ACUTE AND CHRONIC NEPHRITIS
Nephritis is a disease of the kidneys, in which changes occur in the
tissues of the organs themselves; these changes may be caused by
inflammation of the kidneys and renal passages brought on as results
of the retention of certain poisonous substances in the blood, or from
the action of specific bacteria. The disease may be acute or chronic
in form and develop as a result of prolonged exposure to cold and wet,
of tonsillitis, scarlet fever, typhoid fever, and to a less extent of
malaria, syphilis, pregnancy, and tuberculosis, as well as from the
effects of certain irritating drugs, such as cantharides and
turpentine.
~Directing the Treatment.~--In any case the treatment must be directed
toward the relief of the acute symptoms in the beginning and followed
up by a general treatment which will tend to strengthen and relieve
the overtaxed organs and to increase their power to functionate
normally.
~Causes and Effects.~--In acute nephritis, the chief symptoms are
uremia, and edema; the urine is materially diminished in quantity and
at times suppressed; it is often found to be rich in albumen and
containing hyaline and blood casts, red and white blood cells, and
various pigments.
In chronic nephritis, which may be the result of an acute attack, or as
a sequel of other diseases already mentioned, there is seen to be a
progressive loss of flesh and strength, marked anemia, gastro-intestinal
disturbances, increased blood tension and edema, the latter especially
in the face on arising in the morning. Uremia may develop at any time.
~Limiting the Work of the Kidneys.~--In both acute and chronic
nephritis, great effort must be put forth to relieve the tax upon the
kidneys and to stimulate their functioning power.
In other diseases, in which definite organs are involved, the
treatment consists chiefly of resting the affected parts (1) by
starvation, (2) by deflecting the work to other organs when it is
possible, chiefly by changing the diet until the disturbance is
overcome. This is generally effectual in most cases, as has been
specially demonstrated in the treatment of gastro-intestinal diseases.
~Problems to Be Considered.~--But in nephritis, there are other
problems to consider, which make it impossible to institute such a
treatment as will effect a perfect rest of the renal organs. The
kidneys represent the chief source whereby the waste products of the
body are eliminated. This waste consists not only of the end-products
of the nitrogenous foods ingested, but also the end-products of tissue
metabolism, which is the inevitable result of the wear and tear of
life. Hence, when the functions of the kidneys are disturbed, these
products, often toxic in character, are retained instead of excreted.
Thus instead of forming normal constituents of the urine they find
their way into the general circulation, exerting a damaging effect
upon the tissues, especially of the kidneys with which they are
brought into such direct contact.
~Substances Difficult of Excretion.~--It has been proved that the
kidneys in nephritis find it difficult to excrete certain substances,
namely, urea, water, salts, and the purin bodies. Many authorities
claim that the uremia manifested in acute nephritis is the result of
the retention of end-products of the protein metabolism already
mentioned and that the edema is due to a like retention of water and
salts. The greatly diminished quantity of urine voided during the
acute attack would seem to prove this theory. Martin Fisher,[114]
however, claims the condition to be due to an acidulation of the
tissues with a consequent osmosis of water, and directs his treatment
to overcome this condition, not by restricting the quantity of water
and salt, as is generally practised, but by injecting a saline
solution into the body in large quantities with the effect of
increasing the flow of urine by concentrating the salt content of the
blood and therefore its osmotic power. The fluids are withdrawn from
the tissues, thus adding fluidity to the blood stream, which in turn
flushes the kidneys, ridding them of the poisons which interfere with
their normal functioning.
~Adjusting the Diet.~--The uremia and edema must be relieved. Since it
is an undisputed fact, in the majority of cases, that good results
from the regulating of the diet so as to minimize as far as possible
the work of the kidneys, the various diet cures will be included here.
~Milk Cure.~--Milk, as a rule, forms a basis of most of the nephritic
diets chiefly because of its low salt and protein content and on
account of its non-toxic end-products.
The percentage of water in milk is likewise known and for this reason
the fluid content of a milk diet can be easily calculated. However, it
is also true that the greatest drawback to a diet consisting solely of
milk is the large amount of water therein compared with its nutrient
value.
~Resting the Kidneys.~--During the acute stage of nephritis the
kidneys are given as much rest as possible by eliminating all food and
restricting the amount of water entering the body. The thirst is
relieved by small sips of plain or carbonated water or by ice pellets
held in the mouth, or, as is sometimes necessary, by injections of
water into the rectum.
~Adjusting the Fluids.~--The amount of fluid, however, must be
adjusted to meet the condition of the patient, taking into
consideration the amount of urine voided and the uremic symptoms
manifested. If the urine is not suppressed the amount of water taken
may be slightly in excess of the urine voided, thus promoting
diuresis. In many cases an excellent diuretic drink consisting of one
pint of water and one teaspoonful of cream of tartar with a half a
lemon and perhaps a little sugar, serves the purpose of relieving the
thirst, which is at times acute during this period.
The extent of the starvation treatment must depend upon the patient
himself. As a rule, however, it is not carried out longer than two
days, after which milk may be substituted, allowing from twenty to
thirty ounces per day, which is as much fluid as an ordinary nephritic
patient can handle.
The regulation nephritic diet, which is bland in character, contains
nothing that will tend to increase the irritation and inflammation of
the kidneys, and furnishes a certain amount of nourishment when the
symptoms of the disease warrant the giving of any food other than
milk.
