CHOWDHURY TASNEEM HASIN

CHIEF DIETICIAN & HEAD OF THE DEPT

DIETETICS AND NUTRITION
UNITED HOSPITAL LTD
 The Dietitian will look at your…
 Medical History,
 Weight History,
 Blood Levels,
 Recent Dietary Intake with a Diet History.
 Excretion of metabolic waste through urine
 Water and Electrolyte Homeostasis
 Acid/base balance
 Maintenance of bone health
 Activation of vitamin D
 Calcium/phosphorus homeostasis
 Blood Pressure Regulation
 Renin-Angiotensin-Aldosterone
 Stimulate red blood cell production
 Erythropoietin
 Decreased excretion of nutrients/waste
 Abnormal calcium/phosphorus metabolism
leading to bone disease
 Weight loss and malnutrition
 Fluid and electrolyte imbalances
 Cardiovascular disease and mortality
 GFR = (140-age) X body weight (kg) X 0.85 if female
[72 X serum creatinine (mg/dL)]

 GFR of 100 approximates 100% kidney fxn

 Normal GFR = 120 to 130 mL/min

 Best index of kidney function
 Used to establish stage of CKD
 GFR is the amount of filtrate formed per minute
based on total surface area available for filtration
(number of functioning glomeruli)
 Can be determined using injected isotope (inulin)
measurement in urine
 Can be calculated from serum creatinine using
standard equations
Stage 1 CVD risk reduction GFR > 90 ml/min
Treat co-morbidities

Stage 2 Monitor progression GFR = 60-89 ml/min

Stage 3 Evaluate GFR = 30-59 ml/min

Test complications
Stage 4 Preparation for renal GFR = 15-29 ml/min
replacement therapy
Stage 5 Renal replacement GFR < 15ml/min
therapy (RRT) or on dialysis
 Diabetic Nephropathy damage to the nephrons in the
kidneys from unused sugar in the blood, usually due to
Diabetes.

 High Blood Pressure can damage the small blood

vessels in the kidneys. The damaged vessels cannot
filter poison from the blood as they are supposed to.

 Polycystic Kidney Disease (PKD) is a hereditary

kidney disease in which many cysts grow in the
kidneys. These cysts may lead to kidney failure.
 Acute Renal Failure - Sudden kidney failure caused
by blood loss, drugs or poisons. If the kidneys are
not seriously damaged, acute renal failure may be
reversed.

 Chronic Renal Failure - Gradual loss of kidney

function is called Chronic Renal Failure or Chronic
Renal Disease.

 End-Stage Renal Disease - The condition of total or

nearly total and permanent kidney failure.
 Glomerular diseases
 Nephrotic syndrome
 Nephritic syndrome—tubular or interstitial
 Tubular defects
 Acute renal failure (ARF)
 Other
 End-stage renal disease (ESRD)
 Kidney stones
1. BP >140/90
2. Edema
3. Weight changes
4. Urine output
5. Urine analysis:
—Albumin
—Protein
6. Kidney function
Creatinine clearance
Glomerular filtration rate (GFR)
7. Blood values
BUN 10 to 20 mg/dl (<100 mg/dl)
Creatinine 0.7 to 1.5 mg/dl (10-15
mg/dl)
Potassium 3.5 to 5.5 mEq/L
Phosphorus 3.0 to 4.5 mg/dl
Albumin 3.5-5.5 g/dl
Calcium 9-11 mg/dl
 % usual body weight (%UBW)
 % standard body weight (%SBW)
 Height
 Skeletal frame size
 BMI
 Skinfold thickness
 Mid-arm muscle area, circumference, or
diameter
 Use dry weight or edema-free body weight
 In HD: post-dialysis weight
 In PD: weight after drainage of dialysate with
peritoneum empty
 In obese or very underweight people, use
adjusted edema-free body weight
Adjusted EFBW=
BWef + [SBW*-BWef x .25]
*Use NHANES II data for standard body weight (SBW)

National Kidney Foundation. K/DOQI clinical practice guidelines for nutrition in chronic
renal failure. Am J Kidney Dis 2000;35(suppl);S27-S86.
 Eat small meals regularly.

