CNS MNT review Renal disorders

MNT for oxalate stones

-Low-oxalate diet: reduce oxalate foods (black tea, cocoa, spinach, beet leaves, rhubarb, parsley, cranberry, nuts) -Limit dairy products -Magnesium forms soluble complexes with oxalate and inhibits absorption -Pumpkin seeds are protective against calcium oxalate stones in those with recurrent calcium oxalate stones (consume daily) -Vit C supplementation has been linked to calcium oxalate stones -Uric acid stones: -Decrease dietary purines: meat, fish, and poultry -Avoid fructose and alcohol -Incorporate alkali fruits and vegetables -Incorporate citrate foods -Blackcurrant juice increases urine pH, excretion of citric acid, and oxalic acid; may treat or prevent uric acid stones by alkalizing urine

Diagnosis & Monitoring of ESRD

-Markedly impaired glomerular filtration rate (i.e., <25 ml/min) -Greatly elevated BUN is indicative of renal failure -Serum albumin < 5.5g/dL suggestive of renal dysfunction Monitor for: Hypocalcemia or very low levels of serum calcium Hypermagnesemia - due to impaired renal excretion of magnesium Rule of thumb - BUN > 100mg/dL, and Cr exceeding 10-12 mg/dL

Goals of MNT in the management of ESRD intended to do the following

-Prevent deficiency and maintain good nutrient status - adequate protein, energy, vitamin, and mineral intake -Control edema and electrolyte imbalance by controlling sodium, potassium, and fluid intake -Prevent/slow development of renal osteodystrophy by balancing calcium, phosphorus, vitamin D, and PTH Enable patients to eat a palatable, attractive diet that fits their lifestyle as much as possible -Coordinate patient care with families, dietitian nutritionists, nurses, and physicians in acute care, outpatients, or skilled nursing facilities -Provide initial nutrition education, periodic counseling, and long-term monitoring of patients, with the goal of patients receiving enough education to direct their own care and diet

Pathophysiology of ESRD

-Reflects the kidney's inability to excrete waste products, maintain fluid and electrolyte balance and produce certain hormones -Renal failure progression - level of circulating waste products eventually lead to symptoms of uremia -Uremia (elevated BUN)- clinical syndrome of malaise, weakness, nausea and vomiting, muscle cramps, itching, metallic taste in the mouth, and neurologic impairment due to an unacceptable level of nitrogenous waste -Can result from a variety of different kidney diseases

Diagnosis & Monitoring of CKD

-Serum albumin < 5.5g/dL suggestive of renal dysfunction -eGFR - estimated glomerular filtration rate - the rate at which kidneys filter waste mild/moderate kidney injury is poorly inferred from serum creatinine alone - GFR need to be regularly assessed serum phosphorus levels elevate at the same rate as eGFR decreases low eGFR does not necessarily mean CKD must have several blood samples drawn 3 months apart that are consistently low eGFR < 60

Symptoms of AKI

-Too little urine leaving the body -Swelling in legs, ankles and round the eyes -Fatigue and tiredness -Shortness of breath -Confusion -Nausea -Seizures or coma in severe cases -Chest pain or pressure

General recommendations for stones

-Weight loss and/or correction in insulin sensitivity -Balance gut microflora and correct dysbiosis if present -High intake of fruits and vegetables -Moderate animal product consumption -Moderate fat consumption -Limit sodium chloride -Vegetarians have a decreased risk of developing stones -Among meat eaters, those eating fresh fruits and vegetables have a lower incidence of stones -Dietary factors in acidifying or alkalizing urine: depending on stone type, the ability to alter urine pH may help treat and prevent stones -Potassium intake inversely related to risk of kidney stones -Specific dietary pattern: low-oxalate or alkaline diet -Sleep position - do not sleep on the side of the stone -Stress can increase risk of stone formation -Heavy metals are toxic to the kidneys and can increase the incidence of kidney stones -Select herbs may be helpful in both chronic and acute cases- -Client will need to be seen by a physician within 24 hrs when hematuria is present, pain is severe and not improving; client will need to be seen by a physician ASAP if presenting with fever, or if the lose consciousness from pain or due to any other reason

Fluid and sodium balance for dialysis -

-assessed frequently through measurement of BP, edema, fluid weight gain, serum sodium level, and dietary intake -goal is fluid gain of less than 4% BW - A sodium intake of 65 to 87 mEq (1500 to 2000 mg) daily and a limit on fluid intake (usually about 750 ml/day plus the amount equal to the urine output) is usually sufficient to meet these guidelines. - educate pt about managing thirst - some may require not limiting sodium if they tend to lose not retain it

Sodium for CKD:

-control of edema w/ dietary intake of 1500g sodium/day - do not restrict further due to diuretics that could cause hypotension, exacerbation of coaglopathy, or deteriation of renal functions

What causes uric acid stones -

-end product of purine metabolism from food, de nova synthesis, and tissue catabolism -IBD- GI bicarbonate loss from diarrhea - lymphoproliferative and myeloproliferative disorders = cellular breakdown that release purines and thus increases uric acid load -diabetes

Risk factors for kidney stones

-family history, 40's and 50's, (low occurrence in black non Hispanic and Hispanics) -High potassium foods are alkaline and can help to prevent kidney stones (Krause) -Pathogenic causes of kidney stones- hypocitraturia, hypercalciuria, hyperoxaluria and primary hyperparathyroidism (due to decreased Ca???) Studyforxyz CLINICAL INTERVENTION AND MONITORING

Syndrome of inappropriate antidiuretic hormone (SIADH): Excessive amount of anti-diuretic hormone released from pituitary gland is common in what conditions? What does it result in? How is this characterized?

-head injury, meningitis cancer, infection, and hypothyroidism result = hyponatemia caused by hemodilution characterized by: serum sodium <135mEq/L and urine sodium conc >20mEq/L can result in seizures and coma treatment: fluid restriction (<1800mlL/day), IV sodium

Phosphorus in dialysis:

-high-phosphorus foods cannot be eliminated without restricting protein, creating a challenge to balance intake with dietary intervention alone -nearly all patients who undergo dialy- sis require phosphate-binding medications (calcium carbonate, calcium acetate, sevelamer carbonate, sucroferric oxyhydroxide, ferric citrate, and lanthanum carbonate)

some common nutrition dx in CKD pop include: -

-inadequate/excessive mineral intake -imbalance of nutrients -excessive fluid intake -impaired nutrient utilization -altered nutrition-related lab values -food-med interaction -food and nutrition-related knowledge deficit

cysteine stones - What is recommended?

-increases when pH exceeds 7 (achieved almost always w/medication) *fluid intake of 4L/day to prevent cystine crystallization *lower sodium intake to reduce cystine in urine; restrict animal protein (lower intake of cystine and methionine); ingest veggies and fruit high in citrate and malate may help alkalinize the urine

Phosphorus in CKD:

-levels elevate as eGFR decreases -early initiation of phosphate reduction therapies is advantageous for delaying hyperparathyroidism and bone disease -those w/eGFR <60 should be evaluated for renal bone disease and benefit from phosphorus restriction

Potassium in CKD:

-manageable through the use of med such as diuretics, individualized diet prescription, and rate of progression of CKD. -late stage 4, urine output drops below 1L/day are pt may req a change in potassium restriction

fructose in kidney stones -

-may increase urinary excretion of calcium and oxalate -only carb known to increased production of uric acid and its urinary excretion -may increase insulin resistance (associated w/low urine pH) -positively associated w/all types of kidney stones

melamine and indinavir stones - Define What helps with them?

-melamine is an organix base synthesized from urea; when added to lquid milk/milk powder, is deceptively increases protein content and forms crystals and sandlike stones in the distal renal tubules -hydration and alkalinization help w/stone passage -Indinavir: soft, gelatinous and radiolucent and not amenable to basket removal or ureteroscopy; IV hydration and temporary cessation of indinavir should be first choice of treatment

Continuous Renal Replacement Therapy (CRRT) -

-most often used are continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodialysis (CVVHD) -typically used when pt develop anasarca or elevated BP and unable to excrete fluid or uremic wastes -chosen when periodic hemodialysis is to be avoided bc rapid removal of fluid/wastes may put the kidney into a less active state causing decreased blood flow to kidney

Medical diagnosis of CKD -

-must have several blood samples drawn 3 mo apart that are consistently low eGFR

Dietary counseling to reduce oxalate absorption: -

-needed for stone-forming individuals who have large intakes of high-oxalate foods and excrete >30mg oxalate/day -severe oxalate restriction is not necessary -Increase calcium intake to each meal to bind oxalate (divded into at least 3 meals or as many eating occasions) *takes 150mg of calcium to bind to 100mg of oxalate

MNT - Goals of ESRD -

-prevent def and maintain good nutrition status through adquate protein, energy, vitamin, and mineral intake -control edema and electrolyte imbalance by controlling sodium, potassium, and fluid intake -prevent/slow development of renal osteodystrophy by balancing caclium, phosphorus, vit. D, and PTH -enable pt to eat a palatable attractive diet that fits his/her lifestyle as much as possible -coordinate pt care w/families, dietitians, nurses, and physicians in acute care, outpaitent or skilled nursing facilities -provide initial nutrition education, periodic counseling and long-term monitoring of pt, w/the goal of pt receiving enough education to direct their own care and diet

Comments on MNT of AKI -

-pt has uremia, metabolic acidosis, fluid/electrolyte imbalance, and also suffers from physiologic stress that increases protein needs -early attention to nutritional support and early dialysis improves pt survival

Fluid and Sodium in AKI

-should balance net output -sodium is restricted (based on decreased urinary production)

energy for dialysis -

-should be adequate to spare protein for tissue protein synthesis and prevent its metabolism for energy -between 25-40kcal/kg BW w/lower amount for transplantation and PD pt and higher level for the nutritionally depleted pt

Protein for dialysis -

-should be increased due to losses of 20-30 g that can occur in 24hr -those receiving PD need a daily protein of 1.2-1.5g/kg BW (at least 50% from HBV protein) -pt who receive HD 3*/wk req daily protein of 1.2g/kg BW *serum BUN and Cr levels, uremic symptoms, and wt should be monitored -low albumin levels (4g/dl) is not a function of nutritional intake *nutritional supp may be helpful in some pt and occasionally the phosphate restriction may have to be lifted to allow consumption of dairy products to meet protein needs

sodium for kidney stones-

-sodium should be lowered to <2300mg/day in pt w/hypercalciuria -DASH reduces risk of stone formation

If the stones are formed in the kidney, this is known as

'nephrolithiasis'.

More than 95% of the cases of nephrotic syndrome stem from three systemic diseases:

(1) diabetes mellitus, (2) sys- temic lupus erythematosus (SLE), and (3) amyloidosis in addition to (1) mini- mum change disease (seen only with electron microscopy), (2) membranous nephropathy (3) focal glomerulosclerosis, and (4) membranoproliferative glomerulonephritis

What is the protein intake recommendation for non-dialysis patients with renal failure?