The following diets used in cases of high urea or severe hypertension:
LOW PROTEIN DIET[115]
-------------------------------+---------+---------------+----------
|_Protein_|_Carbohydrates_| _Fats_
| _Grams_ | _Grams_ | _Grams_
-------------------------------+---------+---------------+----------
Breakfast: | 6.7 | 160 | 51
Cooked Farina (100 grams)| Total calories for day, 1192
Butter ( 20 grams)| | |
Fruit (100 grams)| | |
Lactose ( 30 grams)| | |
| 200 grams of fruit juice
| served between meals
| | |
Dinner: | | |
Asparagus (100 grams)| | |
Butter ( 20 grams)| | |
Fruit (100 grams)| | |
Lactose ( 30 grams)| | |
| | |
Supper: | | |
Carrots (100 grams)| | |
Fruit (100 grams)| | |
Butter ( 20 grams)| | |
Lactose ( 30 grams)| | |
-------------------------------+---------+---------------+----------
PROTEIN FREE DIET
-------------------------------+---------+---------------+----------
|_Protein_|_Carbohydrates_| _Fats_
| _Grams_ | _Grams_ | _Grams_
-------------------------------+---------+---------------+----------
Breakfast: | | |
Protein-free cookies[116] (5)| | |
Fruit juice (100 grams)| 0 | 166.5 | 39
Lactose ( 15 grams)| | |
| | |
| | |
Dinner: | | |
Protein-free cookies (5)| Total calories, 1045
Fruit juice (100 grams)| | |
Lactose ( 15 grams)| | |
| | |
Supper: | Each cookie weighs 10 grams
Protein-free cookies (5)| | |
Fruit juice (100 grams)| | |
Lactose ( 15 grams)| | |
-------------------------------+---------+---------------+----------
Doctors Chase and Rose advise farina used more frequently than
oatmeal, and the plain cream soup, rice or potato, more often than
soups made of celery or asparagus (the latter used to break the
monotony). They also advise the more frequent use of green string
beans and asparagus in preference to other vegetables.
~Elimination of Salt.~--In many cases of nephritis, especially those
belonging to the parenchymatous type, the kidneys manifest a
difficulty in eliminating salt, and instead of excreting the normal
quantity, find it impossible to eliminate more than two or three grams
or less a day. The retained salts pass into the fluids of the tissues,
giving rise to or increasing the already existing edema. Tests[117]
have been devised to find the extent of the kidney function to excrete
salt. The following diets are among those commonly used:[118]
3 liters of milk (this contains 5 gm. sodium chloride and 100 gm.
protein)
or
Strauss Diet, consisting of 3/4 liter milk, 4 eggs, 150 gm. bread, and
enough fruit and fruit juice, tea and sugar to make it palatable.
(This diet contains about 3 gm. of salt.)
If the kidneys are able to excrete the amount of salt contained in
these diets, salt may be added in quantities of from 5 to 10 grams.
~Salt-poor Diets.~--When the kidneys are unable to eliminate the
normal amount of salt, some of the salt-poor diets should be advised.
Coleman claims,[119] however, that these diets have not fulfilled the
promises held out by them. Coleman groups the salt-poor diets under
three headings:
(1) ~The strict salt-poor diet~, of which Widal's diet is an example.
(2) ~The medium strict salt-poor diet~, allowing from 2.5 to 5 grams
of salt a day. Under this heading the milk diet was placed, in which 2
to 3 grams of salt is served a day at table.
(3) ~The moderate salt-poor diet~, in which from 5 to 10 grams of salt
are allowed each day. In using this diet it is not necessary to
prepare a special menu for the patient, but take precautions to leave
the salt shaker off the tray and exclude bacon, ham, and other salty
foods from the dietary.
~Limiting the Amount of Food.~--It must be kept in mind that the
nephritic condition makes it imperative to fall below rather than
exceed the food requirements of the individual.
WIDAL'S DIET[120]
Salt-free bread 200 gm.
Meat (beef, chicken, or mutton) 200 gm.
Vegetables (beans or rice), salt-free 250 gm.
Butter, salt-free 50 gm.
Sugar 40 gm.
Contains 60 grams of protein, 1 to 2 grams of NaCl, and furnishes
approximately 1500 calories.
Strouse and Perry arranged a dietary from the above diet as follows:
8 A.M. Bread, 60 grams; lamb chop, 50 grams; butter,
10 grams; rice, 100 grams; sugar, 40 grams.
12 M. Bread, 60 grams; roast beef, 100 grams; butter,
20 grams; beans, 150 grams.
5 P.M. Bread, 80 grams; butter, 20 grams; chicken, 50
grams.
HALPIN'S SALT-FREE NEPHRITIC DIET
Milk, 1500 to 2000 c.c., white salt-free bread, 400 to 500 grams;
salt-free butter, 40 grams; eggs, 4 to 6. This diet contains from 5 to
6 grams of salt.
KARELL CURE
Karell has devised the milk cure, which is used possibly more than any
other diet. It not only furnishes a dietary regime, which is used in
nephritis, but it is likewise advocated in organic diseases of the
heart and blood vessels.
~Methods of Administering the Karell Cure.~--The cure is begun by
giving from 3 to 6 ounces of milk three or four times a day. Karell
makes a point of using small quantities to begin with and having the
milk skimmed. The milk is given at regular intervals, is warmed in
winter and given at room temperature in the summer. It may be given
plain or diluted with limewater. After a week if the stools remain
solid, the daily allowance of milk is increased to two quarts.
Constipation is an indication of the agreement of this diet and the
patient's utilization of the milk. If, however, he manifests
gastro-intestinal disturbances, resulting in diarrhea, the amount must
be temporarily reduced. Karell advocates boiling the milk and
relieving the constipation with enemas or mild laxatives. The addition
of small quantities of coffee to the morning portion of milk, or of
stewed prunes or a baked apple to the afternoon feeding, also tends
to overcome the condition.
~Thirst.~--The extreme thirst may be relieved by adding plain water,
limewater, or seltzer to the feedings.
If during the second or third week of the cure the hunger becomes too
great for the patient to endure, a small piece of herring or stale
bread may be given.
