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RENAL MODULE

Objectives Satisfactory Not


Completion Applicable
Review
1.The intern will discuss with the rotation coordinator the normal function
and physiology of the kidney.

2.The intern will discuss with the rotation coordinator the role of nutrition
for renal disease. Include in the discussion but not limited to all the
following that are applicable!
a. etiology and treatment and pre"ention
b. pathophysiology
c. metabolic#nutritional alterations including bone and mineral
metabolism
d. current medical treatments#trends
$. %iscuss the dietitian&s role as part of the health care team
Assess
'. (sing height#weight#labs and other pertinent information the intern will
assess the appropriateness of!
a. the )%&s order
b. diet
c. energy#protein#nutrient re*uirements
+. The intern will obtain diet histories
,------- ./oal of $ or more0
1. The intern will complete nutrition care plans
,------ ./oal of $ or more0
Educate
2.The intern will utili3e the diet history and care plan as well as any other
pertinent educational material to instruct patients and#or family member
on his#her specific dietary regimen.
, ------ ./oal of $ or more0
Document
4. 5bser"e the documentation process
,--------./oal of $ or more0
Observe
6. 5bser"e patient and staff when dialysis is being
'#11
RENAL WORKSHEET
1. Define the following terms related to renal disease!
172
Azotemia! is a medical condition characteri3ed by abnormally high le"els of nitrogen7containing compounds
.such as urea creatinine "arious body waste compounds and other nitrogen7rich compounds0 in the blood. It is
largely related to insufficient filtering of blood by the kidneys.
Uremia! a condition in which nitrogenous waste .urine0 builds up in the body resulting in malaise weakness
nausea and "omiting muscle cramps neurologic impairment itching and a metallic taste in mouth. (nder normal
circumstances kidneys filter urea from the blood and it is e8creted through the urine. If the kidneys are not
working properly urea will build up in the blood and become to8ic to the body.
Anemia: a condition characteri3ed by a lack of red blood cells .9:C0 in the blood. Anemia is common in C;%
patients because the kidneys are not producing a hormone called erythropoietin .<=50 that is in"ol"ed in the
production of 9:C. 9:C carry o8ygen to cells and when the blood is deficient in 9:C 5rgans lose energy due to
the lack of o8ygen.
Hyperkalemia! >igh potassium le"els in the blood. This can occur when the kidney fails to filter potassium from
the blood causing a dangerously high amount of buildup. =otassium&s role in the body is to control muscle and
ner"e functioning. If there is a buildup in the blood the C;% patient will e8perience irregular heartbeats or heart
failure. >igh potassium food sources should be limited.
Oliguria! ?ow urinary output of less than +@@m?#day. This small amount of output is not sufficient in eliminate all
of the daily waste. This is a sign that the kidneys are not filtering waste products and e8creting urine efficiently.
%ialysis patients will ha"e oliguria because treatments may only occur three times per week. 5liguria will cause
fluid retention and edema. The normal amount of urine output is about $'7 +@ ounces per day.
Anuria: a passage of less than +@ m? of urinary output per day due to the kidneys& inability filter and e8crete
waste from the body. <dema shortness of breath and weight gain can be caused by anuria. A patient who has
been on hemodialysis for si8 months will not ha"e urinary output.
roteinuria: An abnormal amount of protein in the urine that results from the kidneys not filtering the blood
properly.
Hyperphosphatemia! The buildup of phosphate in the blood due to the kidneys inability to remo"e#e8crete
e8cess amounts. Symptoms include! an8iety fatigue breathing difficulties sores and itching bone pain bone
weakness and decreased mobility. %ialysis patients are often re*uired to take phosphate binders with their food
to decrease absorption. Aoods rich in phosphorus include! meats dairy nuts dried beans sodas canned and
processed foods.
Acidosis! The build7 up of acid in the blood which causes the blood p> to drop below 2.$+. The kidneys function
in acid# base balance by e8creting acid in the urine and regulating the bicarbonate concentration in the blood.
)etabolic acidosis can result when this acid# base balance is disrupted with a decrease in bicarbonate or
increased acid. Symptoms include! increased rate and depth of breathing confusion and headaches. Sei3ures
coma and death are e8treme outcomes. A diet high in alkaline foods like fruits and "egetables and low in meat
decreases the risk of acidosis.
Anephric! ?ack of functioning kidneys. This occurs in the last stage of chronic kidney disease .C;%0. Bithout
functioning kidneys waste products and fluid builds up to unsustainable le"els in the body. Aluid build7 up causes
fluid retention in the tissues and bloodstream. Bithout functioning kidneys electrolytes including magnesium
sodium and potassium become unbalanced. (nhealthy le"els of electrolytes result in fluid retention irregular
heart rhythm and an abnormal mental state. >ormone imbalances also result from this condition affecting bone
health blood pressure and 9:C formation. These patients re*uire dialysis in order to li"e.
!dema! Swelling that is caused by fluid retention which may result from the kidneys inability to e8crete e8cess
fluid. <dema often occurs in the legs and feet. <dema puts a lot of strain on the body and increases the person&s
risk for CC%. Symptoms include! weight gain shortness of breath discomfort and high blood pressure.
