RENAL

Adapted from the Nutrition Care Manual

Paula Rubello, Dietetic Intern

Table of Contents

Urinary Tract Infections

Renal Replacement Therapy

Nephrotic Syndrome
Kidney Stones
Chronic Kidney Disease
(CKD) Stage 5 Dialisys
Chronic Kidney Disease
(CKD) Stage 1-4 Non-Dialysis
Urinary Tract Infections
(UTI)
Cause: Bacteria that settle and multiply in
urinary tract. Prevalent in women, but men
with enlarged prostate glands are also at
risk

Nutrition treatment: Increase fluid intake

and consume cranberry juice. Cranberry
juice contains acids that are excreted in the
urine as hippuric acid, which may prevent
bacteria from staying in urinary tract.

Fermented milk products with probiotics,

such as kefir, may decrease UTI risk.
 Nutrition tips:
Instead of milk, have yogurt with probiotics or
other fermented dairy products (i.e. Kefir)
Drink a lot of water
Have cranberry juice or other berry juices that list
fruit juice first on ingredient list (such as in the
image below)
 Sample Menu 1-day menu for UTI
Breakfast:
1/2 c of cranberry juice
1 cup of kefir with 1/2 c of cooked oats and 4 sliced
strawberries topped with 1/4 c of walnuts
1 c of water
Lunch:
1 can of white tuna (no salt added), mixed with 3 tbsp of
plain greek yogurt (i.e Chobani), 1 tsp of dill
2 slices of whole wheat toast
2 slices of tomato
2 lettuce slices
1/2 cucumber sliced on the side with 1 tbsp of olive oil
and 1/2 a lemon squeezed
1/2 c of cranberry juice
1 c of water
Snack:
1 medium orange
1 hard boiled egg
1 c of water
Dinner:
3 oz baked salmon fillet
1/2 c of string beans with 1 tbsp of olive oil
1/2 a baked sweet potato with 1 tbsp of plain greek
yogurt
1 c of water
Renal Replacement Therapy
Hemodialysis: The most common procedure for renal
replacement therapy. Removes excessive urea that
cannot be excreted by urine due to kidney disease.
Peritoneal Dialysis: Alternative to hemodialysis
1) Continuous ambulatory peritoneal dialysis: consisting
of manual dialysis exchanges
2) Continuous cyclic peritoneal dialysis: uses an
automated machine (called the cycler) at
nightIntermittent
3) Peritoneal dialysis: rarely used because it requires 36-
40 hours of dialysis/week
Since there are losses of amino acids and albumin
through the peritoneal membrane, adequate intake of
protein is essential
Continuous renal replacement therapy (CRRT): form
of dialysis that slowly removes fluids fluids and
solutes while correcting the electrolyte and metabolic
abnormalities associated with acute renal failure.
Nutrition support is generally requires because of
increased energy expenditure.
 Nephrotic Syndrome
Cause: Protein loss in the urine in excess
Symptoms:
- Proteinuria
- Hypoalbuminemia: low level of albumin in the blood
- Dyslipidemia: altered lipid levels (triglycerides, LDL, HDL)
in the blood
- Edema: swelling caused by excess fluid in body tissues
Can be caused by certain diseases and/or conditions:
- Diabetes
- Lupus
- Infections
- Medications
- Neoplasms
- Chronic allograft nephropathy
- Preeclampsia
Nutrition Treatment:
- Replace nutrients lost in the urine
- Reducing progression of kidney failure
- Decreasing the risk of atherosclerosis
- 0.8 g to 1.0 g protein/kg/day
- Consumption of soy protein and flax seeds, they
decrease proteinuria
- For dyslipidemia: decrease fat intake
- For edema: decrease sodium intake to 1g-2g/day
 Nutrition tips:
Control your intake of protein, sodium, fluid, and
fat
Do not focus on protein as the main part of the
meal. Think of meat and other types of animal
protein as a side dish
Plan meals ahead for special occasions and dining
out
 Sample Menu 1-day menu for
Nephrodic Syndrome
Breakast:
1 c of puffed wheat cereal
1 c of flax seed milk
1/2 c of raspberries
1/2 sliced banana
1 c of coffee
Lunch:
2 slices of whole what bread
2 slices of part skim mozzarella cheese
2 sliced of tomato
6 leaves of spinach
drizzles with 1 tsp of balsamic vinegar
Snack:
1 medium apple
10 almonds
Dinner:
1/2 c of brown rice
1/2 of a 3 oz chicken breast
1/2 c of green beans
1/2 c of sliced strawberries
1 c of water
 Kidney Stones
Most common type of kidney stones:
- Calcium oxalate, both monohydrate (whewellite) and
dihydrate (weddellite) forms
- Calcium phosphate (occurring most commonly as
carbonate apatite, brushite, or hydroxyapatite)
- Uric acid
- Ammonium urate
- Struvite (magnesium ammonium phosphate)
- Cystine
Diet is a contributor to stone formation
Excessive intake of nondairy animal protein increases
risk of calcium oxalate stone formation
Other contributors  to stone formation:
- Genetic Disorders (i.e. primary hyperoxaluria, Bartter
syndromes, Dent disease, renal tubular acidosis)
- Urinary tract infections
- Cystic Kidney Diseases
- Renal Anatomical Abnormalities
- Metabolic Disorders (metabolic syndrome, Sjögrens
syndrome, sarcoidosis, hyperparathyroidism,
inflammatory bowel disease and irritable bowel, short gut,
and diabetes)
 Kidney Stones Nutrition
Therapy
Diet can influence the formation and growth of
kidney stones
Depending on your individual risk factors and on the
type of kidney stones you form, you may be advised
to make dietary changes. 
Risk factors for kidney stones vary between
individuals as well as nutrition therapies

