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Another common cause of acute tubular necrosis is a crush injury, in which the patient undergoes rhabdomyolysis, or muscle death. Toxins such as chemotherapeutic agents and aminoglycoside antibiotics also may cause this condition. An ascending urinary tract infection, most commonly with a gramnegative rod such as Escherichia coli, causes pyelonephritis. Pyelonephritis generally affects the renal cortex, with relative sparing of the vessels and glomeruli. Patients present with fever, costovertebral angle tenderness, nausea, and vomiting. When causing kidney injury, diabetes generally manifests as renal papillary necrosis. This disease manifests as gross hematuria and proteinuria caused by sloughing of the renal papillae. The hallmark of diabetic nephropathy is the presence of acellular, eosinophilic deposits, known as Kimmelstiel-Wilson nodules, on renal biopsy. This syndrome is associated with pyuria (typically eosinophils) and azotemia occurring one-two weeks after administration of the medication. It is also associated with fever, rash, hematuria, and costovertebral angle tenderness. Patients with this syndrome generally present with abrupt onset of oliguria or anuria accompanied by hematuria, flank pain, and hypotension. Renal cortical necrosis has also been associated with obstetric catastrophe, such as placental abruption. Overfilling of the bladder could have caused vesicoureteral reflux to the kidneys. Renal damage results when a bacterial urinary tract infection is superimposed on the reflux. Chronic pyelonephritis results in a kidney that grossly shows blunting and thickened dilation of the calyces and uneven scarring. The condition may happen unilaterally if due to some congenital anatomic abnormality. In the image above, there is a staghorn calculus filling calyces of kidney with chronic pyelonephritis; the cortex and medulla is atrophic and the calyces are dilated. Staghorn calculi (struvite stones) can be seen in association with chronic infection and are classically associated with urease producing organisms such as proteus species. While diabetic patients are susceptible to acute pyelonephritis from increased instrumentation and neurogenic bladder, the kidney shown in the image is not characteristic of acute pyelonephritis. In the acute condition, the kidney surface is frequently studded with microabscesses, indicating a recent infection. It is characterized by fever, rash, eosinophilia, and renal anomalies (hematuria, increased serum creatinine, and oliguria). While passing stones through the penile urethra can be painful, it does not typically cause an obstruction. The prostatic urethra is not a typical location for renal stones to obstruct flow. While staghorn calculi may develop in the renal pelvis or calyces, they do not typically produce obstructive symptoms until they have grown to a considerable size. That is, more compound X is excreted in the urine than is filtered at the glomerulus. The descending limb of the loop of Henle is poorly permeable to solute and instead allows passive efflux of water from the filtrate. The proximal convoluted tubule is responsible for most ultrafiltrate reabsorption. Minimal change disease is a glomerular disease most frequently seen in pediatric patients.

All the others have specific degradation systems that give rise to intermediates that can be metabolized in these oxidative pathways. This is particularly true in non-growing adults, who on average consume, and therefore oxidize, about 10 to 15 percent of their dietary energy as protein (Appendix Table E-17). Protein oxidation also has been shown to rise considerably in highly traumatized or septic individuals, which results in large amounts of body protein loss; this loss can compromise recovery or even lead to death (see below) (Klein, 1990). It is much less in periods of chronic starvation because of various metabolic adaptations related to ketone utilization, or on protein-restricted diets. Whether glucose or fat is formed from the carbon skeleton of an amino acid depends on its point of entry into these two pathways. The carbon skeletons of other amino acids can, however, enter the pathways in such a way that their carbons can be used for gluconeogenesis. This is the basis for the classical nutritional description of amino acids as either ketogenic or glucogenic. Some amino acids produce both products upon degradation and so are considered both ketogenic and glucogenic (Figure 10-3). It has been argued that the majority of hepatic amino acid catabolism is directed in an obligatory fashion to glucose synthesis (Jungas et al. This cycle also involves the peripheral synthesis of glutamine, an amino acid that is utilized in substantial quantities by the intestinal cells in which it is used for energy and for the synthesis of proline, citrulline, and nucleic acids. A significant proportion of the glucose synthesized in the liver is due to recapture and recycling via the liver of 3-carbon units in the form of lactate derived from anaerobic glucose breakdown in muscle (the Cori cycle). Since the nitrogen donors may be either glucogenic or ketogenic amino acids, these cycles function as mechanisms for transporting nitrogen from the periphery to the liver as well as for glucose production. The cycle involving glutamine transport from the periphery to the gastrointestinal tract is also vital to the synthesis of arginine and proline and is critical to the prevention of the build up of excessive ammonia in the circulation. Nonprotein Pathways of Amino Acid Nitrogen Utilization Although in general the utilization of dietary amino acids is dominated by their incorporation into protein and their role in energy metabolism, amino acids are also involved in the synthesis of other nitrogenous compounds important to physiological viability as shown in Table 10-5. Some pathways have the potential for exerting a substantial impact on the utilization of certain amino acids, and may be of potential significance for the requirements for these amino acids. This is particularly true for glycine, which is a precursor for six nitrogenous compounds, as shown in Table 10-5. Its utilization in the synthesis of creatine (muscle function), heme (oxygen transport and oxidative phosphorylation), and glutathione (protective reactions which are limited by the amount of available cysteine) is not only of physiological importance, but can also involve substantial quantities of the amino acid. For example, in the absence of a dietary source of creatine, adults require at least 1. In premature infants, mainly fed human milk, there is evidence that the glycine supply may be a primary nutritional limitation to growth (Jackson, 1991). This so-called dispensable amino acid is then needed in the diet for optimum growth and may be termed "conditionally indispensable. These may be important nutritional considerations in individuals consuming marginal amounts of proteins of plant origin and undoubtedly have an impact on overall amino acid utilization when protein intake is very low. Clinical Effects of Inadequate Protein Intake As outlined above, protein is the fundamental component necessary for cellular and organ function. Not only must sufficient protein be provided, but also sufficient nonprotein energy. Similarly, unless amino acids are present in the diet in the right balance (see later section, "Protein Quality"), protein utilization will be affected (Duffy et al. Hypoalbuminemic malnutrition has been described in hospitalized adults (Bistrian, 1990) and has also been called adult kwashiorkor (Hill, 1992). Clearly, protein deficiency has adverse effects on all organs (Corish and Kennedy, 2000). Furthermore, protein deficiency has been shown to have adverse effects on the immune system, resulting in a higher risk of infections (Bistrian, 1990).