0.5-0.8g/kg Studyforxyz CLINICAL INTERVENTION AND MONITORING

Stage __________ kidney disease- kidney damage, but normal to increased kidney function

1 Studyforxyz CLINICAL INTERVENTION AND MONITORING

Renal Diseases in order of severity:

*order of severity: 1) kidney stones, 2) acute kidney injury, 3) chronic kidney disease (CKD), 4) end-stage renal disease (ESRD)

Medical Nutrition Therapy (Dietary & Lifestyle) for kidney stones

-After corrective treatment, nutrition assessment is needed to determine risk factors for recurrence -Risk rises with increasing urine calcium and oxalate and decreases with increasing citrate and urinary volume -Specific MNT is based on metabolic evaluations consisting of radiologic studies to assess stone burden, crystallographic stone analysis, and lab studies with standard serum chemistries and 24-hour urine collections -Stone composition: diagnosing the type of stone is critical to therapy. Evaluate the following to determine stone composition if one is not available for analysis: (1) diet; (2) underlying metabolic or disease factors; (3) serum and urinary Ca, uric acid, creatinine, and electrolyte levels; (4) urinalysis results; (5) urine culture findings

Diagnosis & Monitoring glomerulonephritis

-Blood tests show elevated serum urea and creatinine as GFR decreases. -Blood levels of Anti-DNase B, streptococcal antibodies, ASO, and ASK are elevated. -Complement level is decreased. It is probably a causative factor in the inflammatory damage that occurs in the kidney. -Metabolic acidosis, with decreased serum bicarbonate and low serum pH, is present. -Urinalysis confirms the presence of proteinuria, gross hematuria, and erythrocyte casts -Recovery usually takes place with minimal residual damage -Prevent future exposure to strep infection and recurrent inflammation -In children - edema usually recedes in 5-10 days -Hypertension - 2-3 weeks -Proteinuria and hematuria improve but often persist for some time -Post-recovery testing is recommended to ensure chronic inflammation is not present -Adult cases are not easily resolved -Acute renal failure in ~2% of cases -Chronic glomerulonephritis in ~10% of cases

MNT for transplantation (renal)

-Calcineurin inhibitors - hyperkalemia, hypertension, hyperglycemia, and hyperlipidemia -1st 6 weeks post-surgery - high protein diet - 1.6-1.5g/kg IBW -Energy intake 30-35kcal/kg IBW -Moderate sodium restriction - 2-3g/day to minimize fluid retention and help control BP -After recovery - decrease protein to 1-1.5g/kg IBW -Balanced low-fat diet to aid in lowering cardiac complications -Hyperkalemia - temporary dietary potassium restrictions -Hypophosphatemia and mile hypercalcemia in most patients -Adequate Ca and phosphorus daily (1200 mg of each) Cholecalciferol (D3) - 2000 IU daily -Monitor hydration closely - typically encouraged to drink 2L/day - needs depend on urine output -The majority have elevated serum triglycerides or cholesterol -Calorie restriction for those overweight Cholesterol <300mg/day Limited total fat -Patients with glucose intolerance - limit carbs, regular exercise regimen -Immunosuppression - care must be taken with food safety

Melamine and indinavir stones MNT

-Can occur in young children who received melamine-contaminated infant formula -Can occur in individuals treated with HIV medications: protease inhibitors such as indinavir -Hypocitraturia and low urine volume/pH

Why don't some patients like to take phosphate binders?

-Cause GI discomfort and acid reflux -Cause severe constipation and can lead to bowel impaction -May be difficult to swallow or chew -May need to take an average of 2-5 pills each meal -Forget to take them -Do not like being reminded of being "sick" -Cannot feel a difference when taking them -May be expensive and not always covered by insurance

Signs/Symptoms poststreptococcal glomerulonephritis (APSGN)

-Dark and cloudy urine - "smoky" or "coffee-colored" because of protein and RBCs -Facial and periorbital edema occur initially -Generalized edema as colloid osmotic pressure of the blood drops and sodium and water are retained -BP is elevated due to increased renin and decreased GFR -Flank and back pain develop as kidney tissue swells and stretches the capsule -General signs of inflammation - malaise, fatigue, headache, anorexia, nausea -Urine output decreases (oliguria) as GFR declines

Dialysis is a drain on body protein - protein intake must be increased

-Dialysis 3x/week can lose about 15g of protein per treatment - require 1.2g/kg/day of protein -24hr PD - can cause losses of 20-30g of protein - avg 1g/hr - require 1.2-1.5g/kg

Struvite stones:

-Diet has no definitive role except avoidance of urine alkalization -Acidify urine with cranberry juice

MNT for cystine stones

-Fluid intake of more than 4 L daily is recommended Restriction of animal protein -Avoid methionine-rich foods (eggs, soy, wheat, dairy products (except whole milk), fish, meat, lima beans, garbanzo beans, mushrooms, and all nuts except coconut, hazelnut, and sunflower seeds) -Ingestion of vegetables and fruit high in citrate and malate (melons, limes, oranges, fresh tomato juice)

acute poststreptococcal glomerulonephritis (APSGN)

-Follows streptococcal infection with certain strains of group A beta-hemolytic Streptococcus -Usually originate as upper respiratory infections, middle ear infections, or "strep throat

Struvite stones:

-Form only in the presence of certain bacteria that cause urea breakdown resulting in ammonia and CO2 -production, raising the urine pH and level of carbonate -Goal is to eliminate or prevent urinary tract infections through regular screening -Diet has no definitive role except avoidance of urine alkalization

Causes of oxalate stones -

-Genetic defect (primary hyperoxaluria) - IBD or gastric bypass related to fat malabsorption (bile acids produced are reabsorbed and fails to occur, bile salts & FA increase permeability to oxalate)

Calcium stones MNT

-High incidence of calcium stones in affluent societies is linked to a diet low in fiber and high in refined carbohydrates, alcohol, animal protein, fat, high-Ca food, vitamin D-enriched food, soft drinks, and fructose Increase fiber, complex carbohydrates, and green leafy vegetables -Decrease simple carbohydrates and purines (meat, fish, poultry, yeast) -Increase high Mg/Ca ratio foods (barley, bran, corn, buckwheat, rye, soy, oats, brown rice, avocado, banana, cashew, coconut, peanut, sesame seed, lima beans, potato). -Avoid soft drinks (phosphate stones) -Using bran supplements and changing to whole-wheat bread lower urinary Ca -Decrease sodium: high intake reduces renal tubular reabsorption of calcium, increasing excretion in urine; high sodium increases urine pH and may reduce urine citrate; high-Na diet increases urine pH and may reduce urine citrate -Citrate inhibits aggregation and growth of Ca oxalate and Ca phosphate crystals -In the past, dietary interventions to increase citrate involved lemonade and orange juice *the results with lemonade are conflicting Avoid grapefruit juice (can increase stone formation in women)

A 65-year-old Asian woman with obesity, well-controlled diabetes, and hypertension was admitted to the hospital with pneumonia. Her baseline serum creatinine was 0.9 mg/dL. During hospitalization, she developed nonoliguric acute kidney injury with a serum creatinine peak of 2.3 mg/dL in the absence of intravascular volume depletion. She sustained no nephrotoxic exposures or hypotensive episodes during hospitalization. One month postdischarge, she is seen in your clinic for a follow up. Her most recent serum creatinine is 1.0 mg/dL. Your next step is all of the below except: a. Reassure the patient that she has normal kidney function and no additional work-up or follow- up is needed at this time b. Check her urinary protein and microalbumin c. Obtain retroperitoneal renal ultrasound d. Instruct her on avoidance of any nephrotoxic exposures e. Monitor her serum creatinine and eGFR closely

a. It is important to recognize and manage the early manifestations of CKD. In this elderly woman with multiple risk factors for CKD, serum creatinine levels of 0.9 and 1.0 might reflect 2an eGFR of <60 cc/min/1.73 m . In addition, acute kidney injury without obvious nephrotoxic exposures or hypotensive episodes warrants a high level of suspicion for compromised kidney function and further work-up, such as obtaining a renal ultrasound, screening for proteinuria, or microalbuminuria, is warranted. Careful monitoring of renal function and avoidance of contrast dye, NSAIDs, and other nephrotoxins are important steps for preventing CKD progression.

Corticosteroids for kidney transplants are associated with what other issues?

accelerated protein catabolism, hyperlipid- emia, sodium retention, weight gain, hyperglycemia, osteopo- rosis, and electrolyte disturbances

Chronic kidney disease (CKD) - Define: Risk factors: 5 stages:

after 1/2 to 2/3 kidney function is lost, progressive further loss of kidney function ensues -diabetes is leading risk factor for CKD followed by hypertension and glomerulonephritis -5 stages related to the estimated GFR (eGFR) - *stages 1 & 2 are early stages w/markers such as proteinuria, hematuria, or anatomic issues. Stages 3 & 4 are considered advanced stages. Stage 5 results in death unless dialysis or transplant is initiated

Low urine pH can be a result of low intake of _______________

alkaline-producing foods or increased consumption of acid-producing foods

renal tubular acidosis (RTA) -

an acidosis accompained by hypokalemia; malabsorption syndrome w/enterichyperoxaluria and excessive meat intake (lower urine pH) are associate w/decreased urinary citrate levels

The functions of the glomerulus that are important with re-spect to disease are production of ______ and prevention of ______..

an adequate ultrafiltrate, certain substances from entering this ultrafiltrate

Restriction of _______________ is associated with lower intake of cystine and methionine (precursor for cystine)

animal protein

What are the dietary interventions for kidney stones?

avoid vit C, normal protein intake, avoid high purines, and normal Ca intake. Avoid high purine foods like eggs. Studyforxyz CLINICAL INTERVENTION AND MONITORING

Medications typically used for kidney transplant for the long term include:

azathioprine (Imuran), corticosteroids (e.g., prednisone), calcineurin inhibitors (cyclosporine A, Gengraf, SangCya, Sandimmune, tacrolimus [Prograf, F506]), sirolimus (Rapamune), everolimus (Zortress), mycophenolate mofetil (CellCept) mycophenolic acid (Myfortic)

These type of stones classically evolve into staghorn calculi a. Uric acid b. Struvite c. Cystine d. Calcium

b. Staghorn calculi are branched and can occupy a significant amount of the renal collecting system. They are also more commonly associated with infections and are often referred to as the "infection stone." Calcium stones rarely grow this large. Cystine and uric acid have the potential to form staghorn calculi but this happens less often. Left untreated, staghorn stones can destroy the kidney function and increase the risk of sepsis.

The afferent arteriole is ______ in diameter than the efferent arteriole which exits the glomerulus -

bigger *difference in size means the pressure of blood in glomerulus is higher enough to filter substances out of the blood (water, glucose, ions, & wastes filter into bowmans capsule and form filtrate)

Of the following uric acid-lowering agents, which has been associated with the best efficacy and the least side effects in patients with CKD? a. Allopurinol b. Probenecid c. Febuxostat d. Losartan e. Bumetanide

c. Febuxostat has been found to be more potent and safer than allopurinol. Losartan has only a small uric acid-lowering effect, probenecid is not recommended with a creatinine clearance of <50 mL/min, and bumetanide can worsen hyperuricemia.

Stones in patients with what type of metabolic abnormality could theoretically be prevented by probiotics containing Oxalobacter formigenes? a. Hypocitraturia (citrate) b. Hypercalciuria (calcium) c. Hyperoxaluria (oxalate) d. Hyperuricosuria (uric acid)

c. This probiotic strain may work by degrading oxalate in the body. Lower oxalate levels help reduce the risk of stone formation.

Urinary oxalate levels are determined by

calcium and oxalate in diet, functional integrity of GI tract, presence of oxalate degrading bacteria in the gut, genetic disorders

tones in the Western hemisphere are typically composed of _______________

calcium oxalate or calcium phosphate, uric acid or struvite.

Chronic intersitial nephritis -

can occur as a result of analgestic abuse, sickle cell disease, diabetes, or vesiocoureteral reflux and manifests primarily as inability to concentrate the urine and as mild renal insufficiency -dietary management: adequate fluid intake (req several L of extra fluid) -hereditary disorder of interstitium, medullary cystic disease also presents with this

Acute renal failure- to prevent body's use of protein for energy, large intakes of ________________are recommended to protect protein stores (protein sparing effect)

carbs and lipids Studyforxyz CLINICAL INTERVENTION AND MONITORING

Acute kidney injury-AKI (acute renal failure-ARF) - How is it characterized? When does it occur? What are the 3 causes?

characterized by a sudden reduction in glomerular filtration rate (GFR) and altered ability of the kidney to excrete the daily production of metabolic waste -occur in association w/oliguria or normal urine flow -causes (3 categories): 1) inadequate renal perfusion (prerenal), 2) diseases within renal parenchyma (intrinsic), 3) urinary tract obstruction (postrenal)

Fanconi syndrome -

characterized by an inability to reabsorb the proper amount of glucose, AA, phosphate, and bicarbonate in the proximal tubule, thus causing urinary excretion of these substances -present w/acidosis, hypokalemia, polyuria, or osteomalacia, rickets, and vomiting -No specific medical treatment available; dietary treatment main form of managment - replacement therapy through large vol of water and dietary supp of bicarbonate, potassium, phosphate, calcium, & vit. D

nephrotic syndrome

characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay large urinary protein losses can lead to hypercholesterolemia, hypoalbuminemia, edema, hypercoagulability Studyforxyz CLINICAL INTERVENTION AND MONITORING

_____________ and _____________ have been associated with a reduced risk of kidney stone formation because they are diuretics

coffee and alcohol Studyforxyz CLINICAL INTERVENTION AND MONITORING

The filtrate from bowmans capsule goes from the proximal convulted tubule (PCT) -->henle loop -->distal convoluted tubule -->then to the?

collecting duct

Define azotemia -

collection of abnormal quantities of waste products in the blood

protein-nitrogen appearance (PNA) rate -

compares to a simplified nitrogen balance study in the dialysis pt; values should be between 0.8-1.4

struvite stones - Define: Who is it common in? How do they form? How is it treated?

composed of magnesium ammonium phosphate and carbonate apatite(also known as triple-phosphate or infection stones) -occur more commonly in women than men (2:1) -form only in prescence of bacteria - Pseudomonas, Klebsiella, Proteus mirabilias, and Urea-lyticum = carry urease (urea-splitting enzyme) -Treatment: extracorporeal shock-wave lithotripsy (ECSWL) w/adjunctive culture-specific antimicrobial therapy that uses urease inhibitors goal: eliminate/prevent urinary tract infections by regulatory screening and monitoring urine cultures; diet has no definitive role except avoidance of urine alkalinization

Dietary advice to reduce oxalate absorption

consume Ca rich foods, consume Ca rich supplements, avoid probiotics (Krause- not sure about the probiotics) Studyforxyz CLINICAL INTERVENTION AND MONITORING

Your patient with stage 3 CKD reports self-prescribing of several supplements and herbs. Which of the following can you recommend continuing based on current evidence and safety profiles? a. L-Arginine b. Niacin c. Vitamin K d. Turmeric e. Cordyceps

d. There is no evidence to support a, b, or c. Cordyceps has had positive but limited reports, mostly in Chinese patients.