1) Increase your Urine Volume by

Drinking more Fluids
Usually 2 liters of urine or more is the goal
Drinking at least 3 liters (at least 3 quarts or 100 ounces) of
fluids per day is the best way to lower your risk for
forming new stones. You may have to drink more than this
if you exercise heavily or are in hot weather for long
periods of time.
Spread your fluid intake throughout the day and night. All
drinks count toward your fluid intake, including water, fruit
juice, coffee, tea, milk, soda, and lemonade.
Drink more low-sugar, low-calorie beverages so you do not
get too many of your calories from beverages.
Drink beer, wine, and alcoholic spirits in moderation, if at
all.
2) Reduce Urine Calcium by Reducing
your Salt Intake
Reducing sodium (salt) intake is a powerful way to reduce
urine calcium
Most diets contain too much sodium. This may increase
the amount of calcium your kidneys let out into the urine
Sodium not only comes from the salt shaker but from
processed and prepared foods
The recommended amount of sodium is 1,500 milligrams
per day. Most people get more than this even if they don’t
use the salt shaker
Choose “no salt added” or “low-salt” foods as much as
possible. Particularly high-salt foods to limit include:
- Cheese (all types)
- Most frozen foods and meals
- Salty, cured meats and deli meats
- Hot dogs, bratwurst, and sausages
- Canned soups and vegetables
- Breads, bagels, rolls, and baked goods
- Salty snacks (chips, pretzels)
- Certain salad dressings
- Certain breakfast cereals
- Pickles and olives
- Pizza, lasagna
- Canned and bottled pasta sauces
- Certain condiments
- Table salt and some spice blends
 3) Reduce Urine Calcium by Avoiding
Foods Causing a "High Acid Load"

