Keywords: CKD, intake of protein, sodium, potassium, liquid, ureum and creatinine.

Abstract: Chronic kidney disease (CKD) is a condition in a decline renal function and progressive and irreversible.

The intake of protein, sodium, potassium and liquid affect the performance of the kidney so that patients

chronic kidney disease should pay attention to the intake. Ureum and creatinine is one parameter that is used

as an assessment of renal function. This study to examine the relationship intake of protein, sodium,

potassium, liquid and ureum, creatinine in patients with chronic kidney disease in the inpatient unit General

Hospital Fatmawati, South Jakarta. This study used a cross-sectional study design, conducted research

respondents as many as 36 people, aged 18-81 and above by way of accidental sampling. Based on the

results of the study Most of the respondents classified the male sex, elderly age and the nutritional status of

more. The ureumandcreatinine levels were relatively high. The average protein intake exceeds the protein

requirements of respondents. There was a significant correlation between protein intake and levelsureum in

patients with chronic kidney disease hospitalizations in Fatmawati Jakarta South. There was a significant

relationship between the intake of protein and creatinine levels in patients with chronic kidney disease

hospitalization in Fatmawati, South Jakarta. There was no significant correlation between the intake of

sodium, potassium, liquid and ureum, creatinine level. Suggestion for a patient with chronic kidney disease

needs to be a disciplined diet.

1 INTRODUCTION

Chronic Kidney Disease (CKD) is a state of the

decline in kidney function that is irreversible.

ChronicalCKDis characterized by a decrease in

glomerular filtration rate during the last 3 months

and no changes (Kresnawan, 2014). This resulted a

decrease in renal function renal could not dispose of

waste from the body, can not maintain the balance of

liquids and body chemicals (Dharma, 2015).

The prevalence of CKD worldwide about 5-10%

(Tjekyan, 2012). According to WHO data CKD has

caused death in 850 thousand people each year. This

figure shows that CKD was ranked the 12th highest

cause of death world (Dharma, 2015). According to

data from the year 2013 RISKESDAS highest

prevalence was found in Sulawesi at 0.5%, followed

by Aceh, Gorontalo and North Sulawesi as much as

0.4%. Meanwhile, NTT, South Sulawesi, Lampung,

West Java, Central Java, Yogyakarta and East

Java as much as 0.3%. The prevalence of chronic

kidney disease increased sharply in the age group

35-44 years as many as 0.3% of the 250 million

population of Indonesia, followed by the age 45-54

years as much as 0.4%, age 55-74 years of as much

as 0.5%, and the highest in the age group ≥ 75 years

of as much as 0.6%. The prevalence in males is

higher, as much as 0.3% than women is as much as

0.2%.

The level of creatinine in the blood is one of the

parameters used to assess renal functionbecause the

concentration in the plasma and the excretion in the

urine within 24 hours is relatively constant.

Creatinine levels in the blood that is not normal

signaled their renal function impairment. Creatinine

can be used to assess the ability of Glomerulus

Filtrate Rate (GFR). Also, the high and low levels of

blood creatinine will also give an idea of the severity

of impaired renal function (Rustiana, 2015).

One of thecompilers of the human body are

protein, a protein in the body is stored in the muscle.

This muscle cell metabolism would be converted

into creatinine in the blood. The kidneys will dispose

Diet Quality and Ureum, Creatinine Levels in Patients with Chronic

Kidney Disease in the Patient Wards of General Hospital Fatmawati,

South Jakarta

Yulia Wahyuni

, Romanti Surya

, Lilik Sri Hartati

and Mertien Sapang

Nutrition Departemen Faculty of Health Sciences, University of Esa Unggul, North Arjuna Street Jakarta, Indonesia

3008

Wahyuni, Y., Surya, R., Sri Hartati, L. and Sapang, M.

Diet Quality and Ureum, Creatinine Levels in Patients with Chronic Kidney Disease in the Patient Wards of General Hospital Fatmawati, South Jakarta.

DOI: 10.5220/0009953430083014

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 3008-3014

ISBN: 978-989-758-458-9

of creatinine in the blood into the urine. If renal

function decreases, creatinine levels in the blood

will increase. This is why their relationship with

creatinine levels of protein intake (IKAPI, 2007).