Urine output! the "olume of urine output correlates with renal functioning. Bell7functioning kidneys filter 2@@
*uarts of blood and produce $'7 +@ o3. of urine daily. A decrease in urine output could be indicati"e of A9A where
many patients can only create 11 ounces of urine per day. ?ow urine output increases fluid retention resulting in
swelling of the legs feet and ankles.
eritoneum: is the serous semi7permeable membrane that forms the lining of the abdominal ca"ity. %uring
peritoneal dialysis a catheter is inserted into this membrane and the peritoneum holds dialysate which acts in
place of the kidneys to filter to8ins and fluid from the blood.
Dialysate: is a cleansing fluid containing a high7de8trose concentration that is inserted "ia a =% catheter into the
peritoneum during peritoneal dialysis. /lucose in the dialysate pulls to8ins and fluids across the semipermeable
membrane and pre"ents it from passing back through the peritoneum. %iffusion carries waste products from the
blood through the peritoneal membrane and into the dialysateD water mo"es "ia osmosis. This fluid is then
remo"ed and replaced with fresh dialysate. This process is called an e8change and can occur manually or
through a cycler machine.
olyuria! <8cessi"e urination commonly seen in uncontrolled diabetes. (sually the kidneys filter glucose from
the blood and then reabsorb them into the bloodstream for energy. In uncontrolled diabetes a high amount of
glucose in the blood will cause an increased amount of glucose lost in the urine. This causes higher urinary output
because glucose is an osmolyte which pulls water into the urine. An e8cessi"e "olume of urination for an adult is
more than 2.+ liters of urine daily.
"enal osteodystrophy! is a bone disease linked to kidney failure. This condition affects up to 6@E of dialysis
patients. Through this disease bones become thin and weak or malformed. Symptoms can be seen in growing
children with kidney disease e"en before they start dialysis. 5lder patients and women who ha"e gone through
menopause are at greater risk for this disease.
A# $istula: is a surgically created connection of an artery to a "ein. This is the Fgold standardG access for
hemodialysis patients because they ha"e low complication rates a lower tendency to clot allows greater blood
flow is functions for a longer period of time and are more cost effecti"e. Bhen the fistula heals and matures it
pro"ides good blood flow and therefore increases the effecti"eness of hemodialysis. The AC fistula becomes a
natural part of the body when it is created.
%hunt! An e8ternal de"ice that connects a tube from the artery to the "ein. This shunts the blood from the tube in
the artery to the tube in the "ein. This process was used as an early form of dialysis.
Hematuria: The presence of red blood cells in the urine which can be caused by inflammation of the glomerulus
of the kidneys. Two types of blood in the urine e8ist. :lood that can be seen in the urine is called gross hematuria.
:lood that cannot be seen in the urine e8cept when e8amined with a microscope is called microscopic
hematuria. )ost people with microscopic hematuria do not ha"e symptoms. =eople with gross hematuria ha"e
urine that is pink red or cola7colored due to the presence of red blood cells .9:Cs0.
Dry &eight: The lowest weight a dialysis patient can reach safely without e8cess fluid that builds up in
between treatments' Accurately assessing dry weight is essential to ensuring that hemodialysis treatment is
effecti"e and safe. The FidealG dry weight also known as the Ftarget weightG is the weight clinicians hope a
patient will achie"e at the end of each >% session. As the patient reaches pre"ious dry weight through solute
remo"al the hemodialysis treatment is reaching optimum results. Bithout accurate dry weight assessment
patients could suffer from one of two dangerous outcomes including hyper"olemia or hypo"olemia. >yper"olemia
is characteri3ed as a fluid o"erload which can result from the o"erestimation of dry weight. )aHor risks associated
with this de"elopment include! hypertension left "entricular hypertrophy and cardio"ascular disease. 5n the
other hand if dry weight is set too low hypo"olemia can occur prompting hypotension cramps di33iness
ischemia and the loss of residual renal function.
2. (riefly describe each of the following abbreviations often found in the medical records
of renal patients:
)*+,)-
A"$ .Acute "enal $ailure/: sudden decline in renal function with waste retention. A9A occurs when the kidneys
fail to function because of circulatory glomerular or tubular deficiencies. A9A can be caused by damage to the
internal organs o"er7e8posure to metals sol"ents certain antibiotics and medications kidney infection or
obstructions in the urinary tract or renal artery. Illness or surgery increases risk of A9A. The patient may
e8perience shock or trauma decreasing blood pressure and blood flow. As a result the kidneys will not recei"e
enough o8ygen to filter blood as efficiently. (rine output decreases fluid retention increases and nausea
"omiting drowsiness and numbness in the hands and feet may result. Bith A9A patients gradually impro"e
although some loss of function may be permanent.
!%"D .!nd %tage "enal Disease/: the complete or almost complete failure of kidney function as e8emplified by
an e/A9 of less than 1+. %ialysis or a kidney transplant is needed to maintain safe le"els of salt body fluid and
waste products throughout the body when kidney function is not sufficient. It is imperati"e for someone suffering
from <S9% to maintain fluid balance and remo"e ade*uate amounts of waste to pre"ent bodily harm. Aailure to
undergo sufficient dialysis treatment can cause edema and hypertension which result in immense amounts of
pressure on the lungs and heart. Symptoms include loss of appetite nausea "omiting headaches fatigue
inability to concentrate itching making little to no urine swelling around the eyes and ankles muscles cramps
tingling and changes in skin color.
