Nutritional Management of Renal Disease, 4th ed

Front Cover Nutritional Management of Renal Disease Copyright Page Dedication Contents List of contributors About the editors Preface I. Normal and altered metabolism of chronic kidney disease 1 The KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 update Introduction The guideline development process Key points addressed in the 2020 updated guideline Conclusion References 2 The influence of kidney disease on protein and amino acid metabolism Introduction Influence of protein intake on CKD Dietary restriction of protein Metabolic acidosis Role of protein metabolism in hypertension Uremic toxins derived from protein metabolism Excessive sodium Phosphates Dysregulation of proteolytic pathways in CKD The ubiquitin–proteasome system Cytokine-induced muscle wasting Myostatin Albumin and other markers of malnutrition Defining decreased protein stores Protein supplementation in dialysis Protein metabolism post-kidney transplantation Conclusion References 3 Carbohydrate metabolism in chronic renal disease Introduction Insulin resistance Consequences of insulin resistance Insulin secretion Insulin clearance Hypoglycemia Carbohydrate metabolism in patients with renal replacement therapy Patients undergoing maintenance hemodialysis Peritoneal dialysis patients Kidney transplant recipients and new-onset diabetes after transplantation Treatment of diabetes mellitus in diabetics with chronic kidney disease Target of treatments Drug management in diabetics with chronic kidney disease Metformin Sulfonylureas Pioglitazone Meglitinides Glucagon-like peptide 1 agonists Dipeptidyl-peptidase 4 inhibitors Acarbose Sodium–glucose cotransporter type 2 inhibitors Insulin References 4 Altered lipid metabolism and serum lipids in chronic kidney disease Introduction Plasma lipid and lipoprotein profile in chronic kidney disease/end-stage renal disease patients Conditions that modify lipid profile in chronic kidney disease/end-stage renal disease The nature and mechanisms of chronic kidney disease–induced lipid abnormalities High-density lipoprotein metabolism and function Effect of chronic kidney disease on structure and function of high-density lipoprotein Effects of chronic kidney disease on very-low-density lipoprotein and chylomicron metabolism Effect of chronic kidney disease on cholesterol metabolism The nature and mechanisms of adverse effects of lipid disorders in chronic kidney disease Inflammation and oxidative stress Atherosclerosis and cardiovascular disease Lipotoxicity and its role in progression of kidney disease Nutrition and energy metabolism Treatment of chronic kidney disease–associated dyslipidemia Statins in primary prevention of cardiovascular disease in end-stage renal disease patients Statins in primary prevention of cardiovascular disease in nondialysis chronic kidney disease patients Effect of statins on progression of kidney disease Mechanisms of protective effects of statins in chronic kidney disease Potential adverse effects of statins Peroxisome proliferator–activated receptor-α agonists Niacin Cholesterol ester transfer protein inhibitors Acyl-CoA cholesterol acyltransferase inhibitors References 5 Energy metabolism and requirements in chronic kidney disease Introduction Energy balance Energy intake Energy expenditure Basal energy expenditure and resting energy expenditure Thermic effect of food Thermic effect of activity Factors that influence energy expenditure Measurement of energy expenditure Direct calorimetry Indirect calorimetry Doubly labeled water Energy balance and chronic kidney disease Predictive energy equations Overview and recommended energy intake in chronic kidney disease patients Abbreviations References 6 Uremic toxins: an integrated overview of classification and pathobiology Introduction Definition of a uremic toxin Classification of uremic toxins by physicochemical characteristics The pathobiologic categorization of uremic toxins according to the processes underlying accumulation in body fluids The linkage of uremic toxins to the pathobiology of uremia Clinical manifestations of uremia and the role of tropisms The effects of diet and dialysis on uremic toxins Diet Dialysis Summary and conclusion References 7 Inflammation in chronic kidney disease General considerations Multifactorial causes of inflammation in chronic kidney disease Inflammation as a cause of protein-energy wasting Inflammation leading to anorexia Inflammation and depression Inflammation and increased energy expenditure Catabolic effects of inflammation Inflammation and anabolic resistance Inflammation as a catalyst for other risk factors Other consequences of inflammation Monitoring inflammation Monitoring inflammation for prognostic purposes Monitoring inflammation for diagnostic purposes Treatment of