Ureum levels in the serum reflectthe balance

between production and excretion. Stipulation

method is to measure the nitrogen or often referred

Blood Urea Nitrogen (BUN). BUN value increases

when a person consumes large quantities of protein

(Ma'shumah, 2014).

Research conducted Higashiyama, et al. in 2010

concluded that there is a significant relationship

between protein intake and glomerular filtration rate

or the effect on renal function.

Based on the results of research conducted by

Ma'shumah (2014) demonstrate that there is a

significant relationship between the intake of protein

with ureum and creatinine levels in patients with

chronic kidney disease.

The Medical Record General Hospital Fatmawati

knew that cases of chronic kidney disease from

November to December 2016 was Chronic Kidney

Disease (CKD) Stage 1:1 person, CKD Stage 5 as

many as 21 people, CKD Unspecified 19 people and

End Stage Renal Disease (ESRD) 23 people. This

case shows that the incidence of chronic kidney

disease are still high, especially in urban.

2 RESEARCH METHODS

This research used cross-sectional design with

accidental sampling technique. This research was

conducted in Fatmawati, South Jakarta in January

2017. The population of research was all patients

with chronic kidney disease who were diagnosed

with Chronic Kidney Disease (CKD) stadium I

through V with conservative therapy, cooperative in

participating in this study, the age of 18-81 years

and had been hospitalized at least a week. Before

processing the data, first tested the normality using

Shapiro - Wilk. In this research so that the data were

not normally distributed statistical test using

Spearman Rank.

3 RESULTS AND DISCUSSION

3.1 Primary Data

In this researchage groups were taken as respondents

are, adults and the elderly, sex male and female, and

nutritional status are grouped into less, normal and

over. The frequency distribution of respondents by

age groups, gender and nutritional status can be seen

in Table 1 below:

Table 1. Distribution of the respondents according to ages,

sex and nutritional status (Kemenkes, 2009)

Variable n %

Ages

Adult (25 – 45

years)

4 11,1

Elderly (> 45

years)

32 88,9

TOTAL 36 100

Sex

Man 21 58,3

Female 15 41,7

TOTAL 36 100

Nutritional Status

Less 3 8,3

Normal 15 41,7

Over 18 50

TOTAL 36 100

Most of the respondents classified as the elderly

age (> 45 years) as many as 32 people (88.9%) and

the classified as mature age (25-45 years) as many as

four people (11.1%). In this research, the youngest

age found at the age of 29 years. This can be caused

the increasing ages the decline in kidney function.

Generally,the quality of life declines with increasing

ages (Indonesian nursing, 2008). This

occursespecially more than 45 years will be a

process of the loss of some nephrons. The estimated

decline in renal function is based on the ageing of

each decade is 10ml / min / 1,73m2 means the same

as has been the decline in renal function around the

10% of the ability of the kidneys. Based on data

from Riskesdas 2013, the prevalence of chronic

kidney disease increases with increasing ages, and

rise sharply at the age above 35 years.

Gender of the respondents at this research are,

man as much as 21 people (58.3%), and female as

much as 15 people (41.7%). This can be due to

lifestyle male patients who are not good, so the risk

of developing chronic kidney disease tend to be

more serious. According to the research results

Benedict, et al. (2003) in Rustiana (2015) one of the

serious risks to health are smoking. Smoking

behavior population 15 years and over is still a

Diet Quality and Ureum, Creatinine Levels in Patients with Chronic Kidney Disease in the Patient Wards of General Hospital Fatmawati,

South Jakarta

3009

decline from 2007 to 2013 and is likely to increase

from 34.2% in 2007 to 36.3% in 2013,and by

gender, men reach 64.9% were still smoking and to

kind female genital 2.1% still smoked cigarettes in

2013. Smokingbehavior causes a person at risk for

developing chronic kidney disease were 2.2 times

higher compared with individuals who did not

smoke (Riskesdas, 2013).