H(# .High (iological #alue/: complete proteins that contain all 6 essential amino acids. <ggs meat fish
poultry cheese and milk are sources of >:C protein. =atients with C;% who are not on dialysis need to limit their
protein intake due to the kidneys inability to sufficiently filter wastes that are produced during protein breakdown.
5n the other hand those that are on dialysis will ha"e an increased protein need due to dialysis filtering e8tra
amino acids from the blood. Aor renal patients not on dialysis it is recommended that much of their protein intake
is of >:C source for it is essential to maintain ade*uate protein le"els in the body which are necessary to pre"ent
protein catabolism and pro"ide essential amino acids needed for repair and maintenance.
0$" .0lomerular $iltration "ate/! is a test used to measure kidney function. This test determines the rate at
which blood is filtered by the glomeruli in the kidneys per minute. The e/A9 .estimated /A90 is based on a
serum creatinine test where the blood is tested for creatinine le"els. Creatinine in the blood accumulates during
decreased kidney function because it is not properly filtered and e8creted into the urine. Age gender race height
and weight is also used in calculating e/A9. Although kidney function declines naturally with age kidney function
declines drastically with C;%. 9esults!
Stage 1 .Normal or minimal kidney damage0! /A9! I 6@712@ m?#min# 1.2$ m2
Stage 2! /A9! 1@7 46 m?#min# 1.2$ m2
Stage $! /A9! $@7+6 m?#min# 1.2$ m2
Stage '! /A9! 1+726 m?#min# 1.2$ m2
Stage + .;idney Aailure0! /A9! J1+ m?#min# 1.2$ m2
UO .Urinary Output/: a marker of acute kidney inHury but also to guide fluid resuscitation in critically ill patients.
A decrease of urine output may be associated to a decrease of glomerular filtration rate due to decrease of renal
blood flow or renal perfusion pressure.
1"$ .1hronic "enal $ailure/: the slow gradual loss of kidney function. An e/A9 of J1@ m?#min# 1.2$ m
2
is
indicati"e of kidney damage. Causes include! lupus ATS chronic >TN prolonged urinary obstruction nephrotic
syndrome =;% %) and cystinosis. Some forms of C9A can be slowed down or controlled but this condition is
not curable.
H23 .Hypertension/! characteri3ed by a sustained systolic and diastolic blood pressure of K1'@#6@.
>ypertension nearly doubles the risk for heart attack stroke and heart failure. >igh blood pressure causes
damage to blood "essels including those in the kidneys. In this case the kidneys will not be as effecti"e in
filtering the blood resulting in e"en higher blood pressure. >TN is one of the leading causes of <S9%. Beight
maintenance .or loss if o"erweight0 e8ercise and a diet high in fruits "egetables whole grains and low7 fat dairy
can help control >TN. Sodium should be limited. Symptoms of hypertension include! fre*uent headaches
impaired "ision S5: nose bleeds chest pain di33iness failing memory snoring and /I distress.
U"" .Urea "eduction "atio0! a blood test that determines effecti"eness of dialysis by comparing the amount of
urea reduction before and after dialysis. The patient is considered well dialy3ed if serum urea reduction is 1+E or
more during dialysis.
2H .arathyroid Hormone0! a protein hormone that is important in bone growth secreted by the parathyroid
gland. =T> is in"ol"ed in the regulation of calcium phosphorous and Citamin % in the blood. The =T> stimulates
calcium resorption from the bone when blood calcium le"els are too low. If the kidneys cannot filter phosphorous
in the blood =T> le"els rise causing e8cess calcium resorption into the blood. %iseased kidneys also cannot
acti"ate "itamin % lea"ing intestines unable to absorb calcium. The bones weaken when there is not enough
calcium and can result in pain fractures and osteoporosis.
4D3 .4ntradialytic parenteral nutrition/: is a supplemental form of parenteral nutrition prescribed to pro"ide
malnourished hemodialysis patients with the protein calories and other nutrients that their body needs for
strength and energy.
!O .!rythropoietin/: is a hormone that controls red blood cell production. It is a cytokine .protein signaling
molecule0 for erythrocyte .red blood cell0 precursors in the bone marrow. This hormone is synthesi3ed in the
kidneys.
5t6#: a number used to *uantify hemodialysis and peritoneal dialysis treatment ade*uacy. An ideal measurement
is 1.' or more per >% treatment or 2 or more for more =% treatment.
;L dialy3er clearance
tL time on dialysis
CL "olume of body water in a gi"en patient
7' Describe the significance of each of the following laboratory tests often ordered for
renal patients and list the normal ranges:
))
8ab 2est
3ormal
"ange
%ignificance
(U3 .blood
urea
nitrogen/
27 2@ mg#d?

This test is primarily used along with the creatinine test to e"aluate kidney
function in a wide range of circumstances to help diagnose kidney disease and
to monitor people with acute or chronic kidney dysfunction or failure. As kidney
function decreases the :(N will increase. /i"en as part of a :)= or C)=.
1reatinine @.17 1.+ mg#d?