 Make every mouthful count…

 Choose nutritious foods that are energy
dense.
 Make sure your drinks are nutritious.
 Your kidneys work harder if you are
overweight.

 Losing weight can help your kidneys work as

well as they can for as long as they can.
 Measure of the nitrogenous waste products
of protein
 High BUN in CKD may reflect high protein
intake, GI bleeding or inadequate dialysis,
increased catabolism due to infection,
surgery, poor nutrition
 Decreased BUN may mean protein
anabolism, overhydration, protein loss, low
dietary protein
Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease.
ADA, 2004
 Nitrogenous waste product of muscle metabolism
 Produced proportionate to muscle mass
 Unrelated to dietary protein intake (DPI)
 Sensitive marker of renal function: the higher the
serum creatinine, the greater the loss of renal
function; may reflect inadequate dialysis or muscle
catabolism
 A decrease in creatinine over time may reflect loss
of lean body mass
Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney
Disease. ADA, 2004
 Protein 0.8 to 1 g/kg IBW 80% HBV
 Sodium based on fluid status
 Potassium and other minerals (calcium,
phosphorus) monitored and
individualized
 Fluid unrestricted
 Diet therapy probably not effective for
hyperlipidemia; may require medication
Byham-Gray L, Wiesen K. A clinical guide to nutrition care in kidney
disease.ADA, 2004
 Protein,
 Sodium (Salt),
 Fluid,
 Potassium,
 Phosphate.
 Diet to treat underlying disease
 Restrict diet if necessary to control
symptoms
 Protein restricted in uremia
 Sodium restriction in hypertension
 Potassium restriction in hyperkalemia
 Energy: BEE X 1.2-1.3 or 25-35 kcal/kg
 Protein: .8-1.2 g/kg noncatabolic, without dialysis;
1.2-1.5 g/kg catabolic and/or initiation of dialysis
 Fluid: 24 hour urine output + 500 ml (750-1500 ml)
 Sodium: 2.0-3.0 grams
 Potassium: 2.0-3.0 grams
 Phosphorus: 8-15 mg/kg; may need binders; needs
may increase with dialysis, return of kidney
function, anabolism

Source: Byham-Gray, Wiesen, eds. A Clinical Guide to Nutrition Care in Kidney Disease.
ADA, 2004
 CKD Hemodialysis CAPD or CCPD
Protein 0.6-1.0 1.1-1.4 1.2-1.5
g/kg/day
Energy 30-35 30-35 30-35
(kcal/kg IBW)
Phosphorus 8-12 indiv <17 indiv <17 indiv
(mg/kg IBW)
Sodium 1000-3000 2000-3000 2000-4000
(mg/d)
Potassium Individualized ~ 40 Individualized
(mg/kg IBW)
Fluid Unrestricted 500-750 + Individualized
(ml/d) urine output
(1000 if anuric)
Calcium Individualized Individualized Individualized
(mg/d) based on serum level ~1000 mg/day ~1000 mg/day

Use adjusted IBW if obese

National Renal Diet Professional Guide 2nd edition, ADA 2002

Calories 30-35 kcals/kg IBW
Protein 0.6-0.8 gm/kg IBW
Sodium 1000-4000mg
Fluids Evaluate need to restrict
Potassium Evaluate need to restrict
Calcium <2000mg
Phosphorus 800-1000 mg
Vitamins Individualized
 Recommended energy intake = 30 to 35 day kcals/kg
▪ Spares body protein
▪ Maintains neutral nitrogen balance
▪ Promotes higher serum albumin levels
 Challenges
▪ Decreased appetite from uremia
▪ Various CKD dietary restrictions
▪ Finding food sources for added calories
 Hard candy 4 pieces
 Jam or jelly 2 T
 Honey 2 T
 Sugar brown or white 2 T
 Fruit snacks and candies 1 oz
 Protein is found in red and white meats, fish,
eggs, dairy products and legumes.
 It’s important to have the right amount of
protein you need for growth, healing and
fighting infection.
too much protein can lead
to a build up of a waste
product called Urea.
Too little protein
could lead to
under nutrition.
 RENAL EXCHANGES FOR MEAL PLANNING