inflammation in chronic kidney disease References 8 Catalytic (labile) iron in kidney disease Introduction Definition of catalytic (labile) iron and its importance in tissue injury Role of catalytic iron in acute kidney injury Catalytic iron in myoglobinuric acute kidney injury Catalytic iron in cisplatin-induced nephrotoxicity Catalytic iron in gentamicin nephrotoxicity 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 contrast media–associated nephrotoxicity Catalytic iron in ischemia–reperfusion injury Catalytic iron in chronic kidney disease Catalytic iron in experimental glomerular disease Role of iron in experimental progressive kidney disease Catalytic iron in human disease Catalytic iron in diabetic nephropathy Catalytic iron in chronic kidney disease Concluding comments References 9 Carbonyl stress in uremia Introduction Increased age and other protein modifications Carbonyl stress Clinical consequences of carbonyl stress Nutrition and carbonyl stress References 10 Metabolic and nutritional responses to acidemia and alkalemia Introduction Responses to acute acidemia and alkalemia Bone buffering and calcium homeostasis in chronic acidemia Increased ammoniagenesis and muscle wasting in acidemia Hypoalbuminemia, inflammation, and innate- and cell-mediated immunities Endocrine responses to acidemia Renal hypertrophy What is the benefit of the catabolic response to metabolic acidosis? Theories of subclinical acidemia, acid stress, or eubicarbonatemic metabolic acidosis Estimated net endogenous acid production and the potential renal acid load Clinical implications for calcium and bone Clinical implications for protein nutrition, muscle function, and mortality Treating metabolic acidosis References 11 The gut microbiome and the kidney Case vignette Introduction to the gut microbiome The Gut Microbiome, Dysbiosis, and CKD Microbiota and the maintenance of the intestinal epithelial barrier Dysbiosis and CKD CKD and the gut barrier function Uremic toxins and CKD Indoxyl sulfate p-Cresol sulfate Trimethylamine N-oxide Endotoxin Short-chain fatty acids Gut microbiome and hypertension Targeted interventions to treat dysbiosis in CKD/ESRD Prebiotics Probiotics Symbiotics Other therapies Dietary modifications and fecal transplantation Microbiome engineering Conclusion and future directions References II. Treatment of altered metabolism in chronic kidney disease 12 Assessment and risk factors for protein-energy wasting and frailty in chronic kidney disease Introduction Assessment for protein-energy wasting Diagnosis of protein-energy wasting Serum biochemical markers of nutrition Serum albumin Serum prealbumin (transthyretin) Normalized protein catabolic rate or normalized protein nitrogen appearance Serum cholesterol Body mass Body mass index Total body fat percentage Muscle mass Serum creatinine Midarm muscle circumference Bioelectrical impedance analysis Computed tomography scan Dietary intake Dietary protein intake Dietary energy intake Comprehensive nutritional assessment Composite nutritional indices Screening for protein-energy wasting Assessment tools for PEW Subjective Global Assessment of nutrition Malnutrition–inflammation score Assessment for frailty Diagnosis of frailty Fried phenotype model of frailty Shrinking Weakness Poor endurance and energy Slowness Low physical activity level Cumulative deficit model of frailty or the frailty index Clinical Frailty Scale Screening for frailty Treatment of frailty Risk factors of protein-energy wasting and frailty Risk factors of protein-energy wasting Increased loss of protein or energy Chronic kidney disease–related factors Increased protein loss Increased proteolysis Increased protein or energy utilization Dialysis-related factors Increased protein loss Non-CKD-related factors Increased proteolysis Decreased regaining protein or energy Chronic kidney disease–related factors Decreased appetite or dietary intake Dialysis-related factors Decreased appetite or dietary intake Non-CKD-related factors Decreased appetite or dietary intake Decreased food access Risk factors of frailty Aging Genetic factors Muscle abnormalities (sarcopenia) Neuronal abnormalities Environmental factors Gene- and chromosome-related factors Chronic kidney disease–related factors Non-CKD-related factors Acknowledgments Funding sources Potential conflict of interests Important disclosure Abbreviations References Further reading 13 Causes and treatment of protein-energy wasting in kidney disease Introduction Causes of protein-energy wasting in chronic kidney disease Pathophysiology of protein-energy wasting in chronic kidney disease Anorexia Decreased nutrient intake Impaired gastric motility Endocrine and hormonal disorders Gut-derived hormones Insulin and insulin-like growth factors Resistance to growth hormone Testosterone