/i"en with C)= or :)= along with :(N tests to monitor kidney function.
)easures amount of creatinine present in the blood or urine. Baste product from
muscle breakdown of creatinine that is e8creted by the kidneys. Increased
creatinine le"els in the blood suggest diseases or conditions that affect kidney
function. These can include! damage to or swelling of blood "essels in the kidneys
.glomerulonephritis0 bacterial infection of the kidneys .pyelonephritis0 death of
cells in the kidneysM small tubes .acute tubular necrosis0 prostate disease kidney
stone or other causes of urinary tract obstruction reduced blood flow to the
kidney due to shock dehydration congesti"e heart failure atherosclerosis or
complications of diabetes.
otassium $.+7+.+ mg#d?
(sed to detect concentrations that are too high .hyperkalemia0 or too low
.hypokalemia0. The most common cause of hyperkalemia is kidney disease. )any
drugs can decrease potassium e8cretion and result in this condition. >ypokalemia
can occur if someone has diarrhea and "omiting or if is sweating e8cessi"ely.
=otassium can be lost through the kidneys in urineD in rare cases potassium may
be low because someone is not getting enough in their diet.
1alcium
4.'71@.2
mg#d?
:lood calcium le"els do not indicate le"els of bone calcium but rather serum
calcium le"els. Calcium absorption use and e8cretion are regulated and
stabili3ed by a feedback loop in"ol"ing =T> and "itamin %. Conditions and
diseases that disrupt calcium regulation can cause inappropriate acute or chronic
ele"ations or decreases in calcium and lead to symptoms of hypercalcemia or
hypocalcemia. A blood calcium test is ordered to screen for diagnose and
monitor a range of conditions relating to the bones heart ner"es kidneys and
teeth. This test is gi"en as part of a :)= or C)=.
hosphorous $.+7+.+ mg#d?
=hosphorous if not filtered properly from the kidneys increases calcium
resorption from the bone. The patient may need phosphate binders and ade*uate
dialysis to control this range.
Albumin $.'7+.' g#d?
%ialysis increases protein catabolism which could cause a decrease in albumin
le"els since it is a protein. This causes fluid to leak from blood "essels into the
tissue causing edema. It is difficult for dialysis to remo"e the fluid from the tissue.
?ow albumin le"els can reflect diseases in which the kidneys cannot pre"ent
albumin from leaking from the blood into the urine and being lost. In this case the
amount of albumin or protein in the urine also may be measured.
Hemoglobin K11 g#d?
<"aluates hemoglobin content in blood. >emoglobin is found in 9:Cs which are
produced by <=5. A decrease in hemoglobin content could indicate that <=5 is
not being synthesi3ed properly a sign that there is a kidney malfunction.
Hematocrit $27 '6E
)easures the E of 9:Cs in the blood. A low E could indicate se"ere and chronic
kidney diseases due to decreased production of erythropoietin a hormone
produced by the kidneys that stimulates 9:C production by the bone marrow.
9 sat
1+7+@E
.males0D
127'+E
females
)easures the amount of iron that is bound to transferrin for transportation. This
percentage decreases in the presence of anemia which is common in renal
patients due to the inability of the kidneys to produce <=5 .a hormone produced
by the kidneys that stimulates 9:C production by the bone marrow0.
$erritin
127 $@@ ng#m?
.males0D
1271+@
ng#m?
females
If the kidneys are not producing <=5 9:C production decreases. Aerritin is the
storage form of iron and low "alues indicate a low production of 9:C. Aerritin is
an acute phase reactant and can be increased in people with inflammation li"er
disease chronic infection autoimmune disorders and some types of cancer.
Aerritin is not typically used to detect or monitor these conditions.
2ransthyretin
.pre,
albumin/
K4 mg#d?
This test measures the amount of prealbumin in the blood. If the kidneys are not
breaking down protein properly this could reflect a high transthyretin le"el. %ue to
its short half7life the test reflects only the current nutritional status of the patient.
(U3:
creatinine
ratio
1@!1 7 2@!1
%etermines the cause of increased concentrations of :(N and creatinine. If the
ratio is high it may be due to a decreased blood flow to the kidneys increased
protein or /I bleeding. A decreased ratio is associated with li"er disease.
+'
1onvert the following:
:- m!; 3a to <<mg 3a
mgL m<* 8 atomic weight# "alence
mg NaL 1@ 8 2$#1 L 1$4@mg Na
:- m!; 5 to <<mg 5
mgL m<* 8 atomic weight# "alence
mg ; L 1@ 8 $6#1 L 2$'@mg ;
=> m!; 3a to <<mg 3a
mgL m<* 8 atomic weight# "alence
mg NaL 4+ 8 2$#1 L 16++mg Na
=> m!; 5 to <<mg 5'
mgL m<* 8 atomic weight# "alence
mg ;L 4+ 8 $6#1 L $$1+mg ;
>'
(riefly describe the major functions and parts of the kidney'
)?
)ost indi"iduals ha"e two kidneys about the si3e of a fist located on either side of the lower back. <ach kidney
contains up to a million functioning units called nephrons. A nephron consists of a filtering unit of tiny blood
"essels called a glomerulus attached to a tubule. Bhen blood enters the glomerulus it is filtered and the
remaining fluid then passes along the tubule. In the tubule chemicals and water are either added to or remo"ed
from the filtered fluid according to the bodyMs immediate needs. The final product of kidney function is urine
which we e8crete.