Thus from dietary data alone, it is only possible to estimate the likelihood of nutrient adequacy or inadequacy. This approach is quantitative and should be used only when the data listed above are available. However, in the more common situation where the estimate of usual intake is not based on actual 24-hour recalls or records, but on dietary history or food frequency questionnaires, a qualitative interpretation of intakes can be used. While the error associated with food frequency questionnaires has been evaluated (Carroll et al. Thus, a practitioner should be cautious when using this method to approximate usual intakes. Such considerations are not applicable in the case of energy intake, which should match energy expenditure in individuals maintaining desirable body weight (see later section, "Planning Nutrient Intakes of Individuals," and Chapter 5). Infants who consume formulas with a nutrient profile similar to human milk (after adjustment for differences in bioavailability) are also assumed to consume adequate levels of nutrients. When an infant formula contains nutrient levels that are lower than those found in human milk, the likelihood of nutrient adequacy for infants who consume this formula cannot be determined because data on infants fed lower concentrations of nutrients are not available. However, the intake at which a given individual will develop adverse effects as a result of taking large amounts of one or more nutrients is not known with certainty. Care must be taken to ensure the quality of the information upon which assessments are made so that they are not underestimates or overestimates of total nutrient intake. Estimates of total nutrient intake, including amounts from supplements, should be obtained. It is also important to use appropriate food composition tables with accurate nutrient values for the foods as consumed. First, the intake distribution must be adjusted to remove the effect of day-to-day variation of individual intake. The statistical adjustments are based on assumptions about the day-to-day variation derived from repeat measurements of a representative subset of the group under study (Nusser et al. When this adjustment is performed and observed intakes are thus more representative of the usual diet, the intake distribution narrows, giving a more precise estimate of the proportion of the group with usual intakes below requirements (Figure 13-2). A statistical approach is then used to combine the information on nutrient intakes with the information on nutrient requirements in order to determine the apparent percent prevalence of nutrient inadequacy in the group. The Probability Approach Using the probability approach requires knowledge of both the distribution of requirements and the distribution of usual intakes for the population of interest. This method assumes that the intake and requirement distributions are independent, an assumption that is not valid for the energy requirements addressed in this report because energy intakes are highly correlated to energy expenditure. The cut-point method further assumes that the variability of intakes among individuals within the group under study is at least as large as the variability of their requirements. This is thought to be true for all of the macronutrients discussed in this report. Examination of the distribution of usual carbohydrate intake reveals that intakes at the 1st and 5th percentiles are 87 and 118 g/day, respectively. Thus, fewer than 5 percent of women in this age group appear to have inadequate carbohydrate intakes. Currently, a method for adjusting intakes to compensate for underreporting by individuals is not available, and much work is needed to develop an acceptable method. Conversely, underestimates of the prevalence of inadequacy could result if foods rich in the nutrient of interest were overreported. Comparison of Assessments Using the Probability Approach and Biochemical Assessment If requirement estimates are correct, dietary intake data are reliable estimates of true usual intake, and biochemical measures reflect the same functional criterion used to set the requirement of a nutrient for the same population, then the prevalence of apparently inadequate dietary intakes and biochemical deficiencies or indicators of inadequacy should be similar. Using the Recommended Dietary Allowance the Recommended Dietary Allowances are not useful in estimating the prevalence of inadequate intakes for groups. Human milk and formulas with the same nutrient composition as human milk (after adjustment for bioavailability) provide the appropriate levels of nutrients for full-term infants of healthy, well-nourished mothers. Groups of infants consuming formulas with lower levels of nutrients than that found in human milk may be at some risk of inadequacy, although the prevalence of inadequacy cannot be quantified. A distribution of usual intakes, including intakes from supplements, is required to assess the proportion of the population that might be at risk of over-consumption.

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