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Nutritional Management of Renal Disease. Edition No. 3

  • Book
  • January 2013
  • Elsevier Science and Technology
  • ID: 1951596

This translational text offers in-depth reviews of the metabolic and nutritional disorders that are prevalent in patients with renal disease. Chapter topics address the growing epidemic of obesity and metabolic syndrome. Each chapter integrates basic and clinical approaches, from cell biology and genetics to diagnosis, patient management and treatment. Chapters in sections 4-7 include new illustrative case reports, and all chapters emphasize key concepts with chapter-ending summaries. New features also include the latest National Kidney Foundation Clinical Practice Guidelines on Nutrition in Chronic Renal Failure, the most recent scientific discoveries and the latest techniques for assessing nutritional status in renal disease, and literature reviews on patients who receive continuous veno-venous hemofiltration with or without dialysis.

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Table of Contents

Chapter 1. The Influence of Kidney Disease on Protein and Amino Acid Metabolism


CKD Interrupts the Components of Protein Metabolism

Defining Muscle Wasting

Mechanisms of Muscle Wasting

The Ubiquitin-Proteasome System

Synergism of Proteolytic Pathways Causes Muscle Wasting in CKD

Proteolytic Activities Present in Muscles of Patients

Factors Triggering Muscle Wasting in CKD and Other Catabolic States

Myostatin and the Regulation of Muscle Protein Wasting

Myostatin in Muscle Increases in Catabolic Conditions

Beneficial Responses from Blocking Myostatin in Models of Muscle Catabolism

Blocking Myostatin can Suppress CKD-Induced Muscle Wasting

CKD Changes the Concentrations of Certain Amino Acids

Links Between Amino Acid and Protein Metabolism



Chapter 2. Carbohydrate Metabolism in Kidney Disease and Kidney Failure


Insulin Resistance

Insulin Secretion

Insulin Clearance


Carbohydrate Metabolism in Patients with Renal Replacement Therapy

Treatment of Diabetes Mellitus in Diabetics with CKD

Drug Management in Diabetics with CKD (Figure 2.1)


Chapter 3. Altered Lipid Metabolism and Serum Lipids in Kidney Disease and Kidney Failure


Plasma Lipid and Lipoprotein Profile in CKD/ESRD Patients

The Nature and Mechanisms of CKD-Induced Lipid Abnormalities

The Nature and Mechanisms of Adverse Effects of Lipid Disorders in CKD

Treatment of CKD-Associated Dyslipidemia

Potential Adverse Effects of Statins


Chapter 4. Uremic Toxicity


Uremic Symptoms and Signs

Toxic Effects of Uremic Plasma or Serum

Definition of a Uremic Toxin

Impact of Dialysis Treatment on Uremic Toxicity

Toxicity of Inorganic Substances in Uremia

Free Water-Soluble Low-Molecular-Weight Solutes

Protein-Bound Solutes

Middle Molecules

General Conclusions



Chapter 5. Inflammation in Chronic Kidney Disease

General Considerations

Multifactorial Causes of Inflammation in Chronic Kidney Disease

Inflammation as a Cause of Protein-Energy Wasting

Inflammation as a Catalyst of Other Risk Factors

Other Consequences of Inflammation

Monitoring Inflammation

Treatment of Inflammation in Chronic Kidney Disease


Chapter 6. Catalytic (Labile) Iron in Kidney Disease


Definition of Catalytic (Labile) Iron and its Importance in Tissue Injury

Role of Catalytic Iron in Acute Kidney Injury

Gentamicin-Induced Mobilization of Iron From Renal Cortical Mitochondria

Evidence Suggesting a Role for Iron in Gentamicin-Induced Acute Renal Failure in Rats

Catalytic Iron in Chronic Kidney Disease (Table 6.3)