deficiency Altered adipokine physiology Effect of volume overload Contribution of comorbidities Altered protein kinetics in chronic kidney disease Nutrient loss during dialysis Inflammation: agent provocateur of protein-energy wasting Role of metabolic acidemia Oxidative stress: other key pathways Treatment of protein-energy wasting in chronic kidney disease Nutritional supplementation Exercise Pharmacological interventions Anabolic steroids Recombinant human growth hormone Appetite stimulants Antiinflammatory agents Antimyostatin agents Summary and conclusion References 14 Prevention and management of cardiovascular disease in kidney disease and kidney failure Introduction Cardiovascular risk factors Hypertension Dialysis Epidemiology Trials and recommendations CKD stages 1–4 Epidemiology Trials and recommendations Dyslipidemia Dialysis Epidemiology Trials and recommendations CKD stages 1–4 Epidemiology Trials and recommendations Diabetes mellitus Dialysis Epidemiology Trials and recommendations CKD stages 1–4 Epidemiology Trials and recommendations Left ventricular hypertrophy Dialysis Epidemiology Trials and recommendations CKD stages 1–4 Epidemiology Trials and recommendations Protein-energy wasting, malnutrition, and inflammation Other risk factors Management of CVD Coronary artery disease Epidemiology Therapy of ischemic heart disease Medical therapy Revascularization Heart failure Epidemiology Treatment of heart failure Conclusion References 15 Effects of nutritional status and changes in nutrient intake on renal function Introduction Impact of nutritional status on kidney function Dietary protein intake on kidney function and structure Protein sources, amino acids, and kidney function Pathways mediating the impact of dietary protein and amino acid intake on kidney health Humoral mediators Growth hormone and insulin-like growth factor-1 axis Glucagon Renin–angiotensin–aldosterone system Dopamine Atrial peptides Local mediators Eicosanoids Nitric oxide Dietary carbohydrate intake and kidney function Dietary fat intake and kidney function Dietary types and kidney function Dietary Approaches to Stop Hypertension diet Mediterranean diet Impact of protein-energy wasting on kidney function Protein-energy wasting and kidney function Protein-energy wasting and renal hemodynamics Protein-energy wasting and laboratory measures of kidney function (serum creatinine and urea nitrogen) Protein-energy wasting and proteinuria Protein-energy wasting and urinary concentration and dilution Protein-energy wasting and acid–base disturbances Protein-energy wasting and sodium retention Effects of maternal nutrition on renal development Protein-energy wasting and renal development Isocaloric protein restriction and renal development Conclusion References III. Nutrition and slowing of progressive chronic kidney disease 16 Dietary interventions to slow the progression of chronic kidney disease and improve metabolic control of uremia Assessing the progression of chronic kidney disease Protein intake and chronic kidney disease: Experimental data Effects on renal hemodynamics Effects on oxidant stress and inflammation Effects of the source of dietary proteins Protein and/or energy intake? Dietary protein intake: Clinical studies Protein requirements in normal individuals Metabolic effects of low-protein diets in human Metabolic adaptation to a reduction in protein intake Effects of low-protein diets on proteinuria Effects of the nature of protein intake Effect of low-protein diets on insulin resistance Effect of low-protein diets on dyslipidemia Effect of low-protein diets on phosphate, mineral, and bone disease Effect of low-protein diets on acidosis, anemia, and blood pressure Nutritional safety of restricting protein intake Clinical evidence of the effects of low-protein diets Clinical trials and cohorts Metaanalyses Conclusion References 17 Disorders of phosphorus homeostasis: emerging targets for slowing progression of chronic kidney disease Introduction 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 Conclusion References 18 Therapeutic strategies to limit tryptophan metabolites toxicity during chronic kidney disease Introduction: Gut-derived uremic toxins Metabolism of tryptophan and indole production Tryptophan metabolites as aryl hydrocarbon receptor ligands Tryptophan metabolites promote CKD progression Role of organic anion transporters in the nephrotoxicity of tryptophan metabolites Tryptophan metabolites induce a vascular procoagulant phenotype and cardiovascular complications Procoagulation state Inflammation state, oxidative stress, and endothelial dysfunction Vascular calcification Tryptophan metabolites and cardiovascular events in CKD patients Tryptophan metabolites involved in musculoskeletal disorders Therapeutic strategies to reduce tryptophan