Once a day a milk soup thickened with a cereal may be given. The above
diet is carried out from five to six weeks, after which the patient is
gradually returned to a normal diet. Milk, however, should still
constitute an important part of the diet. The Karell cure is modified
more or less to meet the condition of the patient, the amount of milk
administered in some cases being more and in others considerably less
than mentioned in the above regime.
~Limiting the Proteins.~--The extent of the damage caused by the
end-products of protein metabolism cannot be easily estimated, but it
is wise not to err on the side of an over-supply, since the retaining
of these materials in the body gives rise to a certain type of
intoxication (uremic poisoning).
~Relative Toxicity of the Animal Proteins.~--The difference between
the various animal proteins as to their relative toxicity has been the
subject of much discussion. As far as their nutrient value is
concerned, they are practically the same, that is, the protein of beef
and the protein of chicken show very similar analyses. The beef
contains, however, more extractives, which we know are high in purins.
These substances have proven detrimental to the welfare of a nephritic
patient.
~Selection and Preparation of Foods.~--For this reason the so-called
red meat is sometimes boiled instead of roasted, as the latter mode of
preparation increases the formation of purins on the brown outer
surfaces of the meat. Chicken and fish contain less purin bases and
for this reason are often included in the diet when beefsteak and
lamb chops are excluded. Meat soups and broths contain little nutrient
value, consisting as they do chiefly of water, salt, and extractives,
all of which are looked upon with disfavor, and classed with the
offending articles of food in the nephritic diet. Cream soups, except
bean or pea soup,[121] may be given in moderation. They are non-toxic
in character and of high nutrient value, furnishing a valuable
addition to the diet when the gastro-intestinal symptoms permit of
such addition.
CONVALESCENT NEPHRITIC DIET[122]
~Advisable Foods.~--The following foods are used in the formation of
diet for an advanced convalescent nephritic patient when not otherwise
contraindicated:
Cereals, potatoes, rice, green vegetables and salads, fruits, fresh
and stewed, ham, bacon, or beef once or twice a week, chicken, lamb,
or mutton[123] several times a week, simple desserts, such as junket,
prune or fig whip, orange, lemon, grape, pineapple or apricot
gelatin, bread, rice or tapioca pudding, plain vanilla ice
cream.[124]
~Foods to Be Avoided.~--The following foods are avoided except the
meats, which must be given not more than once to three times a week,
as directed by physician:
Meat broths, especially those made from commercial meat extracts,
bouillon cubes, etc.
Strong tea or coffee.
Alcoholic beverages, unless especially prescribed by the physician.
Liver, kidney, sweetbreads.[125]
Meat croquettes and other made dishes.
Rich sauces or gravies.
Condiments and spices of all sorts.
Rich pastries.
The salt must be limited and water and other fluids restricted.
~Sample Diet Sheets.~--The following menus[126] formulated from the
above diet list are suggested:
~No. 1.~--8 A.M. Sliced oranges, cream of wheat with
cream, buttered toast, cocoa.
10:30 A.M. 6 ounces of milk with crackers.
12:30 P.M. Cream of spinach soup, rice, string beans,
orange gelatin, bread and butter.
3 P.M. 6 ounces of buttermilk with crackers.
6 P.M. Cereal and cream, baked potato, apple sauce,
cocoa, bread and butter.
~No. 2.~--8 A.M. Stewed prunes, wheatena and cream,
milk or dry toast with butter, cocoa.
10:30 A.M. 6 ounces of malted milk with crackers or 1
slice of zwieback.
12:30 P.M. Cream of corn soup, mashed potatoes, beet
tops or mustard greens, lettuce salad, dressing made with
lemon juice and olive oil, rice pudding.
3 P.M. 6 ounces of orange or grape juice with crackers.
6 P.M. Cream toast, sliced peaches, cocoa.
~No. 3.~--8 A.M. Half a grapefruit, farina and cream,
toast and butter, cocoa.
10:30 A.M. 6 ounces of buttermilk with crackers.
12:30 P.M. Cream of tomato soup, creamed potatoes,
buttered beets, celery salad, apple tapioca pudding, bread
and butter.
3 P.M. 6 ounces of milk with crackers.
6 P.M. Ralston's Health Food with cream, baked potato,
tomato salad, toast and butter, cocoa.
~No. 4.~--8 A.M. Stewed prunes, grits and cream, toast and butter,
cocoa.
10:30 A.M. 6 ounces of malted milk with crackers.
12:30 P.M. Cream of asparagus soup, creamed cauliflower, boiled rice,
lettuce salad, bread and butter, pineapple gelatin.
3 P.M. 6 ounces of orange juice with crackers or zwieback.
6 P.M. Creamed toast, escalloped potatoes, fruit salad, toast, cocoa,
and cocoa junket.
CHRONIC NEPHRITIS (BRIGHT'S DISEASE)
Chronic nephritis may develop as a sequel to an acute attack, and an
individual suffering from chronic nephritis may at any time develop
acute symptoms. In any case the dietetic treatment would necessarily
have to be made to cover the existing symptoms.
~Dietetic Treatment.~--In cases where the patient has entirely
recovered from uremia but still manifests symptoms of water and salt
retention, the diet would be naturally directed to cover the latter,
at the same time taking care not to strain the weakened functions by
giving more food than could be readily handled. The water and salts
still have to be restricted, but a certain amount of fat and
carbohydrate with small additions of nitrogenous food materials may be
added from time to time as the kidneys show improvement. It must be
borne in mind, however, that at this time it is very easy to overtax
the renal organs and it is safer to err on the side of under rather
than over feeding.
The logical treatment, therefore, consists of utilizing the improved
functions while those still failing to react are getting further rest.