In ESRD, phosphate binders are taken with meals and snacks to prevent what? What are some examples?

dietary phosphorus absorption. Calcium carbonate Calcium acetate Mg/Ca11 carbonate Sevelamer carbonate Lanthanum carbonate Aluminum hydroxide Iron-based binders

Most precise measure of kidney disease:

eGFR cystatin C followed by eGFR pairing cystatin C and creatinine

CKD MNT-

energy intake designed to spare protein, possible protein restriction, Na restriction, phosphate binders with meals. 1500mg or less of sodium recommended Studyforxyz CLINICAL INTERVENTION AND MONITORING

IBD and gastric bypass often lead to hyperoxaluria related to ______________

fat malabsorption and dehydration Unabsorbed fatty acids also bind to calcium to form soaps, decreasing availability of calcium to bind oxalate

In end stage renal disease (ESRD), ESR, do not supplement with ______________vitamins.

fat soluble Studyforxyz CLINICAL INTERVENTION AND MONITORING

What is the renal corpuscle? What does it perform? What parts does it consist of?

first part of the nephron and makes up most of the kidneys cortex *process performed: filtration consists of : Bowman's capsule & Glomerulus

magnesium for kidney stones -

forms solbule complexes w/oxalate *like calcium, it inhibits oxalate absorption

What is the nephron? What are its 2 parts? How many does each kidney have?

functional unit of the kidney consists of 2 parts: renal corpuscle & renal tubule *each kidney has 1 million

nephrotic syndrome (nephrosis)

group of conditions in which excessive amounts of protein are lost through the urine Studyforxyz CLINICAL INTERVENTION AND MONITORING

Main sources of dietary acid load

high in sulfur, chloride, P and organic acids When these foods are not balanced with alkaline producing foods, such as fruits and veggies, there is an increased risk of chronic acidosis.

Nephrotic syndrome can lead to what 4 secondary pathologies?

hypercholesterolemia, hypoalbuminemia, edema, hypercoagulability Studyforxyz CLINICAL INTERVENTION AND MONITORING

Calcineurin inhibitors for kidney transplants are associated with other issues?

hyperkalemia, hypertension, hyperglycemia, and hyperlipidemia

In ESRD, activated Vitamin D (calcitriol) is used for the management of

hyperparathyroidism

Renal failure- most common skeletal complication is secondary ______________

hyperparathyroidism which refers to excessive secretion of parathyroid hormone (PTH) by the parathyroid glands in response to low blood Ca and associated hyperplasia of the glands often seen in chronic kidney failure Studyforxyz CLINICAL INTERVENTION AND MONITORING

hyperparathyroidism

hypersecretion of the parathyroid glands, usually caused by a tumor Studyforxyz CLINICAL INTERVENTION AND MONITORING

Acidosis is associated with :

inflammatory related chronic diseases such as urolithiasis, HTN, insulin resistance, low immune function, and osteoporosis

citrate in kidney stones-

inhibits urinary stones by forming a complex w/calcium in urine; less calcium is available to bind urinary oxalate =prevents formation of calcium oxalate or calcium phosphate stones *normal urinary citrate formation - >640mg/day -long-term lemonade or lime or lemon juice therapy in hypocitraturic stone formers increases urinary citrate levels and decreased stone formation rate

One of the major factors leading to the formation of kidney stones is :

insufficient fluid intake (<2 liters per day), with subsequent decreased urine volume.

Pruitis

itching

calculi

kidney stones

end-stage renal disease (ESRD) - Define: What symptoms does it lead to? How high is the BUN and Crt?

kidneys inability to excrete waste products, maintain fluid and electrolyte balance, and produce certain hormones *level of circulating waste products leads to symptoms or uremia -BUN of more than 100mg/dL or creatinine of 10 to 12mg/dL

Urinary oxalate comes from endogenous synthesis, proportional to __________ (body mass)

lean body mass

Urea Reduction Ratio (URR) -

looks at reduction in urea before and after dialysis *pt considered well dialyzed if 65% or greater reduction in serum urea occurs

Lipids in CKD:

lower fat diet to avoid dyslipidemia which could lead to CVD

What is the Glomerulus made up of? What does it produce?

made up of loops of capillaries and completely surrounded by Bowman capsule produces the ultrafiltrate, which then is modified by the next segments of the nephron

peritoneal dialysis (PD) - What is it? How does it work? What is CAPD? What is APD? What are the advantages?

makes use of the body's own semi-permeable membrane (peritoneum); catheter is implanted surgically through the abdomen and into the peritoneal cavity -dialysate containing high-dextrose concentration is instilled into the peritoneum where diffusion carries waste products from the blood through the peritoneal membrane and into the dialysate; water moves by osmosis *in CAPD, the dialysate is left in the peritoneum and exchanged manually by gravity (exchanges of fluid are done 4-5*day =24hr treatment) *In APD, treatments are done at night by a machine that mechanically performs the exchanges -advantages of PD is avoidance of large fluctuation in blood chemistry, long residual renal function, and ability of pt to achieve more normal lifestyle Complications: peritonitis, hypotension, and wt. gain

Uremia in ESRD-

malaise, weakness, nausea, vomiting, muscle cramps, itching, metallic taste in mouth, neuro impairment. Studyforxyz CLINICAL INTERVENTION AND MONITORING

Inadequate calcium intake along with high protein intake induces ________________, increases calcium excretion by inhibiting renal reabsorption of calcium secondary to the acid load, and lowers urinary pH

metabolic acidosis

The majority of the solute load consists of -

nitrogenous wastes , primarily end products of protein metabolism (urea, uric acid, creatinine, and ammonia)

Foods high in purine:

organ meats, anchovies, herrings, sardines, meat-based broth, and gravy

Kombucha contains black tea which is high in ____________and not recommended for kidneys tone recovery or prevention

oxalate Studyforxyz CLINICAL INTERVENTION AND MONITORING

ultrafiltrate production is mainly -

passive and relies on perfusion pressure generated by heart and supplied by the renal artery

Purines and metabolism of sulfur-rich amino acids, cystine and methionine, in animal protein confer an acid load to the kidney, thus lowering urine pH. PRAL value is assigned to groups of foods in terms of their -

positive or negative effect on acidic load

uremia

presence of urinary waste in the blood. It is a result of high levels of nitrogenous wastes in the body Studyforxyz CLINICAL INTERVENTION AND MONITORING

Re-absorption occurs - What does it require?

pretubular capillaries mostly in proximal convoluted tubule ATP

Goal of MNT in children with CKD -

promote normal growth and development Control of calcium and phosphorus balance is especially important for maintaining good growth Restriction of protein is controversial

EPA is an inhibitor of AA metabolism resulting in decreased synthesis of _______________, a substance known to potentiate urine calcium.

prostaglandin 2 (E-2 (PGE2))

What two things too big to be filtrated in the wall of the glomerular capillaries so they stay in the blood -

proteins and blood cells

medical management of Acute kidney injury (AKI) -

ratio of blood urea nitrogen (BUN) to creatinine can be used to assess location of damage to kidney *BUN is increased bc of poor filtration and more actively reabsorbed (BUN/Cr >20:1 = damage is prerenal; intrinsic -BUN/Cr ration decreases to <10:1)

Potassium in dialysis:

reduced in ESRD to 60 to 80 mEq (2.3 to 3.1 g) per day and is reduced for the anuric pa- tient on dialysis to 51 mEq (2 g) per day - some may require increased amounts

the renal pyramids consist of the -

renal tubules of the nephron *nephrons are surrounded by peritubular capillaries that branch off of the efferent arteriole

hemodialysis (HD) -

requires permanent access to bloodstream through a fistula created by surgery to connnect the artery and a vein -outpatient requires treatment of 3-5hr 3*week in dialysis unit

In PN for ESRD, vitamin A should not be provided parenterally unless __________ is monitored during each HD treatment because it is elevated in patients with ESRD

retinol-binding protein

Bioavailability of food oxalate and urine oxalate is affected by:

salt forms of oxalate, food processing and cooking methods, meal comp, and presence of Oxalobacter formigenes (OF) in GI tract (70% risk reduction w/this bacteria)

Potassium for kidney stones-

stone formers often have low-normal intake & high sodium intake which raises Na:K ratio and should be encouraged to increase the potassium in their diets by choosing low-oxalate fruit and vegetables many times throughout the day -Foods high in potassium are replete w/alkali which stimulate urinary citrate excretion

GFR (glomerular filtration rate) -

the amount of filtrate/unit in the nephrons

Define renal failure -

the inability to excrete the daily load of wastes

______ stones are common in the prescence of type 2 diabetes -

uric acid *hyperinsulenima also may contribute to development of calcium stones by increasing urinary calcium excretion

Out of all the stones, which ones are translucent ?

uric acid stones

Oliguria -

urinary volume of <500mL/day

The solubility of uric acid depends on

urine volume, the amount excreted, and urine pH

control of water excretion is regulated by what hormone?

vasopression (anti-diuretic hormone) *small peptide hormone secreted by the posterior pituitary -small rise in osmolality = vasopression secretion & water retention

Medical management of kidney stones -

vegetarian diet - uric acid stones Shockwave therapy Antimicrobial therapy - struvite stones

What is one of the most preventive modalities in stone formations? -

weight control (BMI between 18-25)

MNT of kidney stones -

• Normalize urinary excretion of stone forming solutes • Achieve daily urine volume >2 L • Dietary calcuim based on age • Avoid high oxalate foods • Lower salt intake • Moderate animal protein • Vitamin C not >500 mg/day

90% of pt that reach ESRD have what 3 chronic conditions:

1) Diabetes 2) hypertension 3) glomerulonephritis

Protein needs increase in acute renal failure to __________

1-2g/kg Studyforxyz CLINICAL INTERVENTION AND MONITORING

1. Which of the following does NOT theoretically put one at risk for kidney stone recurrence? a. Increased oxalate intake b. Decreased citrate intake c. Increased sodium intake d. Decreased dietary calcium intake \e. None of the above

1. e. All of the above can increase the risk of stone formation.

When continuous Renal Replacement Therapy (CCRT) protein losses are high in patients with acute renal failure what is generally recommended protein?:

1.5-2.5g/kg Studyforxyz CLINICAL INTERVENTION AND MONITORING

_____(amount) of pt w/calcium stones are hypercalciuric. What does this describe?

1/3, Describes a value of calcium in excess of 300mg/day in men and 250mg/day in women or 4mg/kg/day for either in random urine collections in unrestricted diets

vit. C supp at _____mg/day associated w/increased risk of kidney stone in men but not women

1000, -individuals w/calcium oxalate stone disease and high levels of urine oxalate should avoid vitamin C supp >90mg/day

A 65 to 87 mEq (_____ to _____ mg) sodium diet requires no salt in cooking; no salt at the table; no salted, smoked, en- hanced, or cured meat or fish; no cheese except swiss or cream cheese and no salted snack foods, canned soups, packaged bread products, or high-sodium convenience foods

1500 to 2000 mg

How much is the sodium requirement in CKD?

