Nutrition In Chronic Kidney Disease

Chronic kidney disease (CKD) is a condition characterized by loss of kidney function over time. The kidneys play a vital role as an excretory organ and are crucial in managing the homeostasis of endocrine, fluid, electrolyte, mineral and acid-base balancei. The deterioration of the kidney’s ability to function makes nutritional derangement inevitable in patients with CKD. Because of this impact, the nutrition care process is an important component of treatment, which can help slow and prevent the progression of CKD.

The nutrition care process is a systematic approach towards providing optimal management and incorporates the following 4 steps: assessment, diagnosis, intervention and monitoring. This process can be applied to any nutrition-related condition and allows for individualised care rather than over-generalising. It is important that we treat these cases individually due to differing biochemistry, the stage they’re in and how much stress it has already caused other organs.

Sadly, CKD cannot be cured as the nephrons that make up the kidney are non-regenerative, much like the brain. If it progresses to end stage renal disease, hemodialysis or peritoneal dialysis will be needed or if the opportunity arises, a kidney transplant. It is important to understand that these treatments are not a cure, as donated kidneys eventually fail and dialysis cannot replace all its much-needed functions, so to improve outcomes, dietary change is crucial in delaying further health consequences.

The National Kidney Foundation state that the populations who have a high risk of developing CKD include people with diabetes, hypertension, cardiovascular disease and obesity. In diabetes smaller blood vessels are greatly affected by high blood sugar, including in the ones located in the kidney. In Australia, 1 in 3 people have an increased risk of developing CDK and can lose up to 90% of kidney function before experiencing their first symptom. The most recent study done about people with end stage renal disease was in 2013, and showed a staggering increase of 51% since 1997. The Indigenous population are at a much-increased risk of developing CKD and are hospitalised more frequently than non-Indigenous Australians. This is because they have a higher prevalence of diabetes, cardiovascular disease, alcohol abuse and inadequate nutrition as well as lack of awareness. Of the Indigenous population they are 4 times more likely to die of CKD than the general population.

There are many barriers that prohibit the body from receiving optimal nutrition with CKD. Due to kidney malfunction, the body will experience toxicity overload as it is struggles to regulate homeostasis. As sufferers of CKD may not be symptomatic up to %90 kidney failure, it is imperative that advise be taken gravely. Minor dietary augmentation will be prescribed at first, as the disease progresses the change of diet will be crucial. Kidney function is estimated using glomerular function rate which is calculated using creatine levels, age and gender. Depending on biochemistry results, the following nutrients are affected in someone with CKD: sodium, phosphorus, potassium, protein, calcium, 1,25-dihydroxy vitamin D and fluids

CKD sufferers are prohibited from uptake of 1,25-dihydroxy vitamin D and in turn phosphorus will begin to build-up in the blood resulting in hyperphosphatemia. It is important that the phosphorus intake is in its organic state from foods, as only 40-60% is absorbed, whereas 90% of inorganic phosphorus from additives is absorbed. In the body, phosphorus binds with calcium in the body to build and maintain bone structure, if it runs out of calcium in the blood the parathyroid glands will leach calcium from bones to maintain homeostasis. This increases the risk of ectopic calcification and risk of osteoporosis. Although calcium is important, the majority of foods high in calcium are also high is phosphorus, so doctors usually recommend a calcium supplement.

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High blood pressure can cause intraglomerular pressure within the kidney, so limitation of the consumption of sodium is recommended from beginning of treatment, regardless of CDK progression. Hypernatremia will cause increased fluid retention whilst also contributing to hypoalbuminemia which can further progress CKD. It's important that patients read labels carefully as foods low in sodium are replaced with potassium chloride. Sodium is limited to 2300mg a day.

Advanced stages of CKD result in hyperkalemia as the kidneys struggle to excrete excess potassium. The kidneys are responsible for excreting 90% of the potassium that is consumed daily, with the remaining 10% excreted by feces. As potassium is an electrolyte, abnormal levels are dangerous and cause heart arrhythmias. The recommended intake is 2000-2500 mg a day.

The recommended energy intake is the same for all stages of CKD, with a range of 126-147 kJ/kg of ideal body weight (IBW). We use IBW, as actual body weight can be hard to determine due to edema which most people will experience. Use of current body weight for someone who is underweight or overweight may under or overestimate nutrient needs. That is why we need to use clinical judgement.

In early stages of the disease the kidneys struggle to excrete protein waste. Damage prevention by lowering protein intake is recommended in lieu of excluding. On the other hand if someone is on dialysis, there needs to be an increase in certain proteins as the process can strip away essential amino acids. The protein intake is fixed at 0.75 - 1g/kg IBW in stages 1-4. In a patient on dialysis it is increased to 1.2g/kg to make up for unintentional losses during treatment for both hemo and peritoneal dialysis. In peritoneal dialysis the lining of the abdomen is used as a natural filter. If this lining becomes inflamed the protein intake is further increased to 1.5g/kg as the patient can lose up to 15g in a session. If the person has complications of diabetes, sugars and carbohydrates need to be monitored with all of the above.

Fluids are not usually restricted until stage 5 (ESRD). For someone on hemodialysis there is an allowance of 500ml/day plus the past day’s urinary output. Peritoneal dialysis allows for a further of 250ml per day.

Anemia is common in CKD because of the reduced production of erythropoietin, an essential hormone that facilitates the production of red blood cells. Although dietary intake cannot solve this, erythropoiesis stimulating agents are supplemented.

Although there are other constraints to evaluate, these are the most commonly reviewed nutrients in scientific renal articles. Renal diseases are a difficult area to manage but without precision and use of dietary support, there can be drastic effects on both the patient’s health and mortality.

References

1. Academy of Nutrition and Dietetics. (Producer). (2019). Certificate of Training: Chronic Kidney Disease Nutrition Management [Online training program]. Retrieved from ' https://www.eatrightstore.org/cpe-opportunities/certificates-of-training'
2. Australian Indigenous HealthInfoNet. (2018). Chronic Kidney Disease. [online] Available at: https://healthinfonet.ecu.edu.au/learn/health-topics/kidney/chronic-kidney-disease/ [Accessed 18 Feb. 2019].
3. Australian Institute of Health and Welfare. (2019). Chronic kidney disease compendium, How many Australians have chronic kidney disease? - Australian Institute of Health and Welfare. [online] Available at: https://www.aihw.gov.au/reports/chronic-kidney-disease/chronic-kidney-disease-compendium/contents/how-many-australians-have-chronic-kidney-disease [Accessed 2 May 2019].
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6. Dr. Kamyar Kalantar-Zadeh, University of California Irvine, USA; speaking at the Karolinska Institute Advanced Renal Nutrition Conference 2013, Stockholm
7. Kidney Health Australia Kidney Fast Facts. (2018). [ebook] Melbourne: Kidney Health Australia, pp.1-2. Available at: https://kidney.org.au/cms_uploads/docs/kidney-health-australia-kidney-fast-facts-fact-sheet.pdf [Accessed 9 May 2019].
8. Mitch, W. and Ikizler, T. (2010). Handbook of Nutrition and the Kidney. 6th ed. Philadelphia, PA: Lippincott William & Wilkins, pp.12,13.
9. What is Chronic Kidney Disease - Indigenous Fact Sheet. (2016). [ebook] Kidney Health Australia. Available at: https://kidney.org.au/cms_uploads/docs/kidney-health-australia--what-is-chronic-kidney-disease.pdf [Accessed 18 Feb. 2019].