Medical Nutrition Therapy

Protein-, Mineral- & Fluid-

Modified Diets for Kidney
Diseases
GENITO URINARIUS
SYSTEM

Dr.Brain Gantoro, M.Gz, SpGK

 Patofisiologi Gizi

The Urinary System

 Urinary System : The Functions

Elimination of waste products

Nitrogenous wastes
Toxins
Drugs
Secrete certain hormones.
Filter the blood, cleanse it of waste products, and
recycle other usable substances
 Functions of the Urinary System

Regulate aspects of homeostasis

Water balance
Electrolytes
Acid-base balance in the blood
Blood pressure
Red blood cell production
Activation of vitamin D
 Organs of the Urinary system

Kidneys
Ureters
Urinary bladder
Urethra
 Regions of the Kidney

Renal cortex
outer region
Renal medulla
inside the cortex
Renal pelvis
inner collecting
tube
 Kidney Structures

Medullary pyramids triangular regions

of tissue in the medulla
Renal columns extensions of cortex-
like material inward
Calyces cup-shaped structures that
funnel urine towards the renal pelvis
 Nephrons

The structural and functional units of the

kidneys (1 million)
Responsible for forming urine
Main structures of the nephrons
Glomerulus
Renal tubule
 Glomerulus
A specialized capillary bed

Attached to arterioles on both sides

(maintains high pressure)

Large afferent arteriole

Narrow efferent arteriole

The glomerulus sits within a glomerular

capsule (the first part of the renal tubule)
Glomerulus is the filtering unit.
The kidneys maintain both the composition
and the volume of body fluids.
They maintain fluid balance, acid-base balance
& electrolyte balance.
 Urine Formation Processes

Filtration
Reabsorption
Secretion
 Filtration

Nonselective passive process

Water and solutes smaller than proteins
are forced through capillary walls
Blood cells cannot pass out to the
capillaries
Filtrate is collected in the glomerular
capsule and leaves via the renal tubule
 Reabsorption
The peritubular capillaries reabsorb several
materials
Some water
Glucose
Amino acids
Ions
Some reabsorption is passive, most is active
Most reabsorption occurs in the proximal
convoluted tubule
 Materials Not Reabsorbed
o Nitrogenous waste products(protein metabolism)
o Urea
o Uric acid
o Creatinine
o ammonia, and sulfates

o Excess water (1.5 liters urine/day).

o Nutrients, dead renal cells, and toxic
substances.
 Secretion Reabsorption in
Reverse
Some materials move from the
peritubular capillaries into the renal
tubules
Hydrogen and potassium ions
Creatinine
Materials left in the renal tubule move
toward the ureter
Formation of Urine
 Characteristics of Urine Used for
Medical Diagnosis
Colored somewhat yellow due to the
pigment urochrome (from the
destruction of hemoglobin) and solutes
Sterile
Slightly aromatic
Normal pH of around 6 (varies 4.5-8)
Specific gravity of 1.001 to 1.035
Maintaining Water/Electrolyte Balance
 GANGGUAN
SISTEM URINARIUS
Gagal ginjal

Gagal Ginjal
Ginjal kehilangan kemampuan
mempertahankan volume dan kompartemen
cairan tubuh pada diet normal

Gagal ginjal kronik/ akut

Gagal ginjal akut
Occurs suddenly and may last a few days to a
few weeks.
Renal, nefritis
Sebab postrenal Oliguria (urin <400ml/ hr), non
oliguria
Sebab prarenal (gg. Sirkulasi)
Hipovolemia (perdarahan, dehidrasi, serious
burn, crushing injury, curah jtg / cardiac
arrest, obs. pemb. darah ginjal)
Sebab renal
Iskemia, nefrotoksin, hipertensi
Obs. muara kd. kemih, obs. Ureter, obs.
Duktus koledokus (as. Urat, sulfa)
Gagal ginjal kronik
St. 1: asimptomatik
St. 2: insufisiensi ginjal, azotemia ringan
St. 3: stadium akhir uremia, GFR 10%,
CCT 5-10ml/mnt, oliguria
Penyebab: infeksi, gagal jantung, autoimun,
kel. Herediter, peny. Metabolik, kel.
Obstruktif
Symptoms: nausea, headache, coma,
convulsions. Severe renal failure will result
in death unless dialysis used.
Sindroma uremik
Stadium akhir gagal ginjal
Gg. Fs pengaturan dan ekskresi
Kel. Vol. Cairan dan elektrolit
Ketidakseimbangan asam basa
Retensi metabolit nitrogen
anemia
Gg. Organ lain
Kardiovaskular, pernafasan, neuromuskular, kalsium
dan rangka, dll
Infeksi Saluran Kemih