1500mg or less Studyforxyz CLINICAL INTERVENTION AND MONITORING

Stage ______ kidney disease- mild decrease in kidney function

2 Studyforxyz CLINICAL INTERVENTION AND MONITORING

vit B6 supplement of __to __ mg/day may reduce urinary oxalate in some calcium oxalate stone formers

2-10

Fluid intake should be the focus with all types of stones: urine volume of ____________ L per day (requires 250 mL of fluid at each meal, between meals, at bedtime, and when arising at night *hydration during sleep is important)

2-2.5

Nutritional recommendations for dialysis

25-40 kcal/kg/day Sodium intake 65-87 mEq/day (1500-2000mg) Fluid intake - usually about 750mL/day plus the amount equal to urine output

Stage ________kidney disease - moderate decrease in function

3 Studyforxyz CLINICAL INTERVENTION AND MONITORING

Stage _______ kidney disease- severe decrease in kidney function and requires dialysis or transplant

4 Studyforxyz CLINICAL INTERVENTION AND MONITORING

Stage ________ kidney disease is characterized by a severe decrease in kidney function and requires dialysis or kidney transplantation

4 Studyforxyz CLINICAL INTERVENTION AND MONITORING

Hyperoxaluria more than ______ mg of oxalate in urine per day

40

Uric acid stones form when urine is supersaturated and undissociated with uric acid (occurs at urinary pH of less than ____________)

5.5

Cystine solubility increases when urine pH exceeds _________ so alkaline urine pH must be maintained 24 hours per day

7

Associate disorders of ESRD

90% of ESRD patients have Diabetes mellitus Hypertension Glomerulonephritis Metabolic bone disease - renal osteodystrophy - 4 types Osteomalacia - bone demineralization due to increased release of PTH causing increased release of Ca from the bones - triggered by lack of Ca absorption due to lack of vitamin D Osteitis fibrosa cystica - severe bone demineralization - characterized by dull, aching bone pain Metastatic calcification - imminent if serum Ca multiplied by serum phosphate level is greater than 70 - occurs when calcium phosphate is deposited on nonbone cells May develop in joints, soft tissue, and vessels Adynamic (low turnover) bone disease

Phosphorus - more than _______% of excess is excreted in urine

99

What is RIFLE - Risk, Injury, Failure, Loss, and ESRD

A new form of classification to help clinicians assess the severity and progression of acute kidney injury. Thus, when to increase protein needs or be more moderate to preserve kidney function

2. Renal adaptations that permit "normal" function eventually fail, causing a progression toward ESRD because of a. loss of nephrons. b. uremia. c. increases in blood pressure. d. imbalances between glomerular and tubular functions.

ANS: A As ESRD progresses, the GFR declines because of a continuing loss of nephrons. As nephron number decreases, there is less functional capacity within the kidney to filter blood and promote the excretion of metabolic end products. Uremia results from the inability to excrete nitrogenous waste products. Blood pressure increases as both sodium and water are retained, contributing to an increased blood volume. The filtration and exchange activities that occur within the glomerulus and tubules of the nephron continue in the functioning nephrons, but as the number declines, the dependence upon fewer nephrons places increased stress and wear on those remaining, continuing to promote the decline in nephron number. REF: p. 711

12. Which of the following foods does NOT potentially increase the acidity of urine? a. Lemons b. Cranberries c. Chicken d. Spaghetti noodles

ANS: A Fruits and vegetables contribute alkaline "ash" to urine, increasing alkalinity. However, cranberries, plums, and prunes contain benzoic and quinic acids, which are excreted in the urine as hippuric acid, increasing urinary acidity. Animal protein foods, such as meats, eggs, and cheeses, and bread and grain products contribute the most acid ash. REF: p. 703

4. Glomerulonephritis or nephritic syndrome is one of the causes of a. stage 5 chronic kidney disease (CKD) or end-stage renal disease (ESRD). b. stage 1 CKD. c. kidney stones. d. heart failure.

ANS: A Glomerulonephritis is one of the three most common causes of stage 5 CKD. DIF: Cognitive Level: Knowledge REF: p. 375 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. Which of the following increases the excretion of urinary calcium and uric acid? a. Animal protein b. Carbohydrate c. Fat d. Increased water intake

ANS: A High animal protein intake promotes the excretion of urinary calcium and uric acid, increasing the risk of development of calcium oxalate or uric acid stones. Carbohydrates contribute phytates to the diet, which have been observed to be associated with decreased kidney stone formation. Omega-3 fatty acids in fish oil supplements lower urinary calcium excretion, partly because of less arachidonic acid production, which can increase hypercalciuria. Increased fluid intake decreases the risk of stone formation. REF: p. 707

20. Which of the following diseases is NOT among the top three considered to cause nephrotic syndrome? a. Kidney cancer b. Diabetes c. Lupus d. Amyloidosis

ANS: A More than 95% of the cases of nephrotic syndrome stem from three systemic diseases, diabetes mellitus, SLE, and amyloidosis. REF: p. 711

13. Which kidney condition is associated with hematuria? a. Nephritic syndrome b. Nephrotic syndrome c. Pyelonephritis d. Renal tubular acidosis

ANS: A Nephritic syndrome is a condition of inflammation of the glomerulus, resulting in the loss of blood into the urine. Nephrotic syndrome is characterized by the loss of the glomerular barrier to protein, resulting in hypoalbuminemia. Pyelonephritis is a bacterial condition of the kidney. Renal tubular acidosis involves a defect in the ability of either the proximal or distal tubule's ability to handle bicarbonate. REF: p. 711

3. Disease conditions that can interfere with normal kidney function include a. obstruction and infection. b. chronic caffeine intake. c. chronic alcohol abuse. d. anemia.

ANS: A Obstruction and infection can interfere with normal nephron function. DIF: Cognitive Level: Knowledge REF: p. 373 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The most common renal stones contain calcium precipitates of a. oxalate. b. phosphate. c. phytate. d. struvite.

ANS: A Oxalate stones account for 60% of recurrent stone formation. Calcium phosphate stones account for 10% of cases. Dietary phytate inhibits the crystallization of calcium oxalate and calcium phosphate. Struvite stones contain magnesium ammonium phosphate and carbonate apatite and are only formed in the presence of urease-containing bacteria. These only account for 5% to 10% of cases. REF: p. 702

25. When patients with chronic kidney disease begin dialysis, they can increase their intake of a. protein. b. phosphorus. c. energy. d. fat.

ANS: A Patients treated using dialysis can increase protein intake from 1.1 to 1.5 g/kg body weight because of a more liberal diet. This helps maintain muscle mass. DIF: Cognitive Level: Application REF: p. 381 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. Patients with chronic renal disease may need to restrict their intake of foods high in phosphorus, such as a. milk, nuts, and legumes. b. meat, chicken, and fish. c. bread, cereal, rice, and pasta. d. fruit and potatoes.

ANS: A Phosphorus-containing foods include milk, nuts, and legumes. DIF: Cognitive Level: Application REF: p. 388 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. Symptoms of chronic kidney failure include a. nitrogen retention. b. euphoria. c. jaundice. d. the inability to sleep.

ANS: A Symptoms of chronic kidney disease include fluid imbalances, electrolyte imbalances, nitrogen retention, anemia, hypertension, and azotemia. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

28. The most common type of kidney stone is composed of a. calcium. b. uric acid. c. cystine. d. magnesium.

ANS: A The most common type of kidney stone (approximately 80%) is composed of calcium oxalate or calcium phosphate. DIF: Cognitive Level: Knowledge REF: p. 388 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

1. The microscopic functional units of the kidney are called a. nephrons. b. glomeruli. c. tubules. d. loops of Henle.

ANS: A The nephron is the functional unit of the kidney. It performs functions such as filtration, reabsorption, secretion, and excretion. DIF: Cognitive Level: Knowledge REF: p. 371 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. By what process is water reabsorbed from the filtrate? a. Osmosis b. Active transport c. Cotransport d. Capillary action

ANS: A REF: 492

5. Which of the following describes the normal flow of urine? a. Collecting duct to the renal pelvis to the ureter to the bladder b. Renal pelvis to the urethra to the bladder to the ureter c. Ureter to the renal pelvis to the urethra to the bladder d. Collecting duct to the ureter to the urethra

ANS: A REF: 496

12. From the following, choose the substance likely to appear in the urine when the glomerulus is inflamed. a. Albumin b. Urea c. Sodium d. Creatinine

ANS: A REF: 497

Which of the following indicate a decreased GFR? a. Increased serum urea and decreased serum bicarbonate b. Urine with low specific gravity and dark color c. Albuminuria and hematuria d. Hyponatremia and hypokalemia

ANS: A REF: 497

What is the primary action of the diuretic furosemide? a. Decreased reabsorption of sodium and water b. Decreased reabsorption of H+ in the tubules c. Increased secretion of antidiuretic hormone d. Inhibition of renin

ANS: A REF: 498

What are the significant signs of nephrotic syndrome? a. Hyperlipidemia and lipiduria b. Pyuria and leucopenia c. Hypertension and heart failure d. Gross hematuria and pyuria

ANS: A REF: 504

Reduced urine output resulting from inflammation and necrosis of the tubules is called: a. oliguria. b. anuria. c. pyuria. d. polyuria.

ANS: A REF: 510

What causes polyuria during the stage of renal insufficiency? a. Loss of tubule function b. Increased blood pressure c. Decreased aldosterone secretion d. Increased GFR

ANS: A REF: 510

Why does metabolic acidosis develop with bilateral kidney disease? a. Tubule exchanges are impaired. b. GFR is increased. c. Serum urea is increased. d. More bicarbonate ion is produced.

ANS: A REF: 510

With severe kidney disease, either hypokalemia or hyperkalemia may occur and cause: a. cardiac arrhythmias. b. encephalopathy. c. hypervolemia. d. skeletal muscle twitch or spasm.

ANS: A REF: 513

22. Carbohydrates and fats are important in the diets of patients with kidney disease because they a. prevent fatigue. b. spare protein for tissue synthesis. c. are low in sodium. d. are metabolized before they reach the kidney.

ANS: B Carbohydrate and fat must supply sufficient nonprotein kilocalories to supply energy and spare protein for tissue synthesis. DIF: Cognitive Level: Knowledge REF: p. 379 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation | NCLEX: Health Promotion and Maintenance

7. Classic symptoms of acute glomerulonephritis include a. azotemia. b. proteinuria. c. ascites. d. anemia.

ANS: B Classic symptoms of acute glomerulonephritis include hematuria and proteinuria, although edema and hypertension also may occur. DIF: Cognitive Level: Knowledge REF: p. 375 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. Clinical symptoms associated with chronic kidney disease do not include a. anemia. b. diabetes mellitus. c. hypertension. d. bone pain.

ANS: B Complications of chronic kidney disease do not include diabetes mellitus. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. Which type of dialysis treatment is usually done at night? a. Continuous ambulatory peritoneal dialysis b. Continuous cyclic peritoneal dialysis c. Hemodialysis d. Intermittent dialysis

ANS: B Continuous cyclic peritoneal dialysis involves continuous dialysate exchanges that are machine driven while the patient is sleeping at night. Continuous ambulatory peritoneal dialysis involves the patient manually performing the exchanges throughout the day. Hemodialysis requires that the patient have his or her blood filtered for metabolic end products over a period of several hours, either daily or every other day. Hemodialysis is essentially an intermittent process of performing dialysis. REF: p. 715

29. The type of diet recommended for a person with a calcium stone depends on a. body weight. b. the composition of the stone. c. fiber intake. d. fluid intake.

ANS: B Medical nutrition therapy for calcium stones depends on the composition of the stone. If a stone is composed of calcium phosphate, additional sources of phosphorus should be controlled. If a stone is calcium oxalate, foods high in oxalate should be avoided. DIF: Cognitive Level: Knowledge REF: p. 388 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. Medical nutrition therapy for nephrotic syndrome includes a. high protein intake. b. moderate protein intake. c. high potassium intake. d. fluid restriction.

ANS: B Medical nutrition therapy for nephrotic syndrome includes moderate protein intake at 0.8 g/kg/day, which is sufficient to meet nutritional and growth needs without adding to the burden on the kidney to excrete waste products formed from the breakdown of extra protein. DIF: Cognitive Level: Application REF: p. 375 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation | NCLEX: Health Promotion and Maintenance

9. Nephrotic syndrome, or nephrosis, is a disease that a. is caused by chronic hypertension. b. allows large amounts of protein to escape into the tubule. c. causes the buildup of toxic wastes in the blood. d. results in the formation of kidney stones.

ANS: B Nephrotic syndrome, or nephrosis, results from nephron tissue damage to both the glomerulus and tubule. The primary damage is to the major filtering membrane of the glomerulus, which allows large amounts of protein to pass into the tubule. DIF: Cognitive Level: Knowledge REF: p. 375 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The bone disease osteodystrophy develops because of the kidneys' inability to a. excrete calcium. b. activate vitamin D. c. absorb vitamin D. d. excrete urea.