metabolites accumulation and production AST-120 Probiotics, prebiotics, and fecal microbiota transplantation Low-protein diet and low-tryptophan diet Other directions Conclusion References 19 Alkalization to retard progression of chronic kidney disease Introduction Overview of acid–base balance Epidemiology of the spectrum of “H+ stress” The daily H+ challenge Maintenance of normal acid–base homeostasis H+ buffering H+ sequestration into interstitial fluid Endogenous H+ neutralization Reduced NEAP Enhanced urine H+ excretion Importance of urine buffers in kidney H+ excretion Afferent signal for H+ secretion Efferent response leading to increased kidney tubule acidification Kidney response to H+ accumulation Angiotensin II ET-1 and aldosterone Ammoniagenesis Alkali management strategies to retard CKD progression Reduce H+ intake: dietary management of H+ accumulation Removing/limiting H+-producing dietary components Limiting dietary NaCl Adding base-producing food components like fruits and vegetables Neutralize accumulated H+ intake: Na+-based alkali Remove accumulated H+ intake: H+-binding polymers How might clinicians approach management of H+ stress, as a kidney protective intervention, in individuals with CKD within ... Conclusion Funding References IV. Mineral and vitamin metabolism in kidney disease 20 Nutritional management of sodium, chloride, and water in kidney disease and kidney failure Introduction Regulation of sodium, chloride, and water in healthy conditions Sodium Chloride Water Regulation of sodium, chloride, and water in kidney diseases (stages 3–5) Regulation of sodium balance in chronic kidney diseases Regulation of water balance in chronic kidney diseases Regulation of sodium and water balance in kidney failure (CKD stage 5D) Clinical implications of salt and water excesses in kidney diseases Stages 3–5 Hypertension Proteinuria Kidney disease progression Cardiovascular morbidity and mortality Dialysis Hypertension Cardiovascular morbidity and mortality Recommendations for the nutritional management of sodium, chloride, and water Determination of sodium intake and water balance Recommendations for sodium and fluid intake according to international societies The challenges of reducing salt intake and increasing fluid intake Conclusion References 21 Management of potassium in chronic kidney disease and acute kidney injury Potassium balance in health External potassium balance Internal potassium balance Potassium balance in kidney disease Assessing potassium disorders Managing hyperkalemia Lowering potassium intake Added potassium Concentrating and diluting potassium Removing potassium Increasing potassium excretion Increasing potassium uptake and storage in cells Nondietary approaches to hyperkalemia Managing hypokalemia Case study—hyperkalemia in chronic kidney disease References 22 Magnesium and kidney disease Introduction Serum magnesium in chronic kidney disease Modulation of serum magnesium in chronic kidney disease patients Magnesium dosing Drugs associated with hypo or hypermagnesemia Magnesium and outcomes Magnesium and vascular calcification in chronic kidney disease patients Magnesium and mortality in chronic kidney disease Nutritional aspects Conclusion References 23 Calcium, phosphate, PTH, vitamin D, and FGF-23 in CKD-mineral and bone disorder Calcium metabolism Vitamin D Phosphate metabolism Parathyroid hormone Measurement of PTH levels Fibroblast growth factor-23 and Klotho Alterations in mineral metabolism in CKD Phosphate and cardiovascular disease 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 Phosphate removal with dialysis Aluminum binders Calcium-based binders Sevelamer Lanthanum Newer phosphate binders Therapy with vitamin D sterols Calcimimetics Parathyroidectomy Conclusion References 24 Phosphorus metabolism and fibroblast growth factor 23 in chronic kidney disease Phosphate metabolism in health Phosphate metabolism in chronic kidney disease FGF23’s structure, synthesis, and function FGF23 in chronic kidney disease Role of phosphate and FGF23 excess Role of phosphate excess in people without chronic kidney disease Role of phosphate excess in people with chronic kidney disease Role of FGF23 in people without chronic kidney disease Role of FGF23 in people with chronic kidney disease Mortality Cardiovascular disease Left ventricular hypertrophy Vascular calcification and endothelial function Progression of chronic kidney disease Interventions to target lowering of phosphate and FGF23 Extracorporeal phosphate removal to lower serum phosphate and FGF23 Oral phosphate binders Novel interventions to reduce intestinal phosphate absorption Calcimimetics Nutritional management of phosphate and FGF23 excess in chronic kidney disease Sources of dietary phosphate Organic phosphate Phosphate additives and