Bakteriuria
Bakteri >= 10 5 /ml urin
80% krn E. coli

ISK bawah: uretritis, sistitis, prostatitis

ISK atas: pielonefritis akut, pielonefritis
kronik (infeksi berulang/ menetap)
Infeksi Saluran Kemih
Faktor predisposisi
Obstruksi aliran kemih
Sex, wanita > pria
Umur
Kehamilan
Refluks vesiko-ureter
Kateterisasi
Peny. Ginjal
Gg. Metabolik ( diabetes, gout)
Glomerulonefritis
Peradangan ginjal, biasanya bilateral
Proteinuria, hematuria
Etiologi belum jelas
Klasifikasi
Distribusi: difus, fokal, lokal
Serangan Klinis: akut, subakut, kronik
Sindroma klinis: sindroma nefritis akut,
sindroma nefrotik, kel. Urin persisten, sind.
uremik
Nefrolitiasis
Akibat pengendapan substansi yg jlhnya
berlebih dlm air kemih
Faktor lain yg daya larut: pH, bakteri, faktor
metabolik
Jenis / composition:
batu kalsium (calcium oxalate, calcium
phosphate) dan alkali (magnesium ammonium
phosphate / struvite)
Batu urat, batu sistin
Associated with metabolic disturbances &
immobilization of the client.
Nefrolitiasis: gejala

Nyeri
Nyeri pinggang, kolik ureter
Hematuria
Gross hematuria, hematuria mikroskopik
Proteinuria
Tanda umum peny. Ginjal
Habis olahraga berat, demam
Nefrolitiasis:
pengobatan

Intinya adalah mencapai pH yang sesuai

Obat-obatan
pengaturan diet
Urine makroskopik
Kristal sistein
Sel epitel
Kristal oksalat
Tripel fosfat
Diet and Renal Disease
 I.FUNGSI GINJAL :
1.Mengatur keseimbangan air dan ion
inorganic
2.Mengeluarkan end product metabolism
3.Mengeluarkan benda asing
4.Glukoneogenesis
5.Memproduksi hormon / Enzim :
-Erythopoetin
-Renin / Enzim angiotensin
- 1-25 Dihydroxi vitamin D
6.Indirectly stimulate the bone marrow to
produce red blood cells.
.Kecepatan ekresi urin
GFR Reabsorbsi + Sekresi
. FILTRASI :
-terjadi melalui memb.glomerulus
-Komposisi filtrat = plasma
kecuali
tanpa proten dan sel.
 .Mekanisme Reabsorbsi :
-Transfort aktif
-Difusi
-Pinositosis
-Osmosis
 Reabsorbsi glukosa:
@glukosa difiltrasi glomerulus-Reabsobsi Tub
proks---Trans aktif
@Transfort maksimum 375 mgr/menit
@Biasanya terjadi bersamaan dengan Na
REABSORBSI Na:
@65 % reabs Na di Tub proks/25 % di
Henle
REABSORBSI KLORIDA:aktif/pasif biasanya
Bersamaan dengan Na:(65% tub proks/25 %
Henle/10 % diantara tub distal-kolligen
 REABSORBSI KALIUM:
-50% diserap di tub prksimal/40 % pars
ascnden L/H /10 % dukt koligen
REABSORBSI ASAM AMINO:
-semua asam amino direabsorbsi tub
proksima
REABSORBSI PROTEIN PLASMA:
-<<< protein yang filtrasi di glomerulus
-Reabsorbsi di tubuli proksimal
REABSORBSI UREA:hasil akhir metabolis
Protei di hepar.(50 % tub proksimal/40 % urea
menetap filtratdiekresikan
 REABSORBSI BIKARBONAT:
@tubuli proksimal-aktif(Duk koligent<)
FUNGSI ENDOKRIN GINJAL:
@Renin
@1-25 dihidroksi vitamin D3minerali-
sasi tulang
@eritropoitin--merupakan respon da-
ri iskhemia ginjal berfungsi
pembentukan sel-sel darah merah
V.Konsep Clearance Ginjal
-Kemampuan ginjal membersihkan
plasma darah dari suatu zat persatuan
waktu
- Cs = Us x V
Ps
 Bahan yang dipergunakan :
Inulin
PAH
Creatinin
Iotalamat radioaktif