The kidneys filter and return about 2@@ *uarts of fluid daily to the bloodstream. About two *uarts are remo"ed
from the body in the form of urine and about 164 *uarts are reco"ered. The urine we e8crete has been stored in
the bladder for anywhere from 1 to 4 hours.
The kidney is responsible for the following functions!
&aste e@cretion7 9emo"al of the waste products of metabolism. .(rea uric acid creatinine0
Acid,base balance7 ;idneys regulate p> by eliminating e8cess >
N
O P and controlling composition of the blood.
:lood plasma p> is maintained by the kidney at a neutral p> of 2.'. (rine is either acidic or alkaline. ;
N
and
phosphate re*uire renal control as well.
(lood ressure 1ontrol7 =lay an important role in blood pressure management through the renin7angiotensin
system. Bhen blood pressure is too low renin is secreted. 9enin acts on the blood protein angiotensinogen
con"erting it to angiotensin I. Angiotensin I is then con"erted to angiotensin II which stimulates the secretion of
aldosterone by the adrenal corte8. Aldosterone stimulates increased reabsorption of Na
N
from the kidney tubules
which causes an increase in the "olume of water that is reabsorbed from the tubule. This increase in water
reabsorption increases the "olume of blood which ultimately raises the blood pressure.
lasma volume and osmolality, A rise or drop in osmotic pressure due to too little or too much water is
detected by the hypothalamus which notifies the pituitary gland. A lack of water causes the posterior pituitary
gland to secrete antidiuretic hormone which results in water reabsorption and an increase in urine concentration.
Tissue fluid concentration then returns to normal.
Hormone secretion7 <=5 is secreted for 9:C production. (rodilatin is a natriuretic peptide that mediates
natriuresis. Cit %$ is con"erted from its inacti"e form .%20 to its acti"e form 12+7dihydro8y"itamin % in the
pro8imal tubule.

1arnitine synthesis7 Carnitine carries AAs to mitochondria for muscle fuel. ?ysine methionine "it C iron "it :1
and niacin are needed to produce carnitine.
0lucose homeostasis7 9ole in gluconeogenesis and glucose counterregulation.
rostaglandin !?7 )aHor renal cycloo8ygenase metabolite of arachidonic acid that impacts renal hemodynamics
and salt and water e8cretion.
:' Describe each of the following types of dialysis' 8ist the advantages and disadvantages
of each type'
eritoneal dialysis .D0 is a treatment that remo"es wastes chemicals and additional water from the body
through the lining of the abdomen to filter blood. A dialysis solution consisting of minerals and de8trose dissol"ed in
water tra"els through a catheter into the abdomen. The mi8ture is responsible for pulling waste chemicals and
e8cess water from the blood "essels of the peritoneal membrane into the solution. Se"eral hours later the used
solution is remo"ed from the abdomen taking the wastes from blood with it. The cycle is then repeated with the
abdomen being refilled with fresh dialysis solution. The cyclic process of draining and refilling of the dialysis fluid is
called an e8change. This kind of treatment does re*uire a surgically placed catheter into the abdomen or chest of
the patient. This treatment option re*uires indi"iduals to ha"e a strong internal locus of control for it is their
responsibility to ensure that treatments are performed supplies are a"ailable and sterile procedures are followed.
eritoneal dialysis

1ontinuous Ambulatory eritoneal Dialysis .1AD/ %ialysate is placed into the peritoneal ca"ity .membrane
inside of the abdomen0. %ialysate pulls to8ins and fluid across the membrane of the peritoneum. The dialysate
solution is drained and replaced e"ery $7' hours manually. This process does not re*uire a machine.
Ad"antages! can be performed at home or Fone the goG easier to tra"el work or attend school fewer dietary
restrictions no weekly appointments necessary no tra"el time#money needed to attend appointments.
%isad"antages! burden on time to manually change dialysate e"ery few hours may cause weight gain and
difficulties in controlling glucose risk of infection may not be an option if the patient has had pre"ious operations on
the abdomen must keep up with all supplies and keep process sterile must ha"e some e8plicit training.
1ontinuous 1yclical eritoneal Dialysis .11D/ =eritoneal dialysis occurs o"er 47 1@ hours while the patient is
hooked up to a machine called a cycler which automatically e8changes the dialysate. =atients typically undergo
this process while they are sleeping and the %ialysate is left in the abdomen during the day.
Ad"antages! allow dialysis to occur while the patient is sleeping patient is able to li"e normal life during the day can
be done at home .sa"ing money and time on tra"el0 fewer dietary restrictions easily becomes routine
%isad"antages! may be uncomfortable to use while sleeping may cause weight gain and difficulties in controlling
glucose may not be an option if the patient has had pre"ious operations on the abdomen increased risk of
infection must be hooked up to machine for 471@ hours at the time must keep up with all supplies and keep
process sterile must ha"e some e8plicit training.