Balancing your diet for acid is important if your urine

calcium is high
A high “acid load” diet may cause your bones to release
more calcium into the bloodstream than they should. This
can add to high urine calcium.
The foods causing the highest acid load are:
- Cheese
- Meats of all types
- Fish and seafood
- Poultry
Reduce the number of times you eat these foods in a week
and eat smaller portions of these foods.
Foods in the grain group—breads, cereals, rice, and pasta—
also add to the acid load of the diet, but not as much as
cheese, meat, poultry, and fish. Fewer grain foods, or
smaller portions, may help reduce urine calcium.
Milk and yogurt do not need to be restricted unless
otherwise recommended.
Nearly all fruits and vegetables have the opposite effect of
acid. Eating more of these will help balance your diet
against the acidic effects of meats and cheese.
 4) Reduce Urine Oxalate
Eat or drink something with about 300 milligrams of
calcium at each meal and snack. Calcium and oxalate
bind in the digestive tract and get removed in the stool.
 Less oxalate is absorbed and available to the urine.
Foods and beverages are best  for including calcium;
non-dairy sources are available for those who may be
lactose intolerant or who otherwise avoid or limit dairy.
Calcium supplements may be included, but you should
not have more than 1,200 to 1,500 milligrams of calcium
a day. (If you have short bowel or malabsorption, you
may be advised to use more calcium.)
Eat fewer “high-oxalate” foods. The more oxalate
absorbed from your digestive tract, the more in your
urine. High-oxalate foods to limit, if you eat them, are:
- Spinach
- Rhubarb
- Beets
- Potato chips
- French fries
- Nuts and nut butters
You do not need to cut out other healthy foods that
provide some oxalate. In fact, oxalate is practically
unavoidable, because most plant foods have some. 
Stop taking vitamin C supplements. When the body
gets more vitamin C than it needs, some of the vitamin
C breaks down into oxalate. The oxalate then goes to
the kidneys and into the urine. You do not need to limit
fruits and vegetables with vitamin C.
Increase the amount of oxalate-eating bacteria in your
digestive tract. If you’ve ever been on an antibiotic,
especially recently, or if you’ve had part of your
digestive tract removed, you are at special risk of not
having enough good bacteria (also known as
probiotics). Many different bacteria eat oxalate, which
reduces the amount of oxalate that is absorbed and
reduces oxalate in urine. Eating foods with live cultures,
such as yogurt and kefir, may help, but you may need a
large dose of probiotics. Start a daily probiotic
supplement. Choose one with at least 3, preferably
more, different strains of bacteria to increase the
chance that some of them will lower the level of
oxalate.
In certain cases, vitamin B-6 and/or fish
oil supplements are recommended.
 5) Reduce Urine Acidity
Especially relevant for those who form uric acid or
cystine stones
Sometimes, only medication can address acidic urine
effectively
Decrease the acidity of your urine by increasing your
intake of fruits and vegetables, which provide potassium
and other compounds that alkalinize urine.

6) Reduce Urine Uric Acid

All meats of all types, including poultry and fish,
contribute to uric acid production in the body. You are
advised to eat fewer of these foods within a week and/or
to eat smaller portions. 
Organ meats, water fowl, game meats, and certain types
of seafood (anchovies, sardines, herring) are especially
high in purines. When purines are consumed, they
increase uric acid levels.
Make 2 or more days a week “non-meat” days (you may
use dairy and eat non-meat protein foods like beans).
Limit yourself to one serving per day of meat, fish,
poultry or seafood.
Limit portion sizes of meat, fish, poultry, or seafood to no
more than one-quarter of your plate (or 3 to 4 ounces by
weight).
 7) Increase Urine Citrate
If your citrate is very low, a medication may be
prescribed to help increase it.
Eating more fruits and vegetables—at least 5 a day—and
choosing beverages high in citric acid can increase your
urine citrate. Pure lemon juice (not lemonade) and lime
juice are very rich in citric acid. You may try using 2
ounces of lemon or lime juice diluted in water or other
beverage twice daily. Beverages with citric acid in them
include some diet sodas and powdered drink mixes.

8) Increase Urine Magnesium

If your urine magnesium is low, you are advised to take a
magnesium supplement, which is available over-the-
counter. Your registered dietitian will specify how much
magnesium you need; you may require a formulation
providing in the range of 300 to 500 milligrams per day,
depending on your current intake of foods providing
magnesium.
Chronic Kidney Disease (CKD) Stage 5
Dialysis
Chronic kidney disease (CKD) is a permanent, progressive
loss of kidney function characterized by a decline in
glomerular filtration rate (GFR). The National Kidney
Foundation Kidney Disease Outcome Quality Initiative
(NKF-K/DOQI) classifies CKD into five stages based on
GFR level. At Stage 5D, dialysis is needed to support life
A sodium and fluid restriction is recommended in
maintenance dialysis to avoid large interdialytic weight
gains, hypertension, edema, pleural effusion and
congestive heart failure.
A low-potassium diet in addition to maintaining optimal
blood glucose control and treatment of constipation are
indicated as needed to avoid hyperkalemia
Patients undergoing maintenance dialysis must also
decrease phosphorus intake to avoid
hyperphosphatemia.
Phosphate binders are usually required to decrease
intestinal absorption of phosphorus found in most foods.
Foods higher in protein (and also higher in phosphorus)
may be needed to maintain adequate protein stores, thus
increasing the need for phosphorus binding therapies.
Patients who are using calcium containing phosphate
binders should limit total daily calcium intake from food
and medications to <2000 mg per day to avoid
hypercalcemia, which can cause hypertension and
calcification of blood vessels, soft tissue, and organs
 Stage 5: Hemodialysis Nutrition
Needs
Protein: >1.2 g/kg of body weight
Energy :< 60 yrs of age: 35kcal/kg; >60 yrs of age: 30-35
kcal/kg
Sodium: less than 2.4g/day
Potassium  less than 2.4g/day
Phosphorus 800 mg/day to 1,000 mg/day or 10-12mg
phosphorus per gram of protein  when serum
phosphorus >5.5 mg/dL or intact
Calcium total elemental intake (including dietary calcium,
calcium supplementation and calcium-based binders)
should not exceed 2 g/day
Fluid: Urine output plus 1000 mL