inorganic phosphates Inadequacy of food labels and regulatory policy Dietary therapy for CKD-associated hyperphosphatemia and FGF23 excess Direct blockade of FGF23 activity Summary References 25 Vitamin D in kidney disease Introduction Normal vitamin D metabolism and functions Intake and metabolism of vitamin D Normal functions of vitamin D in bone mineralization Nonskeletal actions of vitamin D Vitamin D binding protein and the free hormone hypothesis Genetics and heterogeneity of vitamin D metabolism Vitamin D physiology in CKD Detailed sources of vitamin D and burden of vitamin D deficiency Outcomes associated with vitamin D deficiency Supplementation of vitamin D General principles of supplementation Supplementation of vitamin D in mild-to-moderate CKD Vitamin D in prevention of kidney outcomes Vitamin D, secondary hyperparathyroidism, and bone outcomes in mild-to-moderate CKD Vitamin D and cardiovascular disease in mild-to-moderate CKD Formulations of vitamin D in CKD Vitamin D supplementation in special CKD populations Vitamin D supplementation in diabetic kidney disease Vitamin D supplementation in nephrotic syndrome Vitamin D supplementation in advanced CKD and end-stage kidney disease Vitamin D supplementation in pediatric kidney disease Current controversies and summary recommendations References 26 Vitamin metabolism and requirements in chronic kidney disease and kidney failure Vitamin A, physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin A physiology and biochemistry Vitamin A intake in chronic kidney disease patients Vitamin A nutritional status in chronic kidney disease, chronic dialysis, acute kidney injury, and kidney transplant patients Clinical effects of altered vitamin A nutrition Potential risk of vitamin A toxicity Vitamin A and hypercalcemia Vitamin A and outcomes Vitamin A supplementation in chronic kidney disease, chronic dialysis, and transplant patients Vitamin E, physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin E physiology and biochemistry Vitamin E intake in chronic kidney disease patients Vitamin E nutritional status in chronic kidney disease 1–5D, kidney transplant, and acute kidney injury patients Vitamin E, oxidant stress, and contrast-induced nephropathy in chronic kidney disease Vitamin E–coated hemodialysis membranes Vitamin E and cramps in maintenance hemodialysis patients Vitamin E supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin K, physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin K physiology and biochemistry Vitamin K intake in chronic kidney disease patients Vitamin K nutritional status in nondialyzed chronic kidney disease, chronic dialysis, and kidney transplant patients Clinical effects of vitamin K deficiency in chronic kidney disease Glomerular filtration rate decline Bone status in chronic kidney disease patients Vascular calcifications, calciphylaxis, and outcomes Vitamin K supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin B1 (thiamine), physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin B1 (thiamine) physiology and biochemistry Dietary vitamin B1 intake in chronic kidney disease patients Vitamin B1 (thiamine) nutritional status in chronic kidney disease, maintenance hemodialysis, chronic peritoneal dialysis, ... Clinical significance of thiamine deficiency in chronic kidney disease patients Thiamine supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin B2 (riboflavin), physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin B2 or riboflavin physiology and biochemistry Dietary riboflavin (vitamin B2) intake in advanced chronic kidney disease, maintenance hemodialysis, and chronic peritoneal... Riboflavin (vitamin B2) nutritional status in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Riboflavin supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin B6 (pyridoxine) physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin B6 physiology and biochemistry Dietary vitamin B6 intake in chronic kidney disease patients Nutritional status of vitamin B6 in advanced chronic kidney disease, chronic dialysis, kidney transplant, and acute kidney ... Clinical significance of vitamin B6 deficiency in chronic kidney disease Vitamin B6 and oxalate metabolism in chronic kidney disease Vitamin B6 supplementation in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin C (ascorbic acid), physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin C physiology and biochemistry Dietary vitamin C (ascorbic acid) intake in chronic kidney disease patients Vitamin C nutritional status in advanced chronic kidney disease, chronic dialysis, kidney transplant, and acute kidney inju... Scurvy in chronic kidney disease patients The oxalate burden in chronic kidney disease Vitamin C and anemia management in chronic kidney disease Vitamin C, inflammation, oxidant