~Adjusting the Proteins in Diet.~--If the individual shows a definite
anemia, as is often the case after acute attacks, either as a result
of the disease itself or the necessarily low diet, which the acute
symptoms of uremia and edema made necessary, other measures are
necessary to bring the body back to a normal condition. It has been
found that in these cases where there has been no permanent damage to
the renal organs, but merely a temporary impairment of the functioning
power, the treatment must be, first, a rest to the affected parts;
second, the temporary restriction of all articles of food which impose
a tax on the kidneys to eliminate; the third, the gradual return to
normal diet as the acute symptoms decrease and the function of the
kidneys no longer shows impairment. Such a case is cited by Strouse
and Perry[127] as occurring in the Michael Reese Hospital. Mr. X.
recovered from the acute stage of nephritis and all signs of edema and
uremia disappeared; the man was kept on a low salt and low protein
diet for a long time. His urine was clearing up, but he did not feel
up to standard and remained anemic. Thinking in all probability that
his symptoms were due to a low protein diet, meat was slowly added to
his dietary until he was receiving 60 grams of protein a day. There
was an immediate general improvement in his condition with no
increased renal disturbance. It is an obvious fact that chronic
nephritis, like any other chronic condition, requires a different
method of treatment from that practised to relieve the acute stage.
The very fact that it is chronic proves that the strenuous methods are
neither necessary nor wise.
~Testing the Kidney Functions.~--The authorities of to-day endeavor to
ascertain the extent of the damage to the renal organ by testing its
functioning power. These renal function tests have been the subject of
much interest and investigation. Probably the ones most commonly
employed are those devised by Hedinger and Schlayer[128] and adapted
for use in the Johns Hopkins Hospital by Mosenthal.
~Diets Used in Tests.~--The diet employed in making these tests
consists of different amounts of certain substances known to be
diuretic in character. This diet is rigidly adhered to and a careful
analysis of the urine passed, the total quantity and specific gravity
of each specimen made and in this way the various functions of the
kidneys and the impairment thereof are tested. Thus an intelligent
adjustment of the diet may be made.
~Renal Functional Tests.~--The following schedule is used by
Mosenthal, of the Johns Hopkins Hospital, in making what is known as
the "Two-Hour Test for Renal Function":
HEDINGER-SCHLAYER-MOSENTHAL DIET[129]
For _________________
Date _________________
All foods to be salt-free from the diet kitchen, salt
for each meal will be furnished in weighed amounts.[130]
All foods or fluids not taken must be weighed or
measured after each meal and charted in spaces below.
Allow no food or fluid at any time except at meal times.
Note any mishaps or irregularities that occur in giving
the diet or collecting the specimens.
Breakfast 8 A.M. Boiled oatmeal 100 grams
Sugar 1 to 2 teaspoonfuls
Milk 30 c.c.
2 slices of bread 30 grams each
Butter 20 grams
Coffee 160 c.c. }
Sugar 1 teaspoonful } 200 c.c.
Milk 40 c.c. }
Dinner--Noon Meat soup 180 c.c.
Beefsteak 100 grams
Potatoes, boiled, mashed
or baked 130 grams
Green vegetables as desired
2 slices bread--each 30 grams
Butter 20 grams
Tea, 180 c.c. }
Sugar, 1 tsp. } 200 c.c.
Milk, 20 c.c. }
Water 250 c.c.
Pudding, tapioca or rice 110 grams
Supper 5 P.M. 2 eggs cooked any style
2 slices of toast 30 grams each
Butter 20 grams
Tea, 180 c.c. }
Sugar, 1 tsp. } 200 c.c.
Milk, 20 c.c. }
Fruit, stewed or fresh 1 portion
Water 300 c.c.
8 A.M. No food or fluid is to be given during the night
or until 8 o'clock next morning (after voiding) when the
regular diet is resumed.
Patient is to empty bladder at 8 A.M. and at the end of
each period as indicated below. The specimens are to be
collected for the following periods in properly labeled
bottles:
8 A.M. to 10 A.M.; 10 A.M. to 12 Noon; 12 Noon to 2
P.M.; 2 P.M. to 4 P.M.; 4 P.M. to 6 P.M.; 6 P.M. to 8
P.M.; 8 P.M. to 8 A.M.
~Chart Used in Johns Hopkins Hospital.~--The following chart is
inserted here to show the method used in the Johns Hopkins Hospital
for carrying out the Two-hour Renal Test:
===============+==================+==================+==================
| _Urine_ | _NaCl_ | _Nitrogen_
_Time of Day_ +-------+----------+----------+-------+----------+-------
| |_Specific_| | | |
|_C.C._ |_Gravity_ |_Per cent_|_Grams_|_Per cent_|_Grams_
---------------+-------+----------+----------+-------+----------+-------
| | | | | |
8 A.M.-10 A.M.| | | | | |
10 A.M.-12 Noon| | | | | |
12 Noon-2 P.M. | | | | | |
2 P.M.-4 P.M. | | | | | |
4 P.M.-6 P.M. | | | | | |
6 P.M.-8 P.M. | | | | | |
8 P.M.-8 A.M. | | | | | |
Total day | | | | | |
Night, 8 P.M. | | | | | |
to 8 A.M. | | | | | |
Total 24 hours | | | | | |
Intake of fluid| | | | | |
NaCl | | | | | |
===============+=======+==========+==========+=======+==========+======
Urine to be collected punctually every two hours and kept in the
ice-box, every specimen having twenty drops of tutuol added to insure
preservation.
Another ~modification of the Hedinger-Schlayer diet~ is used in the
~Peter Bent Brigham Hospital~,[131] Boston, Massachusetts, as follows:
7 A.M. Coffee, milk, sugar, toast, and butter.
10 A.M. Milk, toast, and butter.
12:30 P.M. Bouillon, broiled steak, butter, mashed potatoes, toast,
coffee, milk, sugar.
4 P.M. Tea, milk, sugar, crackers.
7 P.M. Soft egg, blanc-mange (1 egg, sugar, cornstarch, and milk)
and cream. Amounts sufficient to give 2500 calories, 1500
c.c. fluid, 76 grams of protein, 127 grams of fat, 245
grams of carbohydrate, and from 5 to 8 grams of sodium
chloride.