FIGURE 167
Renal handling of three hypothetical substances X, Y, and Z. X is
filtered and secreted but not reabsorbed. Y is filtered, and a
fraction is then reabsorbed. Z is filtered and completely reabsorbed.
 PEMERIKSAAN FUNGSI GINJAL

1.NITROGEN UREA DARAH (BUN)

Urea: produk akhir metabolisme protein
dan asam amino mengandung
nitrogen.
BUN indikasi: fungsi ginjal .
BUN ditentukan:
/ asupan protein
cedera otot
sakit hepar
Rasio BUN : creatinin = peny hepar <10:1
atau >15:1
2. Creatinin Normal 0,7-1,5/100 cc darah
> 1,5 mgr% ggn fungsi ginjal
fungsi ginjal 50% 2X
fungsi ginjal 75% 3X
3. Urinalisis (makros/mikroskopis)
4. Sistoskopi: teropong uretraeVU
melihat kelainan pada VU
3. Voiding Cystourethrography kateterisasi
VU & infus pewarna radioaktif
4. Urografi intra vena Ro serial
5. Ultrasound ginjal
 KONSEP PATOFISIOLGI
PERUBAHAN FILTRASI GLOMERULUS
@ Perubahan P kapiler MAP
@ Perubahan tekanan koloid osmotik plasma
kadar protein plasma
@ Perubahan tekanan koloid cairan intertitial
kadar protein c.intertitial
@ Perubahan tekanan cairan intertitial
AZOTEMIA: abnormal bahan sisa
bernitrogen dlm darah (urea / asam urat /
kreatinin)
UREMIA: suatu sindroma pd stadium akhir
peny ginjal akibat:
asidosis
anemia
penumpukan semua end product.
SINDROMA NEFROTIK:
proteinuria > 5 gr/hari
edema anasarka (krn hipoalbuminemia)
OSTEODISTROFI GINJAL: demineralisasi
tulang akibat penyalit ginjal, sebab:
pengaktifan Vit D3 oleh ginjal
penumpukkan ion phosphat
peranan tulang sbg penyanggah ion H+ dlm
plasma
ASIDOSIS METABOLIK (Asidosis ginjal):
pH plasma yg tdk disebabkan oleh ggn
pernafasan.
ENSEFALOPATI UREMIK: perubahan
neurologi akibat peny ginjal yg parah.
 Dietary Treatment of Renal
Disease
Extremely complicated.
Intended to reduce the amount of
excretory work demanded of the
kidneys while helping them maintain
fluid, acid-base, and electrolyte
balance.
Clients with chronic renal failure may
have protein, sodium, potassium and
phosphorus restricted.
 Dietary Treatment of Renal
Disease
Sufficient calories necessary: 25 to 50
kcal per kilogram of body weight.
Energy requirements should be fulfilled by
carbohydrates and fat.
Protein increases the amount of nitrogen
waste the kidneys must handle.
Diet may limit protein to 40 grams based
on glomerular filtration rate and weight.
 Dietary Treatment of Renal
Disease
Sodium may be limited if the client tends
to retain it.
Fluids are typically restricted for renal
clients.
Calcium supplements may be
prescribed.
Vitamin D may be added and
phosphorus limited, to prevent
osteomalacia.
 Dietary Treatment of Renal
Disease
Potassium may be restricted in some
clients because hyperkalemia tends to
occur in end stage renal disease (ESRD).
Excess potassium can cause cardiac
arrest.
Renal clients often have an increased
need for vitamins B, C, and D, and
supplements are often given.
Iron is commonly prescribed.
 Diet After Kidney Transplant

