Nutrition in CKD, Dialysis and Kidney transplant

Objectives
• Kidney Anatomy and Physiology
• Types of Kidney Failure
• Challenges and recommendation for renal failure patients
• Estimating dialyzed calories
• Overview of PN provided to patients with AKI in the ICU setting as
well as intradialytic parenteral nutrition (IDPN) provided to patients in
the chronic outpatient dialysis setting
• Considerations for Implementation of ERAS in Kidney Transplant
Patients
 Basic Kidney Structure and Function

renal corpuscle
What is the functional unit of the kidney
• A) Glomerulus
• B) Loop of Henle
• C) Nephron
• D) Medulla
Kidney Function and Physiology

• Glomerular filtration, tubular reabsorption, and tubular secretion are

the three primary steps in which kidneys filter blood and maintain
proper electrolyte balance.
• Glomerular filtration removes solutes from the blood; it is the first
step of urine formation.
• In tubular reabsoption, the second step of urine formation, almost all
nutrients are reabsorbed in the renal tubule by active or passive
transport.
• Tubular secretion is the last step of urine formation, where solutes
and waste are secreted into the collecting ducts, ultimately flowing to
the bladder in the form of urine.
How much protein should be present in the urine?

A) none
B) ACR between 30-300 mg/g
C)ACR > 300 mg/day
D)The more the better
Diabetes and hypertension are leading causes of kidney failure

Incident ESRD rates, by primary diagnosis, adjusted for age, gender, & race.

ESRD, end stage renal disease

USRDS ADR, 2007
Dietitians role in renal failure patients

• Performs nutrition screening to evaluate individual health,

malnutrition and disease while adhering to the Standards of Practice
(SOP) in Nutrition Care for dietitians
• Implements the Nutrition Care Process to ensure individual health
goals are established, monitored and achieved while adhering to the
Standards of Practice in Nutrition Care for dietitians.
• Documents and maintains records according to the SOP for the
dietitians
Why diet is important in CKD
▪ Maintain optimal nutritional status
▪ Prevent protein energy malnutrition
▪ Slow the rate of disease progression
▪ Prevention/treatment of complications and other medical conditions
✓ DM
✓ HTN
✓ Dyslipidemias and C V D
✓ Anemia
✓ Metabolic acidosis
✓ Secondary hyperparathyroidism
Why diet is important in HD
• Renal diet minimizes the amount of wastes
• A good meal plan choices can:
• Minimize build-up of waste products & fluid between
treatments
• Improve nutritional and functional status
• Conserve muscle mass
Nutrition Care Process
Sign & symptoms identified in nutrition assessment are used to diagnose nutrition problems
Nutrition Diagnosis that may occur in patients with AKI
Intake Domain
Increased energy expenditure
Inadequate energy intake
Inadequate oral intake
Inadequate EN infusion
Inadequate PN infusion
Excessive fluid intake
Increased nutrient needs (specify protein, energy, vitamins, etc.)
Malnutrition
Inadequate protein-energy intake
Decreased nutrient needs (specify potassium, phosphorous, magnesium etc.)
Inadequate protein intake
Excessive mineral intake (specify potassium, phosphorous, magnesium etc.)
Clinical Domain
Food –medicine interaction
Unintentional weight gain
Behavioral-Environmental Domain
(For those individuals who would require long-term renal replacement therapy)
Food and nutrition related knowledge deficit
Not ready for lifestyle change

Reference manual standardized language for the nutrition care process. 3rd ed. American Dietetic Association, Chicago. 2011
Characteristics Associated with Chronic Kidney Disease

Characteristic Severe Malnutrition

Reduced Energy Intake ≥1 month of consuming
<75% energy needs
Weight loss >5%, 7.5%, 10%, or 20% of
weight loss over 1, 3, 6, and
12 months, respectively
Muscle wasting/Fat loss Moderate-to-severe loss of fat or lean body mass or localized or
generalized fluid accumulation
Decreased Functional Capacity Measurably reduced functional measures