On two days previous to the test the patient usually had a diet
containing 2000 calories, 75 grams of protein, 4 grams of sodium
chloride.
The test diet is a mixed diet containing known amounts of water,
nitrogen, and chloride, together with the food diuretics (purins,
salt, and water), as can be seen. The diet is divided into unequal
portions containing known but varying amounts of fluid, nitrogen, and
salt. Two-hour specimens are collected from 7 A.M. to 9 P.M., and one
night specimen is obtained containing all the urine passed between 9
P.M. and 7 A.M. Each specimen is analyzed for volume, specific
gravity, total nitrogen, nitrogen concentration, total chloride, and
chloride concentration.
~Purpose of Tests.~--The purpose of the test is to find out to what
extent and in what manner the diseased kidney under stimulation by the
various diuretics taken in the food reacts in putting out the varying
amounts of salt.
Dr. O'Hara likewise describes another test known as ~The Added Urea
and Salt Test~, which was first described by von Monakow and also
carried out in the Peter Bent Brigham Hospital. The method used was as
follows:
ADDED UREA AND SALT TEST
Patient is given 75 grams of protein, 4 grams of sodium chloride, and
1500 c.c. of water, with a caloric value of from 2000 to 2200
calories. After the output of fluid, salt and nitrogen reaches an
equilibrium on this diet on one day 10 grams of additional salt is
given and several days later the patient receives 20 grams of urea.
This order may be reversed. The daily output of urine, salt, and
nitrogen is determined and charted. After the salt and nitrogen is
added to the diet in normal individuals, their excretion after
forty-eight hours returns to its previous level. In diseased kidneys
this may not be the case.
~Value of Tests.~--Thus it is seen that in these tests for kidney
functions, an effort is made to determine the extent of damage wrought
by the disease upon the renal organs and the manner in which they
react under definite circumstances. However, it is not so simple as it
would seem to formulate a dietary based on the findings resulting from
the renal tests. Notwithstanding this, these tests are coming more and
more into use, both in hospitals and private practice, and a nurse
must understand just how they are carried out, and must realize that
unless her part is performed with absolute accuracy the entire value
of the test will be obliterated. Too much stress cannot be laid upon
this phase of the test, if it is to be of any value whatsoever in
determining the condition of a diseased kidney.
CHRONIC INTERSTITIAL NEPHRITIS
This form of nephritis is more insidious in character, developing more
slowly and manifesting different characteristics, than those seen in
some of the other types already mentioned. The condition is, as a
rule, associated with heart symptoms and high blood pressure. The
blood shows an increase in urea and other end-products of protein
metabolism, whereas there is no manifest change in the metabolism of
salt or water. The great increase in volume of urine voided would show
an inability on the part of the kidneys to eliminate a highly
concentrated urine. This hypothesis is further demonstrated in the
urine tests.
~Urinalysis.~--Upon analysis the urine in these cases shows less
albumen and fewer casts than found in other types of nephritis. The
disease is manifested by slight headache, gastric disturbances, and a
frequent desire to urinate.
~Dietetic Treatment.~--The treatment here depends upon the extent of
the impairment of the functions of the kidney. If the damage is not
extensive and the diagnosis has been sufficiently early to insure
prompt improvement upon treatment, the diet is so directed as to
prevent the occurrence of any of the acute symptoms. The patient is
warned against overeating and drinking, over-exercise and nervous
excitement. When it is possible, a change to a warm, dry climate is
advisable with more rest and sleep and less work and worry. He is
advised to eat less at meals and if hungry to eat a light lunch of
milk or buttermilk with crackers in the mid-morning. The same dietary
precautions must be taken in these disturbances as in other nephritic
conditions, keeping always in mind the fact that the kidneys are the
chief organs of excretion in the body, and through them must pass the
majority of all end-products of nitrogen metabolism.
~Limiting the Nitrogen.~--The nitrogenous foods cannot be eliminated
entirely, especially if, as is often the case, the individual suffers
from chronic nephritis and is up and about attending to business; but
they can be judiciously regulated in the diet. All such foods as fried
foods, rich pastries, rich sauces and gravy, spices of all kinds, tea
and coffee, celery and asparagus, must be avoided.
~Limiting the Fluids.~--von Noorden limits the amount of fluid to
1-1/4 liters per day. This does not include the water content of the
various foodstuffs. He advises a period of observation to determine
the amount best suited to the condition of the patient and reducing
this amount from 250 to 150 c.c. a day until the desired quantity is
reached. He advises a drinking day once a week, allowing the patient
to drink as much water as he likes.
~Development of Uremia.~--Whenever evidences of uremia appear the
treatment must be changed to meet the condition. It is necessarily
more strenuous than that used ordinarily in the chronic nephritis. If
the uremia becomes positive, then the treatment laid down for acute
nephritis already described must be at once instituted. The patient
must be put to bed at once and every effort made to assist the body in
getting rid of the causes.
In certain cases of nephritis, in which uremic poisoning is due to the
retention of the end-products of nitrogen metabolism, or to the toxins
formed as a result of the tissue changes due to the disease, the water
then instead of being restricted in the dietary is greatly increased
to encourage a free diuresis with a consequent washing out of the
accumulated poison. Certain authorities recommend a strict milk and
water diet, as has already been described in the beginning of the
chapter. A light or soft diet is advised until the condition improves,
resting the renal organs as far as possible. This diet may consist of
fruit juices, strained cereals with cream, cocoa, milk, buttermilk,
toast, butter, strained apple sauce, cream soups, except those made
with beans or peas. The above diet is gradually increased by adding a
mashed or baked potato, well-cooked green vegetables, stewed or raw
fruit, rice and tapioca pudding, and chocolate blanc-mange.