Need for extra protein or for the

restriction of protein.
Carbohydrates and sodium may be
restricted.
Additional calcium and phosphorus
may be necessary if there was
substantial bone loss before the
transplant.
 Stop and Share

A client with renal disease is on a

potassium restriction of 3,000 mg.
What recommendations would you
give the client?
 Stop and Share

Regulate intake by making careful

choices.
Milk is normally restricted to cup a
day because it is high in potassium.
Suggest use of potassium content
charts to select low potassium foods.
 Stop and Share

Low potassium (< Lemon, lime

150 mg/serving) Nectars
fruits include: Mandarin
Applesauce oranges
Peaches
Berries Pears
Figs Plums
Fruit cocktail Rhubarb
Grapes
 I. Nephrotic Syndrome
Not a specific disease Causes
kidney disorders that Infection
result in urinary protein Chemical damage
losses in excess of 3 Immunological &
grams/day hereditary disorders
Occurs most often in Diabetes mellitus
children between 1 -4 Other disorders
years old involving glomerulus
Damage to glomeruli
Clinical findings
increases permeability Proteinuria
to plasma proteins, Low serum albumin
levels
allowing protein to
Edema
escape into the urine
Elevated blood lipids
Can progress to renal
Blood coagulation
failure disorders
 Nephrotic Syndrome
Treatment goals:
include relief of
symptoms & prevention
of kidney damage
Drugs
Anti-inflammatory drugs
(usually corticosteroids)
ACE inhibitors
Diuretics
Antihypertensives
Immunosuppressants
Lipid-lowering
medications
Nutrition
Meet protein (.8-1g/Kg)&
energy (35 kcal/Kg)needs
to minimize muscle tissue
loss
Low sat fats, cholesterol
Low refined sugars
Sodium restriction(1-2g/d)
Potassium-rich foods (if
potassium-wasting
diuretics are used)
Vitamin & mineral
supplements
 II. Acute Renal Failure
Rapid deterioration of kidney function
Reduction of urinary output
Accumulation of nitrogenous wastes in blood
Degree of renal dysfunction varies from mild to severe
Causes
Can result from number of disorders
Often develops as consequence of severe illness,
infections, injury or surgery
Causes usually classified as prerenal, intrarenal or
postrenal
 Acute Renal Failure
Consequences
Fluid & electrolyte imbalance
- Oliguria: production of <400
mL urine/day
- Hyperkalemia: elevated
serum potassium levels
- Hyperphosphatemia: elevated
serum phosphate levels
Uremia
- Accumulation of nitrogen-
containing waste products in
blood
Blood urea nitrogen (BUN)
Creatinine
Uric acid
Treatment
Drug therapy
- Diuretics
- Correction of hyperkalemia
Nutrition
- Meet protein (.6-.8g/Kg)&
energy (35kcal/Kg) needs
- Restoration of fluid balance
(urine+500ml)
- Replacement of electrolytes
(2-3g Na/d, K & P restricted)
- Enteral & parenteral
nutrition (cal, pro and
electrolytes)
Renal dialysis
 III.Chronic Renal Failure
Characterized by gradual & irreversible
deterioration in kidney function; may follow
acute renal failure
Causes
Diabetes mellitus (about 43% of cases)
Hypertension (about 26% of cases)
Inflammatory, immunological or hereditary diseases
that directly affect kidneys
End-stage renal disease (ESRD): advanced
stage of chronic renal failure in which dialysis or
kidney transplant is necessary to sustain life
 Chronic Renal Failure
Consequences
Early Stages Advanced Stages
Anorexia Anemia, bleeding tendency
Fatigue Cardiovascular disease
Headache Confusion, mental impairment
Hypertension Electrolyte abnormalities
Fluid retention
Itching
Metabolic acidosis
Kidney inflammation or Peripheral neuropathy
nephrotic syndrome
Protein-energy malnutrition
Nausea & vomiting Reduced immunity
Proteinuria, hematuria Renal osteodystrophy
 Chronic Renal Failure
Uremic syndrome
Cluster of symptoms & complications that
develops during final stages of chronic renal
failure
- GFR (rate of kidneys form filtrate)<15 mL/minute
- BUN exceeds 60 mg/dL
- Anemia
- Bone disease
- Hormonal imbalance
- Bleeding impairment
- Increased risk of cardiovascular disease
- Reduced immunity
 Chronic Renal Failure
Treatment goals: slow
disease progression &
prevent or alleviate
symptoms
Drug therapy
Antihypertensives
Erythropoetin
Phosphate binders(P)
Na bicarbonate(acidosis)
Cholesterol-lowering
drugs
Vitamin D
supplementation(Ca)
Dialysis
Hemodialysis
Peritoneal dialysis
Nutrition
Energy intake to maintain
healthy weight & prevent
wasting
Low-protein (unless dialysis),
low sat fat
Regulation of fluid & sodium
intakes based on total urine
output, changes in body
weight, blood pressure &
serum sodium levels
Regulation of potassium
intake based on potassium
levels & use of diuretics
Vitamin & mineral
supplementation
Enteral & parenteral
nutrition
 Chronic Renal Failure
Kidney transplants
Preferred alternative to
dialysis in ESRD
- Restores kidney
function
- Allows more liberal diet
- Frees patient from
routine dialysis
Barriers to
transplantation
- Supply of suitable
kidneys vs. demand
(<20% are recipients)
- Patient-related barriers:
age, financial difficulties,
abnormalities of urinary
tract
Immunosuppressive drug
therapy
- Used to prevent tissue
rejection
- Include side effects that
alter nutrition status (FDI)
Nutrition
- Increased E & protein
requirements after surgery
- Control of hyperglycemia,
blood lipids, electrolyte
balances, calcium levels
- Avoidance of foods that
can cause food-borne
illnesses
 BATU GINJAL
Batu di saluran kemih
Komponen pembentuk batu: magnesium /
amonium / asam urat
Etiologi:
/ pH urin
diet tertentu
stasis urin
faktor risiko BB
KLINIS:
Kolik renal / asimtomatik
Hematuria / produksi urin turun
Pengenceran urin
 DIAGNOSTIK:
-Pemeriksaan darah / urin
-Radiografi / urografi intra vena
KOMPLIKASI:
-Obstruksi urin
-Kolaps nefron / kapiler iskemia ginjal
atau gagal ginjal.
PENATALAKSANAAN:
-banyak minum
-modifikasi diet
-perubahan pH urin
-Litotripsi / tindakan bedah
 IV. Kidney Stones
Crystalline mass that forms within urinary tract
May be asymptomatic or may cause severe pain or
blockage of urinary tract as the stone passes
Tend to recur, but can be prevented with diet & medical
treatment
Formation of kidney stones
Develop when stone constituents become concentrated in urine
Allows formation & growth of crystals
Composed of calcium oxalate (75%) or uric acid, amino acid
cystine, magnesium ammonium phosphate
Formation promoted by factors that reduce urine volume, block
urine flow or increase concentrations of stone-forming
substances
 Kidney Stones
Renal stones:
Chemical analysis can indicate why they have
formed

