIS
• Nephrosis is also called nephrotic syndrome and is caused by a variety of diseases.
• These diseases attacks on our body lead to our kidneys being unable to prevent
proteins from leaking into our urine.
• Nephrosis is a condition that describes multiple symptoms which indicate our kidneys
are not working like they should.
• Nephrotic syndrome is a kidney disorder that causes our body to excrete too much
protein in the urine.
• Nephrotic syndrome is usually caused by damage to the clusters of small blood
vessels in the kidneys that filter waste and excess water from blood.
• Nephrotic syndrome causes swelling (edema), particularly in our feet and ankles,
and increases the risk of other health problems.
 • Treatment for nephrotic syndrome includes treating the underlying condition that's
causing it and taking medications.
• Nephrotic syndrome can increase the risk of infections and blood clots.
Symptoms
It includes:
• Severe swelling (edema), particularly around the eyes and in ankles and feet
• Foamy urine, which may be caused by excess protein in the urine
• Weight gain due to excess fluid retention
• Fatigue
• Loss of appetite

Causes
• Nephrotic syndrome is usually caused by damage to the clusters of tiny blood vessels
(glomeruli) of the kidneys.
• The glomeruli filter the blood as it passes through the kidneys, separating things
that body needs from those it doesn't.
• Healthy glomeruli keep blood protein (mainly albumin) — which is needed to
maintain the right amount of fluid in the body — from seeping into the urine.
• When damaged, glomeruli allow too much of blood protein to leave the body,
leading to nephrotic syndrome.

Many possible causes include:

 Diabetic kidney disease: Diabetes can lead to kidney damage (diabetic nephropathy)
that affects the glomeruli.
 Minimal change disease:
• This is the most common cause of nephrotic syndrome in children.
• Minimal change disease results in abnormal kidney function, but when the kidney
tissue is examined under a microscope, it appears normal or nearly normal.
• The cause of the abnormal function typically can't be determined.
 Focal segmental glomerulosclerosis:
• Characterized by scattered scarring of some of the glomeruli, this condition may
result from another disease or a genetic defect or occur for no known reason.
 Membranous nephropathy:
 • This kidney disorder is the result of thickening membranes within the glomeruli.
• The exact cause of the thickening isn't known, but it's sometimes associated with
other medical conditions, such as hepatitis B, malaria, lupus and cancer.
 Systemic lupus erythematosus: This chronic inflammatory disease can lead to
serious kidney damage.
 Amyloidosis. This disorder occurs when substances called amyloid proteins
accumulate in our organs. Amyloid buildup often affects the kidneys, damaging
their filtering system.
 Blood clot in a kidney vein. Renal vein thrombosis, which occurs when a blood clot
blocks a vein connected to the kidney, can cause nephrotic syndrome.

Complications
• Blood clots: The inability of the glomeruli to filter blood properly can lead to loss of
blood proteins that help prevent clotting. This increases our risk of developing a
blood clot (thrombus) in our veins.
• High blood cholesterol and elevated blood triglycerides: When the level of the
protein albumin in our blood falls, our liver makes more albumin. At the same time,
our liver releases more cholesterol and triglycerides.
• Poor nutrition. Loss of too much blood protein can result in malnutrition. This can
lead to weight loss, but it may be masked by swelling. One may also have too few red
blood cells (anemia) and low levels of vitamin D and calcium.
• High blood pressure. Damage to our glomeruli and the resulting buildup of wastes in
our bloodstream (uremia) can raise our blood pressure.
 Acute kidney failure:
• If kidneys lose their ability to filter blood due to damaged glomeruli, waste products
may build up quickly in blood.
• If this happens, one may need emergency dialysis — an artificial means of removing
extra fluids and waste from blood — typically with an artificial kidney machine
(dialyzer).
• Chronic kidney disease. Nephrotic syndrome may cause kidneys to gradually lose
their function over time. If kidney function falls low enough, one may require dialysis
or a kidney transplant.
• Infections. People with nephrotic syndrome have an increased risk of infections.

