PHS 405/505 Advanced Nutrition Course Assignments



Medical Nutrition Therapy Diet

Purpose

Nutrition Indicators

Diagnostic measures for acute renal failure look at change in electrolytes, blood urea nitrogen (BUN), and creatinine levels. Serum levels of potassium, magnesium, and phosphorus are generally elevated because of decreased renal clearance. Low levels of these three nutrients may also occur due to carbohydrate delivery and anabolism. Elevated BUN and creatinine are also evidence of renal failure.

Criteria to Assign the Diet

An individual may need to be assigned an acute renal failure diet if they are experiencing rapid decrease in urine output, acidosis, electrolyte imbalances (hyperkalemia or hyperphosphatemia), fluid disturbances, impaired glucose utilization, protein catabolism, and/or accumulation of metabolic waste products.

Rationale for Diet

An initial low protein, high carbohydrate diet is necessary to allow the kidneys to rest if dialysis is not part of the therapy. A high protein and calorie diet is necessary because of the loss of lean body mass and essential and nonessential amino acids during dialysis therapy. The diet is also restricted on fluid because the kidneys cannot provide its normal functions like processing fluid. Calcium, phosphorus, sodium, and potassium levels all need to be within normal ranges because the kidneys are unable to process these nutrients as well.

Population

Overview

Acute renal failure is often a complication of sepsis, trauma, or multiple organ failure. Approximately 1% for all hospitalized patients, 3-5% for general surgery patients, 5-25% for ICU patients, 5-20% for open-heart surgery patients, 10-30% for those on aminoglycoside therapy, and 20-60% for severe burn patients will develop acute renal failure.

Disease Process

The cause of acute renal failure is divided into three main categories: prerenal, intrarenal, and postrenal. Prerenal is due to kidneys not getting necessary blood flow which decreases the glomerular filtration rate. This could be a result of congestive heart failure, hypotension/shock, and renal vasoconstriction due to medications. Intrarenal kidney failure is caused when parts of the kidneys are damaged from hypertension, interstitial inflammation from an infection, intrarenal obstruction, and nephrotoxicity. Postrenal is caused when crystals, protein deposits, or malignant tumor infiltration obstruct urine flow.

Biochemical and Nutrient Needs

A diet high in and calories is required because of the risk of malnutrition and loss of lean body mass. The protein requirements depend on the clinical condition, degree of catabolism, extent of renal function, and whether renal replacement therapy has been initiated.

|Degree of Catabolism |None |Mild/Moderate |Severe |Burn/Sepsis |

|Glomular filtration rate (mL/min) |5-10 |- |- |- |

|Urea Nitrogen Appearance |4-5 g/d |5 g N/d + |5 g N/d + |5 g N/d + |

|Dialysis |None |As needed |Hemodialysis/peritoneal |CRRT |

| | | |dialysis | |

|Protein g/kg/d |0.6-1.0 |1.0-1.2 |1.2-1.8 |1.5-2.0 |

|CHO (% kcal) |60 |60 |60 |60 |

|Fat (% kcal) |35 |20-30 |20-30 |20-30 |

|Kcal/kg recommended body wt (RBW)/day |30 |35 |35-50 |35-50 |

Fluid and sodium intake need to be restricted because the kidneys are unable to function properly anymore. Calcium, phosphorus, and potassium levels should be monitored because of the high risk of toxicity of hyperkalemia and hyperphosphatemia without the clearance from the kidneys. Water soluble vitamins will be needed as a supplement because of the loss of vitamins that can be lost during dialysis.

General Guidelines

Nutrition Rx

The following are the Nutrition Care Manual guidelines for acute renal failure.

• Protein: 0.8-1.2 g/kg of body weight noncatabolic, without dialysis

1.2-1.5 g/kg of body weight catabolic and/or initiation of

• Energy: 25-35 kcal/kg of body weight depends on stress/status of nutrition and include kcal from continuous renal replacement therapy

• Sodium: 2-3.0 g/day based on blood pressure, edema; replace loss in diuretic phase

• Potassium: 2.0-3.0 g/day, replace loss in diuretic phase

• Phosphorus: 8-15mg/kg

• Calcium: Maintain serum value within normal limits

• Fluid: 500 cc + urine output which depends on urinary sodium, total fluid output including urine, and modality of dialysis, if any

• Vitamins/Minerals: Dietary Reference Intakes, adjust to level of catabolism

Adequacy of Nutrition Rx

The purpose of the diet is to improve kidney function by prescribing a lower protein diet while the kidney’s recovery. A positive nitrogen balance is important to maintain to allow for nutrient absorption. Sodium, potassium, and phosphorus must be watched closely to ensure a positive nitrogen balance.