Oxalate usually hyperoxaluria, low magnesium

and vitamin B6 levels

Uric acid usually hyperuricemia

Calcium phosphate possibly primary

hyperparathyroidism or renal tubular acidosis

Magnesium, ammonia or phosphate may indicate

urinary tract infections

Cystine rare inherited metabolic disorder

cystinuria
Calcium Oxalate

Uric acid
Calcium phosphate

Cystine
 Kidney Stones
Calcium oxalate stones
Usually associated with
hypercalciuria
Results from excessive or
impaired calcium
reabsorption, elevated
levels of parathyroid
hormone or vitamin D
Reduction of dietary
intake of oxalate
recommended
Uric acid stones
Develop in highly acidic
urine or in presence of
high amounts of uric acid
or both
Frequently associated
with gout
Diet rich in purines also
contributes
 Kidney Stones
Consequences
Renal colic
Hematuria
Urinary tract complications
Prevention & treatment
Increased fluid intake of 12-16 cups daily
- Water, tea, coffee, wine, beer acceptable
- Avoid apple & grapefruit juices( risk)
Diet & drugs to reduce urinary calcium &
oxalate levels, uric acid levels
Adjustment in calcium (moderate), oxalate (
levels), moderate protein & sodium intakes, ?
purine restriction for uric acid stones
 Dietary Treatment of Renal
Stones
Treatment varies based on type of
stone.
Clients should drink lots of fluid.
Eat a well-balanced diet.
Once stones have been analyzed,
specific diet modifications may be
indicated.
 Calcium Oxalate Stones

A diet low in calcium can reduce the

risk of calcium oxalate renal stones. In
fact, higher dietary calcium intake may
decrease the incidence of renal stones
for most people.
Reduce level of oxalate, which is found
in beets, wheat bran, chocolate, tea,
rhubarb, strawberries, spinach.
 Uric Acid Stones

Purine-rich foods restricted.