Nutritional status in this research were divided

into three categories,ie less as much as 3 people

(8.3%), normal 15 people (41.7%) and over 18

(50%). In this research, the majority of respondents

are nutritional status nutritional status. If the

viewsfrom the diagnosis of chronic kidney disease

were obtainedat this research is a complication of

cardiovascular disease, diabetes mellitus, stroke and

heart disease.

Nutritional status is a factor that should be

considered in patients with chronic kidney disease

because is one indicator of living a quality life. The

method of taking the nutritional status data that is by

measuring the weight and height of the respondents,

and then determined their nutritional status.

Anthropometric measurementis considered an

indicator of the status of the adequacy of energy and

protein in patients with chronic kidney disease.

Results of research conducted by Angraini, 2015

concluded that the proportion of malnourished

research subjects was 16.3% (36 of 43). Results of

research conducted by Sulistyowati nutritional status

of patients with chronic kidney disease 3.8%

categorized as underweight, normal 80.8%, and

overweight 15.4% (Angraini, 2015).

Malnutrition is a major factor of morbidity and

mortality in patients with chronic kidney disease and

often occurs. Malnutrition can be caused due to

intake of food that is not in accordance with the

needs of both micro-nutrients and macro-nutrients.

Table 2: Distribution Protein intake, ureum and creatinine

Variables Mean SD Min-Max

Protein intake

(g)

58,07 14,11 42 - 100

Intake of

Sodium (mg)

1420,99 208,07 1018 - 1789

Intake of

Potassium (mg)

2004,36 339,60 1245 - 2532

Liquid intake

(mL)

1922,99 169,75

1587 –

2433,6

Ureum (mg /

dL)

127,05 52,14 50 - 250

Creatinine (mg /

dL)

4,16 2,28 1,4 - 10

Variables Mean SD Min-Max

Needs Protein

(g)

46,19 4,23 40 - 52

Needs Sodium

(mg)

1297,22 102,77 1200 - 1500

Needs

Potassium (mg)

2205,66 342,72 1365 - 2730

Liquid needs

(mL)

1748,61 271,36 1250 - 2200

In this research the highest protein intake reaches

100 grams and the lowest protein intake are 42

grams and an average of 58.07 grams of protein

intake. Average protein requirement respondents

surveyed as many as 46.19 grams. Based on the

results of research conducted, the average protein

intake exceeds the protein requirements of

respondents. Protein intake of respondents who

studied not only from food and drink intake but no

additional therapy such as additional parenteral

octalbin, fujimin, aminoluid, clinimix, ivelip extra

egg white or resulting complications of the disease

which resulted in the occurrence of hipoalbumin.

Several sources of protein from foods consumed

by inpatients with chronic kidney disease are fish,

chicken, eggs, especially for patients with

hypokalemia given once daily vegetable and

commercial liquid foods such as hepatosol, nefrisol

or Diabetasol.

The average intake of sodium respondents as

many as 1420.99 ± 208.07 mg. From the results of

the analysisshow, the lowest sodium intake is 1018

mg,and the highest sodium intake is 1789 mg. The

average requirement of sodium is 1297.22 ± 102.77

mg with the needs of the lowest sodium is 1200 mg

and the highest is 1500 mg. Calculation of sodium

obtained through the consensus of nutrition on

chronic kidney disease from PERNEFRI 2011 and

obtained sodium intake through food weighing

method and calculated the intake using Food

Composition Tables Indonesia in 2009.

If the sodium levels in the blood increases, the

kidneys remove it through the urine, and if low

sodium levels in the blood, the kidneys will restrain

spending. In this particular problem, the kidneys

cannot excrete sodium, the sodium will accumulate

in the blood. (Maria,et al., 2012).

Sodium intake in this research apart from food

and drinks, there are also in patients with established

therapies like drugs Bicnat and NaCl 0,9%. Sodium

intake is obtained by calculating the intake through

food weighing method and are added to the sodium

intake of the drug and the infusion of respondents.

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The average intake of sodium in the respondents of

this research is 1420,99 mg higher than the average

requirement was only reached 1297,22 mg. This

study agrees with research conducted by Nagata et

al, 2016 research on the Association between 24

hour Urinary Sodium and Potassium Excretion and

Estimated Glomerular Filtration Rate (eGFR)

Decline or Death in Patients with Diabetes Melitus

and eGFR more than 30ml/min/1,73 m

stated that

the average intake of sodium in patients exceed their

needs. Food sources containing sodium most

consumed by the respondents are of the dry noodles,

vermicelli, fish, chicken, eggs, bread and biscuits.