J Acad Nutr Diet. 2012;112:730–738. supportline 2015 feb

Causes of PEW

Consequences of PEW

14
Diagnostic Criteria for Protein Energy Wasting
(PEW)
Diagnostic Category Diagnostic Criteria

Laboratory Serum albumin <3.8 g/dL

Transthyretin <30 mg/dL
Cholesterol <100 mg/dL
Body fat mass and weight Body mass index <23
Total body fat mass <10%
Weight loss: 5% over 3 months or 10% over 6 months
Muscle mass Muscle mass loss: 5% over 3 months or 10% over 6 months
Mid-arm muscle circumference: decreased >10% compared to
. 50th percentile of reference population
 Is albumin can predict mortality at onset of dialysis
Strong predictor of morbidity and mortality
(CANUSA• .study)
However,
Albumin is affected by non-nutritional
factors
▪ Infection
▪ Inflammation
▪ Co-morbidities
▪ Fluid overload
▪ Inadequate dialysis
▪ Blood loss
▪ Metabolic acidosis

Albumin may not increase in response

to nutritional intervention

There is No Single Nutritional Index Kidney Res Clin Prac. 2017; 36: 182–191
 What are the
normal ranges?
90-140 ml/min

incompatible with life,

without dialysis or transplantation.
Pathologic manifestations of CKD treatment
• Anemia: When the hemoglobin level is below 10 g/dL, treat with
erythropoiesis-stimulating agents
• Hyperphosphatemia: Treat with dietary phosphate binders and dietary
phosphate restriction
• Hypocalcemia: Treat with calcium supplements with or without calcitriol
• Hyperparathyroidism: Treat with calcitriol or vitamin D analogues or
calcimimetics
• Volume overload: Treat with loop diuretics or ultrafiltration
• Metabolic acidosis: Treat with oral alkali supplementation
• Uremic manifestations: Treat with long-term renal replacement therapy
(hemodialysis, peritoneal dialysis, or renal transplantation)
 How can Kidney disease lead to bone and heart disease?

•. • Help keep right amount of calcium and phosphorus

• Activate vitamin D

• No longer filter out extra phosphorus or activate vitamin D

• High Phosphorus, Low Vitamin D and Low Calcium

• Elevated P and Low Ca release PTH

• Parathyroid glands make too much PTH.
• High PTH cause calcium and phosphorus to leave bones

• Bones become weak, brittle, more likely to break

• Calcium and phosphorus can end up in the heart and blood vessels
• May cause or worsen heart disease
Nutrition recommendations for CKD not on
dialysis
CKD stages 1 and 2 CKD stages 3–5
Calories 25–35 kcal/kg/d, medically stable 25–35 kcal/kg/d, medically stable

Protein 0.6–0.8 g/kg/d 0.55–0.60 g/kg/d if metabolically stable or 0.6–0.8g/kg/d

with DM
Fluid Oliguric: usually not restricted unless hyponatremia or Oliguric: usually not restricted unless hyponatremia or
CHF, as tolerated CHF, as tolerated

Sodium 2–2.3 g/d, as tolerated 2–2.3 g/d unless fluid overload

Potassium <2,000 mg/d <40 mg/kg/d if serum levels are elevated

Phosphorus 800–1,000 mg/d; if serum levels are elevated use binders 800–1,000 mg/d; if serum levels are elevated, use binders

Vitamin A Not typically supplemented due to potential toxicity Not typically supplemented due to toxicity

Vitamin D Aim for levels similar to the general population Aim for levels simi lar to the general population
Indications for renal replacement therapy
• Severe metabolic acidosis
• Hyperkalemia
• Pericarditis
• Encephalopathy
• Intractable volume overload
• Failure to thrive and malnutrition
• Peripheral neuropathy
• Intractable gastrointestinal symptoms
• In asymptomatic patients, a GFR of 5-9 mL/min/1.73 m², [5] irrespective of
the cause of the CKD or the presence or absence of other comorbidities
What level of creatinine requires dialysis?
• Decision made between a nephrologist and a patient. It is based on
the level of kidney function and the symptoms that the patient is
experiencing
• National Kidney Foundation guidelines recommend you start dialysis
when your kidney function drops to 15% or less — or if you have
severe symptoms caused by your kidney disease, such as: shortness
of breath, fatigue, muscle cramps, nausea or vomiting.
Considerations for Parenteral Nutrition Support during Renal Failure Espen 2021

• Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute illness.
• After day three, caloric delivery can be increased up to 80-100% of measured energy expenditure.
• To avoid overfeeding, early full EN and PN shall not be used in critically ill patients but shall be prescribed
within three to seven days.
• For patients undergoing KRT, the total energy provision by additional calories given in the form of citrate (3.0
kcal/g), lactate (3.62kcal/g), and glucose (3.4 kcal/g) from dialysis/hemofiltration solutions should be
included in the calculations to determine the total daily energy provision to avoid overfeeding

Lactate 0.32 g /L RL
Citrate dialysate helps to control acid base balance by correcting. acidosis between
sessions and avoiding/reducing post dialysis alkalosis.
Sodium citrate 4% citrate
ESPEN protein guidelines
• Hospitalized patient with CKD without acute/critical illness: 0.6-0.8 g/kg BW/d. Nutrient intake
must fully cover the essential amino acids and the energy requirement, and metabolic acidosis
must be prevented or adequately corrected
• Hospitalized patient with CKD and KF on conventional intermittent chronic KRT without
acute/critical illness: 1.2 g/kg BW/d
• Hospitalized patient with AKI, AKI on CKD without acute/critical illness: 0.8-1.0 g/kg BW/d
• Hospitalized patient with AKI, AKI on CKD, CKD, with acute/critical illness, not on KRT: start with 1
g/kg BW/day, and gradually increase up to 1.3 g/kg BW/d if tolerated
• Critically ill patients with AKI or AKI on CKD or CKD with KF on conventional intermittent KRT: 1.3-
1.5 g/kg/d
• Critically ill patients with AKI or AKI on CKD or CKD with KF on CKRT or PIKRT: 1.5 g/kg/d up to 1.7
g/kg/d

E. Fiaccadori, A. Sabatino, R. Barazzoni et al. Clinical Nutrition 40 (2021) 1644-1668

Case study
• The patient is a 43 year-old male who has a longstanding history of
hypertension and diabetes and presents with a complaint of pruritis,
lethargy, lower extremity edema, nausea and emesis. He denies any
other medical illnesses.
• On physical exam the patient is a well-developed, well-nourished
male in moderate distress. Blood pressure 180/110, pulse 80,
respirations 24 and he was afebrile. Body weight 76.5 kg. 2+ lower
extremity edema and superficial excoriations of his skin from
scratching.
Laboratory Data
Laboratory Data Normal values Urinalysis
Sodium 133 136-146 mmol/L pH 6.0
Potassium 6.2 3.5-5.3 mmol/L Specific gravity 1.010
Chloride 100 98-108 mmol/L Protein 1+
Total CO2 15 23-27 mmol/L Glucose negative
BUN 170 7-22 mg/dl Acetone negative
Creatinine 16 0.7-1.5 mg/dl Occult blood negative
Glucose 108 70-110 mg/dl Bile negative
Calcium 7.2 8.9-10.3 mg/dl Waxy casts
Phosphorous 10.5 2.6-6.4 mg/dl
Alkaline phosphatase 306 30-110 IU/L
Parathyroid hormone 895 10-65 pg/ml
Hemoglobin 8.6 14-17 gm/dl
Hematocrit 27.4 40-54 %
Mean cell volume 88 85-95 FL
 Case study related questions
• presents with a complaint of pruritis, lethargy, lower extremity edema, nausea and emesis."
what does the symptoms suggest to you? Uremia
• Symptoms of uremia are non-specific. You have to keep this possibility in mind whenever
there is consideration for renal disease.
• Lethargy, Nausea and vomiting, Fatigue, Pruritus

What is the significance of the finding " superficial excoriations of his skin from
scratching.“? Uremia leads to pruritus and explains the excoraitions from scratching.
• What are the possibilities for his symmetrical 2+ lower extremity edema?
• Congestive heart failure
• Hypoalbuminemia
• Water retention from renal failure
What is the most likely diagnosis for his kidney disease? How
did you arrive at that conclusion