Catalytic Iron in Diabetic Nephropathy

Catalytic Iron in Chronic Kidney Disease

Concluding Comments


Chapter 7. Carbonyl Stress in Uremia


Increased Age and other Protein Modifications

Carbonyl Stress

Clinical Consequences of Carbonyl Stress

Nutrition and Carbonyl Stress


Chapter 8. Effect of Acidemia and Alkalemia on Nutrition and Metabolism


Acute Responses to Acidosis and Alkalosis

Comparing Effects of Acidemia to those of Starvation

Endocrine Responses to Acidemia

Calcium Metabolism

Protein Malnutrition

Metabolic Acidemia Stimulates the Ubiquitin/Proteasome Proteolytic Pathway

Clinical Implications of Acidemia for Protein Nutrition


Chapter 9. Prevention and Management of Cardiovascular Disease in Kidney Disease and Kidney Failure


Cardiovascular Risk Factors

Management of CVD



Chapter 10. Assessment of Protein and Energy Nutritional Status


Definition of Protein and Energy Wasting

Assessment of Protein Mass

Assessment of Protein and Energy Homeostasis

Summary and Recommendations


Chapter 11. Causes of Protein-Energy Wasting in Chronic Kidney Disease


Causes of Pew in CKD

Pathophysiology of Pew in CKD

Endocrine and Hormonal Disorders

Effect of Volume Overload

Contribution of Co-Morbidities

Altered Protein Kinetics in CKD

Nutrient Loss During Dialysis

Inflammation: Agent Provocateur of Pew

Role of Metabolic Acidemia

Oxidative Stress: Other Key Pathways

Summary and Conclusion


Chapter 12. Protein-Energy Wasting as a Risk Factor of Morbidity and Mortality in Chronic Kidney Disease


Pertinent Outcomes in Patients with CKD

Association of Measures of Nutrition with Outcomes

Nutrient Intake and Outcomes

Body Size, Body Composition and Outcomes

Laboratory Measures and Outcome

Nutritional Scoring Systems and Outcomes

Nutritional Interventions and Outcomes



Chapter 13. Effect of Nutritional Status and Changes in Protein Intake on Renal Function


Role of Specific AA

Factors Mediating the Renal Response to Protein and Amino Acids

Humoral Mediators

Local Mediators

Intrinsic Renal Mechanisms

Effects of Nutritional Status or Protein Deprivation on Renal Function

Levels of Plasma Creatinine and Serum Urea Nitrogen in Patients with Protein-Energy Malnutrition

Concentration and Dilution of the Urine in Patients with Protein-Energy Malnutrition

Acid Excretion and Acid-Base Balance in Patients with Calorie-Protein Malnutrition

Effects of Chronic Protein-Energy Malnutrition on Renal Sodium Excretion

Effects of Maternal Nutrition on Renal Development

Protein Energy Wasting in Advanced Renal Disease


Chapter 14. Low Protein, Amino Acid and Ketoacid Diets to Slow the Progression of Chronic Kidney Disease and Improve Metabolic Control of Uremia


Assessing the Progression of Chronic Renal Insufficiency

Protein Intake and Chronic Renal Insufficiency: Experimental Data

Dietary Protein Intake: Clinical Studies

Clinical Evidence of the Effects of Low Protein Diets



Chapter 15. Reducing Tryptophan Metabolites to Reduce Progression in Chronic Kidney Failure

Search for Uremic Toxins

Metabolism of Indoxyl Sulfate, a Tryptophan Metabolite

Protein Metabolite Theory as a Mechanism of CKD Progression

Indoxyl Sulfate Induces Reactive Oxygen Species (ROS) in the Kidney

Role of Organic Anion Transporters in Nephrotoxicity of Indoxyl Sulfate

Indoxyl Sulfate Reduces Klotho and Induces Senescence in the Kidney

Vascular Toxicity of Indoxyl Sulfate

Clinical Effects of AST-120



Chapter 16. Altering Serum Lipids to Reduce Progression of Chronic Kidney Disease