3octurnal 4ntermittent eritoneal Dialysis .4D/ A catheter is placed inside and outside of the body for the
dialysate to flow into and out of the abdominal ca"ity. =% occurs as the patient is sleeping much like what is
characteri3ed in CC=% e8cept that the patientMs abdominal ca"ity is left empty during the day.
Ad"antages! allow dialysis to occur while the patient is sleeping patient is able to li"e normal life during the day can
be done at home .sa"ing money and time on tra"el0 fewer dietary restrictions easily becomes routine
%isad"antages! may be uncomfortable to use while sleeping may not be an option if the patient has had pre"ious
operations on the abdomen increased risk of infection must be hooked up to machine for 471@ hours at the time
must keep up with all supplies and keep process sterile must ha"e some e8plicit training.
Hemodialysis .HD/ cleanses and filters blood using a machine to momentarily rid your body of harmful wastes
e8tra salt and additional water. >emodialysis assists in controlling blood pressure and helps regulate important
chemicals including! potassium sodium calcium and bicarbonate. %uring hemodialysis blood tra"els through
tubes into a dialy3er which is a special filter that functions as an artificial kidney. Then the prepared blood flows
back into the body. The hemodialysis machine monitors blood flow and remo"es wastes from the dialy3er.
Treatment is usually done three times a week and lasts from $ to + hours each. This kind of treatment re*uires
immediate access to the blood stream. The two most common types of access are fistulas and grafts.
>emodialysis is typically completed in a dialysis center by speciali3ed technicians that are closely managed by
nurses and doctors. In ha"ing in7center treatment the burden of ha"ing to plan each treatment is eliminated for
each patient is gi"en a fi8ed time slot three times per week on )onday7Bednesday7Ariday or Tuesday7Thursday7
Saturday. This permits the patient to e8hibit an e8ternal locus of control for the responsibility of the treatment
e8cept for transportation to the clinic falls into the hands of the dialysis center&s employees.
Hemodialysis
Ad"antages! ?ess responsibility placed on the patient no need for e8tensi"e training and lower risk of infections
%isad"antages! more costly more dietary restrictions tra"eling to and from appointments costs time and money
ha"e to plan life around appointments.
:'
$or the following stages6types and6or treatments of renal disease* define* e@plain
etiology and give the nutritional recommendations .include calorie* protein* sodium*
fluid* potassium and phosphorous/:
)?
Acute 0lomerulonephritis: sudden inflammation of the glomeruli in the kidneys. These tiny filters remo"e e8cess
fluid electrolytes and waste from your bloodstream and pass them into your urine. Typically occurs due to damage of
the glomeruli form infection lupus or kidney disease. Symptoms include hematuria and hypertension.
1hronic 0lomerulonephritis: silent gradual inflammation of the glomeruli in the kidneys* often leading to complete
kidney failure. This condition can be hereditary caused by changes in the immune system or de"elop after one acute
attack of the disease.
3ephritic syndrome! inflammation of the capillary loops of the glomerulus. This often leads to hematuria and can
lead to complete kidney failure. >ypertension mild loss of renal function IgA nephropathy and hereditary nephritis
are associated with nephritic syndrome.
Acute "enal $ailure .A"$/: sudden drop in kidney functioning resulting in a build7up of wastes in the blood. A9A
can be caused by damage to internal organs o"er7 e8posure to metals sol"ents certain antibiotics and medications
kidney infection or obstructions in the urinary tract or renal artery. Illness or surgery increases risk of A9A. The patient
may e8perience shock or trauma decreasing blood pressure and blood flow. As a result the kidneys will not recei"e
enough o8ygen to filter blood as efficiently. (rine output decreases fluid retention increases and nausea "omiting
drowsiness and numbness in the hands and feet may result.
!nd %tage "enal Disease: last stage of C;%. In"ol"es the complete or almost complete failure of kidney function
as e8emplified by an e/A9 of less than 1+. %ialysis or a kidney transplant is needed to maintain safe le"els of salt
body fluid and waste products throughout the body when kidney function is not sufficient. It is imperati"e for someone
suffering from <S9% to maintain fluid balance and remo"e ade*uate amounts of waste to pre"ent bodily harm. The
<S9% patient cannot sur"i"e without dialysis or a kidney transplant. .
1hronic "enal $ailure: progressi"e loss in kidney function. %iabetes and hypertension are the leading risk factors for
C;%.
1alories rotein 3a $luid 5 hosphorous
Acute
/lomerulonep
hritis
.%iet restricted
to treat
underlying
disease0
$@7
'@kcal# kg
I:B
@.1 g#kg kilogram
I:B adHusted
depending on the
glomerular filtration
rate plus gram7for7
gram replacement of
urinary protein
losses
Cariable
At
liberty
Cariable
potassium
restriction in
hyperkalemia
.potential
symptom0
@.47 1.2g# day or
47 12mg#kg I:B
Chronic
/lomerulonep
hritis
$@7
'@kcal# kg
I:B
@.17@.4g# kg I:B 27$g#day
At
liberty
Cariable
@.47 1.2g# day or
47 12mg#kg I:B
Nephritic
Syndrome
$@7
$+kcal# kg
I:B
@.171.@g# kg I:B
Cariable
2@@@7
$@@@mg#
day
At
liberty
CariableD may
need to
increase to
co"er for losses
from medication
@.47 1.2g# day or
47 12mg#kg I:B
Acute 9enal
Aailure
$@7 '@
kcal#kg
dry :B#
day
@.47 1 g#kg I:B
Increase as /A9
returns to normal
1@E >:C
2@7 '@
m<*#day
.'1@7 62@
mg0
9eplace
output
from
pre"ious
day plus
+@@ m?