Stage 5: Peritoneal Nutrition Needs

Protein: >1.2 g/kg to 1.3 g/kg
Energy: < 60 yrs of age: 35kcal/kg; >60 yrs of age: 30-35
kcal/kg
Sodium: 2 g/day; monitor fluid balance
Potassium: 3 g/day to 4 g/day; adjust to serum levels
Phosphorus: 800 mg/day to 1,000 mg/day when serum
phosphorus: >5.5 mg/dL or PTH elevated
Calcium: <2 g/day; include binder load
Fluid: Urine output plus 1000 mL
Chronic Kidney Disease Stage 5 Tips
For People On Dialysis
Avoid salt when cooking, use different spices/herns such
as onion, garlic, dill or oregano
Soaking vegetables can lower potassium. Peel and cut into
pieces that
are approximately 1/8 inch thick. Rinse and soak them in
warm water for at least 2 hours. Use approximately 10
times more water than vegetables. Drain and rinse them
under warm water, and then boil them for 5 minutes.
Measure portions of food and ingredients
Foods that are liquid at room temperature, such as soup,
contain water. Gelatin, pudding, ice cream, and other
foods that include a lot of liquid in the recipe also count.
Most fruits and vegetables contain water, such as melons,
grapes, apples, oranges, tomatoes, lettuce, and celery.
When you count up how much liquid you have in a day, be
sure to count these foods.
Avoid processed foods to reduce your intake of sodium
and phosphorus. Select fresh or frozen
Look for the word phos on the ingredient list since most
processed foods will have added phosphorus
Sample Menu 1-day menu for Stage
5 CKD on dialysis
Breakfast:
2 poached eggs
2 slices of whole wheat toast with 1 tbsp of almond
butter
½ c of berries
½ c of coffee
Lunch:
3 oz chicken breast
1 slice of rye bread with 2 tsp of mustard
10 baby carrots
1 c of water
Snack:
1/2 c of grapes
2 tbsp of hummus
5 no salt pita chips
Dinner:
4 oz fish fillet, baked with lemon juice and parsley
½ c of boiled green beans
⅓ c of cooked white rice
Snack:
1/2 c of cheerios
1/2 c of soy milk
Chronic Kidney Disease (CKD) Stage
1-5 Non-Dialysis
Chronic kidney disease (CKD) causes damage to the health
of your kidneys, usually over time. When your kidneys are
not in good health, it is time to change what you eat and
drink so your body will work well and you will feel better.
Nutrient recommendations:
For all stages of CKD, limit portion sizes of all protein foods,
such as meat, poultry, fish, eggs, dairy, and legumes, to reduce
how hard your kidneys have to work
Replacing some animal proteins (meat, fish, poultry, dairy) with
proteins from plant sources, such as beans, nuts, nut butters,
and soy products may further reduce how hard your kidneys
have to work.  Plant proteins help lower the levels of unhealthy
fats in your blood and improve blood glucose control
Plant proteins may have higher levels of potassium and
phosphorus.  They may need to be limited in stage 3 and/or 4,
only if your blood potassium or phosphorus levels are
elevated.
In CKD stages 1 through 4, controlling your blood pressure is
very important.
Too much sodium (salt) in your diet may make it harder to
control blood pressure.
The kidneys normally remove extra fluid from the body.
In the latest stage of kidney disease (late stage 4 to stage 5),
your kidneys may not make as much urine as usual and
medications that help remove fluid may be less effective. When
this happens, you may be told to drink less fluid.
High blood levels of phosphorus may be an early sign that your
kidney failure is affecting your bones
You may need to eat fewer high-phosphorus foods or take a
medication called phosphorus binder
In CKD stages 1 through 4, there is usually no restriction in
potassium. But, if blood levels of potassium become too high,
you will need to restrict potassium intake
Controlling your blood glucose (sugar) is important.
Poor blood glucose control can damage your kidneys and other
parts of your body.
Don’t add salt to your food when cooking or at the table
Read labels and choose foods with 300 milligrams of sodium
per serving or less.
Use food labels to help you plan for a total of 400 milligrams of
sodium (or less) for breakfast, 600 milligrams (or less) for lunch
and dinner, and 150 milligrams (or less) for snacks.
Sample Menu 1-day menu for Stage
4 CKD not on dialysis
Breakfast: 
1/3 c of dry oats cooked in water
1/2 c of almond milk
½ c of berries
½ c of coffee
Lunch:
1 egg
2 slices of whole wheat bread
Snack:
1 c of raspberries
1/4 c of unsalted popcorn
Dinner:
1/2 c of cooked pasta
1 small chicken drumstick
Sautéed vegetable medley (1/2 small onion, 2 tbsp of
peas, 4 slices of green pepper sautéed in 1 tsp of oil)
Snack:
1/4 c of unsalted almonds
1 tangerine
 Acute Renal Failure
Acute renal failure is often a complication of the following:
- Sepsis
- Trauma
Multiple Organ Failure