~Selection and Preparation of Food.~--The preparation of foods for the
nephritic differs in certain particulars from that used in other
pathological conditions, namely, the restriction of certain food
constituents; dishes made with meat and eggs are cut out of the diet,
and salt is used as sparingly as possible, when it is used at all. The
nurse must weigh or measure out the maximum quantity allowed and
divide this in portions for each feeding, measuring carefully any that
is not used and charting it. In this way it is possible to increase or
decrease the amount according to the symptoms of the individual. The
water content of the various foods comprising the diet is, as a rule,
not considered, but it is necessary to adhere strictly to the orders
of the physician and to curtail the beverages, water, tea, coffee,
etc., until the amount conforms to that laid down in the dietary.
The nitrogenous foods, with the exception of milk, are as a rule
eliminated from the nephritic diet. The nurse must study the tables
and learn which food materials come under this head. It may seem
difficult to prepare diet for the sick without eggs, but it is
possible and at times obligatory.
~Combating Anemia.~--In chronic (ambulatory) nephritis the anemia must
be reckoned with. It is not safe to upset the nitrogen equilibrium of
the body, but it has been proved that this may be maintained on as
little as 30 or 40 grams of protein a day. This will be seen not to be
difficult to obtain when milk forms an important part of the diet. The
wheat and oat cereals, as well as the bread, contain protein, and a
judicious use of these foods will enable the nurse to give her patient
the necessary quantity to offset, in a measure, the anemia which is at
times most troublesome.
~Advice to Patient.~--One important point must be observed by the
nurse and impressed upon the patient when he leaves her care. This is
moderation in the amount of food eaten. The kidneys must never be
overtaxed, even with foods which in themselves seem harmless. As
danger lies in overindulgence, this point cannot be too strongly
emphasized.
~Advice to the Nurse.~--The use of the formulas included in this text
is left to the discretion of the nurse. In those calling for
seasoning, such as pepper, mustard, etc., the condiments must be
omitted. A small amount of celery salt may be substituted in certain
instances if the dish is unpalatable without something of the kind. In
cases where the salt is restricted the dishes are prepared as
directed, with the exception of the salt. The recipes calling for eggs
and meat are not to be used unless directed by the physician.
Cornstarch, sago, and tapioca may be used instead of gelatin. The
following menus may be used as guides in selecting foods to prepare
for the nephritic patient after the rigid regime is to a certain
extent relaxed:
FULL NEPHRITIC DIET (NITROGENOUS FOODS RESTRICTED)
BREAKFAST
Grapefruit, orange, prunes, pears, peaches, or strawberries.
Cereals: cream of wheat, farina, Pettijohn's, Ralston's, hominy,
grits, and oatmeal with cream.
Toast, buttered or creamed.
Cocoa, tea, or coffee, as directed by the physician.
DINNER
Milk or cream soup, well-cooked green vegetables with butter or cream
sauce.
Potatoes, white or sweet, baked, mashed, or boiled, with butter, bread
or rolls.
Stewed tomatoes, rice.
Salads: lettuce, tomato, romaine, chicory, or fruit salad, with a
dressing of oil and lemon, or cream and lemon.
Simple desserts: junkets, cornstarch, sago or tapioca pudding, baked
bananas, rice pudding, apple tapioca, orange tapioca, and ice cream.
Beverages: cocoa or tea, as directed by the physician.
SUPPER
Cereals and cream.
Baked or escalloped potatoes.
Baked or stewed apples.
Salads, excepting those made with meat or eggs.
Junket, raw or stewed fruit.
Toast or rolls with butter.
Cocoa.
Meat, fish or poultry once a day.[132]
BREAKFAST
Stewed or fresh fruit.
Cereals with cream.
Toast with butter.
Cocoa, milk, or tea.
DINNER
Cream soups.
Boiled chicken or fish.
Potatoes, white or sweet.
Green vegetables.
Salads, except with meat or eggs.
Simple desserts.
Rolls or bread and butter.
Milk or buttermilk.
SUPPER
Cereals or rice with cream or butter.
Baked or escalloped potatoes.
Stewed or escalloped carrots.
Salads, except those made with meat or eggs.
Fresh or canned pears, cherries, or pineapple.
Bread pudding, junkets, or cornstarch blanc-mange.
Bread, rolls, or toast, with butter.
Cocoa, milk, tea, or buttermilk.
TABLE
SALT CONTENT OF FOOD[133]
According to Leva
Analysis marked thus: * from Atwater & Bryant.