Goals

The main goals are to eliminate cause of kidney failure, prevent further kidney damage, support kidney functions and other affected organ systems. When protein requirements are low, the diet should provide alternative sources of calories to maintain organ function. As much leans body mass should be preserved as possible, but when the kidneys begin to recover a high protein diet should be introduced. Other goals during the recovery period include preventing nutritional deficiencies, and maintaining electrolyte and fluid imbalance.

Does it Meet DRI

In general, a multivitamin is recommended and additional supplements may be needed based on laboratory values. If the patient receives a form of dialysis for treatment then water soluble nutrients should be supplemented. Vitamin a and c are typically restricted due to advice affects. Vitamin d and K are typically supplemented because of deficiency.

Education Material

Nutrition Therapy

During the time in which the kidneys are not working to their full potential the goal is to provide sufficient calories, vitamins, and minerals to avoid malnutrition. Nutrition therapy should try to prevent complications, and correcting fluid, electrolyte, and uremic abnormalities. When the patient begins the recovery period, nutrition therapy should correct any lean body loss that may have occurred while continuing to stabilize the electrolyte balance.

Ideas for Compliance

After giving an individual with lists of foods to avoid, provide a list of foods that are recommended or “safe.” Ask the patient what some of their favorite foods are and see if they match any of the foods on the recommended list. When explaining the amount of liquids an individual may need, explain it in terms of high/medium/or low.

Sample Menu

Foods Recommended

When the kidneys are still recovering an individual needs a high carbohydrate, low protein diet. Foods high in carbohydrates include: breads, bagels, cornbread, doughnuts, pitas, crackers, cereals and grains, tortillas, and desserts. After the kidney recovery the individual will need a diet high in protein to help rebuild protein loss. High protein foods include: beef, eggs, fish, lamb, pork, poultry, shellfish, veal, and wild game. Low potassium foods are also recommended: alfalfa sprouts, bamboo shoots, cabbage, carrots, cauliflower, corn ,cucumber, eggplant, green beans, lettuce, mushrooms, onions, radishes, water chestnuts, apples, apricots, berries, grape juice, peaches, papayas, pineapples, tangerines, and watermelon.

Foods to Avoid

High potassium and high phosphorus foods are typically avoided with acute renal failure. Foods containing high amounts of potassium include: artichokes, avocadoes, beets, brussels sprouts, chard, kohlrabi, okra, parsnips, potatoes, pumpkins, rutabagas, spinach, sweet potatoes, tomatoes, wax beans, winter squash, yams, apricots, banana, dates, honeydew melon, nectarines, and oranges. Foods high in phosphorus include: cheese, cooked dried beans and peas, milk, nut butters, organ meats, soy milk, sweetened condensed milk, tofu, yogurt, biscuits, cake, cornbread, fruit pie, oatmeal, pancakes, dry cereals, sandwich cookies, and whole wheat crackers.

The following is an example of a meal plan for an individual with kidneys that are not function normal who needs a low protein diet.

Breakfast ½ c cranberry juice

1 c puffed wheat cereal

1 egg

1 slice toast with 2 tsp margarine and 1 tbsp jelly

1 c coffee with 1 tsp sugar and ½ tsp non-dairy creamer

Lunch Turkey sandwich: 2 slices bread, 1 oz sliced turkey, 2 lettuce leaves, 1 slice tomato, and 2 tsp mayonnaise

½ c cucumber salad

1 tbsp oil and vinegar dressing

1 medium apple

1 c lemonade

Evening Meal ½ c pineapple juice

1 oz broiled fish

½ c rice

½ c green beans

1 c tossed lettuce salad with 2 tbsp oil and vinegar dressing

1 dinner roll with 2 tsp margarine

½ c sliced peaches

1 c iced tea

Snacks 1 baked apple with non-dairy whipped topping

Nutrient Analysis

Calories: 1,662

Protein: 38g (9% of calories)

Carbohydrate: 280g (66% of calories)

Fat: 48g (25% of calories)

Websites

Organizations with Websites

health/kidney-failure

clinical/guidelinesection/AcuteKidenyInjury.aspx

Government Websites

nal.fnic/foodcomp/Data

References

“Acute Kidney Failure.” Medline Plus. 2012. Web. 26 March 2012. .

“Acute Kidney Injury.” The Renal Association. 2011. Web. 26 March 2012. .

“Kidney Failure, Acute.” MayoClinic. 2012. Web. 26 March 2012. .

Mahan L., Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders, 2008.

Nelms M, Sucher K, Long S. Nutrition Therapy and Pathophysiology. 2nd ed.

Belmonte, CA: Thomson Brooks/Cole, 2007.

Nutrition Care Manual. 2012 Web. 24 March 2012. .

USDA Nutrient Database. Web. 26 March 2012. .

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