Food Groups Kcal CHO g. PRO g. FAT g. Na mg. K+ mg. PO4 mg.

Milk ( ½ c.) 85 6 4 5 80 185 110

Meat 65 0 7 4 25 100 65

Starch 80 15 2 1 80 35 35

Vegetable 25 5 1 0 15 150 20

Fruit 60 15 0.5 0 5 150 15

Fat (1TB.) 100 0 0 11 150 0 5

Calorie 60 15 0 0 15 20 5
Boosters

Beverages: 0 0 0 0 0 100 0
Coffee (1c.)
tea (1 bag)
wine (4 oz.)
beer (12 oz.)
 Reduces nitrogenous waste
 Reduces inorganic ions
 Reduces metabolic/ clinical disturbance
(uremia)
 Slows rate of decline in GFR
 0.75 grams per kg/day for CKD stages 1 thru 3
 0.6 grams per kg/day for CKD stages 4, 5
 50% of the dietary protein should be HBV
 HBV protein produces less nitrogenous waste
 45 to 60 grams protein per day
 No Protein Restriction for Dialysis Patients
▪ 1.2 g per kg/day hemodialysis
▪ 10-12 grams lost per HD treatment
▪ 1.3 g per kg/day peritoneal dialysis
▪ 5-15 grams lost per PD treatment
 Carbohydrate Protein Fat
Food 4 kcals/g 4 kcals/g 9 kcals/g

1 cup milk 12 8 0 –10

1 oz meat 0 7 1 – 12
1 oz bread 15 3 0
1 cup veg 5 2 0
1 fruit 15 0 0
1 teaspoon 0 0 5
fat/ oil
 1 tsp

3 oz
1 cup
&

½ cup

¼ cup
1 oz
 1 oz meat, poultry, fish = 7 g
 ¼ cup tuna
 ½ cup beans, peas, or lentils
 2 Tablespoons peanut butter
 2 egg whites = 7 g
 1 cup milk = 8 g
 1 oz cheese
 1/3 cup cottage cheese
 1 cup veg = 2 g
 1 slice bread = 3 g
 ½ cup rice or pasta
 ½ cup cereal
 Fruit, fats, sugars = 0
 Milk
 Cheese
 Beans
 Peanut butter
 Potassium is a mineral needed by the body to
make your muscles and cells work.

 High or Low blood levels can be dangerous for

your heart.

 Not everyone needs a low potassium diet.

 You will only need to start a low potassium diet
if your blood levels are high.
 >6 mEq/L – abnormal,  Metabolic acidosis
potentially dangerous  Drug interactions
 Renal failure (kidney is  Catabolism of malnutrition
primary filter) or cell damage caused by
 Excessive nutritional
intake injury or surgery
 Chronic constipation  Decreased urinary output
 Infection  Chewing tobacco
 GI bleeding
 Insulin deficiency (high BG)
 Vomiting, diarrhea
 Diuresis
 Potassium binder
 K+ too low in dialysate

 Urine output >1000 mL/day or serum NL, do

not need to restrict K+
 Potassium Restriction Indications
 Urine output < 1 liter per day
 GFR < 10 mL/min
 ACE inhibitors, beta blockers, lasix
 Hyperglycemia
 Serum potassium > 5.0 mEq/L
 Dietary Potassium Restriction = 2 grams/day
 Serum Potassium Goal: 3.5- 5.0 mEq/L
 Apple  Peach
 Apple juice ½ c  Pear
 Applesauce ½ c  Pineapple
 Apricot nectar ½ c  Plums (1)
 Blackberries ½ c  Watermelon
 Fruit cocktail ½ c
 Grapes ½ c
 Lemon
 Lime
 Apricots  Prunes (5)
 Bananas  Raisins
 Dates
 Kiwifruit
 Orange
 Orange Juice
 Prune juice
 Potato
 Phosphate is a mineral that is important for
strong bones and teeth.