====================================================
_Per Cent. of Sodium_
_Chloride in_
_Raw Material_
_Meats_
Mutton 0.17
Veal 0.13
Calf's brains 0.20
Calf's kidney 0.32
Calf's liver 0.14
Beef (lean) 0.11
Pork (lean) 0.10
_Fish_
Trout 0.12
Halibut 0.30
Herring 0.27
Cod 0.16
Carp 0.086
Salmon 0.061
Mackerel 0.28
Haddock 0.39
_Poultry_
Duck 0.14
Goose 0.20
Chicken 0.14
Pigeon 0.15
Turkey 0.17
Venison 0.11
Oysters (washed) 0.52
Oysters (with sea water) 1.14
_Prepared Foods_
Plasmon 0.21
Roborat 0.0051
Sanatogen 0.42
Somatose 0.66
Bovril's preparations 0.26-14.1
Valentine's meat juice 0.08-1.20
Egg (white and yolk) 0.21
Egg (white alone) 0.21
Egg (yolk alone) 0.039
Caviar 3.00
Milk (whole) 0.16
Cream 0.13
Buttermilk 0.16
Whey 0.11-0.15
Condensed milk 0.40
Butter (unsalted) 0.02-0.21
Butter (salted) 1.00-3.00
Peanut butter 4.10
Oleomargarine 2.15
Palmin 0.0016
Fructin 0.10
_Smoked and Salted Foods_
Ham (raw) 4.15-5.86
Ham (boiled) 1.85-5.35
Salmon (smoked) 7.50
Bacon (smoked) (German) 1.01
Bacon (smoked) (American) 11.61
Corned beef (German) 2.04
Corned beef (American) 11.52
Cod (salt)* 23.50
Cod (salt, boneless)* 10.00
Herring (smoked) 11.70
Mackerel (salt dressed) 10.40
Salmon (salted, smoked) 10.37
Sardines (French in oil) 1.34
Cod liver oil 0.17
Gelatine (dry) 0.75
Beef marrow 0.11
Sausages (Frankfurters) 2.20
Sausages (various kinds) 2.90-8.10
Anchovy paste (Cross &
Blackwell's) 40.10
_Meat Extracts_
Liebig's 2.60
Kemmerich's 1.40
Various bouillon capsules,
extracts, etc. 9.40-22.0
_Foods Prepared for Table_
Bouillon 0.5-1.0
Thick soups 0.54
Roast beef 0.98
Roast pork 1.54
Chops 0.97
Roast chicken 0.39
Sauces 0.7-1.5
Spinach 0.91
Cauliflower 0.49
Stewed pears 0.019
Macaroni (a la Napolitaine) 1.04
Scrambled eggs (salted) 1.10
Carrots 0.46
Apple sauce 0.41
Tapioca pudding (unsalted) 0.026
Rice, with apples 0.18
_Vegetables_
Potatoes 0.016-0.078
Beets 0.053
Beans 0.09
Peas 0.058
Lentils 0.13-0.19
Lentils (dried) 0.155
Artichokes 0.036
Cauliflower 0.05-0.15
Cucumber (fresh) 0.06-0.08
Horseradish 0.02-0.06
Radish 0.075
Celery, stalks 0.25-0.49
Celery, roots 0.089
Asparagus 0.04-0.06
Spinach 0.084-0.21
Tomatoes 0.094
Cabbage 0.11-0.44
Onions 0.016-0.09
_Canned Vegetables_
Green corn* 0.40
Green peas* 0.70
Tomatoes 0.10
Mushrooms 0.04-0.06
_Cheese_
Parmesan 1.93
Swiss 2.00
American (pale) 0.82
Pineapple cheese 2.13
Edam 3.30
English cream cheese 0.70-1.15
_Infant Foods_
Nestle's Food 0.29
Rademan's 0.03
Robinson's patent groats Trace
_Bread, etc._
Graham bread 0.61
Pumpernickel 0.46
White bread 0.18-0.20
Zwieback 0.38
Macaroni 0.067
_Cereals, etc._
Barley 0.037
Oats 0.046
Rye 0.014
Wheat 0.013
Rice 0.039
Corn (maize) 0.019
Wheat flour 0.002-0.008
Oatmeal (American) 0.29
Oatmeal (German) 0.28
Quaker oats 0.082
Sago 0.19
_Fruits_
Pineapple 0.071
Orange 0.057-0.055
Apricot 0.0047
Lemon 0.0045
Strawberry 0.010-0.020
Chestnuts 0.045-0.010
Cherry 0.013
Cocoanut juice 0.035
Olives 0.008-0.210
Plums 0.0046
Gooseberry 0.021
Watermelon juice 0.011
Grape 0.024
Almonds, dry 0.010
Walnuts, dry 0.019
Cane sugar 0.110
Lump sugar 0.049
Chocolate (Lindt) 0.073
_Spices_
Capers (preserved in salt) 2.10
Capers (preserved in vinegar) 0.20
Pepper, black 0.51
Pepper, white 0.019
Mustard 2.66
Vanilla 0.055
Cinnamon 0.061
Cocoa beans 0.05-0.095
Coffee, roasted 0.045
Tea 0.15
_Drinks_
Ground water 0.0012-0.0060
Spring water 0.00055-0.0046
Ale 0.0017
Beer, German 0.016
Beer, English 0.10
Champagne (Moet & Chandon) 0.0045
Apollinaris 0.043
Fachinger 0.039
Giesshuble (Mattoni) 0.0021
Vichy 0.053
===============================================
SUMMARY
~The kidneys~ find difficulty in eliminating certain substances,
namely, the end-products of protein metabolism--urea, water, salts,
and purin bodies.
~The Urine~ constitutes the chief point of investigation. Analysis
shows the presence of albumen, casts, blood cells, and pigments, with
a corresponding deficiency in the normal constituents, water, urea,
and salts.
~Volume of Urine.~--The volume of urine is reduced, and at times
suppressed, owing to the difficulty with which the kidneys eliminate
water in nephritic conditions.
~The Blood~ shows the presence of the toxic substances on account of
the inability of the kidneys to eliminate them properly.
~Edema~ is a common symptom and is probably due to the retention of
salts and water by the tissues of the body. It is treated and at times
relieved by limiting the intake of fluids and reducing the amount of
sodium chloride in the diet.
~Uremia~ is the most dreaded symptom and develops as a result of the
retained toxins in the blood. Its development is prevented, if
possible, by reducing the amount of fluid and food, even of milk, in
the diet.
~Uremic Poisoning~ is an acute intoxication due to the abnormal
retention of these poisons and the inability of the kidneys to
eliminate them. It is combated by instituting a starvation treatment
which is followed by the above-mentioned restricted diet.
~Gastro-intestinal Disturbances~, especially diarrhea, are apt to
develop in chronic nephritis. Care must be taken to keep the meals
small in size, simple in proportion, and constituted only from the
allowed foods.
~Anemia~ follows the acute attack and is especially noticeable in
those cases in which a rigid starvation regime has been found
necessary. It may likewise be the result of a long-continued diet in
which the proteins have been reduced to the lowest possible amount.