The average intake of potassium respondents as

many as 2004,36 ± 208,07 mg. From the analysis, it

can be seen that low potassium intake as much as

1245 mg and 2532 mg potassium intake high.

Potassium intake was obtained by the method of

weighing the food and was calculated using Food

Composition Tables Indonesia in 2009. The average

need for potassium respondents, 2205,66 ± 342,72

mg with the needs of the lowest potassium

respondents, 1365 mg and 2730 mg highs.

Potassium is the major intracellular cation. The

concentration of potassium inside cells is about 150

mmol/L equivalent to 2700 mg, in the extracellular

liquid as much as 4 mmol/L, equivalent to 72 mg

(O'Callaghan, 2009).

Potassium easily absorbed in the small intestine.

Potassium is consumed excreted through the urine,

the rest is excreted through faeces and bit through

sweat and gastric juices. The kidneys maintain

normal blood potassium level through the ability to

filter, absorb and emit potassium back under the

influence of aldosterone. Potassium is issued in the

form of replacing the sodium ions through ion

exchange mechanism in the kidney. If renal function

is impaired, the exchange will be disrupted and lead

to increased potassium in the blood and the risk of

heart failure. In patients with chronic kidney disease

should be noted potassium intake in order not to

aggravate kidney function.

The average intake of liquids respondents as

many as 1922.99 ± 169.75 mL. From the analysis, it

can be seen that its lowest liquid intake as much as

1587 ml of liquid intake and the highest 2433.6 ml.

The needs of the average liquid respondents in this

study is 1748.61 ± 271.36 mL premises liquid needs

the lowest was 1250 mL and 2200 mL highest.

Liquid intake in patients with chronic kidney

disease also need regulations that require special

attention. Prevention of excess liquid needs to be

done to prevent circulatory overload, edema and

intoxication when lack of liquids will cause

dehydration, hypotension and worsening kidney

condition (Haryanti, 2015). Liquid intake calculated

based on the amount of urine that comes out for 24

hours was added with water coming out through the

excretion through sweat or breath which is about

500 ml.

In this research the average ureum 127,05 mg /

dL. This is a very high ureum levels. Normal levels

of ureum is 20-40 mg / dL. The results of this study

together with the results of research conducted by

Rachmawati in 2013 on her researchconcerning the

relationship nutrition knowledge with the intake of

energy, protein, phosphorus and potassium in

patients with chronic kidney disease in Tugurejo

hospitals Semarang said that the average level of

ureum in the blood is high reaching 88,9% (of the

total number of respondents 27 people).

Ureum is the end product of protein metabolism

in the body that synthesized removed from the body.

High levels of ureum in the blood that can not be

removed from the body because of declining renal

function can be toxic to the body. High levels of

ureum in the blood is the result of many protein.

Ureum is a product of the largest nitrogen released

through the kidneys through food (Nabella, 2011).

In this research, the average serum creatinine

level is 4,16 mg/dL,and creatinine levels were

relatively high. Normal creatinine levels in the blood

is 0,6 to 1,5 mg / dL. The results of this study are

similar to studies conducted by Rachmawati in 2013

on her researchconcerning the relationship nutrition

knowledge with the intake of energy, protein,

phosphorus and potassium in patients with chronic

kidney disease in hospitals Tugurejo Semarang said

that the average levels of creatinine in the blood is

high reaching 96, 3% (of the total number of

respondents 27 people).

Examination of renal function is important to

identify the presence of kidney disease. Examination

of the best kidney function is by measuring

Glomerular Filtration Rate (GFR) as assessed

through renal clearance of a filtration marker. One of

the markers used in clinical practitioners,i.e. serum

creatinine (Riskesdas, 2013)

Serum creatinine cannot be used as a

determining factor for kidney refugees someone as

influenced by many things, among others, race, diet,

age, sex, drug consumption. Increasing age a person

can lower serum creatinine clearance depicting a

decrease in kidney function. By gender, the

proportion of men with abnormal serum creatinine

levels three times higher than females (Riskesdas,

2013).

