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DIABETIC NEPHROPATHY
INTRODUCTIONHypertension, is the medical term for high blood pressure. Hypertension, on its own, is
the second most common cause of end-stage renal failure, next to diabetes. It is common
for all types of chronic kidney disease to eventually cause hypertension (approx. 80% of
chronic kidney disease patients develop hypertension at some point). The reason for this
is two-fold. With reduced kidney function, there may be a certain amount of clinical and
sub-clinical fluid retention in the body, due to poor elimination of fluids and poor control
of sodium. Perhaps more importantly, the kidneys are a major component in the body's
regulation of blood pressure. As such, the kidneys have their own ability to raise blood
pressure via release of a hormone called renin. Release of renin triggers a cascade of
events all over the body which eventually cause constriction of the blood vessels
(vasoconstriction). This cascade of events is called the renin-angiotensin-system, or RAS
for short. When the kidneys sense that the glomeruli (the actual filters in the kidneys) are
not getting the blood perfusion that they need (this means good, adequate blood flow
within the glomeruli), they cause release of more renin, and blood pressure is eventually
raised throughout the body. Since chronic kidney disease does affect blood perfusion
within the glomeruli, chronic kidney disease is almost always accompanied by
hypertension to some extent, even if there is no fluid retention. Some high blood pressure
medications work by inhibiting the renin-angiotensin-system specifically, and these are
therefore most effective in the context of chronic kidney disease.
Causes, incidence, and risk factors
Chronic kidney disease (CKD) slowly gets worse over time. In the early stages, there
may be no symptoms. The loss of function usually takes months or years to occur. It may
be so slow that symptoms do not occur until kidney function is less than one-tenth of
normal.
The final stage of chronic kidney disease is called end-stage renal disease (ESRD). The
kidneys no longer function and the patient needs dialysis or a kidney transplant.
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Chronic kidney disease and ESRD affect more than 2 out of every 1,000 people in the
United States.
Diabetes and high blood pressure are the two most common causes and account for most
cases.
Many other diseases and conditions can damage the kidneys, including:
Problems with the arteries leading to or inside the kidneys
Birth defects of the kidneys (such as polycystic kidney disease)
Some pain medications and other drugs
Certain toxic chemicals
Autoimmune disorder
Injury or trauma
Glomerulonephritis
Kidney stones and infection
Reflux nephropathy (in which the kidneys are damaged by the
backward flow of urine into the kidneys)
Other kidney diseases
Chronic kidney disease leads to a buildup of fluid and waste products in the body. This
condition affects most body systems and functions, including red blood cell production,
blood pressure control, and vitamin D and bone health.
Symptoms
The early symptoms of chronic kidney disease often occur with other illnesses, as well.
These symptoms may be the only signs of kidney disease until the condition is more
advanced.
Symptoms may include:
General ill feeling and fatigue
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Generalized itching (pruritus) and dry skin
Headaches
Weight loss without trying to lose weight
Appetite loss
Nausea
Other symptoms that may develop, especially when kidney function has worsened:
Abnormally dark or light skin
Bone pain
Brain and nervous system symptoms
Drowsiness and confusion
Problems concentrating or thinking
Numbness in the hands, feet, or other areas
Muscle twitching or cramps
Breath odor
Easy bruising,bleeding, or blood in the stool
Excessive thirst
Frequent hiccups
Menstrual periods stop (amenorrhea)
Sleep problems, such as insomnia, restless leg syndrome,
and obstructive sleep apnea
Swelling of the feet and hands (edema)
Vomiting, typically in the morning
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Treatment
Controlling blood pressure is the key to delaying further kidney damage.
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARBs) are used most often.
The goal is to keep blood pressure at or below 130/80 mmHg
Other tips for protecting the kdineys and preventing heart disease and stroke:
Smoking restriction.
Consumption of meals that are low in saturated fat and cholesterol
Regular exercise
Drugs to lower your cholesterol, if necessary.
Keeping blood sugar under control.
Other treatments may include:
Special medicines called phosphate binders, to help prevent
phosphorous levels from becoming too high
Treatment for anemia, such as extra iron in the diet, iron pills, special
shots of a medicine called erythropoietin, and blood transfusions
Extra calcium and vitamin D (always talk to your doctor before taking)
Fluid restriction.
Restriction of salt,potassium, phosphorous, and other electrolytes.
When loss of kidney function becomes more severe, dialysis or kidney transplants
become the potential options
Dialysis depends on different factors, including lab test results, severity
of symptoms, and readiness.