DIET MANAGEMENT
1. Energy:
 • 2000 Kcal.
• To spare protein for tissue synthesis.
• Food should be innovative, appetizing, and tasty, due to poor appetite.
2. Protein:
• An adequate protein diet to compensate the heavy protein loss, and avoiding too
much protein, which will put unnecessary burden on the kidneys.
• 0.5 g/kg body wt- 1g/kg body wt of protein is acceptable, taking into account the
proteinuria.
• Total dietary protein intake should be able to balance out the protein lost through
urine.
• High quality protein are preferred.
3. CHO:
• A high CHO diet to supply adequate calories, without increasing protein content is
recommended.
4. SODIUM:
• A low Na diet may help with edema.
• 500-750 mg/day.
5. VITAMINS:
• Vitamin D supplements is needed if nephrotic syndrome is long term and not
responding to treatment.
• Vit C supplements should be given.
• In case of Ca and K def., appropriate supplements should be provided.
6. Cholesterol:
• A moderate or low fat diet is recommended depending on the cholesterol level of the
blood.
7. Fluids:
• A restricted fluid diet.
• In case of oliguria (urine output less than 25ml/kg/day) fluid restriction becomes
necessary.
* Foods allowed and avoided- Go through books.

III. Acute kidney failure and Chronic kidney failure

Acute Kidney failure
 • Acute kidney failure occurs when the kidneys suddenly become unable to filter
waste products from the blood.
• When kidneys lose their filtering ability, dangerous levels of wastes may
accumulate, and the blood's chemical makeup may get out of balance.
• Acute kidney failure — also called acute renal failure or acute kidney injury —
develops rapidly, usually in less than a few days.
• Acute kidney failure is most common in people who are already hospitalized,
particularly in critically ill people who need intensive care.
• Acute kidney failure can be fatal and requires intensive treatment.
• Acute kidney failure may be reversible. If a patient otherwise in good health, she/he
may recover normal or nearly normal kidney function.
Symptoms:
Signs and symptoms of acute kidney failure may include:
• Decreased urine output, although occasionally urine output remains normal
• Fluid retention, causing swelling in your legs, ankles or feet
• Shortness of breath
• Fatigue
• Confusion
• Nausea
• Weakness
• Irregular heartbeat
• Chest pain or pressure
• Seizures or coma in severe cases

Causes
Acute kidney failure can occur when:
• A person have a condition that slows blood flow to the kidneys.
• He/she experiences direct damage to the kidneys.
• Kidneys' urine drainage tubes (ureters) become blocked, and wastes can't leave the
body through the urine
Impaired blood flow to the kidneys:
Diseases and conditions that may slow blood flow to the kidneys and lead to kidney injury
include:
 • Blood or fluid loss
• Blood pressure medications
• Heart attack
• Heart disease
• Infection
• Liver failure
• Use of aspirin, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, others)
or related drugs
• Severe allergic reaction (anaphylaxis)
• Severe burns
• Severe dehydration

Damage to the kidneys:

These diseases, conditions and agents may damage the kidneys and lead to acute kidney
failure:
• Blood clots in the veins and arteries in and around the kidneys
• Cholesterol deposits that block blood flow in the kidneys
• Glomerulonephritis, inflammation of the tiny filters in the kidneys (glomeruli)
• Hemolytic uremic syndrome, a condition that results from premature destruction of
red blood cells

Urine blockage in the kidneys:

Diseases and conditions that block the passage of urine out of the body (urinary obstructions)
and can lead to acute kidney injury include:
• Bladder cancer
• Blood clots in the urinary tract
• Cervical cancer
• Colon cancer
• Enlarged prostate
• Kidney stones
• Nerve damage involving the nerves that control the bladder
• Prostate cancer
Complications:
Potential complications of acute kidney failure include:
• Fluid buildup. Acute kidney failure may lead to a buildup of fluid in lungs, which
can cause shortness of breath.
• Chest pain. If the lining that covers heart (pericardium) becomes inflamed, one may
experience chest pain.
• Muscle weakness. When body's fluids and electrolytes —are out of balance, muscle
weakness can result.
• Permanent kidney damage: Acute kidney failure causes permanent loss of kidney
function, or end-stage renal disease.
 People with end-stage renal disease require either permanent dialysis — a
mechanical filtration process used to remove toxins and wastes from the body — or a
kidney transplant to survive.
• Death. Acute kidney failure can lead to loss of kidney function and, ultimately, death.

DIETARY MANAGEMENT
1. ENERGY:
• High calorie from CHO and fats.
• 600-1000 Kcal
• When blood urea level is over 200mg/100ml (in dialysis condition), energy may be
raised to 2000-3000 Kcal.