 High levels can weaken your bones and damage

your blood vessels.
 As renal function decreases, phos accumulates in
the blood
  phos triggers release of PTH that releases calcium
from bone
 Phos binders prevent phosphorus from being
absorbed in the gut; form insoluble compound so
phos is excreted in stool
 ↓ phos may mean excess phos binder or poor p.o.
 High serum phosphorus
 Bone decalcification
 Soft tissue calcifications
 Hyperparathyroidism
 Phosphorus restriction for GFR < 25mL/min
 Normal dietary phosphorus = 1000 to 1800 mg/day
 Dietary restriction = 560 to 850 mg/day
 Phosphate binders:
 Bind phosphorus in the GI tract
 Must take with meals
 Phoslo (calcium containing)
 Renvela (Sevelamer) (calcium free)
 Fosrenol (chewable)
DAIRY
Cheese 1 oz 150 mg
Milk ½ cup 120 mg
PROTEIN
Egg 1 large 100 mg
Liver 1 oz 150 mg
Peanut butter 2 Tbsp 120 mg
Sea Fish 1 oz 75 mg
Nuts 1 oz 100 mg
VEGETABLES
Baked beans ½ cup 130 mg
Soybeans ½ cup 160 mg
BREADS
Bran ½ cup 350 mg
Cornbread 2 inch square 200 mg
Whole-grain bread 1 slice 60 mg
BEVERAGES
Cola 12 oz can 50 mg
 Most abundant mineral in human body
 Nearly half of calcium is bound to albumin; if serum
calcium is low, evaluate albumin level; can correct for
low albumin
 Calcium-Phosphorus Product: multiply serum calcium
x serum phos: if >55-75, calcification can occur
 <2000 mg/day elemental calcium from diet + binders
stage 3-4
 High ca+: calcification, nausea, vomiting, muscle
twitching may mean too much Ca+ from meds or diet
 Kidney Failure leads to…
▪ Decreased production of active Vit D
▪ Low serum calcium
▪ Phosphorus retention
▪ Elevated PTH
▪ Secondary Hyperparathyroidism
 Mineral and Bone Disorder
 Not a reliable indicator of sodium intake in
CKD
 Fluid retention due to decreased urine
production can dilute an elevated level
 Serum levels must be evaluated in
conjunction with fluid status
 Dietary sodium restriction prevents:
 Excessive thirst
 Edema
 Hypertension
 CHF
 Sodium restriction = 2000 mg/day
 Range from 1000mg to 4000mg
 Varies depending on co-morbidities
 More liberal sodium with frequent dialysis
 Sodium excretion falls at GFR < 20mL/min
1 tsp salt = 2,300 mg sodium
 Fresh foods
 Limit
 Cured/pickled foods
 Processed
 Can/bottled/packaged
 Instant cereals, mixes
 Avoid salt substitutes (potassium chloride)
 Flavor foods with spices, vinegar, lemon juice,
pepper
 Fluid: “any food that is liquid at room temp”
Soup, gelatin, ice cream, popsicles

 Excess fluid can cause:

 High blood pressure,
 Swelling in the ankles, hands and face,
 Shortness of breath.