Continuous Renal Replacement Therapy (CRRT) is generally

used to manage patients with acute renal failure
Acute renal failure causes several nutritional imbalances:
- Rapid decrease in urine output
- Acidosis
- Electrolyte imbalances (hyperkalemia, hyperphosphatemia)
- Fluid disturbances
- Impaired glucose utilization
- Protein catabolism
- Accumulation of metabolic waste products
Goals for Clients with Acute Renal
Failure
Eliminate cause of kidney failure
Prevent further kidney damage
Support kidney functions and other affected organ systems
Provide adequate calories and protein
Preserve lean body mass
Prevent nutritional deficiencies
Maintain and improve electrolyte and fluid imbalance
Manage anemia
Reassess use of nephrotoxic drugs
 Protein
Clinical condition
Degree of catabolism
Extent of impairment of renal function
Whether renal replacement therapy has been initiated

Fluid Needs
Treatment modality
Hydration state
Increased insensible losses with fever, sepsis, or burns
Urine Output

Electrolytes
Serum electrolytes should be closely monitored as
nutritional support will need to be adjusted accordingly.
Hyperkalemia and hyperphosphatemia can occur during
acute renal failure.
Serum magnesium, calcium, and phosphorus should be
supplemented as needed.
Sodium intake should be prescribed based on hydration
status and urinary losses.
CRRT causes significant loss of magnesium, calcium,
phosphorus, and potassium, which requires careful
monotoring
 Nutrition Tips of AKI
You may or may not need to limit certain foods due to
acute kidney failure.
Your registered dietitian (RD) will help you determine which
foods are appropriate to include in your diet and which
foods you should avoid.
Based on your individual needs, your RD will determine
how many calories and how much protein, sodium,
potassium, and phosphorus you can have on a daily basis.

Sample Menu 1-day menu for AKI

Breakfast: 
1/2 cup cranberry juice
1/2 cup low-fat, plain yogurt
1 c of cheerios
1/2 c of raspberries
1 cup coffee
Lunch:
2 slices whole-wheat bread
2 leaves lettuce
1 slice tomato
1 tablespoon mayonnaise
1/2 cup cucumber slices
2 tablespoons oil and vinegar dressing
1 medium peach
 Dinner
3 oz broiled fish
1 cup rice
1/2 cup green beans
1 cup tossed salad
1 tablespoon oil and vinegar dressing
1 teaspoon margarine
1 mandarin
1 cup tea of water
Snack
3 c of no salt popcorn
1/2 c of sliced strawberries