Purines are the end products of
nucleoprotein metabolism.
Found in meats, fish, poultry, organ
meats, anchovies, sardines, meat
extracts, broths.
Usually associated with gout, GI
diseases that cause diarrhea, and
malignant disease.
 Cystine Stones

Cystine is an amino acid.

Cystine stones may form when the
cystine concentration in the urine
becomes excessive because of a
hereditary metabolic disorder.
Increase fluids and recommend an
alkaline-ash diet.
 Struvite Stones

Composed of magnesium ammonium

phosphate.
Sometimes called infection stones
because they develop following urinary
tract infections caused by certain
microorganisms.
Low phosphorus diet is often
prescribed.
 Nutrition in PracticeDialysis
Dialysis offers life-sustaining treatment
for chronic renal failure
Permanent treatment or temporary measure
Can restore fluid & electrolyte balances
Removes excess fluids & wastes
through processes of diffusion, osmosis
& ultrafiltration
Hemodialysis
Peritoneal dialysis
 Dialysis

Done be either hemodialysis or

peritoneal dialysis.
Hemodialysis requires permanent
access to the bloodstream through a
fistula.
Hemodialysis is done 3 times a week
for 3-5 hours at a time.
 Nutrition in PracticeDialysis
Dialysate (solution similar in composition
to normal blood plasma) delivered to
compartment beside semi-permeable
membrane
Blood flows along other side of membrane
Concentrations of dialysate & blood affect
movement of solutes across the semi-
permeable membrane
Semi-permeable membrane acts as filter
Small molecules (i.e. urea & glucose) can
pass through membrane pores
Large molecules are unable to cross
 Dialysis

Peritoneal dialysis makes use of the

peritoneal cavity.
Less efficient than hemodialysis.
Treatments usually last about 10 to 12
hours a day, 3 times a week.
Complications include peritonitis,
hypotension, weight gain.
 Nutrition in PracticeDialysis
Hemodialysis
Dialyzer used to cleanse blood
Treatments usually require 3-4 hours, at least
3 times per week
Most patients receive treatment in dialysis
centers; some (about 2%) are treated at home
Complications
- Infection & blood clotting at vascular access site
- Hypotension
- Muscle cramping
- Blood losses, worsening anemia
- Other: headaches, weakness, n&v, agitation
 Nutrition in PracticeDialysis
Peritoneal dialysis
Peritoneal membrane surrounding abdominal
organs serves as the semi-permeable membrane
- Dialysate infused through catheter into peritoneal space (4-
6 hrs)
- Dialysate solution drained & exchanged (avg.4x/d, 30min.)
Advantage over hemodialysis: vascular access not
required, fewer dietary restrictions
Complications
- Infection (peritonitis)
- Blood clotting in catheter, catheter migration
- Abdominal hernia
 Diet During Dialysis

Dialysis clients may need additional

protein.
Amount must be carefully controlled.
A client on hemodialysis requires 1.0 to
1.2g of protein per kilogram of body
weight to make up for losses during
dialysis.
A client on peritoneal dialysis requires
1.2 to 1.5g protein per kilogram body
weight.
 Diet During Dialysis

75% of this protein should be high

biological value (HBV) protein, found in
eggs, meat, fish, poultry, milk, and
cheese.
Potassium is usually restricted.
A typical renal diet could be written as
80-3-3 which means 80g protein, 3g
sodium, and 3g potassium daily.
 Diet During Dialysis

Healthy people ingest from 2,000 to

6,000 mg of potassium per day.
Daily intake allowed clients in renal
failure is 3,000 to 4,000 mg.
End stage renal disease clients intake
allowed is 1,500 to 2,500 mg per day.