ANS: B The disturbed metabolism of calcium and phosphate from lack of vitamin D activation, a process that occurs in the kidneys, leads to bone pain from osteodystrophy. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The rennin-angiotensin mechanism a. regulates calcium and phosphorus balance. b. regulates blood pressure. c. is the first function of the kidney to deteriorate in AFI. d. is responsible for the production of EPO.

ANS: B The renin-angiotensin mechanism is a major control for blood pressure. It works in concert with vasopressin, which is secreted by the pituitary. REF: p. 701

16. Which of the following blood parameters is associated with uremia? a. Sodium greater than 145 mEq/L b. Blood urea nitrogen greater than 100 mg/dl c. Creatinine level between 0.6 and 1.5 mg/dl d. eKt/V greater than 1.2

ANS: B Uremia is a clinical syndrome of malaise, weakness, nausea and vomiting, muscle cramps, itching, and a metallic taste brought on by high levels of nitrogenous wastes in the body. BUN greater than 100 mg/dl is commonly associated with the condition. Sodium levels above normal are usually associated with dehydration. Normal creatinine levels run between 0.6 and 1.5 mg/dl; uremia is associated with creatinine levels between 10 and 15 mg/dl. Equilibrated kinetic modeling (eKt/V) is a measure of dialysis efficiency, and levels of 1.2 or higher indicate that urea is effectively being cleared. REF: p. 713

19. The type of renal therapy that requires the patient to restrict fluid intake is a. impaired renal function. b. hemodialysis. c. CAPD. d. CCPD.

ANS: B When a patient is on hemodialysis, kidney function usually results in oliguria. Most patients receiving hemodialysis undergo the procedure on an every-other-day basis. Because of the inability to urinate, the patient needs to be careful not to drink excessive fluids between dialysis treatments. During impaired renal function, as long as urination is still possible, the patient can consume fluids. During peritoneal dialysis, because treatments are occurring daily, there is little risk of the patient becoming fluid overloaded. REF: p. 715

4. Which of the following describes the flow of filtrate in the kidney? a. The collecting duct to the distal convoluted tubule to the renal pelvis b. Bowman's capsule to the proximal convoluted tubule to the loop of Henle c. The loop of Henle to the collecting duct to Bowman's capsule d. The distal convoluted tubule to the loop of Henle to the collecting duct

ANS: B REF: 492

10. Under what circumstances do cells in the kidneys secrete renin? a. The urine pH decreases. b. Blood flow in the afferent arteriole decreases. c. Serum potassium levels are high. d. Serum osmotic pressure increases.

ANS: B REF: 495

6. Which statement about the bladder is TRUE? a. The bladder wall lacks rugae. b. Three openings from the urinary bladder form the trigone. c. It contracts when stimulated by the sympathetic nervous system. d. Continuous peristalsis in the bladder wall promotes urine flow.

ANS: B REF: 496

17. Which disease is manifested by dysuria and pyuria? a. Nephrotic syndrome b. Cystitis c. Glomerulonephritis d. Urolithiasis

ANS: B REF: 502

14. When a respiratory infection with high fever is present in the body, how would the kidney tubules maintain normal pH of body fluids? a. Increase the flow of filtrate. b. Secrete more acids and reabsorb more bicarbonate ions. c. Excrete a larger volume of more dilute urine. d. Retain more potassium ions in exchange for sodium ions.

ANS: B REF: 502-503

Renal disease frequently causes hypertension because: a. albuminuria increases vascular volume. b. congestion and ischemia stimulate release of renin. c. antidiuretic hormone (ADH) secretion is decreased. d. damaged tubules absorb large amounts of filtrate.

ANS: B REF: 503

Common causes of urolithiasis include all of the following EXCEPT: a. hypercalcemia. b. hyperlipidemia. c. inadequate fluid intake. d. hyperuricemia.

ANS: B REF: 506

68. Uncontrolled essential hypertension may cause chronic renal failure because of: a. predisposition to recurrent urinary tract infections. b. damage to afferent arterioles and renal ischemia. c. failure of tubules to respond to hormonal controls. d. glomerular congestion causes damaged capillaries.

ANS: B REF: 508

Which of the following is a significant indicator of renal insufficiency? a. Urine with pH of 5 b. Increased serum urea and creatinine c. Urine with high specific gravity d. Decreased blood pressure

ANS: B REF: 510

69. Urine with a low specific gravity is usually related to: a. an infection of the gallbladder. b. renal failure due to tubule damage. c. lack of sufficient fluid intake. d. presence of numerous renal calculi.

ANS: B REF: 510 | 512

55. Uremic signs of renal failure include all of the following EXCEPT: a. encephalopathy. b. high blood pressure. c. osteodystrophy. d. azotemia and acidosis.

ANS: B REF: 513

70. Excess urea and other nitrogen wastes in the blood is referred to as: a. dysuria. b. azotemia. c. bacteremia. d. hematuria.

ANS: B REF: 513

Which factor contributes to severe anemia in individuals with chronic renal failure? a. Increased erythropoietin secretion b. Limited protein intake c. Compensatory increase in bone marrow activity d. Inability to absorb vitamin B12 and iron

ANS: B REF: 513

The normal pH of urine is: a. 7.35-7.45. b. 4.5- 8.0. c. 1.5-7.5. d. 1.0-7.0.

ANS: B REF: 596-597

27. One of the first recommendations for any type of kidney stone is to a. increase the fiber in the diet. b. reduce calcium intake. c. increase fluid intake. d. decrease protein intake.

ANS: C A large fluid intake is the primary therapy that helps produce more dilute urine and prevent accumulation of materials that form stones. DIF: Cognitive Level: Knowledge REF: p. 388 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A major clinical symptom of acute kidney failure is a. hematuria. b. proteinuria. c. oliguria. d. massive edema.

ANS: C A major symptom of acute kidney failure is oliguria, which is caused when the cellular debris from the tissue damage blocks the renal tubules. DIF: Cognitive Level: Knowledge REF: p. 376 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. A progressive increase in serum urea levels occurs in a. acute renal failure. b. glomerulonephritis. c. chronic kidney failure. d. nephrotic syndrome.

ANS: C A progressive increase in serum urea levels occurs in chronic kidney failure. Increasing loss of nephron function results in elevated amounts of nitrogenous metabolites, such as urea. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. The sudden shutdown of kidney function as the result of traumatic injury is called a. nephrosis. b. glomerulonephritis. c. acute kidney failure. d. chronic kidney failure.

ANS: C Acute kidney failure results when renal function in healthy kidneys shuts down suddenly after some metabolic insult or traumatic injury, causing a life-threatening situation. This is a medical emergency. DIF: Cognitive Level: Knowledge REF: p. 376 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. Mr. Jones has chronic kidney disease. He is 55 years of age, weighs 165 lbs, and has a glomerular filtration rate (GFR) of 22 mL/min. His estimated energy needs per day are approximately a. 1125 to 2200 kcal/day. b. 1500 to 2350 kcal/day. c. 1875 to 2625 kcal/day. d. 2250 to 2850 kcal/day.

ANS: C Carbohydrate and fat must provide enough energy to spare protein and maintain body weight (BW). A GFR of 22 mL/min is consistent with stage 4 chronic kidney disease (CKD). Recommended energy intake is 25 to 35 kcal/kg of BW/day. In this case, 165 lb = 75 kg; 75 kg 25 kcal/kg/day = 1875 kcal; 75 kg 35 kcal/kg/day = 2625 kcal. DIF: Cognitive Level: Application REF: p. 379 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation | NCLEX: Health Promotion and Maintenance

9. In children with CKD, the primary goal of MNT is a. to control hypertension. b. fluid balance. c. normal growth and development. d. adherence to protein restriction.

ANS: C Cyclosporine is an immunosuppressive medication that promotes hyperkalemia, hypertension, and hyperlipidemia. Because of the potential for excessive potassium levels, planning of diets should account for potassium intake. Sodium intake need not be restricted below levels recommended by the Dietary Guidelines. To obtain protein, lean sources should be used in the diet. Adequate intake of calcium by transplant patients is necessary because of the risk of osteopenia promoted by other immunosuppressive medications. REF: p. 712

4. At least how much protein should be provided by the diet of a patient who receives hemodialysis three times per week? a. 0.6 g/kg of body weight b. 1 g/kg of body weight c. 1.2 g/kg of body weight d. 1.5 g/kg of body weight

ANS: C Dialysis processes promote protein loss, and therefore, daily protein intake needs to be increased to compensate for this. For patients on hemodialysis, the recommendation is to consume 1.2 g protein per kg of body weight. Patients using peritoneal dialysis should consume 1.2 to 1.5 g protein per kg of body weight. REF: p. 715

3. Intake of which of the following nutrients is generally NOT decreased in the nutrition therapy of patients with ESRD? a. Sodium b. Phosphorus c. Calcium d. Potassium

ANS: C Dietary calcium is usually not decreased to prevent the development of renal osteopenia. In ESRD, sodium, phosphorus, and potassium are all retained in the blood. Increases in blood phosphorus levels in relation to blood calcium levels can stimulate the release of parathyroid hormone. PTH promotes the resorption of calcium from bone to increase blood calcium levels in proportion to the phosphorus. The only time calcium may be restricted is in the case of a patient demonstrating hypercalcemia while taking calcium supplementation. REF: p. 719

31. For patients treated with dialysis, a good source of protein could be a. sherbet. b. green beans. c. a scrambled egg. d. apple crisp.

ANS: C Eggs are a high-biologic value protein for patients on dialysis. DIF: Cognitive Level: Application REF: p. 382 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

26. For patients with uric acid stones, health practitioners may recommend a diet low in a. calcium. b. vegetable protein. c. purines. d. fat.

ANS: C Excess excretion of uric acid may be caused by some impairment with the metabolism of purine, a nitrogen end product of dietary protein from which uric acid is formed. DIF: Cognitive Level: Knowledge REF: p. 388 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. The massive edema of nephrotic syndrome is caused by a. blockage in the nephron tubules. b. excessive fluid intake. c. large protein losses in the urine. d. a diet too high in sodium.

ANS: C In nephrotic syndrome, large amounts of protein pass into the tubule. The large protein loss leads to massive edema and ascites as well as proteinuria. DIF: Cognitive Level: Application REF: p. 375 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. Which of the following guidelines should be followed by a patient who has a history of kidney stones? a. Decrease fluid intake to keep urine output to less than 1 L/day. b. Decrease intake of magnesium-containing antacids. c. Increase fluid intake to maintain urinary output at or above 2 L/day. d. Use sodium bicarbonate to alkalize urine.

ANS: C Low urine volume is the most common abnormality noted with patients who develop kidney stones, and increasing fluid intake by 2 to 2.5 L/day will prevent stone formation. This helps by both increasing urine volume and decreasing renal solute load. Magnesium potassium citrate can decrease the development of renal stones. Acidity of urine contributes to stone formation. REF: p. 705

24. The method of dialysis that allows patients to be mobile is a. hemodialysis. b. renal dialysis. c. peritoneal dialysis. d. continuous dialysis.

ANS: C Peritoneal dialysis is an alternative form of treatment for dialysis that allows patients to be mobile. In this process, the patient introduces the dialysate solution directly into the peritoneal cavity 4 or 5 times a day, where it can be exchanged for fluids that contain the metabolic waste products. DIF: Cognitive Level: Knowledge REF: p. 380 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The presence of protein in the urine is called a. hematuria. b. oliguria. c. proteinuria. d. anuria.

ANS: C Proteinuria results from an abnormal excess of serum proteins in the urine. DIF: Cognitive Level: Knowledge REF: p. 375 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The bone disease osteodystrophy is associated with a. glomerulonephritis. b. acute renal failure. c. chronic renal failure. d. nephrotic syndrome.

ANS: C The disturbed metabolism of calcium and phosphate from lack of vitamin D, a process that occurs in the kidneys, leads to bone pain from osteodystrophy in patients with chronic renal failure. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation | NCLEX: Physiological Integrity: Reduction of Risk Potential

11. The primary cause of anemia that presents in chronic renal failure is a. lack of heme and nonheme iron intake. b. loss of iron through the diseased kidney. c. deficiency of the hormone erythropoietin. d. loss of blood through dialysis.