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Expectations (prognosis)
Many people are not diagnosed with chronic kidney disease until they have lost much of
their kidney function.There is no cure for chronic kidney disease. Untreated, it usually
progresses to end-stage renal disease. Lifelong treatment may control the symptoms of
chronic kidney disease.
Complications
Anemia
Bleeding from the stomach or intestines
Bone, joint, and muscle pain
Changes in blood sugar
Damage to nerves of the legs and arms (peripheral neuropathy)
Dementia
Fluid buildup around the lungs (pleural effusion)
Heart and blood vessel complications
Congestive heart failure
Coronary artery disease
High blood pressure
Pericarditis
Stroke
High phosphorous levels
Highpotassium levels
Hyperparathyroidism
Increased risk of infections
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Liver damage or failure
Malnutrition
Miscarriages and infertility
Seizures
Weakening of the bones and increased risk of fractures
Prevention
Treating the condition that is causing the problem may help prevent or delay chronic
kidney disease. People who have diabetes should control their blood sugar andblood
pressure levels and should not smoke
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CASE SCENARIO
Ab a 22 year old college student presented to the emergency room with headaches and
shortness of breath. On examination he had a blood pressure of 200/120 mmHg.Ab reports that over the past year his weight has increased about 5 kilos although his diet
has remained unchanged. He attributed this weight gain to decrease exercise and a busy
class schedule.
Past medical history
Ab has had no recent viral illness sore throat or occurred respiratory infection. He has no
family history of renal disease. He is not taking any medications and has no drug or food
allergies.
Social history:He shares a dormitory room with a fellow student who is in good health.
He does not consume alcohol and dose not smoke.
Review of systems
General: fatigue, weakness, shortness of breath
Vital signs: temperature, pulse rate are normal except for blood pressure as recorded.
Anthropometry:
Height: 0 5 ft 9
Current weight: 77.3 kgs
Usual weight: 70.5 kgs
Extremities: peripheral edema on both legs, abdomen no hepatomegaly, general well
developed male
Biochemical investigation
Biochemical parameters Actual value Reference range
Chloride 111meq/L
Heamoglobin 8.3g/dl 13 16 g/dlBUN 30 mg/dl 8.0-23.0 mg/dl
Creatinine 2 mg/dl 0.8-1.6 mg/dl
Sodium 158 mmol/l 134-145 mmol/l
Potassium 6 mmol/l 3.5-5.2 mmol/l
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Urine output 200 ml/day
NUTRITION CARE PLAN
PRINCIPLE/NUTRITION CARE GOALSDiabetic Nephropathy can be managed by adopting the following principles:
To achieve:
Regular meal timings.
Incorporation of fiber rich food over refined food and unsaturated fats over
saturated fats
Low salt/low sodium and potassium intake
Fluid restriction
Different ways in which the client can abide by the low sodium and low
potassium intake.
Concept and importance of leeching and the foods that have to be subjected to
leeching.
A change in lifestyle
PATIENT PROFILEName: AB
Age: 22 years
Gender: Male
Lifestyle: Sedentary physical activity
Socio economic status: Middle Income Group
Food Habit : Not specified
ANTHROPOMETRY
Height: 5 ft 9
Current weight: 77.3 kg
Usual weight: 70.5 kg
BMI: 23.8
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Interpretation: The calculated Body Mass Index for Mr. AB was found to be 23.8.
This explains that the BMI lied in the normal range (i.e between 18 -24.9)
which indicates that the weight of Mr. AB was under control and the diet
planned should emphasize on diabetes management in combination with
sodium, potassium and fluid restriction.
BIOCHEMICAL ASSESSMENT
Biochemical parameters Actual value Reference range
Chloride 111meq/L 95 105 meq/L
Heamoglobin 8.3g/dl 13 16 g/dl
BUN 30 mg/dl 8.0-23.0 mg/dl
Creatinine 2 mg/dl 0.8-1.6 mg/dl
Sodium 158 mmol/l 134-145 mmol/l
Potassium 6 mmol/l 3.5-5.2 mmol/l
Urine output 200 ml/day 800 2000 ml/day
Interpretation:
The elevated levels of BUN in blood indicate renal failure.
The level of Creatinine is also elevated indicating possible malfunction or
failure of the kidneys.
Sodium values are elevated, elevated sodium values increase hypertension
which in turn worsens the functioning of kidney.
Decrreased urine output indicated oliguria due to kidney malfunction
Shows higher concentration of sodium, potassium and chloride /electroytes
due to kidneys inability to excrete them.
