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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.