ANS: C The kidneys produce the hormone erythropoietin, which is involved in the production of red blood cells. The anemia that results in kidney failure is because of EPO deficiency. Ensuring adequate dietary intake provides adequate iron for hemoglobin formation when synthetic EPO is given to patients with renal failure. The kidneys are not the primary route of iron excretion, so their failure does not promote iron loss. Dialysis involves minimal blood loss. REF: p. 701

10. Which of the following can minimize the resorption effects of increased parathormone on bone calcium that occurs in renal disease? a. eliminating carbonated beverages to decrease phosphates b. using thiazide diuretics to eliminate calcium c. supplementing calcium early in the disease d. decreasing protein products high in phosphate

ANS: C The supplementation of calcium early in kidney disease is provided to reduce the imbalances in serum calcium and serum phosphorus levels that occur. Parathormone secretion is stimulated by increased serum phosphorus levels. PTH promotes bone resorption to elevate serum calcium levels. Calcium supplementation can help increase serum calcium levels and prevent phosphorus absorption from the gut. This is preferred over the increase of calcium-containing foods such as dairy because these foods provide calcium but also phosphorus. Carbonated beverages increase urinary acidity and contribute to calcium excretion. Thiazide diuretics cause potassium losses. REF: pp. 722-723

15. During which stage of chronic kidney disease does the National Kidney Foundation (NKF) recommend that a protein intake of 0.6 g/kg/day be initiated? a. for acute kidney injury b. when HD is started c. when the GFR falls below 25 ml/min d. protein should never be as low as 0.6 g/kg/day

ANS: C When the patient's GFR falls below 25 ml/min and she is not receiving dialysis treatment, the NKF recommends a restriction of protein of 0.9 g/kg/day. Protein intake should be increased to 1.2 g/kg/day when HD is initiated. Protein intake for AKI is variable and depends on the underlying cause. REF: p. 713

11. Which of the following should be present in the filtrate in the proximal convoluted tubule? a. Plasma proteins b. Erythrocytes c. Sodium ions d. Leukocytes

ANS: C REF: 492

The reabsorption of water and electrolytes by the kidneys is directly controlled by: 1. atrial natriuretic hormone. 2. antidiuretic hormone. 3. angiotensin. 4. the levels of bicarbonate ion. a. 2 only b. 3 only c. 1, 2 d. 2, 4

ANS: C REF: 492

1. Which of the following structures is most likely to be located in the renal medulla? a. Proximal convoluted tubule b. Glomerulus c. Loop of Henle d. Afferent arteriole

ANS: C REF: 492-493

7. Which of the following increases glomerular filtration rate? a. Increased plasma osmotic pressure b. Dilation of the efferent arteriole c. Increased hydrostatic pressure in the glomerular capillaries d. Constriction of the afferent arteriole

ANS: C REF: 495

Which pathophysiological process applies to acute post-streptococcal glomerulonephritis? a. Streptococcal infection affects both the glomerular and tubule functions b. Ischemic damage occurs in the tubules, causing obstruction and decreased glomerular filtration rate (GFR) c. Immune complexes deposit in glomerular tissue, causing inflammation d. Increased glomerular permeability for unknown reasons

ANS: C REF: 502-503

Which of the following does NOT usually result from nephrosclerosis? a. Secondary hypertension b. Chronic renal failure c. Acute renal failure d. Increased renin and aldosterone secretions

ANS: C REF: 508

Which of the following would likely cause chronic renal failure? a. Cystitis with pyelonephritis in the right kidney b. Circulatory shock c. Diabetes d. Obstruction of a ureter by a renal calculus

ANS: C REF: 510

16. Ms. Jones comes to the emergency department with a severe drug reaction to penicillin. She may be at risk for a. diabetes or heart disease. b. high sodium intake. c. protein-energy malnutrition. d. acute kidney failure.

ANS: D Acute kidney failure can result from drug reactions in allergic or sensitive persons, such as a reaction to antibiotics (such as penicillin) or antimicrobial agents. DIF: Cognitive Level: Application REF: p. 376 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The hormone that causes the kidneys to reabsorb water and decrease urine production is a. renin. b. vitamin D. c. erythropoietin. d. antidiuretic hormone.

ANS: D Antidiuretic hormone (ADH) works on the distal nephron tubule to conserve water by reabsorption. DIF: Cognitive Level: Application REF: p. 372 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

1. A reduction in which of the following parameters is the first alteration that leads to the development of chronic renal failure or end-stage renal disease? a. Blood pressure b. Left ventricular ejection c. Blood volume d. Glomerular filtration rate

ANS: D As chronic renal failure progresses, the glomerular filtration rate (GFR) decreases. The kidneys adapt to the decrease in GFR as a means of preserving function; however, in the long run, it results in an increased loss of nephrons. Blood pressure may be affected by these adaptations, but because blood pressure may be affected by heart and blood vessel function as well as water and electrolyte alterations, it is not specific to impaired kidney function. Left ventricular ejection reflects the strength and structure of the heart. Blood volume is not affected until the end stages of renal failure. REF: p. 708

17. A complication of intradialytic parenteral nutrition that is NOT commonly associated with usual PN is a. vitamin deficiency. b. hypophosphatemia. c. infection. d. hypoglycemia.

ANS: D Because intradialytic parenteral nutrition (IPN) is only provided during the several hours of dialysis treatment, abrupt cessation of parenteral nutrition could result in hypoglycemia. This happens because the continuous infusion of dextrose promotes insulin secretion. When the IPN is discontinued, insulin levels are still elevated, yet glucose infusion has stopped. To prevent this, the glucose administration should be tapered up and down during the first and last 1/2 hour of infusion. Although vitamins and trace elements are not administered in IPN, they may be provided to the patient between dialysis and IPN treatments. Hypophosphatemia is a complication that can occur in either method because of the patient's use of phosphate binders. Infection risk occurs in both as open access to the blood system is maintained whether infusion is through a peripheral fistula or central line. REF: p. 724

14. When acute kidney injury (AKI) is caused by hypertrophy of the prostate, the ARF is classified as _____ AKI. a. secondary b. prerenal c. intrinsic d. postrenal

ANS: D Benign prostatic hypertrophy is an example of postrenal acute renal failure as the cause of the AKI is obstructive in nature. Prerenal causes of AKI include dehydration and circulatory collapse that result in inadequate renal perfusion. AKI resulting from diseases within the renal parenchyma, such as glomerulonephritis, is considered to be intrinsic AKI. Most instances of AKI are secondary to some other disease or condition; however, this is not one of the classification categories. REF: p. 709

19. The classic symptoms of chronic kidney failure result from a. a diet high in sodium. b. a diet chronically low in fluid intake. c. severe trauma to the body. d. the progressive loss of nephrons.

ANS: D Chronic kidney failure, or chronic renal insufficiency, is caused by the progressive breakdown of renal tissues, which impairs all renal function. Few functioning nephrons remain, and they gradually deteriorate. DIF: Cognitive Level: Application REF: p. 378 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. Azotemia refers to elevated blood levels of a. glucose. b. cholesterol. c. amines. d. urea.

ANS: D Elevated blood levels of urea nitrogen and other nitrogenous products are reflected in the characteristic laboratory finding of azotemia. DIF: Cognitive Level: Knowledge REF: p. 378 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The "cleaning solution" used in hemodialysis is called the a. filtrate. b. plasma. c. urine. d. dialysate.

ANS: D The "cleaning solution" used in hemodialysis is called the dialysate. DIF: Cognitive Level: Knowledge REF: p. 381 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The structure responsible for filtering the blood is the a. loop of Henle. b. proximal tubule. c. distal tubule. d. glomerulus.

ANS: D The glomerulus filters the blood. Only the larger blood proteins and cells remain behind in the circulating blood as it leaves the glomerulus. DIF: Cognitive Level: Knowledge REF: p. 371 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. Which of the following is NOT a function of the kidney? a. Regulation of body fluid concentrations b. Removal of nitrogenous and acidic wastes c. Activation of vitamin D d. Production of albumin

ANS: D REF: 491

9. Which substance directly controls the reabsorption of water from the collecting ducts? a. Renin b. Aldosterone c. Angiotensin d. Antidiuretic hormone

ANS: D REF: 492

3. Which of the following describes the correct flow of blood in the kidney? a. Afferent arteriole to the peritubular capillaries to the venule b. Efferent arteriole to the glomerular capillaries to the peritubular capillaries c. Peritubular capillaries to the glomerular capillaries to the venule d. Afferent arteriole to the glomerular capillaries to the efferent arteriole

ANS: D REF: 494

Which of the following results from decreased blood flow into the kidneys? a. Decreasing blood pressure b. Dilation of the afferent arterioles c. Decreased aldosterone secretion d. Increased angiotensin and systemic vasoconstriction

ANS: D REF: 496

15. When comparing normal kidney function with dialysis, which of the following mechanisms is not possible in dialysis? a. Diffusion b. Osmosis c. Ultrafiltration d. Active transport

ANS: D REF: 500

41. Which of the following indicates the early stage of acute renal failure? a. Polyuria with urine of fixed and low specific gravity b. Hypotension and increased urine output c. Development of decompensated acidosis d. Very low GFR and increased serum urea

ANS: D REF: 510

Which of the following causes acute renal failure? a. Polycystic kidney disease b. Pyelonephritis in the right kidney c. Nephrosclerosis d. Bilateral acute glomerulonephritis

ANS: D REF: 510

What factors contribute to headache, anorexia, and lethargy with kidney disease? 1. Increased blood pressure 2. Elevated serum urea 3. Anemia 4. Acidosis a. 1 only b. 2, 4 c. 1, 3, 4 d. 1, 2, 3, 4

ANS: D REF: 513

What is the primary reason for hypocalcemia developing during end-stage renal failure or uremia? a. Decreased parathyroid hormone secretion b. Insufficient calcium in the diet c. Excessive excretion of calcium ions in the urine d. A deficit of activated vitamin D and hyperphosphatemia

ANS: D REF: 513

Sodium bicarbonate increases urinary monosodium urate and calcium and should be

AVOIDED

Vitamin important for conversion of glyoxylate to glycine:

B6

Diagnosis & Monitoring of AKI

BUN to Cr ratio can be used to diagnostically assess the location of damage to the kidney Depending on area of injury - BUN is increased because of poor filtration and is more actively reabsorbed -Greater than 20:1 - damage is prerenal (before kidney) -< 10:1 - damage is intrinsic (within the kidney)

Signs/symptoms of chronic disease Glomerulonephritis

Blood/protein in urine Swelling in ankles or face High blood pressure Frequent nighttime urination Very bubbly or foamy urine

MNT for CKD -

CKD patients routinely are recommended a water-soluble renal customized vitamin supplement, because restrictions on fruits, vegetables and dairy foods may cause the diet to be inadequate.

When patients undergo intestinal surgeries, such as ileum resection, they are at risk of ________________.

Ca oxalate stones Therefore, it is best they reduce consumption of oxalates Studyforxyz CLINICAL INTERVENTION AND MONITORING

hose who undergo dialysis will most likely require a phosphate-binding medication

Calcium carbonate, calcium acetate, sevelamer carbonate, sucroferric oxyhydroxide, ferric citrate and lanthanum carbonate Bind phosphorus and transport through the GI tract for elimination

Types of kidney stones

Calcium oxalate: most common, 60% Calcium oxalate and calcium phosphate: 10% Calcium phosphate: 10% Uric acid: 5-10% Struvite: 5-10% Cystine: 1%

Supplements for ESRD

Capsaicin - topical - can remove dialysis-induced pruritus Carnitine - 1 g TID - helps fatigue and libido and can help normalize dyslipidemia Fish oil- 6-9 g QD- monitor clotting capacity with such doses Pantetheine - 300-400 mg TID Vitamin E - 600 mg QD - offsets LDL cholesterol oxidation from dialysis Iron - information for IV/IM dosing given above (avoid if multiple transfusions (can have iron overload) Pyridoxine - 200 mg QD-BID Biotin - 1-10 mg QD Folate - 5 mg QD Vitamin B12 - 1-3 mg QD- helps to control hyperhomocysteinemia

Kidney Stones (nephrolithiasis) - How are they characterized? What does it consist of? Which are most common? What is a major risk factor?

Characterized by frequent occurrences during the 4th and 5th decade of life and a high recurrence rate Consists of saturation; supersaturation; nucleation; crystal growth or aggregation; crystal retention; and stone formation in presence of promoters, inhibitors, and complexors in urine Calcium stones most common (calcium oxalate - 60%) & calcium oxalate and calcium phosphate (10%) & 10% calcium phosphate; other stones 5-10% uric acids, struvite & 1% cystine Risks: -Doubles w/family history of stones -Obesity, diabetes, and metabolic syndrome increases risk

GFR decreases - serum Ca also decreases for several reasons

Decreased ability for kidneys to convert Vit D to the active form - leads to poor absorption of Ca Need for serum Ca increases as serum phosphate levels increase both lead to hypertrophy of the parathyroid gland - responsible for Ca homeostasis over secretion of PTH leads to increases resorption of bone to provide a Ca source

Potassium recommendations in ESRD

Depends on serum level, urine output, medications, and frequency of hemodialysis -60-80 mEq (2.3-3.1g) per day for ESRD -51 mEq (2g) per day for anuric patient on dialysis Patients with high-flux dialysis, or increased dialysis times require higher intakes Point out that some low-sodium foods contain potassium chloride as a salt substitute

Affected populations of AKI

Diabetics

ESRD options for treatment:

Dialysis Transplantation Medical management progressing to death

In ESRD, iron needs are increased because of ____ therapy

EPO (erythropoietin)

All about dialysis - What are the options? What are some deciding factors?