Kidney Disease and Dyslipidemia

Lipid Lowering and Pleiotropic Effects of Statins

Statins in Experimental Kidney Disease

Effects of Dyslipidemia and Statins on the Progression of Kidney Disease in Human Subjects


Chapter 17. Disorders of Phosphorus Homeostasis: Emerging Targets for Slowing Progression of Chronic Kidney Disease


Role of Dietary Phosphorus Intake in Disturbances of Mineral Metabolism in CKD

Disorders of Phosphorus Homeostasis and Kidney Disease Progression

Dietary Phosphorus Restriction in CKD: Practical Considerations Moving Forward



Chapter 18. Alkalinization to Retard Progression of Chronic Kidney Failure

Epidemiology of Metabolic Acidosis in Kidney Disease

Mechanism of Acidosis in CKD

Animal Models of Kidney Damage With Acidosis

Animal Models of Treatment

Observational Studies in Humans



Chapter 19. Calcium, Phosphate, PTH, Vitamin D and FGF-23 in Chronic Kidney Disease


Calcium Metabolism

Vitamin D

Phosphate Metabolism

Parathyroid Hormone

Fibroblast Growth Factor 23 (FGF-23)

Alterations in Mineral Metabolism in Ckd

Phosphate and Cardiovascular Disease (CVD)

Phosphate and Vascular Calcifications

Control of Serum Phosphate in CKD

Dietary Phosphorus Restriction

Inorganic Phosphorus and Food Additives

Dietary Phosphorus, Protein Intake and Phosphorus-Protein Ratio

Phosphorus Removal With Dialysis

Phosphate Binders

Therapy With Vitamin D Sterols




Chapter 20. Phosphate Metabolism and Fibroblast Growth Factor 23 in Chronic Kidney Disease


Phosphate Metabolism in Health

Phosphate Metabolism Across the Spectrum of CKD

The Role of Phosphate and FGF-23 Excess in the Pathophysiology of CKD Outcomes

Therapeutic Approaches to Lowering Phosphate and FGF-23 Excess

Impact of Dietary Phosphate on Phosphate/FGF-23 Excess

Questions and Controversies





Chapter 21. Vitamin D in Kidney Disease

Normal Vitamin D Metabolism

Prevalence and Etiology of Deficiency in The Vitamin D Axis in CKD



Other Compounds

Therapeutic Considerations




Chapter 22. Nutritional Management of Water, Sodium, Potassium, Chloride, and Magnesium in Kidney Disease and Kidney Failure

Sodium and Chloride





Chapter 23. Trace Elements, Toxic Metals, and Metalloids in Kidney Disease


Alterations in Essential Trace Elements in Patients With Kidney Disease

Alterations in Nonessential Trace Elements, Metals, and Metalloids in Patients With Kidney Disease

Trace Element Abnormalities in Renal-Specific Syndromes

Diagnostic and Therapeutic Approaches



Chapter 24. Vitamin Metabolism and Requirements in Renal Disease and Renal Failure


Structure and Physiological Role of Vitamins

Vitamin Intake in Chronic Renal Disease

Vitamins Status in Chronic Renal Disease

Vitamins as Therapy for People with Kidney Disease

Recommendations for Vitamin Supplementation and Vitamin Therapy in Renal Diseases



Chapter 25. Nutrition and Anemia in End-stage Renal Disease



Vitamin C

Vitamin D

Folic Acid

Vitamin B6 (Pyridoxine)

Vitamin B12


Growth Hormone and Insulin-Like Growth Factor-I (IGF-I)