• Is the cause of this patient renal failure acute or chronic? How did you
arrive at that conclusion? Chronic
• Acute: Short duration and rapid rise of BUN and creatinine.
• Chronic: Long duration of BUN and creatinine elevation, Hemoglobin
is low, Calcium and Parathyroid hormone disturbances
Case study related questions
• If you were to place this patient on a 2 gram sodium diet how many milliequivalents of
sodium would this diet contain? 2,000/23 m.w.=87 meq.
• How many grams of sodium chloride would this be? (87 meq) x (58 m.w.) = 5 grams.
• What is the most likely cause of this patient’s anemia? Decreased erythropoietin. This is
typically a normochromic and normocytic type of anemia.
• Should this patient be started on dialysis? What are the indications for dialysis?
Yes, indications to be considered for dialytic therapy include abnormalities in acid-
base, balance electrolyte disturbances, volume overload, dialyzable toxins, uremia.
• This patient demonstrates symptoms of uremia.
• Why is the parathyroid hormone elevated? Due to the decrease in GFR there is
decreased excretion of phosphate. This results in a decrease in serum ionized calcium
and stimulation of parathyroid hormone release.
 Urea-Creatinine Ratio
(Helps to determine the cause of AKI)

BUN/Creatinine >20 BUN/Creatinine <10

Dehydration Malnutrition

Hypovolemia Pregnancy

High protein intake Acute tubular necrosis

SIADH (syndrome of inappropriate

Congestive heart failure
antidiuretic hormone)

Shock Liver disease

Case- Nephrotic –range proteinuria
(Spot protein creatinine ratio)
Lab. case normal
Spot urine protein 129.7 mg/dl 0 to 14 mg/dL
Urine creatinine 22 mg/dl around 20 – 275 mg/dL
PCR 5.9 mg/mg <0.2 mg/mg normal
0.2 to 3.5 mg/mg non nephrotic
proteinuria
>3.5 mg/mg nephrotic proteinuria

Evidence of kidney damage/persistent albuminuria-

>30 mg of urine albumin per gram of urine creatinine (UACR)
 Case Study
• 35 year old male with no PMH or PSH
• Height 5’11” (180 cm), weight 55 kg (121 lb),
BMI 19
• Presents to ED with progressive SOB
• Diagnosed with severe bacterial endocarditis affecting his
aortic valve
• Emergently taken to the OR for an aortic valve replacement
Case Study
Postoperatively
• Hypotensive and hemodynamically unstable
• Multiple vasopressors to support blood pressor
• UOP less than 400 ml per day
• Non-responsive to IVF, plasma expanders, or diuretic therapy
Labs:

Na 127 (135-145)
K 3.7 (3.5-5.5)
Cl 87 (95-108)
CO2 11 (20-29)
BUN 55 (6-20)
sCR 2.16 (0.8-1.2)
Glu 204 (65-120)
Case Study
35yoM p/w Endocarditis, s/p AVR, POD1 hypotensive and
hemodynamically unstable.

What is the likely diagnosis?

A) Acute on CKD
B) Metabolic acidosis CKD stg 4
C) Pre-renal AKI perioperative ischemia
D) Intra-renal AKI perioperative ischemia
 Kidney Disease: Improving Global Outcomes criteria for AKI - primary types and how to calculate AKI

Stage Increase in serum Urine output Management

creatinine
1 Prerenal ≥0.3 mg/dL (26.5 μmol/L) within 48 hr <0.5 mL/kg/hr for 6–12 hr Correct adverse hemodynamic factors
Blood flow impaired, nephrons remain or 1.5–1.9 times baseline within seven and replace the depleted volume as
intact, but decrease of UOP days needed.
• Cardiac disorders: CHF Individualized fluid therapy
• Vasodilation: sepsis, anaphylaxix, Avoid positive fluid balance
medication Isotonic saline
• Hypovolemia: hemorrhage,
dehydration
• Renal artery occlusion:thrombosus,
stenosis
2 Postrenal 2.0–2.9 times baseline within seven <0.5 mL/kg/hr for ≥12 hr Urinary tract obstruction
Obstruction of urinary system days
• Prostate hypertrophy
• Tumors
• Blood clots
• Kidney and ureteral calculi

3 Intrinsic-Renal ≥3.0 times baseline, ≥4.0 mg/dL (354 <0.3 mL/kg/hr for ≥24 hr or anuria ≥12 Consider a trial of IV fluids; identify and
When parts of the kidney are damaged μmol/L) increase within seven days of hr treat underlying causes that require
• Inflammation from infection: initiation of RRT or in patients <18 specific interventions
pyelonephritis years of age, decrease in estimated
• Acute tubular necrosis: radiographic glomerular filtration rate to <35
dyes, rhabdomyolysis, prolonged pre- mL/min/1.73 m2
renal causes
• Nephrotoxicity: medication
• Glomerulonephritis: autoimmune KDIGO summary (part 1). Crit Care. 2013;17:204. AJKD,2020;76
disorders Kidney Disease: support line august, 2021
metabolic abnormalities associated with AKI/AKD