Diet Quality and Ureum, Creatinine Levels in Patients with Chronic Kidney Disease in the Patient Wards of General Hospital Fatmawati,

South Jakarta

3011

3.2 Relationship Analysis Protein,

Sodium, Potassium, Liquid and

Ureum, Creatinine

Table 3: Bivariate analysis of the relationship of protein

intake, sodium, potassium, liquid and ureum, creatinine.

Variable p-value r-value

Protein - Ureum 0,015 0,402

Protein – Creatinine 0,001 0,529

Sodium – Ureum 0,896 0,023

Sodium - Creatinine 0,436 -0,134

Potassium – Ureum 0,318 -0,171

Potassium –

Creatinine

0,802 0,043

Liquid – Ureum 0,230 0,205

Liquid - Creatinine 0,686 -0,070

3.2.1 Relationship between the Intake of

Protein and Ureum, Creatinine

Based on the results of testing the relationship

between the intake of protein and ureum using Rank

Spearman test with the acquisition value of r count

of 0,402 with a p-value (0,000) <ɑ (0,05), so Ho

rejected, which means that the higher the intake of

protein eaten the higher the levels of ureum in blood.

If seen from the test results can be concluded that

increasing protein intake will increase the levels of

creatinine in the blood. Based on these results it can

be concluded that there is a significant relationship

between the intake of protein and ureum levels in

patients with chronic kidney disease hospitalizations

in Fatmawati, South Jakarta.

The results of this research equal with research

conducted by Ma'shumah, et al. (2014) about the

relationship between protein intake with high levels

of ureum, creatinine and blood haemoglobin levels

in patients with chronic renal failure in hospital

outpatients Tugurejo Semarang.

Based on the test results of the relationship

between the intake of protein and creatinine levels

using Rank Spearman test with the acquisition value

of r count of 0,529 with a p-value (0.001) <ɑ (0,05),

so Ho rejected, which means when the protein intake

increases the levels of creatinine in the blood will

increase too. If seen from the test results there is a

correlation where increased protein intake will result

in increased creatinine also.

Based on these results it can be concluded that

there is a significant relationship between the intake

of protein and creatinine levels in patients with

chronic kidney disease hospitalizations in

Fatmawati, South Jakarta. The results of this

research equal with research conducted by Nabella

2011 about the relationship of protein intake with

high levels of ureum and creatinine in a bodybuilder.

3.2.2 Relationship between Intake of

Sodium and Ureum, Creatinine

Results of testing the relationship between the

intakeof sodium and ureum using Pearson Product

Moment test with the acquisition count r-value of

0,023 with a p-value (0,896)> ɑ (0,05), so Ho failed

rejected. Based on these results it can be concluded

that there was no significant association between the

intake of sodium and ureum levels in patients with

chronic kidney disease hospitalizations in

Fatmawati, South Jakarta. Results of testing the

relationship between the intake of sodium and

creatinine levels using Spearman Rank test with the

acquisition value of r-value of -0134 with a p-value

(0,436)> ɑ (0,05), so Ho failed rejected. Based on

these results it can be concluded that there was no

significant association between the intake of sodium

and creatinine levels in patients with chronic kidney

disease hospitalizations in Fatmawati, South Jakarta.

Salt restriction is one of the strategies to optimize

antihypertensive therapy and resolve edema.

Broadly speaking sodium did not affect levels of

ureum and creatinine. However, if the sodium in the

blood increases, the kidney will be burdened to

excrete excess sodium in the body. The excretion

setting is done to maintain homeostasis (Yaswir,

2012).

3.2.3 Relationship between Intake of

Potassium and Ureum, Creatinine

Results of testing the relationship between the intake

of potassium and ureum using Pearson Product

Moment test with the acquisition value of r

count

equal

- 0.1.71 with a p-value (0,318) > ɑ (0,05), so Ho

failed rejected. Based on these results it can be

concluded that there was no significant association

between the intake of potassium and ureum levels in

patients with chronic kidney disease hospitalizations

in Fatmawati, South Jakarta.