 Check with your Renal Team regularly about how

much fluid you should drink.
 Fluid is not just water.
 .
 Approx 48oz/day
 Pre-measure mealtime liquids
 Drink very hot or very cold
beverages
 Drinking from smaller cups
 Use spray bottle to mist mouth
 Freeze juice in ice cube tray and
eat like popsicles
 Vitamin C 90 mg/day
 Over 75% of kidney disease patients have increased
homocysteine levels.
 Folic acid 1 mg/day
 B6 5 mg/day
 No Vitamin A due to its accumulation in CKD
 Vitamin D in its active form
1,25 dihydroxycholecalciferol
[1,25 (0H2)D3]
 iron supplementation
 Prevent deficiencies
 Control edema and serum electrolytes
 Prevent renal osteodystrophy
 Provide an attractive and palatable diet
 Removes concentrated molecules and excess
fluid from pts blood through diffusion and
ultrafiltration
 Three parts of the system are the dialyzer
(artificial kidney), the dialysis machine, and
the dialysate
 Requires vascular access, usually through an
AV (arteriovenous) fistula
 Typical diet order
 2000 calorie, 80 g protein, 2 g Na+, 3 g K+, low
phosphorus, 1500 cc fluid restriction
  10-12 g free amino acids lost per treatment
during dialysis
 Greater amino acid losses with glucose-
free dialysate and high flux dialyzers
 1.2 g protein/kg standard body weight
(SBW) with 50% high biological value
(meat, poultry, fish, eggs, soy, dairy)
 Most HD patients take in less than 1 g/day

NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in Byham-

Gray, p. 45-46
 Adults <60 years: 35 kcal/kg SBW
 Adults > 60 or obese: 30-35 kcals/kg body
weight
 Actual intakes of HD patients in studies are
lower than that (mean 23 kcals/kg in HEMO
study)

NKF K/DOQI practice guidelines. Am J Kid Dis 2000;35(suppl):S40-S41, Cited in

Byham-Gray, p. 46
 HD patients at risk for lipid disorders
 Recommended fat intake<30% of calories
and saturated fat<10%; cholesterol <300
mg/day
 Optimum fiber intake 20-25 g/day
 These restrictions are difficult to achieve
along with other restrictions of HD diet
 ≥ 1 L fluid output: 2-4 g
Na and 2 L fluid
 ≤ 1 L fluid output: 2 g Na
and 1-1.5 L fluid
 Anuria: 2 g Na and 1 L
fluid
 Restrict Na+ if ↑
interdialytic wt gain, CHF,
edema, HTN, low serum
sodium
 Potassium needs related to urinary output
 Most patients on HD can tolerate 2.5 g of K+
 Stricter diet may be indicated for pts w/
insulin deficiency, metabolic acidosis, treated
with beta blockers or aldosterone
antagonists, hypercatabolic
 Individuals: 40 mg/kg edema-free IBW or
SBW
 Maintain s. phos 3.5-5.5 mg/dL
 Usually ok until GFR ↓ to 20-30 mL/min
 Dialysis removes 500-1000 mg/treatment
 Use phosphorus binders with meals: absorb
50% of dietary phosphorus
 Dietary intake: 800 to 1000 mg/day or <17
mg/kg IBW.
 Identify high protein, low phos food sources
 High from excess Ca++ type binders, vitamin
D analogs, Ca++ fortification
 Goal 8.4-9.5 mg/dl
 CaXPhos product: goal <55
 H2O soluble vitamins
 Dialyzable – take after H.D.
 B vitamins and vitamin C in renal vitamin
↑ Vit. C → ↑ oxalate → calcification of soft tissues
and stones

 Individualize need for:

 Fe++ (IV most common), Vitamin D, Ca++, Zinc.
 Vitamin D is activated in the kidney to
calcitriol, or vitamin D3
 As D3 levels fall, calcium absorption ↓ and
phos excretion ↓
 Vitamin D3 therapy helps prevent renal bone
disease but may cause hypercalcemia
 Renal pts should use calcitriol supplements
under the supervision of a physician
 Energy: 35 kcals/kg/day SBW or adjusted
body weight for pts<60 years; 30 kcals/kg for
those >60
 Calories provided in the dialysate should be
included in total intake (may absorb as much
as 1/3 of daily energy needs)
 PD patients lose 5-15 grams of protein a day,
primarily as albumin
 Goal 1.2-1.3 g/kg SBW
 PD clears sodium very well, so sodium can be
fairly liberal
 However, high salt diets increase thirst and
may make adherence to fluid limits more
difficult
 General recommendation is 2-4 grams
sodium
 Potassium: is easily cleared by PD; some
patients may need K+ supplementation
 Calcium: limit to 2000 mg elemental calcium
 Generally pts get ~1500 mg from calcium-based
phosphate binders
 Serum calcium should be maintained in low
normal range (8.4-9.5 mg/dl)
 Phosphorus: limited to 800-1000 mg/day
which is difficult with high protein diet
 Use phosphate binders
 Fluid: can be adjusted by varying the dextrose
concentrations of the dialysate
 May need to be restricted if pts cannot achieve
fluid balance without frequent hypertonic
exchanges
 Increase exercise as allowed
 Limit sodium and fluid to minimize
hypertonic exchanges
 Modify energy intake to facilitate wt loss
 Modify intake of sugars and fats, especially
saturated fats
 Patient education regarding protein goals
and ways to meet them
 Suggest pt eat protein foods first and limit
fluids at mealtime
 Frequent smaller portions of protein and easy
to eat proteins such as egg white, cottage
cheese, etc
1. Types: related donor
2. Posttransplant management:
Corticosteroids
Cyclosporine
3. Diet while on high-dose steroids:
1.3 to 2 g/kg BW protein
30 to 35 kcal/kg BW energy
80 to 100 mEq Na
4. Diet after steroids:
1 g/kg BW protein
Kcal to achieve IBW
Individualize Na level
Well Mr. Osborne, it may not be kidney stones after all.
1. Particulate matter crystallizes
Ca salts (Ca oxalate or Ca phosphate)
Uric acid
Cystine
Struvite (NH4, magnesium and phosphate)
2. Ca salts in stones—Rx: high fluid; evaluate
calcium from diet; may need more!
3. Treat metabolic problem; low-oxalate diet
may be needed; acid-ash diet is sometimes
useful but not proven totally effective
4. Uric acid stones
Alter pH of urine to more alkaline
Use high-alkaline-ash diet
Food list in Krause text
5. Cystine stones (rare)
6. Struvite (infection stones) antibiotics and/or
surgery
 Increases acidity of urine (contains chloride,
phosphorus, and sulfur)
 Meats, cheese, grains emphasized
 Fruits and vegetables limited (exceptions are
corn, lentils, cranberries, plums, prunes)
 Increases alkalinity of urine (contains sodium,
potassium, calcium, and magnesium)
 Fruits and vegetables emphasized
(exceptions are corn, lentils, cranberries,
plums, prunes)
 Meats and grains limited
 Your kidney team will tell you if you need to
start a special diet.

 There is no need to avoid potassium or

phosphate foods unless your blood levels are
high.
 There is no one special diet for people
with renal disease.

 It all depends on…

 Your level of renal function.
 What your blood tests show.
 What kind of dialysis you choose.
 NKF K/DOQI practice guidelines. Am J Kid Dis
2000;35(suppl):S40-S41, Cited in Byham-Gray, p.
46
 Byham-Gray L, Wiesen K. A clinical guide to
nutrition care in kidney disease.ADA, 2004
 Byham-Gray L, Wiesen K. A clinical guide to
nutrition care in kidney disease.ADA, 2004
 National Kidney Foundation. K/DOQI clinical
practice guidelines for nutrition in chronic renal
failure. Am J Kidney Dis 2000;35(suppl);S27-S86.
 National Kidney Foundation. K/DOQI clinical
practice guidelines for nutrition in chronic renal
failure. Am J Kidney Dis 2000;35(suppl);S27-S86.