The simple proteins in the diet must, at times, be increased and the
patient advised to take plenty of fresh air and sunshine, in order to
overcome this progressive anemia.
~Restrictions~ in the diet are essential. These consist of limiting
the amount of food and fluids as well as the type of food ingested.
~Restricting the Proteins.~--Proteins are restricted on account of the
difficulty with which the end-products are eliminated by the kidneys,
also on account of the toxic character of these substances.
~Restricting the Fluids.~--It is necessary, on account of their
difficulty of elimination and because they impose an excessive tax
upon the circulatory organs.
~Treatment~ is largely dietetic in character by reason of the
advantages just mentioned.
~Starvation Treatment~ is instituted in order that the work of the
kidneys may be lessened. This treatment consists of abstinence from
food with a definite reduction in the fluid intake. It is found to be
necessary during the acute stage of the disease.
~Extreme Thirst~, which is apt to be an annoying symptom at this time,
is relieved, as far as possible, with small sips of water or ice
pellets held in the mouth.
~Nephritic Cures~ are devised, as far as possible, to relieve the
acute symptoms and to prevent the disease from developing into a
chronic condition. Milk is the basis of most of these cures. It is
given in definite amounts at stated intervals; the quantity and
frequency with which it is given being adjusted to the state of the
disease and the condition of the patient.
~The Karell Cure~ is one of the best known diet cures used in the
relief of acute nephritis. It consists of the giving of skimmed milk
three or four times a day in doses ranging from three to six ounces
for one week, at the end of which time, provided the stools remain
solid, an increase to two quarts a day is made.
~Constipation~ under the circumstances is a favorable symptom,
indicating as it does the agreement of the milk.
~Diarrhea~ as a result of gastro-intestinal disturbances has directly
the opposite indication. In these cases the milk must be reduced.
Karell advises the boiling of milk and relieving the constipation by
means of mild laxatives or enemas.
~Duration of the Karell Cure~ is from four to six weeks, after which a
gradual return to a normal diet is made.
~Hunger~ is apt to be prominent at this stage of the treatment and is
relieved during the second or third week by giving a small piece of
dry bread and milk, soup thickened with a cereal, once a day.
~Functional Kidney Tests~ are made to determine the character and
extent of the impairment of the functions of the kidneys. The diets
used in these tests contain definite amounts of certain diuretic
substances, and the analysis of the urine voided during the
twenty-four-hour period required by the test shows the nature of the
impairment and furnishes, in a measure, a means of determining the
amount of food and fluid which is safe for the patient to take. It
likewise shows the extent to which the restrictions in the salt and
proteins are necessary.
~Salt-free, or Salt-poor Diets~ are necessary in some cases. While
restriction in the amount of salt used in the preparation of food for
the nephritic patient is always advisable, if there is a tendency to
edema, the salt shaker should be left off the tray, and when there is
a definite amount of salt prescribed, it should be weighed or measured
for the day rather than for the meal, and the amount consumed recorded
after each feeding.
~Special Points~ for the nurse to remember are the necessity for an
early recognition of unfavorable symptoms--of instructing the patient
upon leaving her care in the need for keeping the size of the meals
small;--of the danger of indulging in alcoholic or other stimulating
beverages;--of eating highly spiced foods, or of eating anything which
may cause gastro-intestinal disorders.
She should emphasize the need for regular examination of the urine and
the value of rest and freedom from nervous excitement, and the need of
living in the sunshine as much as possible.
The nurse should study the diet list and become familiar with the
foods allowed and those to be avoided. The tables show the foods which
are rich in salts and proteins. She should likewise understand and be
able to make the simple test for albumen in the urine and the method
of collecting the urine for the test made in the laboratory.
PROBLEMS
(a) Outline a salt-poor diet for patient in which the fluids are
limited to 1500 c.c. per day.
(b) Formulate a diet for child of ten years with nephritis following
scarlet fever.
(c) Write a diet order, using a salt-free diet.
FOOTNOTES:
[114] Fisher's Solution.
Sodium carbonate (pure crystals) 14
Sodium chloride 10
Water 1000
[115] The above diets used in the Olmstead Hospital, Rochester, Minn.
Courtesy of M. Foley and D. Ellithorpe, Mayo Clinic.
[116] See Section of Recipes, p. 145.
[117] For more extensive lists see Table of "Ash Constituents of
Common Food," pp. 472 to 477.
[118] "Journal of Internal Medicine," Vol. XIV, 1914.
[119] _Ibid._
[120] "Food for the Sick," p. 108, by Strouse and Perry.
[121] Beans and peas belong to the class of foods known as legumes,
which are high in protein and must be treated as any other protein
food.
[122] Author's list and diet sheets.
[123] Meats of all sorts should be boiled, or only the inside portions
allowed.
[124] Some physicians exclude ice cream from the diet, while others
permit a small portion, provided it is not so rich as to cause
digestional disturbances.
[125] Boiled sweetbreads are sometimes allowed, but should never be
given without the advice of a physician.
[126] The preparation of the menus requires care and attention; meal
must be small and all fried foods avoided.
[127] "Food for the Sick," p. 112, by Strouse and Perry.
[128] "Medical Clinics of Chicago," Vol. II, No. 5, 1917.
[129] Copied from "Medical Clinic of Chicago," Vol. II, No. 5, 1917.
[130] NaCl, 2 to 3 grams in a capsule accompanying each meal. Any salt
unused is returned to the diet kitchen, where it is weighed and the
amount used is indicated on the chart.
[131] Carried out by Dr. Henry Christian and described by James O'Hara
in the "Archives of Internal Medicine," Vol. XVII.
[132] The outside parts of roast meat must be avoided, even when meat
is allowed once a day. Meat is only added after the condition
materially improves.
[133] Coleman, in Forchheimer's "Therapeusis of Internal Diseases,"
Vol. I, p. 642.