$@7 +@ m<*# day
.112@7
16+@mg0
Cariable
<nd Stage
9enal %isease
.no dialysis0
.with
transplant0
'71 weeks
after! $@7
$+ kcal# kg
I:B
K1 weeks!
achie"e
I:B
'71 weeks after! 1.$7
2g#kg I:B
K1 weeks! 1g#kg :B
2@@@7
$@@@mg#
day
At
liberty
Cariable At liberty but
calcium must be
12@@mg#day
<nd Stage
9enal %isease
.peritoneal
dialysis0
$@7$+
kcal#kg
I:B
1.271.+g# kg I:B
+@E from >:C
sources
2@@@7
'@@@ mg#
day
)inimu
m 2@@@
m?## day
urine
output
$@@@7 '@@@
mg#day
@.47 1.2g# day
<nd Stage
9enal %isease
.hemodialysis0
$+ kcal#
kg I:B
1.2g# kg I:B +@E
from >:C sources
2@@@7
$@@@ mg#
day
2+@7
1@@@
m?# day
urine
output
2@@@7 $@@@
mg#day or '@
mg#kg I:B
@.47 1.2g# day or
J12mg#kg I:B
Chronic 9enal
Aailure
$+ kcal#
kg I:B
@.1mg#kg# day
+@71@E >:C
Cariable
At
liberty
CariableD may
need to
increase to
co"er for losses
from diuretics
@.47 1.2g# day or
47 12mg#kg I:B
=' !@plain the rationale for the restriction and the symptoms of e@cess for each of the
above nutrient alterations'
)?
1alories6!nergy: intake should be ade*uate to spare protein for tissue protein synthesis and to pre"ent its
metabolism for energy.
rotein: reduction in protein intake may decrease proteinuria without ad"ersely affecting serum albumin. >igh
amounts of protein is belie"ed to increase glomerular pressure leading to accelerated loss of renal function. If dialysis
treatment is started protein intake must be increased accordingly for this treatment is a drain on body protein.
3a: >ealthy kidneys filter and e8crete e8tra sodium through the urine. Bhen renal conditions occur the body is
not able to get rid of sodium and it can build up. This e8tra sodium can lead to e8tra fluid buildup in the body
resulting in swelling increased weight gains ele"ated blood pressure and possibly difficulty with breathing .shortness
of breath0. Increased sodium in the diet can also lead to increased thirst which can lead to further fluid retention in
renal patients.
$luid: /oing o"er the recommended fluid allowance can lead to fluid build7up in the body. This build up causes
swelling and increases blood pressure. Too much fluid can build up in the lungs making it difficult to breathe.
5! too much potassium can build up when the kidneys no longer function properly. %angerous heart rhythms may
result which can lead to death.
hosphorous: if the kidneys cannot filter phosphorous in the blood =T> le"els rise causing e8cess calcium
resorption into the blood. The bones weaken when there is not enough calcium and can result in pain fractures
and osteoporosis.
A' 4dentify the role of the following medications in the management of renal disease:
hosphate (inders .Oscal* 2ums* $osrenol* hos8o* "enagel* "envela* %ensipar/: A build7up of phosphate
occurs as kidneys lose the ability to filter phosphate from the blood. This build7up causes the release of =T>
stimulating calcium resorption from the bone into the blood. This is a condition called secondary
hyperparathyroidism. 5scal Tums Aosrenol =hos?o 9en"ela and 9enagel are medicines that bind to
phosphate from food sources pre"enting the body from absorbing phosphate and allowing it to be remo"ed from
the body. This pre"ents the release of =T> to stimulate calcium resorption from the bone. 5scal Tums and
=hos?o contain calcium further enhancing calcium absorption in the body. Sensipar does not bind to phosphate
but is used to treat secondary hyperparathyroidism by signaling the body to produce less =T>.
#itamin D %upplements ."ocatrol* 1alcije@* Hectoral* Bemplar/: Acti"e "itamin % maintains normal =T>
le"els which may be warranted in renal patients. %iseased kidneys cannot acti"ate "itamin % lea"ing intestines
unable to absorb calcium. Although dairy contains "itamin % it must be limited due to the phosphorous content in
these foods. =atients who are not undergoing dialysis may need "itamin % in the form of oral supplements such
as 9ocaltrol CalciHe8 >ectoral and Qemplar. Qemplar is commonly administered intra"enously in dialysis
patients.