2. PROTEIN:
• Protein intake is calculated keeping in mind the urea content of the food.
• When the patient is under the conservative treatment and blood urea nitrogen is rising,
all Protein containing foods should be restricted.
• When blood urea level is over 200mg/100ml, an allowance of 40 g protein is made (to
reduce endogenous protein breakdown).

3. CHO:
• 100g/day of CHO is necessary.
• 2 liters of 5% glucose solution can be given, when food sources are unavailable to
fulfill this requirement.
 • A nasogastric tube feeding of 700 ml of 15% glucose solution will meet the
requirements.
4. FLUID:
• Extra 500 ml above the fluid loss through urine and intestinal tract.
• If perspiration is visible an additional 500 ml may be given.
• For increased consumption it is advisable to include a variety of beverages, cold or
hot, preferably spiced by mild spices or sugar.
5. POTASSIUM:
• Hyperkalemia is common in kidney failure
• (0.7ml/day rise in serum K), so K intake need to be kept under check.
• High K foods coffee, tea, cocoa, bananas, oranges, potatoes, spinach and tomatoes
should be avoided.
• Low K foods such as apples, cabbage, green beans, grapes and strawberries can be
given.

6. SODIUM:
• An estimation of Na lost through urine is made and that amount is replaced.
• The amount of Na consumption should be lowered by avoiding products, with added
salt, including convenience foods, such as frozen dinners, canned soups, fast foods,
salty snack foods, canned vegetables, and processed meats and cheeses.
• Freshly prepared or low or no seasoned foods are preferred.

7. PHOSPHOROUS:
• In case of impaired kidney function the body in unable to regulate Ca effectively
creating a Ca/P imbalance.
• Too much P in the blood causes leaching of Ca into the [Link] causes
weakening of the bones and skin itchiness.
• Therefore, too much of P rich foods should be avoided or antacids can be given that
excrete P.

Chronic kidney disease

• Chronic kidney disease, also called chronic kidney failure, describes the gradual
loss of kidney function.
 • Our kidneys filter wastes and excess fluids from our blood, which are then excreted in
our urine.
• When chronic kidney disease reaches an advanced stage, dangerous levels of fluid,
electrolytes and wastes can build up in our body.
• In the early stages of chronic kidney disease, one may have few signs or symptoms.
• Chronic kidney disease may not become apparent until our kidney function is
significantly impaired.
• Treatment for chronic kidney disease focuses on slowing the progression of the
kidney damage, usually by controlling the underlying cause.
• Chronic kidney disease can progress to end-stage kidney failure, which is fatal
without artificial filtering (dialysis) or a kidney transplant.
Signs and symptoms of chronic kidney disease may include:
• Nausea
• Vomiting
• Loss of appetite
• Fatigue and weakness
• Sleep problems
• Changes in how much you urinate
• Decreased mental sharpness
• Muscle twitches and cramps
• Swelling of feet and ankles
• Persistent itching
• Chest pain, if fluid builds up around the lining of the heart
• Shortness of breath, if fluid builds up in the lungs
• High blood pressure (hypertension) that's difficult to control

Causes:
Diseases and conditions that cause chronic kidney disease include:
• Type 1 or type 2 diabetes
• High blood pressure
• Glomerulonephritis, an inflammation of the kidney's filtering units (glomeruli)
 • Interstitial nephritis, an inflammation of the kidney's tubules and surrounding
structures
• Polycystic kidney disease
• Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate,
kidney stones and some cancers
• Vesicoureteral reflux, a condition that causes urine to back up into our kidneys
• Recurrent kidney infection, also called pyelonephritis
Risk factors:
Factors that may increase your risk of chronic kidney disease include:
• Diabetes
• High blood pressure
• Heart and blood vessel (cardiovascular) disease
• Smoking
• Obesity
• Family history of kidney disease
• Abnormal kidney structure
• Older age

Different stages of CRF

Stage 1 means normal filtering function of the kidney excluding those patients that are at
risk of progressive renal disease, such as those with proteinuria or hematuria.
Stage 2 defines patients with a GFR of 60 to 90 mL/minute.
Stage 3 defines patients with a GFR of 30 to 60 mL/minute.
Stage 4 defines patients with a GFR of 15 to 30 mL/minute.
Stage 5 defines patients with a GFR of less than 15 mL/minute, but who are not on
dialysis.
Stage 6 defines patients who have a glomerular filtration rate of less than 15 mL per minute
and requires dialysis intervention for their renal failure.
Patients who reach Stage 4 and Stage 5 eventually reach End stage renal disease (ESRD)
where dialysis or renal transplant are needed.