Either in outpatient facility or with hemodialysis (HD) at home using either conventional daily or nocturnal dialysis -can choose peritoneal dialysis (PD) with a choice of either: continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD -formerly called continuous cyclic peritoneal dialysis or CCPD) *factors: availability of family/friends to assist w/therapy, type of water supply at home, capability to perform sterile tech, previous abdominal surgeries, body size, cardiac status, ability to create a vascular access, desire to travel, etc

Energy for CKD:

Energy: ~35kcal/kg/day to spare protein for tissue repair and maintenance

__________ name implies traditional use for urinary stones ("gravel"); mildly astringent, stimulant, and tonic with specific action on urinary organs and power to dissolve concretions

Eupatorium purpureum (gravel root):

Why does serum calcium decline as GFR declines?

First, decreased ability of the kidney to convert to inactive vitamin D to its active form, 1,25-(OH)2D3 leads to poor GI ab- sorption of calcium. Second, the need for serum calcium increases as serum phosphate levels increase. Both of these causes lead to hypertrophy of the parathyroid gland, which is responsible for calcium homeostasis. The resultant oversecretion of PTH increases resorption of bone to provide a calcium source. *this will cause pain known as osteitis fibrosis cystica

What nutrient is lost the most in dialysis?

Folate Studyforxyz CLINICAL INTERVENTION AND MONITORING

Kidney transplant MNT: Before and After recovery

For 1st 6 weeks after: high protein (1.2-1.5 g/kg IBW) Energy: 30-35 kcal/kg IBW Sodium restriction: 2-3g/day Fluid: 2L per day After recovery: Protein 1 g/kg IBW Energy: weight maintenance low-fat diet aids in lowering cardiac complications, and sodium intakes are individualized based on fluid retention and blood pressure

Associated disorders of CKD

Half-and-half nails (Linday's nails) - part of the nail closest to the hand is white and the half closest to the fingertip is pink or brown Muehrcke's lines (with hypoalbuminemia)- white arcuate lines (across the nail horizontally) Mee's lines (longitudinal white streaks from the cuticle to the nail edge) Protein deficiency is common Edema Hypoalbuminemia Hyperlipidemia CKD increases the risk category for CVD and exacerbates any existing CVD Growth in children with CKD is usually delayed

Tests for urolithiasis

History - family history, passage, onset, frequency Medical history- hyperparathyroidism, renal tubular acidosis, UTI, sarcoidosis, hypertension, osteoporosis, IBD, metabolic syndrome, diabetes, obesity Blood work- serum Ca, P, Creatinine, Uric acid, CO2, albumin, parathyroid hormone, HgbA1C Urinaylsis 24 hour urine collection Medications and vitamins- allopurinol, Vit C, B6, vit D, cod liver oil, calcium carbonate, glucoocorticoid therapy, potassium citrate, antacids Occupational history and strenuous exrercise Environment Dietary evalulation- intake of Ca, oxalate, animal protein, salt, purines, fructose, potassium, fruits and veggies (related to urine pH_, herbal products, volume of fluid intake Types of fluids

associated disorders of uric acid stones

IBD, lymphoproliferative/myeloproliferative disorders, diabetes, obesity, hypertension related to uric acid stones

_________________familiar disorder characterized by abnormal serum calcium in the absence of causes

Idiopathic hypercalciuria Known causes of hypercalciuria: primary hyperparathyroidism, sarcoidosis, excess vit D intake, hyperthyroidism, glucocorticoid use, renal tubular acidosis

Causes of AKI

Inadequate renal perfusion - prerenal Diseases within the renal parenchyma - intrinsic Urinary tract obstruction - postrenal Diseases/conditions that cause decreased blood flow Diabetes Direct damage to kidneys Blockage of the urinary tract An in-hospital complication of sepsis, heart conditions, surgery Associated Disorders Chronic kidney disease Diabetes hypertension

MNT kidney stones Fluid goal: What liquids may benefit certain stones?

Increase urine flow rate -2-2.5L/day should prevent stone reoccurence (req intake of 250mL of fluid at each meal, between meals, at bedtimes, and when arising) *cranberry juice acidifies urine and is successful in treatment of struvite stones *black currant juice increases urinary citrate and oxalate (alkalinizing effect) and may prevent occurrence of uric acid stones -tea, coffee, (diuresis) decaffeinate coffee, orange juice (alkali load), beer, and wine (diuresis) is associated w/decreased risk of stone formation

_____________ (at least eight glasses of water per day) can assist in removing small stones quickly from the urinary tract

Increasing fluid intake -Stones usually cause manifestations only when they obstruct flow of urine (e.g., in the ureter) -Calculi may lead to infection because they cause stasis of urine in the area and irritate the tissues; this may be an early indication of calculi formation

Glomerulonephritis

Inflammation of the tiny filters in your kidneys (glomeruli) Remove excess fluid, electrolytes, and waste from blood stream - pass them to urine Sudden (acute), or gradual (chronic)

Protein for AKI

Influenced by underlying cause; range from 05.-0.8kg/kg for nondialysis pt to 1-2g/kg for pt receiving hemodialysis; w/CRRT protein losses are high and estimated protein needs increase to 1.5-2.5g/kg

what is the most devastating intrinsic AKI?

Ischemic acute tubular necrosis. Patients with AKI caused by drug toxicity generally recover fully after they stop taking the drug. On the other hand, the mortality rate associated with ischemic acute tubular necrosis caused by shock is approximately 70%

Nephrotic syndrome is a kidney disorder that causes the body to excrete too much protein the body. Name the diseases it can occur from.

It can occur from SLE, diabetes mellitus, and amyloidosis, but not diabetes insipidus Studyforxyz CLINICAL INTERVENTION AND MONITORING

What is nephritic syndrome?

It incorporates a group of diseases characterized by inflammation of the capillary of the glomerulus *these acute glomerulonephritides are sudden in onset and brief and may proceed to complete recovery, development of chronic nephritic syndrome, or ESRD *primary manifestations: hematuria (a consequence of capillary inflammation that damages the glomerular barrier to blood cells) ALSO characterized by hypertension and mild loss of renal function other causes: primary kidney diseases (IgA nephritis, and secondary diseases-systemic lupus erythematosus (SLE), vascultis, and glomerulo-nephritis (GN) associated w/endocarditis, abscessess, or infected ventriculoperitoneal shunts

Intradialytic PN (IDPN)

It is administered typically through a connection to the venous side of the extracorporeal circuit during dialysis. Because of the high blood flow rate achieved through use of the surgically created fistula and the high blood pump speeds that are attained, hypertonic glucose and protein can be administered without danger of phlebitis

Recombinant EPO

Laboratory-derived EPO as distinct from that which is naturally produced by the kidneys

Risk Factors & Causes of CKD

Leading cause - diabetes Second leading cause - hypertension Third leading cause - glomerulonephritis (inflammation of the filters within the kidney) -increased intake of high-sugar -high-fat dairy products - correlates with increased fasting insulin, C-peptide, leptin, C-reactive protein, and increases the risk of CKD -Heavy metals associated with kidney damage and disease -Interstitial nephritis - inflammation of kidney's tubules and surround structures -Polycystic kidney disease -Prolonged obstruction of the urinary tract - enlarged prostate, kidney stones, some cancers -Vesicoureteral reflux - condition that causes urine to backup into kidneys -Recurrent kidney infection - pyelonephritis Risk factors: heart and blood vessel disease, smoking, obesity, being African-American, Native America, or ---Asian American, family history, abnormal kidney structure, older age

Typical diet recommendations for hemodialysis: *The diet should allow for less than 4% fluid weight gain between dialyses.

Limit dairy products to one serving per day Limit fruits, vegetables, and juices to six servings per day. Limit sodium to 2,000-3,000 mg per day. Avoid all convenience foods; no salt in cooking Limit water and other fluids as needed to prevent fluid gains of more than 2.0 kg (4.5 lb) between treatments. Do not limit fluid if sodium is not restricted.

The _______ (LAKE) score can be a simple and useful tool to evaluate dietary PRAL (potential renal acid load)

Load of acid to kidney evaluation -fruits, juices, veggies, potatoes, and legumes have negative effects on PRAL values

______________ is the single most important risk factor for all types of nephrolithiasis

Low urine volume

Herbs/Supplements:

Magnesium: deficiency linked to stone formation Vitamin B6: reduces endogenous production and urinary excretion of oxalates Glutamic acid: deficiency linked to kidney stones Calcium (taken with food, binds to oxalate and prevents its absorption): supplementation can decrease or increase risk of stone formation (mixed) Citrate (calcium, potassium, and/or magnesium citrate): low urinary citrate is a risk factor for kidney stones Vitamin K: urinary glycoprotein inhibitor of calcium oxalate monohydrate growth requires post transcription of carboxylation of glutamic acid (vit K essential for this carboxylation) Folic acid (uric acid stones) Cranberry juice (struvite stones) Omega-3s: may decrease arachidonic acid content of cell membranes and reduce urinary excretion of calcium and oxalate Furanocoumarin-containing herb Ammi visnaga (khella) is effective at relaxing the ureter and allowing stone to pass

What is the main function of the kidney? How is it accomplished? How many L does the kidney filter?

Maintain balance of fluids, electrolytes, and organic solutes -accomplished by continuous filtration of blood w/alterations in secretion and reabsorption of this filtered fluid *filters approx 1600L/day pf blood and producing 180L of ultrafluid -1.5L of urine is excreted/day

What are some of the consequences of transplants?

May increase breakdown of protein, cause hyperlipidemia, sodium retention, weight gain, elevated blood glucose, osteoporosis, and electrolyte disturbances

Energy in AKI

Measured by bedside indirect calorimetry; if not available, estimation at 25-40cal/kg of upper end IBW or adjusted IBW/day -large intakes of carb and fat are needed to prevent use of protein for energy production

Signs/symptoms of CKD

Nausea, vomiting, loss of appetite, fatigue & weakness, sleep problems, changes in how much you urinate, decreased mental sharpness, muscle twitches and cramps, swelling of feet and ankles, persistent itching, chest pain - if fluid builds up around the lining of the heart, shortness or breath - fluid in the lungs, high blood pressure that is difficult to control

_____________ is a kidney disorder that causes the body to excrete too much protein in the urine. Some of the causes include amyloidosis ,systemic lupus erythematosus and diabetes mellitus

Nephrotic syndrome Studyforxyz CLINICAL INTERVENTION AND MONITORING

What nutrient can help lower phosphate?.

Niacin It interferes with Na- Phosphate pump and causes decreased transport of phosphate Studyforxyz CLINICAL INTERVENTION AND MONITORING

Herbs/Supplements for ESRD

Omega-3 fatty acids and L-carnitine may be used to reduce the circulating triglyceride concentrations 1200-1600 mg/day of elemental calcium due to inadequate intake with diets low in protein and phosphorus, as well as typically poor GI absorption of those with uremia Supplementation with trace elements may be necessary for those on dialysis as it can remove trace elements Potassium - usually requires restriction Phosphorus - more than 99% of excess is excreted in urine

in renal function impairment, what mineral should be monitored?

POTASSIUM. Hemodialysis helps control hyperkalemia Studyforxyz CLINICAL INTERVENTION AND MONITORING

________________ value is used to describe a food's effect on acid load

PRAL (potential renal acid load) Studyforxyz CLINICAL INTERVENTION AND MONITORING

Calcium regulation summary: When serum Calcium is low, the _______ gland releases ______________ which signals bone, kidney and small intestine to break down stored calcium to increase calcium absorption. When serum Calcium levels are high, _____________ is released to store the calcium in the bones

PT gland, PTH, calcitonin Studyforxyz CLINICAL INTERVENTION AND MONITORING

Calcium-phosphorus homeostasis involves: - Hormones? Effector organs?