Results of testing the relationship between the

intake of potassium and creatinine levels using

Spearman Rank test with the acquisition value of

count

at 0,43 with a p-value (0,802) > ɑ (0:05), so Ho

failed rejected. Based on these results it can be

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concluded that there was no significant association

between the intake of potassium and creatinine

levels in patients with chronic kidney disease

hospitalizations in Fatmawati, South Jakarta.

Potassium imbalance is a serious disorder that

can occur in patients with chronic kidney disease

because the normal levels of potassium in the blood

are only allowed in the range of 3,5 to 5,5 mEq. The

kidney is the main regulator of potassium in the

body that become levels remain in the blood by

controlling excretion (Winarno, 1995).

Patients with chronic kidney disease risk

increased potassium. Functions of potassium one is

to maintain liquid balance in the body, nerve

impulse transmission and muscle tension and helps

the enzymes in energy metabolism (Maria, 2012).

The results of this study the same as those

investigated by Rustiana (2015) concerning the

relationship protein intake and intake of potassium

to the levels of creatinine in patients with chronic

renal failure in hospitals Sukoharjo, namely that

there is no relationship between intake of potassium

to creatinine values r

count

= 0,280 with ɑ = 0,05

means that there is no relationship between intake of

potassium to creatinine levels.

3.2.4 The Relationship of Liquid Intake

and Levels of Ureum, Creatinine

Results of testing the association between liquid

intake and ureum using Pearson Product Moment

test with the acquisition count r-value of 0,205 with

a p-value (0,230)> ɑ (0,05), so Ho failed rejected.

Based on these results it can be concluded that there

was no significant association between liquid intake

and ureum levels in patients with chronic kidney

disease hospitalizations in Fatmawati, South Jakarta.

Results of testing the association between liquid

intake and creatinine levels using Spearman Rank

test with the acquisition value of r count of -0,070

with a p-value (0.6.86)> ɑ (0,05), so Ho failed

rejected. Based on these results it can be concluded

that there was no significant association between

liquid intake and creatinine levels in patients with

chronic kidney disease hospitalizations in

Fatmawati, South Jakarta.

Liquid requirements calculated based on the

amount of urine that comes out for 24 hours was

added with water coming out of the sweat and

breathing slightly more than 500 ml. Restriction of

liquid intake in patients with chronic kidney disease

are given according to the patient's condition is

adjusted by the amount of urine produced plus IWL

(insensible water Lost). It aims to prevent the

occurrence of edema and cardiovascular

complications (Rahman, 2014).

According Smeltzer & Bare (2013) explains that

the ureum and creatinine are not excreted in excess

liquid volume due to decreased renal perfusion and

decreased excretion of metabolic waste and cause

azotemia (elevated levels of nitrogen in the blood).

4 CONCLUSIONS AND

SUGGESTION

4.1 Conclusion

There was a significant relationship of protein intake

and levels of ureum, creatinine in patients with

chronic kidney disease in the inpatient hospital

Fatmawati, South Jakarta. There was no significant

relationship between the intake of sodium and ureum

creatinine in patients with chronic kidney disease in

the general hospital inpatient center Fatmawati,

South Jakarta. There is no significant relationship

between the intake of potassium and ureum

creatinine in patients with chronic kidney disease in

the general hospital inpatient center Fatmawati,

South Jakarta.Therewas no significant relationship

between liquid intake and ureum creatinine in

patients with chronic kidney disease in the general

hospital inpatient center Fatmawati, South Jakarta.

4.2 Suggestion

For patients with chronic kidney disease patients

need to be disciplined diet so as not to aggravate

kidney. For hospital dietitians need to increase the

role of nutritionists in motivating and monitoring

food intake in patients with chronic kidney disease

and the need for increased counseling to patients and

their families in complying with the diet. For

educational institutions there should be more

research on the relationship of protein intake,

sodium potassium and on levels of ureum,

creatinine, albumin, sodium and potassium in the

blood in patients with kidney disease in the inpatient

unit kronilk with inspection methods BUN (Blood

Urea Nitrogen).

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