Signs and symptoms:

 • Patients suffering from CKD stage 1, 2 or 3 generally shows no symptoms.
• Symptoms generally start becoming apparent in stages 4 or 5.
• In these stages, metabolic derangements or disturbances in water or electrolyte
balance becomes clinically manifest.
ACIDOSIS:
• Metabolic acidosis is a common complications associated with progressive renal
failure.
• Diminished maintenance of acid-base homeostasis results in acid accumulation,
leading to poor nutritional status, worsened uremic bone disease and increased
mortality.
• Metabolic acidosis may also cause kidney damage, through the stimulation of
adaptive mechanisms aimed at maintaining acid-base homeostasis.
• Increased retention of acids, results in protein catabolism and protein-energy
wasting and decreased functional capacity.
Signs of metabolic acidosis in stage 5 CKD includes:
• PEM- loss of lean body mass and muscle weakness.
• Salt and water imbalance- peripheral edema, pulmonary edema and hypertension.
• Anemia
• Development of CVD

Other indicators of uremia in ESRD:

• Pericarditis
• Encephalopathy
• Peripheral neuropathy
• Restless leg syndrome
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Dry skin with itchiness and pigmentation
• Fatigue and tiredness
• Malnutrition
 • Platelet dysfunction with tendency to bleed

DIETARY MANAGEMENT
• To provide rest to the kidneys, a diet limiting protein, fluids and certain minerals in
the food is recommended.
• Points to be kept in mind when suffering from CKD:
 Limiting fluids
 Eating a low-protein diet
 Limiting salt, potassium, phosphorous, and other electrolytes.
 Getting enough calories if losing weight
1. ENERGY:
• Adequate energy is required to supply energy to the body and maintain optimum
weight.
• Excess wt gain need to be checked as it imposes unnecessary burden on the kidneys.
• Calories should be derived from CHO and fats sources, since the end products of
catabolism-metabolism are CO2 and H2O, which don't have detrimental effect on
renal failure.
• Endogenous protein catabolism results in unnecessary burden on the kidneys,
aggravating condition of uremia.

2. PROTEIN:
• Very low protein diets are advised.
• The amount of protein needed is based on body size, kidney problem, and the amount
of protein that may be in the urine.
• Diet very high in protein can make the kidneys work harder and may cause more
damage.
• Protein allowance- 0.5g/kg body weight, helps in reducing blood urea.
• Older children and adolescents are advised a protein intake of 0.25 g/kg body weight
or 15-20 g/day .
3. CHO:
• CHO food sources which are high in K and P, may need to be limited.
• In case of diabetes, special attention needs to be given to CHO sources and amounts
in the diet.
 • Hard candies, sugar, honey, jelly, high calorie desserts are permitted.
3. FATS:
• Excess fat can lead to weight gain or heart diseases.
• Monounsaturated and polyunsaturated fats (olive oil, canola oil, safflower oil) are
recommended to protect heart health.
4. FLUIDS:
• In CKD, fluid restriction is exercised, as damaged kidneys do not get rid of extra
fluid.
• Too much fluid may cause high BP, swelling and heart failure.
• Extra fluid may build up around the lungs and make it hard to breathe, water toxicity,
hyponatraemia, and hypokalaemia.
• Fluid restrictions depend on the stage of kidney disease and the treatment.
• Besides water and other beverages, food sources with large amounts of water need to
be restricted/avoided.
• Thirst increase fluid intake. Limit Na to help cut down on thirst.
• Patients are administered diuretics for fluid flushing.
• Limiting fluids between dialysis is very imp. Because most people on dialysis urinate
very little.
5. Sodium:
• 1-2 mMol/kg body weight – infants
• 40-60 mMol/day – children
• Na restriction is made when the chronic renal failure is accompanied with
hypertension and/or edema.
• 0.2 mMol/kg body weight/day in addition of diuretics is given to tide over the critical
condition.
6. Potassium:
• When kidneys are not working well, K levels may be too high or too low. Having too
much or too little K can cause muscle cramps, irregular heartbeat, and muscle
weakness.
• Dangerous heart rhythms may result to death.
• 1 m/Mol/kg body weight/day should be given in CRF.
• In hypokalemia, small doses of K should be given and serum level should be
monitored.
• In hyperkalemia, sever K restriction is advised.
 • To remove K, food should be boil in excess water and then discarding that water.
7. PHOSPHOROUS:
• Healthy kidneys keep the right balance of P in the body.
• When kidneys are not working well, P can build up in the blood, and cause low Ca (as
it causes Ca to pull from the bones).
• Too much P in the blood can lead to weak and brittle bones.
8. CALCIUM:
• The amounts of dairy foods need to be limited as they contain large amounts of P.
• Dairy products low in P can be given (tub margarine, butter, cream cheese, heavy
cream, etc).
• Ca supplements need to be given to prevent bone diseases, and Vit D to control the
balance of Ca and P in the body.
9. IRON:
• People with advanced kidney failure also have anemia and usually need extra iron.
• Liver, beef, pork, chicken, lima and kidney beans, iron fortified cereals may be given.
• Iron supplements may be given.