PTH; calcitonin; active vit D; and 3 effector organs: kidney, gut, & bone

__________ has been used as the first line of treatment for uric acid stones

Potassium citrate

Potassium For AKI

Potassium intake must be individualized according to serum levels -control of serum levels between dialysis administrations relies mainly on IV infusions of glucose, insulin, and bicarbonate (drive potassium into cells

MNT for CKD - Primary objectives:

Primary objectives: 1. manage symptoms associated w/syndromes (edema, hypoalbuminemia, & hyperlipidemia), 2. Decrease the risk of progression to renal failure 3. decrease inflammation, and maintain nutritional scores -diet should attempt to provide sufficent protein and energy to maintain a positive nitrogen balalnce and support tissue synthsis while not overtaxing kidneys -suff intake from carb and fat needed to spare protein for anabolism

MNT for AKI

Protein 0.5-0.8g/kg for non-dialysis patients 1-2g/kg for dialysis patients Energy- indirect calorimetry No indirect calorimetry - estimate 25-40 kcal/kg/day of upper end of Ideal Body Weight (IBW) Excess calorie intake can lead to excess CO2 production, depressing respiration Large intakes of carbs and fat are needed to prevent the use of protein for energy production Potassium 30-50mEq/day Sodium 20-40 meEq/day Fluid- replace output from previous day plus 500mL Phosphorus- limit as necessary

MNT recommendations for CKD

Protein 0.6-0.8 g/kg/day calories- 35 kcal/kg/day Sodium 2-3g/day Potassium-restrictions in those with urine output <1L/day (Stage 4) Phosphate binders <1000mg per day Lipid lowering meds when needed Water soluble renal customized vitamin supplement Pharmacologic Treatment(s) Sodium bicarbonate, blood pressure medicines (ACE inhibitors, angiotensin II receptor blockers (ARBs)), diuretics ACEs and ARBs work poorly when not in the setting of a low sodium diet Medications to lower cholesterol, treat anemia, relieve swelling, protect bones Drug/Herb/Supplement Interacts Recommended to not use statins in CKS - do not improve cardiovascular outcomes despite lowering cholesterol

Nutrient recommendations for ESRD

Protein- 1.2g/kg/day (due to dialysis) Energy 25-40 kcal/kg bodyweight Fluid- restricted to 750mL/day Sodium 2-3g/day Potassium 2.3-3.1g per day Phosphorus- <1200mg/day Lipid lowering medications Iron-recombinant EPO Vitamins-supplement to counterbalance losses in dialysis (B vitamins and vitamin C) and as a result of potassium and phosphorus-restricted diet -Folate 1 mg/d

Protein in CKD:

Protein: -0.8g/kg/day *50-60% of protein should be sources of high biologic value (HBV) -easy to digest -pt whose GFR is <25ml/min and who have not yet begun dialysis = 0.6g/kg/day or protein & 35kcal/kg/day (if improper caloric intake, should be increased to 0.7g w/both at 50% from HBV) *blood glucose control is more important than protein restriction in hypertensive/diabetic pt. for delaying onset of renal failure

Protein requirements for CKD

Provide enough protein and energy to maintain a positive nitrogen balance and support tissue synthesis while not overtaxing the kidneys Sufficient intake of carbs and fats to spare protein from anabolism With a diagnosis of nephrotic syndrome - excess protein can cause more protein to spill into the urine and further damages the kidneys Protein intake of 0.8g/kg/day may decrease proteinuria without adversely affecting serum albumin National Institute of Diabetes and Digestive Kidney Disease (NIDDKD) 0.8g/kg/day with 60% high biologic value with GFR > 55mL/min 0.6g/kg/day with 60% high biologic value with GFR 25-55mL/min National Kidney Foundation Patients with GFR < 25mL/min and not yet on dialysis maintain 0.6g/kg/day of protein and 35 kcal/kg/day If they cannot maintain adequate caloric intake their protein intake should be increased to 0.75g/kg/day

Signs/symptoms of acute disease Glomerulonephritis

Puffiness of your face Blood in the urine (brown urine) Urinating less than usual

Foods associated with uric acid stones

Purines and metabolism of sulfur-rich amino acids, cystine, and methionine in animal protein confer an acid load to the kidney, thus lowering the pH Dietary factors that increase purines including fructose, excess animal protein, and alcohol should be minimized

Dosing abbreviations

QD - once per day BID - 2 times per day TID - 3 times per day QID - 4 times per day

MNT for ESRD

Require 35 kcal/kg/day -Elderly and obese have somewhat lower energy needs -Restriction of protein intake to 0.6g/kg daily may delay the need for dialysis -Replacing some protein with the alpha- keto-analogues of essential amino acids may aid in the preservation of body nitrogen stores when low total protein intake is necessary -Hemodialysis - 1.1-1.3g/kg of protein daily - at least 50% of high biological value -Less than 30% of total calories from fat, less than 20% from saturated fat, and lest than 300mg/day of cholesterol Phosphorus restriction and oral phosphate binders recommended when the glomerular filtration rate decreases to very low levels Daily intake of sodium <3g Daily intake of water 1200-2000mL Potassium consumption should not exceed 60-70 mEq/day

Foods to avoid for low-oxalate

Rhubarb Spinach Strawberries Chocolate Wheat bran and whole-grain wheat products Nuts (almonds, peanuts, or pecans) Beets Tea (green, black, iced, or instant) High doses of turmeric

urolithiasis is higher in malabsorptive bariatric procedures such as ________ bc of increased prevalence of hyperoxaluria and hypercitaturia in RYGB pt. -

Roux-en-Y

Obese stone formers excrete increased amounts of? What happens with increasing body weight? What decreases in excretion? What types of stones increas with BMI?

Sodium, calcium, uric acid, and citrate and have a lower urinary pH Excretion of calcium, oxalate, and uric acid increases with increased body weight Decrease in ammonia excretion and impaired hydrogen ion buffering Uric stone become more dominant than calcium oxalate stones

____________: pain comes in part from spasm in ureters;

Spasmolytic herbs spasmolytic herbs control ureteral spasm, whereas diuretic herbs push small stones through ureters slowly and tolerably

Medical Nutrition Therapy (Dietary & Lifestyle) for CKD

Specific nutritional measures may be undertaken to prevent or delay development of protein and energy malnutrition, uremic toxicity, and alterations in mineral and vitamin metabolism Aim to manage symptoms: Edema, hypoalbuminemia, hyperlipidemia, metabolic acidosis Decrease risk of progression to renal failure and maintain nutritional stores Decrease inflammation Many patients with CKD will be on statins, diuretics, and low sodium diets

5 stages of renal disease according to the National Kidney Foundation - related to estimated glomerular filtration rate (eGFR)

Stage 1 - kidney damage with normal function (estimated GFR ≥ 90 mL/min) and persistent ≥ 3-month proteinuria Stage 2 - kidney damage with mild loss of function (eGFR 60-89 mL/min), persistent ≥ 3-month proteinuria Stage 3 - mild-to-severe loss of kidney function (eGFR 30-59 mL/min) Stage 4 - severe loss of kidney function (eGFR 15-29 mL/min) Stage 5 - kidney failure requiring dialysis or transplantation for survival - aka End Stage Renal Disease (ESRD)

Composed of magnesium ammonium phosphate and carbonate apatite Also known as triple-phosphate or infection stones

Struvite stones

Pathophysiology of acute kidney injury (AKI)

Sudden and temporary loss of kidney function Sudden reduction in glomerular filtration rate (GFR), the amount of filtrate per unit in the nephrons and altered ability of the kidney to excrete the daily production of metabolic waste Can occur in association with oliguria - decreased output of urine, or normal urine flow Typically occurs in previously healthy kidneys Duration - a few days to several weeks

Approximately half of the purine load is from endogenous sources and is constant The other half comes from exogenous dietary sources True or False

True

Ingestion of vegetables and fruit high in citrate and malate (melons, limes, oranges, fresh tomato juice) may help alkalize urine True or False

True

True or False As GFR decreases, phosphorus is retained in the plasma

True

True or False Calculi (stones) can develop anywhere in the urinary tract

True

True or False Serum ferritin - an accurate indicator of iron status in renal failure - anemia of chronic renal disease is common

True

True or False Uric acid stones are the only stones amenable to dissolution therapy by urine alkalization (pH of 6-5.6)

True

True or False because Ca is bound to albumin in the blood, Ca will appear low when albumin is low

True

True or False Albumin - not recommended to be used as an indicator of protein - more predictive of survival than nutritional status

True

True or false Decreased calcium intake is NOT recommended, chronic prolonged restriction decrease bone mineral density (BMD)

True

T/F calcium supplements do NOT have same protective effect against stone formation as dietary calcium

True Increases urinary calcium & citrate but decreases urinary oxalate, thus increase in citrate and decrease in oxalate counter-balance effects of elevate urinary calcium (IF needed they SHOULD BE TAKEN AT MEALS) Urinary calcium should be measured before starting the supp and afterward to see effect

T/F. DHA and EPA may reduce urinary excretion of calcium and oxalate.

True, The intake of omega-3 fatty acids such as EPA and DHA may decrease the AA content of cell membranes and reduce urinary excretion of calcium and oxalate.

Associated Disorders poststreptococcal glomerulonephritis (APSGN)

Type III Hypersensitivity Increased blood pressure Edema Proteinuria Oliguria Hematuria Chronic glomerulonephritis End-stage renal disease or uremia - in about 10% of adult case

____________ is an end product of purine metabolism from food, de novo synthesis (synthesis of complex molecules from simple molecules such as sugars or amino acids, as opposed to recycling after partial degradation), and tissue catabolism

Uric acid

Dietary advice for oxalate:

Use of OF probiotic & reduction of dietary oxalate and simultaneous consumption of calcium-rich food or supp to reduce oxalate absorption

Symptoms of kidney stones

Usually asymptomatic Diagnosed adventitiously or by acute symptoms of urinary tract Excruciating intermittent radiating pain to groin area originating in flank or kidney Nausea, vomiting, abdominal distention Chills, fever, and urinary frequency if infection is present

Dialysis vitamin recommendations:

Vitamin C 60 mg <200 Folic acid 1 mg Thiamin 1.5 mg Riboflavin 1.7 mg Niacin 20 mg Vitamin B6 10 mg Vitamin B12 6 mcg Pantothenic acid 10 mg Biotin 0.3 mg

pyelonephritis -

a bacterial infection of the kidney, does not req extensive dietary management -in chronic cases, use of cranberry juice to reduce bacteriuria may be useful -conc tannins or proanthocyanidins in cranberry juice and blueberry juice may inhibit the adherence of E.coli to epithelial cells of urinary tract

uremia -

a clinical syndrome of malaise, weakness, nausea, and vomiting, muscle cramps, itching, metallic taste in mouth, and neurological impairment that is brought about by an unacceptable level of nitrogenous wastes in the body

(kidney also produced) eryhropoietin (EPO) - What does def cause?

a critical determinant of erythoid activity in the bone marrow -def in EPO is primary cause of severy anemia in chronic renal disease

Renal tubular acidosis (RTA) -

a defect in tubular handling of bicarbonate that can be caused by either a defect in the distal tubule (type 1) or a proximal tubular defect (type 2) *distal = severe osteomalacia, kidney stones, or even nephrocalcionosis; teated w/small amounts of bicarbonate (70-100mEq/day w/complete resolution of disease manifestations) -isolate proximal RTA is a benign disease made worse by bicarbonate and should NOT be treated

idopathic hypercalciuria (IH) - Define Do they form kidney stones often?

a familial disorder characterized by abnormal serum calcium in the absence of known causes of hypercalciuria such as primary hyperparathyroidism, sarcoidosis, excess Vit D intake, hyperthyroidism, glucocorticoid use, or renal tubular acidosis (RTA) *90% never form a kidney stone; more sensitive to forming stones; formation may be triggered by excessive calcium intake, increased intestinal absorption of calcium that may/may not by vitamin-D mediated, increased renal tubular re-absorption of calcium, or prolonged bed rest -tend toward negative phosphorus balance even on normal intakes -low calcium diets = bone loss

Renin-angiotensin mechanism -

a major control of blood pressure *decreased blood volume causes cells of glomerulus to react by secreting renin (proteolytic enzyme) that acts on angiotensinogen in plasma to form angiotensin I, which is converted to angiotensin II (a powerful vasoconstrictor and potent stimulus of aldosterone secretion by the adrenal gland *sodium and fluid and reabsorbed & blood prssure is returned to normal

kinetic modeling -

a method for evaluating the efficacy of dialysis that measures the removal of urea from the patient's blood over a given period

Cystine stones

a rare cause of kidney stones that occur seen in children. They are related to cystinuria. Contributed to acidic ph urine Treatment is hydration and alkalinization of the urine. They may *also form staghorn calculi.*