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NUTRIENT RECOMMENDATIONSNUTRIENT RDA PRINCIPLE OF
MODIFICATION
MODIFIED RDA
Energy 2320 kcal 35 kca/kg IBW 2537.5kcal
Protein 60g 1.2g /kg IBW 87 g
Fat 25 g 25g 25 g
DISTRIBUTION OF ENERGY
NUTRIENT PERCENTAGE IN KCAL IN GRAMS
Carbohydrates 60 % - 70 % 1522.50 -1776.25 380.6 444.06
Protein 12% 304.50 76.12
Fat 10 % -15 % 253.75 380.62 28.19 - 42.29
EXCHANGE PLAN
Food Group Exchange Amount
(g)
Energy
(kcal)
Protein
(g)
Fat
(g)
Cereals 10 300 1000 30.0 8.0
Pulses 5 150 500 30.0 2.8
Milk 3 300 210 9.0 9.0
Roots and
Tubers
2 200 160 2.6 -
Green Leafy
Vegetables
1 100 46 3.6 0.4
Other
vegetables
2 200 56 3.4 0.4
Fruits 2 200 80 - -
Sugar 3 15 60 - -
Fats and oils 4 20 340 - 20TOTAL 2452.0 78.6 40.6
SKELETAL MENU
Early Morning (6:30 a.m) 1 glass milk
Breakfast (8:30 a.m) 3 gobi paranthas with curds and 1 apple
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Mid Morning (11:00 a.m) 1 aloo mehti sandwich
Lunch (2:30 p.m) 1 bowl of rajma salad, 1 bowl of steamed rice with mixed pulse curry
With ladies finger sabji
Evening (5:00 p.m) 1 bowl of upma and 1 bowl of papaya
Pre Dinner (6:30 p.m) 1 bowl of cucumber salad
Dinner (8:00 p.m) 1 bowl of amaranth khichdi
Bed Time(10:30 p.m) 1 glass of skimmed milk
DETAILED CALCULATIONS
Meal/
Time
Menu Ing Ex Amt
(g)
E
(kcal)
P
(g)
F
(g)
Na
(mg)
K
(mg)
Phos.
(mg)
Early
Morning
(6:30 a.m)
Milk 1 100 67 3.2 4.1 73 140 90
Gobi
paranthhas
Wheat flour 3 90 306.9 10.
8
1.5 18 283.5 319.5
Cauliflower 1 100 30 2.6 0.4 53 138 57
Onion 25 12.5 0.3 0.02 1.0 31.7 12.5
Curds Curds 50 30 1.5 2.0 16 65 46.5
Apple Apple 1 100 59 0.2 0.5 28 75 14.0
Mid
Morning
(11:00 am)
Aloo mehti
sandwich
Bread 2 60 73.5 2.3 0.21 8.3 39 -
Potato 50 48.5 0.8 0.05 5.5 123 20
Mehti 50 24.5 2.2 0.45 38 15 25.5
Lunch
(2:30 p.m)
Rajmah
salad
*rajmah 1 30 103.8 6.6 0.39 - - 93
Onion 25 12.5 0.3 0.02 1.0 31.7 12.5
Tomato 25 5.0 0.2 0.05 3.2 36.5 10.0
Rice Rice 3 90 310.5 6.1 0.45 - - 144
Soy bean
curry
*soybean 2 60 219.0 26 11.1 - - 280
Tomato 25 12.5 0.3 0.02 1.0 31.7 12.5
Ladies
finger
sabji
Ladiesfinger 50 5.0 0.2 0.05 3.2 36.5 10.0
Onion 25 12.5 0.3 0.02 1.0 31.7 12.5
Tomato 25 5.0 0.2 0.05 3.2 36.5 10.0
Curds Curds 50 30 1.5 2.0 16 65 46.5
sugar 1 5 19.9 - - - - 0.05
Evening
(5-00 pm)
Upma Semolina 2 60 104.4 3.1 0.24 6.3 24.9 30.6
Onion 25 12.5 0.3 0.02 1.0 31.7 12.5
Papaya Papaya 1 100 32 0.6 0.1 6 69 13
Dinner Cumber Cumber 1 100 45 2.6 0.03 16 35 41.2
Amaranth Rice 2 60 200.5 4.1 0.25 - - 94
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(8.00 pm) Khichidi 2
Green gram
dal
2 60 369 54 10.4 - - 320
Amaranth 50 24 0.3 0.8 - - 31
Bed time
(10.00 pm)
Milk Milk 1 100 67 3.2 4.1 73 140 90Sugar 1 5 19.9 - - - - 0.05
Total Oil 4 20 340 - 20 - - -
Total 2478.6 79.3 31.6 276.7 1236.4 1259.2
* leach before use
EVALUATION :
NUTRIENT PRESCRIBED
VALUES
CALCULATED
VALUES
Energy (kcal) (E) 2537.5 2478.6
Protein (g) (P) 87 79.3Fat (g) (F) 25 31.6
Potassium (mg) (K) 2000 (2g) 1236.4 = 1.23g
Sodium (mg) (Na) 2000 (2g) 276.70
Phosphate 0.8 g 1.2g 1.25 g
EVALUATION OF THE DIET
A Nutrition Care Plan was formulated for Mr. AB, a 22 year old student who is
hypertensive and has been diagnosed with renal failure.