NEPHROLITHIASIS (UROLITHIASIS OR URINARY CALCULI)

Kidney stones are hard objects made of minerals and salts in urine. They form inside the
kidneys. It can be referred as kidney stones as renal calculi, nephrolithiasis or urolithiasis.

Kidney stones have various causes. These include diet, extra body weight, some health
conditions, and some supplements and medicines. Kidney stones can affect any of the organs
that make urine or remove it from the body — from the kidneys to the bladder. Often, stones
form when the urine has less water in it. This lets minerals form crystals and stick together.

Passing kidney stones can be quite painful. But prompt treatment usually helps prevent any
lasting damage. Sometimes, the only treatment needed to pass a kidney stone is taking pain
medicine and drinking lots of water. Other times, surgery or other treatments may be needed.
It depends on size, location and the type of stone you have.

Symptoms
Kidney stones
A kidney stone usually doesn't cause symptoms until it moves around within the kidney or
passes into one of the ureters. The ureters are the tubes that connect the kidneys and bladder.

If a kidney stone gets stuck in one of the ureters, it may block the flow of urine and cause the
kidney to swell and the ureter to spasm. That can be very painful. At that point, you may have
these SYMPTOMS:

 Serious, sharp pain in the side and back, below the ribs.
 Pain that spreads to the lower stomach area and groin.
 Pain that comes in waves and varies in how intense it feels.
 Pain or a burning feeling while urinating.
Other symptoms may include:

 Pink, red or brown urine.

 Cloudy or foul-smelling urine.
 A constant need to urinate, urinating more often than usual or urinating in small
amounts.
 Upset stomach and vomiting.
 Fever and chills if an infection is present.
Pain caused by a kidney stone may change as the stone moves through urinary tract. For
instance, the pain may shift to a different part of the body or become more intense.

DIALYSIS:
What Is Dialysis?
• Dialysis is a procedure that is performed routinely for patients suffering from acute or
chronic kidney (renal) failure, or who have end stage renal disease (ESRD).
What Happens During Dialysis?
• Normally, the kidneys are responsible for removing waste substances and fluid from
the blood.
• If a person have kidney failure, kidneys can no longer perform their function.
• Dialysis takes over the job of kidneys, removing waste and fluid.
• We may also use dialysis if we have been exposed to or ingested toxic substances, in
order to prevent renal failure from occurring.
Types of Dialysis:
There are two types of dialysis we may use: peritoneal and hemodialysis.
1. Peritoneal Dialysis
• Surgically place a soft, hollow tube into the lower abdomen near the navel.
• Instill a special solution called dialysate into the peritoneal cavity.
• The peritoneal cavity is the space in the abdomen that houses the organs and is lined
by two special membrane layers called the peritoneum.
• Leave the dialysate in the abdomen for a certain period of time.
• The dialysate fluid absorbs the waste products and toxins through the peritoneum.
• Drain the fluid from the abdomen, measure it and then discard it.
Types of Peritoneal Dialysis:
There are three different types of peritoneal dialysis:
1. Continuous ambulatory peritoneal dialysis (CAPD): Does not require a machine.
Exchanges, often referred to as "passes," can be done three to five times a day, during
waking hours.
2. Continuous cyclic peritoneal dialysis (CCPD): Requires the use of a special dialysis
machine that can be used in the home. This type of dialysis is done automatically,
even while you are asleep.
3. Intermittent peritoneal dialysis (IPD): Uses the same type of machine as CCPD,
but treatments take longer. IPD can be done at home, but it is usually in the hospital.
Peritoneal Dialysis: Possible Complications:
• An infection of the peritoneum, or peritonitis, where the catheter enters the body.
• Peritonitis causes fever and stomach pain.
2. Hemodialysis:
• Hemodialysis can be performed at home or in a dialysis center or hospital.
• Surgically place a special type of access, called an arteriovenous (AV) fistula,
usually in arm.
• Then an artery and a vein will be joined.
• Patient will be connected to a large hemodialysis machine.
• The machine drains the blood, immerses it in a special dialysate solution to
remove waste substances and fluid and then returns it to bloodstream.
Hemodialysis: Possible Complications
• Muscle cramps and hypotension (sudden drop in blood pressure).
• Hypotension may cause to feel dizzy, weak and stomach pain.

