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The human kidney is a small, fist-shaped organ (about 11-12 cm, 6 cm wide, and 3 cm thick) symmetrically located in the lower back, from T12 to L3 vertebrae.
Meal Plan For Renal Diet
Each kidney has a cortex, an outer region, and a medulla, which is an inner region divided into renal pyramids. There is also what is called the functional unit of the kidney, the nephron, and there are about 1 million of them in one kidney.
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The human kidney may be small in size, but it is a powerful machine that can process about a cup of blood every two minutes.
Kidney failure does not usually come with warning and may come on suddenly, thus causing Acute Renal Failure (ARF). The good news is that patients with ARF can still recover with Medical Nutrition Therapy (MNT). However, when ARF is not treated or managed, it can progress to Chronic Kidney Disease (CKD).
Chronic kidney disease is a condition in which the patient’s kidneys stop working at their optimal capacity, usually due to glomerular disease (eg, glomerulonephritis), hypertension, or diabetes (diabetic nephropathy). This means it fails to filter waste from the blood and causes waste to accumulate in the body. CKD usually has no early signs, and this may mean that patients usually become aware of the condition at an advanced stage. According to the National Kidney and Transplant Institute,
While CKD is usually asymptomatic, it can present with high blood pressure, edema, easy fatigability, nausea and vomiting, and loss of appetite. CKD can be functional or structural. In the elderly (age 60 and above), the loss of kidney function can occur naturally, so dietary adjustments should be made to prevent further decline. In the Philippines, where CKD cases are on the rise, the leading cause of CKD is diabetes.
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CKD is classified based on the cause which is: Category of Glomerular Filtration Rate (GFR) or albuminuria (abnormal loss of albumin through urine).
Glomerular Filtration Rate, which is the amount of filtrate formed per minute based on the total number of functioning glomeruli, can be calculated using the following equation.
CKD status can then be predicted using GFR, albuminuria category, and cause of CKD based on this chart:
The stages and modalities of treatment are further described by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines:
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For the elderly (60 years and older), there may be a decrease in GFR (Stage 1 to 2), and this is normal. In elderly and non-elderly patients with CKD up to Stage 3 GFR, MNT can be used as an intervention, to prevent worsening of the condition.
Generally, during GFR Stages 1-4, the treatment plan is to screen for and manage cardiovascular disease. In addition, care providers should plan care to prevent diabetes, hypertension, and dyslipidemia as much as possible. If this exists, it must be maintained.
Specifically for Stage 2 GFR, management still includes reducing the risk of cardiovascular disease, but more importantly at this stage, care providers must monitor kidney function more closely. In this way, the care provider can decide if the patient should finally undergo kidney replacement therapy (for example, dialysis or a kidney transplant).
Most CKD-related complications start at GFR Stage 3; thus, the care provider should treat the pain as it comes. After the diagnosis, it is treated with CKD through various methods. Anemia and secondary hyperparathyroidism are two common complications that can occur at this stage.
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If a CKD patient is at GFR Stage 4, patient education about dialysis and kidney transplantation should be initiated. This is the stage when the patient is prepared for dialysis or a kidney transplant. Options are available based on many factors, including patient preference, comorbidities, and family support. In addition, kidney transplantation is indicated after the patient is further assessed.
During GFR Stage 5, there is renal failure and renal replacement therapy is started at this stage. Kidney transplant candidates have better outcomes than those receiving dialysis treatment.
Medical Nutrition Therapy (MNT) is one of the main and initial treatments for CKD. MNT aims to maintain the quality of life at the highest level, minimize the secondary effects of CKD, slow the progression of CKD, and delay the need for dialysis. For patients waiting for a kidney transplant (pre-transplant), MNT ensures optimal health until the transplant has taken place, and MNT can continue into the post-transplant phase. This suggests that MNT is important and belongs to the spectrum of CKD.
MNT for CKD patients is very specific. This is to ensure that, given the grade of CKD, the kidney is still working at its best. Done correctly, a good diet can prevent CKD from worsening, and it is best to work closely with your doctor and RND for proper guidance. Once the patient is diagnosed, the RND can start working on a kidney diet. The RND can then begin to build on the patient’s urinalysis results and include other assessments, such as BMI and other anthropometric measurements.
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As mentioned, MNT is highly specific for patients with CKD as it involves the modification of certain nutrient intakes to adjust for the existing kidney health.
The table below contains general recommendations for RNDs to start building a diet for CKD patients. In this table are protein, sodium, potassium, and phosphorus, the four most important nutrients that should be observed in CKD patients.
Usually, patients with CKD are given a diet low in protein since protein can increase the stiffness of the kidneys while sodium affects water retention and can promote swelling, which can also make the kidneys work harder.
The kidneys, as mentioned earlier in this article, maintain electrolyte balance, and potassium is one of the electrolytes that must be balanced. Too much or too little potassium can cause muscle cramps, heart rate problems, and muscle weakness, among others.
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Phosphorus is another nutrient regulated by the kidneys. Unregulated phosphorus can cause calcium resorption from the bones, and this can lead to bone fragility. Phosphorus and potassium are more focused on dialysis patients.
RNDs and doctors don’t forget to remind patients about their daily intake of fiber and water to take advantage of the weight loss and weight management properties of fiber. Preventing other complications, such as hypertension, obesity, and diabetes in patients with CKD will prevent worse outcomes.
By following the Nutrition Care Process (NCP): Assessment, Diagnosis, Intervention, Monitoring, and Evaluation (ADIME), RNDs and physicians can prioritize the patient’s quality of life in the care plan they implement. With MNT, the RND must ensure that the patient is on a healthy diet by eating in moderation and balancing nutrient intake. To ensure optimal patient compliance and quality of life, the diet plan should also be varied.
The RND may also recommend keeping a food diary to improve monitoring once the CKD diet has been started. Two important markers can be checked: serum albumin and normal protein similar to nitrogen appearance (nPNA). Serum albumin can indicate the level of protein in the blood; If serum albumin is very low, there may be low protein intake, protein loss in the urine, or an infection. On the other hand, nPNA refers to protein intake.
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Protein energy wasting (PEW) is a problem among hemodialysis patients. According to the International Society of Renal Nutrition and Metabolism, PEW is a nutritional and metabolic disorder in CKD and end-stage renal disease (ESRD). It is characterized by wasting muscles and easily depleting energy stores, where both can lead to poor results and quality of life. A hypercatabolic state caused by uremia, anorexia due to lack of appetite, inflammation of secondary systemic conditions (diabetes), and autoimmune conditions (which lead to CKD and ESRD) all contribute to PEW.
Because of this, there are Oral Nutritional Supplements (ONS) used to feed patients and combat PEW. ONS is given to patients to supplement their main meals to reach their daily protein targets and other serum markers.
It should be noted that if the patient can still consume 75% of their dietary requirements, there is no need for ONS. Consumption lower than 75% or 3/4 of the plate (about 60%-50%) requires ONS. Apart from the oral method, other routes of supplemental nutrition are parenteral (delivery into the bloodstream) and enteral (delivery into the intestine).
For better visualization, below is an example case and computational set for a 61-year-old patient in the pre-dialysis stage.
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In preparing a diet plan for patients with CKD, it is important to remember that food can be changed; unusual foods can be replaced with original and indigenous foods. The key is to collaborate with the patient and take note of their preferences when considering what foods are available in the area. Prescription books may help, if they make it easier for patients to follow instructions. This is all so that the quality of life and adherence to the diet regimen remains.
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