A diet was planned which was formulated keeping in mind the principles of hypertension
management in combination with sodium, potassium and fluid restriction.
Potassium, sodium and fluid restriction was crucial in order to reduce the load on the
kidneys and to prevent further complications like water retention etc.
The diet focused on timely, regular and portion controlled meals that were rich in fiber in
order to manage diabetes.
Mostly vegetables with moderate amounts of potassium were carefully chosen during the
construction of the diet. Group III vegetables (K > 200 mg) that were used were leeched
pre use.
Pulses used for the preparation of rajmah salad, dal and khichdi were also leeched before
cooking in order to drain out the excess potassium.
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A very low sodium diet was planned consisting of 276.70 mg of sodium excluding salt.
Only 1 tsp of salt was permitted and could be achieved by using salt in sachet form
during meals.
The fluid intake in the form of coffee and milk was given an allowance of 3 exchanges i.e
300ml in order to achieve adequate consumption of proteins and the water intake was
kept low keeping in mind fluid restriction as adviced by the physician.
Minimum amounts of fats in the form of oil were used for seasoning purpose. Saturated
fats were discouraged which is crucial for hypertension management.
COUNSELLING
Establish a good rapport with the client
Assess the clients nutritional status through anthropometric measurements,
biochemical investigations, clinical signs and symptoms and diet therapy.
Plan a diet to serve diabetes management along with sodium, potassium and fluid
restriction
Educate the client
about the disease condition
About the consequences of the disease.
About hidden salt
To read food labels.
Dos
Have regular and timely meals
Have portion controlled meals
Have small and frequent meals
Choose foods rich in fiber over refined food
Do not add extra salt at the table.
Cook the food without salt and use only 4-5 g per day, i.e. 1 tsp per day).
Do not consume any raw vegetables, except cucumber.
Reduce the consumption of oil, salt & coconut used in cooking
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LEACHING:
Leaching is very important to remove excess potassium that is present in
pulses/legumes/lentils and vegetables.
Boil excess water & soak dal & vegetables in it for 1 hour, after that discard the
water & then cook the dal and vegetables.
FOODS TO BE AVOIDED:
CEREALS: Ragi, Maida, bajra, barley
PULSES: Consume in moderation
VEGS: potatoes, beetroot, green leafy vegetables,
Soya bean, mushrooms.
FRUITS: Avoid all fruits & fruit juices & tender coconut water.
DAIRY PRODUCTS: Condensed milk, cheese, cream, butter, ghee.
MEAT: Liver, kidney, sausages.
MISCELLANEOUS FOODS: Sugar, honey, jaggery, soups, chocolates, bourn vita,
horlicks, pickles, papads,
Sauces, instant coffee.BAKERY FOODS: buns, puffs, cakes, pastries. .
FRIED FOODS: chips, mixtures, vada, bonda, Fried meats.
DRINKS: Tender coconut water, coca-cola, Pepsi, etc.
NUTS: All nuts like coconut, groundnut, and cashew nut
SPICES: All spices like chilly powder, pepper, garam masala & garlic to be used in
moderation.
FOODS ALLOWED:
CEREALS: Rice, wheat, jowar, maize, rava (moderation)
PULSES: Urad dal, thur dal, green gram, sprouted grams after leaching.
NON-VEG: egg whites, chicken, fish- 2 medium pieces (thrice a week.)
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VEGS: Cucumber, pumpkin, cabbage, beans, carrot, onion, bottlegourd, ridgegourd,
snake gourd, capsicum, raddish, khnol-khol, ladiesfinger.
FRUITS: Apple/Guava/Pear/Papaya: once a week(100g)
MILK: milk, buttermilk, curd in moderation
DRINKS: Tea/ coffee in moderation.
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