Chapter 26. Nutritional and Non-nutritional Management of the Nephrotic Syndrome


Dietary Protein

Albumin Homeostasis in the Nephrotic Syndrome

Dietary Protein and Renal Injury

Effects of the Nephrotic Syndrome on Solid Tissue Proteins

Dietary Proteins as Potential Allergens Responsible for Renal Disease

Dietary Fat

The Effect of Altered Glomerular Permselectivity on Lipid Metabolism

Cardiovascular Effects of Hyperlipidemia in the Nephrotic Syndrome

Thromboembolic Complications

Effects of Lipids on Renal Disease

Polyunsaturated Fatty Acids

Derangements in Divalent Cation Metabolism in the Nephrotic Syndrome

Derangements in Salt and Water Metabolism in the Nephrotic Syndrome (Volume Homeostasis)

Recommendations for Nutritional and Non-Nutritional Treatment of the Nephrotic Syndrome



Chapter 27. Nutrition and Blood Pressure


Obesity and Energy Intake

Individual Nutrients, Miscellaneous Substances and Blood Pressure

Nutritional Management Strategies for The Prevention or Treatment of Hypertension

Health Enhancing Diets and Lifestyles

Long-Term Adherence and Blood Pressure Responses to Health Enhancing Lifestyles

Challenges to Diet and Lifestyle Approaches for Preventing and Treating Hypertension

Conclusions and Recommendations

Key Points


Chapter 28. Effect of Obesity and the Metabolic Syndrome on Incident Kidney Disease and the Progression to Chronic Kidney Failure


Definitions of Obesity/Metabolic Syndrome

Obesity and Metabolic Syndrome as Risk Factors for Incident CKD

Obesity and Metabolic Syndrome as Risk Factors for Progression of CKD

Pathophysiology of Obesity on the Kidney

Effect of Weight Loss Interventions on Kidney Disease



Chapter 29. Nutritional and Metabolic Management of Obesity and the Metabolic Syndrome in the Patient with Chronic Kidney Disease


Obesity-Related Chronic Kidney Disease (CKD)

Obesity-Related Glomerulopathy

Measuring GFR

Metabolic Syndrome

Treatment of Obesity and Obesity-Related Kidney Disease

Bariatric Surgery (see also Chapter 28)

Metabolic Syndrome


Chapter 30. Bariatric Surgery and Renal Disease

Magnitude of Problem

Pathogenesis of Obesity

Clinical Manifestations

Medical Therapy

Role of Bariatric Surgery in Treatment of Morbid Obesity

Surgical Techniques of Bariatric Surgery (see Figure 30.1)

Outcomes of Bariatric Surgery

Renal Disease and Morbid Obesity

Pathogenesis of Renal Disease in Obesity

Role of Bariatric Surgery in Chronic Kidney Disease

Role of Bariatric Surgery in Transplant Candidates

Bariatric Surgery and Nephrolithiasis

Other Renal Effects of Bariatric Surgery

Future Research


Chapter 31. Nutritional and Metabolic Management of the Diabetic Patient with Chronic Kidney Disease and Chronic Renal Failure


Glucose/Insulin Homeostasis

Value of Glycemic Control, and its Determination in CKD


Diabetes/Bone and Mineral Metabolism

Dietary Protein Intake and Diabetic Kidney Disease

Salt Intake and Diabetic Kidney Disease


Chapter 32. Nutritional Management of Maintenance Hemodialysis Patients


Factors Altering Nutrient Intake in Maintenance Hemodialysis Patients

Loss of Nutrients During Maintenance Hemodialysis Treatment

Importance of Pew and Diet as Patients Approach Esrd and Commence MHD

Assessment of Nutritional Status in MHD Patients

Acidemia and Protein Wasting

Goals of Nutritional Management of MHD Patients

Dietary Nutrient Requirements (see Table 32.3)

Management of Pew in MHD Patients

Treatment of Acute Catabolic Illness

Daily or Long Duration Hemodialysis and Nutritional Status


Chapter 33. Nutritional Management of End-Stage Renal Disease Patients Treated with Peritoneal Dialysis


Type of Peritoneal Dialysis

Peritoneal Dialysis Solutions

Specific Effects of Peritoneal Dialysis on Nutritional Status and Metabolism

Dietary Recommendations for ESRD Patients Undergoing Peritoneal Dialysis

Protein-Energy Wasting in Peritoneal Dialysis Patients

Management of Protein-Energy Wasting in Patients Treated with Peritoneal Dialysis