stress, and endothelial dysfunction in chronic kidney disease Vitamin C in critically ill patients Vitamin C supplementation in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Folate (vitamin B9), physiology, biochemistry, and nutritional status in chronic kidney disease patients Folate physiology and biochemistry Dietary folate intake in chronic kidney disease Folate nutrition in advanced chronic kidney disease, chronic dialysis, kidney transplant, and acute kidney injury patients Clinical consequences of folate nutriture in advanced chronic kidney disease Folate and anemia Folic acid, Hcy, and methylenetetrahydrofolate reductase gene polymorphisms Folate supplementation in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Vitamin B12, physiology, biochemistry, and nutritional status in chronic kidney disease patients Vitamin B12 physiology and biochemistry Vitamin B12 intake in chronic kidney disease Nutritional vitamin B12 status in advanced chronic kidney disease and chronic dialysis patients Vitamin B12 and anemia management in chronic kidney disease Vitamin B12 and Hcy Vitamin B12 supplementation in advanced chronic kidney disease, chronic dialysis, kidney transplant, and acute kidney injur... Niacin (vitamin B3) physiology, biochemistry, and nutritional status in chronic kidney disease patients Niacin physiology and biochemistry Dietary niacin intake in chronic kidney disease Nutritional niacin status in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Clinical syndromes involving niacin in acute kidney injury and chronic kidney disease patients Niacin supplementation in chronic kidney disease, chronic dialysis, kidney transplant, and acute kidney injury patients Biotin (vitamin B8) physiology, biochemistry, and nutritional status in chronic kidney disease patients Biotin physiology and biochemistry Dietary biotin intake in chronic kidney disease Nutritional biotin status in advanced chronic kidney disease and chronic dialysis patients Biotin supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients Pantothenic acid (vitamin B5) physiology, biochemistry, and nutritional status in chronic kidney disease patients Pantothenic acid physiology and biochemistry Dietary pantothenic acid intake in chronic kidney disease Nutritional status of pantothenic acid in advanced chronic kidney disease, chronic dialysis, and kidney transplant patients Pantothenic acid supplementation in chronic kidney disease, chronic dialysis, and kidney transplant patients General comments regarding vitamin supplements in kidney disease Conclusion References 27 Trace elements, toxic metals, and metalloids in kidney disease Introduction Trace elements Definitions Trace element functions Overview of trace elements in kidney disease Alterations in essential trace elements in patients with chronic kidney disease Zinc (Zn) Zn distribution Zn functions Zn measurements Zn toxicity Zn deficiency Zn in kidney disease Zn and chronic kidney disease Zn and hemodialysis Zn and peritoneal dialysis Zn and continuous renal replacement therapy Zn and kidney transplantation Zn supplementation Copper (Cu) Cu distribution Cu functions Cu measurements Cu toxicity Cu deficiency Cu and kidney disease Cu and acute kidney injury Cu and dialysis treatment Manganese Selenium Boron Chromium Fluoride Cobalt Silicon Alterations in nonessential trace elements, metals, and metalloids in patients with kidney disease Aluminum Antimony Arsenic Cadmium Gadolinium Germanium Lanthanum Lead Mercury Molybdenum Nickel Strontium Vanadium Trace element abnormalities in renal-specific syndromes Diagnostic and therapeutic approaches Conclusion References V. Nutritional management of clinical conditions associated with kidney disease 28 Nutritional and nonnutritional management of the nephrotic syndrome Introduction Albumin homeostasis in the nephrotic syndrome Dietary protein Effects of the nephrotic syndrome on solid tissue proteins Dietary proteins as potential allergens responsible for renal disease Effects of lipids on renal disease and nephrotic syndrome Disordered lipoprotein metabolism in the nephrotic syndrome The effect of altered glomerular permselectivity on lipid metabolism Cardiovascular effects of hyperlipidemia in the nephrotic syndrome Thromboembolic complications The role of polyunsaturated fatty acids Derangements in divalent cation metabolism in the nephrotic syndrome Derangements in salt and water metabolism in the nephrotic syndrome (volume homeostasis) The management of edema Recommendations for nutritional and nonnutritional treatment of the nephrotic syndrome The role of dietary protein modification in the management of the nephrotic syndrome Hyperlipidemia Antioxidants Acknowledgments References 29 Nutritional approaches and plant-dominant diets for conservative and preserv