4ron %upplementation .3iferr@ )>-* #enofer* $errlecit/: )any renal patients are anemic because the kidneys
lose the ability to synthesi3e the hormone <=5 that stimulates production of 9:Cs. <=5 may be administrated to
the patient and re*uires the presence of iron in order to produce 9:Cs. >owe"er much of the body&s iron is lost
through hemodialysis and must be replaced with iron supplementation. Niferr8 is a polysaccharide7 iron comple8
that may be gi"en orally to renal patients. :ecause oral iron supplements can cause nausea or stomach aches
iron that is administered intra"enously such is commonly preferred. Aerrlecit and Cenofer are iron sucrose
inHections that come as solutions to be inHected intra"enously. It works by replenishing iron stores so that the body
can make more red blood cells
2ransplant Acceptance Cedicines .3eoral* 1yclosporine* 4muran* 1ell1ept* rednisone/: =atients who
undergo a kidney transplant may e8perience an autoimmune response causing the body to reHect the transplant.
To pre"ent an immune response kidney transplant patients are often gi"en medication such as Neoral
Cyclosporine Imuran CellCept or the corticosteroid =rednisone that decreases acti"ity of the immune system.
$luid and !lectrolyte (alance .5aye@alate* 8asi@/: As the kidneys lose the ability to remo"e e8cess fluid in the
body edema may result. %iuretics such as ?asi8 help the kidneys take up unneeded water and salt from the body
and e8crete it through the urine reducing edema and fluid retention. If the kidneys fail to filter potassium from the
blood hyperkalemia can result. This is characteri3ed by a dangerously high amount of potassium in the blood and
can cause irregular heartbeat slow pulse and heart failure. ;aye8alate controls high amounts of potassium in
the body if kidneys ha"e not properly filtered it from the blood.
(, #itamin %upplementation .3ephro,#ite/: Bater7soluble "itamins are flushed out with dialysis and must be
replenished daily. ;idney diets are "ery restricted and may not pro"ide ade*uate amounts of the "itamins.
Nephro7 Cite may be gi"en as oral "itamin : supplementation to make up for this loss.
(lood %ugar 1ontrol .%orbitol/: %iabetes is a common co7morbidity in renal patients. Sugar alcohols such as
sorbitol may be recommended for diabetics in order to maintain blood sugar.
"eferences:
1. National ;idney and (rologic %iseases Information Clearinghouse. Treatment )ethods for ;idney Aailure!
=eritoneal %ialysis. A"ailable at! http!##kidney.niddk.nih.go"#;(%iseases#pubs#peritoneal#inde8.asp8,condition.
Accessed Ruly 12 2@1'.

2. )c)ahon : =helan % )urray = et al. 5liguria and Anuria .acute kidney inHury part I0. PACT. 5ctober 2@1@! 17
2'. A"ailable at! http!##pact.esicm.org#media#5liguriaE2@$@E2@5ctE2@2@1@E2@final.pdf. Accessed Ruly 12
2@1'.
$. Collins A. C;% and =ublic >ealth Initiati"es. A"ailable at! http!##www.kdigo.org#ControConf#plenary
E2@session#=ublicE2@=olicyE2@Initiati"esE2@7AllanE2@Collins.pdf. Accessed! Ruly 1$ 2@1'.

'. Bilkens ; RuneHa C Shanaman <. )edical Nutrition Therapy for 9enal %isorders. In ;rause&s Aood and the
Nutrition Care =rocess. 1$th ed. St. ?ouis )5! <l Se"ier SaundersD 2@12!26674$1.
+. National Institute of >ealth. )edline=lus. A"ailable at! http!##www.nlm.nih.go"#medlineplus#medlineplus.html.
Accessed Ruly 11 2@1'.
1. ;urt3 I ;raunt RA. )etabolic acidosis of C;%! diagnosis clinical characteristics and treatment. Am J Kidney
Disease. Rune 2@@+D '+ .10! 624766$. A"ailable at! http!##www.ncbi.nlm.nih.go"#pubmed#1+6+2121. Accessed
Ruly 12 2@1'.
2. San )iguel S. >emodialysis dry weight assessment! A literature re"iew. 9en Soc Aust R 1.10 1672'D 2@@6.
A"ailable at! http!##www.renalsociety.org#9SAR#Hournal#mar1@#San)iguel.pdf. Accessed! Rune 26 2@1'.
4. <scott7Stump S. 9enal %isorders. In Nutrition and %iagnosis79elated Care. 2th ed. :altimore
)%! ?ippincott Billiams S BilkinsD2@12!4+67441.
6. :arnard N% Beissinger 9 Raster :R ;ahan S ?anou AR. <nd7Stage 9enal %isease! Nutritional Considerations.
Nutrition )%. A"ailable at! http!##www.nutritionmd.org#health-care-pro"iders#renal#renal-nutrition.html.
Accessed! Rune 26 2@1'.
1@. ?egrand ). =ayen %. (nderstanding (rine 5utput in Critically Ill =atients. Ann Intensive Care. 2@11D1!1$. 17$4.
A"ailable at! http!##www.ncbi.nlm.nih.go"#pmc#articles#=)C$22''21#. Accessed! Ruly 11 2@1'.
11. ?ab Test 5nline. A"ailable at! http!##labtestsonline.org#understanding#analytes#glucose#tab#test. Accessed! Rune
24 2@1'.

12. <scott7Stump S. 9enal %isorders. >uman ;idney Aunctions. In! <scott7Stump S ed. Nutrition and Diagnosis-
Related Care. 2
th
ed. :altimore )%! ?ippincott Billiams and BilkinsD 2@12!41@7461.