Chapter 34. Nutritional Management of Kidney Transplant Recipients



Bone Disease

Diabetes Mellitus



Food Safety




Protein and Energy Requirements

Nutritional Management

Pretransplant Status and Posttransplant Outcome




Chapter 35. Nutritional Management of the Child with Kidney Disease


Etiology of Protein-Energy Wasting

Assessment of Nutritional Status

Nutritional Requirements

Bone Mineral Metabolism

Acid-Base and Electrolytes

Vitamins and Micronutrients

Nutrition Management


Chapter 36. Nutritional Management of Acute Kidney Injury


Metabolic Environment of the Patient with AKI

Metabolic Alterations Specifically Attributable to AKI

Metabolic Interventions of Controlling Catabolism

Clinical Studies on Protein Catabolism in AKI

Amino Acid/Protein Requirements in Patients with AKI

Carbohydrate Metabolism

Lipid Metabolism

Micronutrients and the Antioxidant System in AKI


Metabolic and Nutritional Factors and the Prevention and Therapy of AKI

Impact of Renal Replacement Therapy (RRT) on Metabolism and Nutrient Balances

The Effect of Nutrition Status and Nutrient Supply on Prognosis

Practice of Clinical Nutrition in Patients with AKI

Oral Nutrition in Patients with AKI

Nutritional Support in Patients with AKI

Enteral Nutrition in AKI

Parenteral Nutrition in AKI

Complications of Nutritional Support

Monitoring of Nutrition Support in Patient with AKI


Chapter 37. Nutritional Management of Patients Treated with Continuous Renal Replacement Therapy


Modes of CRRT

Generic Effects of CRRT on Energy Metabolism

Specific Effects on Nutrient Balance

Recommendations on Nutritional Therapy




Chapter 38. Anorexia and Appetite Stimulants in Chronic Kidney Disease

General Considerations

Prevalence of Anorexia, Methods of Assessment and Clinical Implications

Pathogenesis of Anorexia in CKD

Treatment of Anorexia in CKD


Chapter 39. Oral and Enteral Supplements in Kidney Disease and Kidney Failure


Oral and Enteral (Tube Feeding) Nutrition in CKD Patients

Oral and Enteral Nutrition for Patients with Nephrotic Syndrome

Oral and Enteral Nutrition in Chronic Dialysis Patients

Oral and Enteral Nutrition in Acute Kidney Injury



Chapter 40. Intradialytic Parenteral Nutrition, Intraperitoneal Nutrition and Nutritional Hemodialysis


Intradialytic Parenteral Nutrition (IDPN)

Randomized Prospective Controlled Trials of IDPN

Advantages and Disadvantages of IDPN

Indications for IDPN

IDPN in the United States

Nutritional Hemodialysis and Intraperitoneal Nutrition


Chapter 41. Therapeutic Use of Growth Factors in Renal Disease


Treatment of Protein-Energy Wasting (PEW) in ESRD Patients

Therapeutic Use of Growth Factors in Renal Disease

Growth Factors in the Management of Wasting in Renal Disease



Chapter 42. Nutritional Prevention and Treatment of Kidney Stones


Pathophysiology of Kidney Stone Formation

General Dietary Effects on Kidney Stones

Effect of Diet Based on Urinary Findings

Dietary Recommendations Based on Stone Type

Obesity and Kidney Stones

Melamine Stones


Chapter 43. Herbal Supplements in Patients with Kidney Disease


Acute Kidney Injury

Chronic Kidney Disease

Five Herbals with Some Proven Efficacy


Clinical Implications


Chapter 44. Drug-Nutrient Interactions in Renal Failure


Effect of Food Intake on Drug Absorption

Effects of Nutrients on Drug Metabolism

Interactions of Food Supplements with Drugs

Drug-Induced Nutritional Deficiencies

Taurine and ACE-Inhibitor Effects

Nutrient Interactions with Oral Anticoagulants

Interactions of Calcineurin Inhibitors with Nutrients

Enteral Tube Feeding and Oral Drug Administration


Chapter 45. Exercise Training for Individuals with Advanced Chronic Kidney Disease