Dietary management
• Special care needs to be taken in terms of protein, sodium, potassium, phosphorous,
and fluid intakes.
• The diet may vary according to the type of dialysis.
• Haemodialysis patients need to be more careful about the diet.
Goals of DM are:
1. To ensure/maintain adequate protein stores in the body.
2. Provide a conducive environment for wound healing.
3. Protect the individual against infection.
• Anemia and hypertension are of concern with patients on dialysis, as it cannot take
over the endocrine function of the kidneys.
Dietary principles:
1. Provide adequate calories, preferably non- proteins:
 To minimize tissue protein catabolism,
 Spare AA’s use for protein synthesis
 Maintain optimum body weight.
2. High or good quality protein foods.
3. Restrict high salt, high Potassium, and high Phosphorous foods.

1. ENERGY:
 • Adequate calories, from CHO and fats to be provided.
• 2000-3000 Kcal.
• Amount of calories will depend on the age, gender and stage of illness.
• Optimum calories are required to maintain optimum weight and to avoid
overweight or obesity, minimize tissue protein catabolism, and spare AA’s use for
protein synthesis.
2. Carbohydrates:
• A high CHO diet to supply the body with adequate calories, without increasing the
protein content is recommended.
• Sugar, simple CHO and starches are preferred.
• Care should be taken if their need to be reduction in calorie intake for weight loss or
manage CHO intake for blood sugar control.
3. Fats:
• Unsaturated fats and essential FA’s food sources should be provided to supply the
body the required energy.
• Person at risk of heart disease, need to be on restricted fat.
4. Proteins:
• People on dialysis need to eat more quality protein.
• It can help to maintain blood protein levels & improve health.
• Peanut butter, nuts, seeds, dried peas, and lentils are not recommended as they are
high in both K and P.
• Low protein diet may be given before starting dialysis.
• A moderate-protein diet (1 gm of P/kg body weight/day) is administered while on
dialysis.
• A high protein diet with fish, poultry, pork, or eggs at every meal may be
recommended.
• To increase protein intake egg whites, egg white powder, or protein powder may be
suggested.
• This will help to replace muscles and other tissues that are lost.

5. Minerals:
Na, K and P are restricted while on dialysis:
a. Sodium:
 • Na causes the body to hold more fluid, resulting in edema and raises BP.
• Eating less Na and drinking less fluid can help before and after dialysis sessions.
• Using less salt and fewer salty foods help to control BP and reduces weight gain
between dialysis sessions.
• Using herbs, spices and low salt flavor enhancers in place of salts are helpful.
b. Potassium:
• It can be easily removed by dialysis, but when it builds up in the blood between
treatments, it can cause muscle weakness and cause heart to stop beating.
• Fruits, vegetables, dairy products, and other foods that are high in K, need to be
restricted.
• Boiling and draining excess water reduces the K content of foods by leaching
mechanism.
c. Phosphorous:
• It is difficult for hemodialysis to filter P, so foods rich in P should be restricted.
• K can build to high levels in the bloodstream and cause weak bones, heart problems,
joint pain and skin ulcers.
• Whole grain and high fiber foods should be avoided (like whole wheat bread, bran
cereal, and brown rice) to limit intake of P.
• Milk, yoghurt and cheese intake should be limited.
• Limiting dairy-based foods protect bones and blood vessels.
• P content is same for all types of milk- skim, low fat and whole.
6. Vitamins:
• There is loss of Vit. C and folic acid during dialysis.
• Therefore, it should be replenished through food rich in these vits and supplements if
needed.
7. Fluids:
• Too much fluid gain between hemodialysis session may cause discomfort (swelling,
shortness of breath or hypertension).
• Fluid restriction is recommended, but special care should be taken to avoid
dehydration.
• Fluid intake calculation has to be done on the basis of the amount of fluid one drinks
and the water content of the foods.