Characteristics of Advanced CKD Patients

Value of Exercise and Physical Activity in Advanced CKD

Principles of Exercise Training

Patient Assessment

Components of the Exercise Training Prescription

Exercise Training Program Design for Patients with Advanced CKD

Components of the Exercise Training Session

Risks of Exercise in the Advanced CKD Patient

Urgent Need for Development of Renal Rehabilitation Programs



Chapter 46. Motivating the Kidney Disease Patient to Nutrition Adherence and Other Healthy Lifestyle Activities


What is Motivational Interviewing?

What isn't Motivational Interviewing?


Handling Resistance

Empirical Support

Applications in Kidney Disease Management

Learning Motivational Interviewing

Dissemination of Motivational Interviewing

Future Research Directions in Kidney Disease Management



Color Plates



Joel D. Kopple The Lundquist Institute at Harbor-UCLA Medica Center, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Torrance and Los Angelese, CA, United States. Joel D. Kopple, MD, editor of the book's first three editions, is Professor Emeritus of Medicine and Public Health at the David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, CA, and is a member of the Division of Nephrology and Hypertension and The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California. Dr. Kopple was Chief of the Division of Nephrology and Hypertension at Harbor-UCLA Medical Center from 1982 to 2007. He has published over 600 scientific papers and book chapters and has edited or coedited 15 seminars and proceedings. Dr. Kopple is a former president of the National Kidney Foundation (NKF), the American Society of Parenteral and Enteral Nutrition, the International Society for Renal Nutrition and Metabolism, and the International Federation of Kidney Foundations and was a founder of World Kidney Day. Shaul G Massry Professor of Medicine, Physiology and Biophysics, University of Southern of California, Los Angeles, CA, United States. Shaul G. Massry, MD, editor of the book's first three editions, is Professor Emeritus of Medicine and Physiology and Biophysics at the Keck School of Medicine, University of Southern California, Los Angeles, California. He served as Chief of its Division of Nephrology from 1974 to 2000. He has published over 600 scientific papers and over 80 book chapters, and he is editor or coeditor of 28 books. Dr. Massry has received honorary doctorates from 14 universities across Europe, including the oldest and prestigious Charles University (Prague, Czech Republic), The University of Bologna (Italy), and the University of Padua (Italy). Dr. Massry is a former president of the National Kidney Foundation (NKF). Kamyar Kalantar-Zadeh Harold Simmons Center for Kidney Diseae Research and Epidemiology, Division of Nephrolofy, Hypertension and Kidney Transplantation, Department of Medine, University of California Irvine School of Medicine, Orange, CA, United States;
Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, United States;
The Lundquist Institute at Harbor-UCLA Medical center, Torrance, CA, United States;
Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, United States. Kamyar Kalantar-Zadeh, MD, PhD, MPH, editor of the book's third edition and an Editor-in-Chief of the Journal of Renal Nutrition, is Professor of Medicine, Pediatrics, Public Health and Nursing Sciences, and Chief of Nephrology, University of California Irvine School of Medicine, Irvine, CA; Adjunct Professor of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA; and a staff physician in Veterans Affairs Hospital, Long Beach, CA. Dr. Kalantar is a former president of the International Society for Renal Nutrition and Metabolism and the International Federation of Kidney Foundations, co-chair of the joint steering committee of World Kidney Day, and Chair of the Medical Advisory Committee of the National Forum of the ESRD Networks. He has served as PI of a dozen National Institutes of Health grants and has coauthored over 800 manuscripts in peer-reviewed journals.