• - protein catabolism
• - alteration of metabolism of specific amino acids
• - peripheral insulin resistance
• - reduction of lipolysis and impaired fat clearance
• - depletion of antioxidant systems
• - induction of a pro-inflammatory state
• - immunodeficiency
AKI results from abrupt decrease kidney functioning

consequences Treatment of AKI focuses Nutritional considerations

accumulation of uremic toxins, • supporting the patient while Severity of AKI
volume overload, and the kidneys recover from the initial Type of dialysis involved
electrolyte abnormalities. insult. This can include IV fluids,
renal replacement
therapy (such as HD),
• correction of the
underlying damage if possible,
limiting exposure to nephrotoxic
medications, and dosing
medications for the patient’s renal
function
Nutrition recommendations while on dialysis
Type of Caloric needs Protein needs Fluid Recommendation
dialysis for
tube-feeding
product
30–35 kcal/kg/d >1.2g/kg/d Oliguric: usually not Standard if meets
HD restricted protein/caloric
requirements and no need for
unless CHF or
volume restriction or low
hyponatremia as K+/PO4.
tolerated If the electrolytes are
elevated,
choose a high protein renal
formula

PD 30–35 kcal/kg/d, >1.2g/kg/d Oliguric: usually not Standard if meets protein/

including restricted caloric requirements and no
need for volume restriction
calories from dialysate unless CHF or
or low K+/PO4. If the
hyponatremia as aforementioned, choose a
tolerated highprotein
renal formula

CRRT 30–35 kcal/kg/d; may need >2.5g/kg/d May have very high Standard formulas may be
to consider calories from needs; monitor suitable; however, careful
dialysate carbon, but that
closely for fluid balance monitoring of labs and
may be offset by CRRT
induced hypothermia volume status should
occur
Common Medication Issues in Dialysis Patients
• potassium binders for treating hyperkalemia; (calcium oxalate, D25W and
Insulin.) K-oxalate 60g retention enema
• treatments for chronic kidney disease mineral bone disorder,
• including phosphate binders, vitamin D receptor antagonists, and calcimimetics;
Calcium acetate(lowphos), Sevelamer carbonate( can decrease bioavailability of
many other medications, causes bioavailability of many other medications,
diarrhea, nausea, abdominal pain
• protein supplements for maintaining nutrition; multivitamin supplementation in
the HD population;
• Medications used and avoided in acute kidney injury;e.g. Acyclovi, Metformin,
Apixaba, Rivaroxaban
Metformin (a diabetes drug) is excreted by the kidneys, and therefore raises the risk of AKI – Metformin may
need suspending - NOT because it increases AKI risk, but because the levels of this drug can accumulate during
AKI, causing metformin toxicity (lactic acidosis) - so suspending this drug reduces patient harm due to
metformin toxicity, but does not reduce AKI risk
 To estimate the calories absorbed from dialysate, one must know the patient’s prescription

▪ Number of exchanges X exchange volume (L) X g dextrose/L X 3.4 kcal/g dextrose= dextrose kcals
Dextrose kcals x 60-76% = absorbed kcals in CAPD or Dextrose kcals x 40-50% = absorbed kcals in CCPD

▪ For example, for a CAPD patient completing four exchanges of 2 L each using 2.5% dextrose, the estimated
dextrose calories would be calculated as such:

• 4 exchanges x 2 L/exchange x 25 g dextrose/L x 3.4 kcal/g dextrose = 680 kcals in dialysate

680 kcals x 60% absorption = 408 kcals/d or
680 kcals x 76% absorption = 517 kcals/d

Exchanges may be confirmed manually continuous ambulatory PD (CAPD) or automated by a cycler machine continuous cyclic PD (CCPD)
 TPN is appropriate to use for an ESRD patient on
. dialysis via PICC line.
IDPN is typically used in the dialysis world (outpatient
clinics) based on their definitions of malnutrition. It is
I have a patient currently on Clinimix E via a PICC and is receiving dialysis PRN. Does usually supplemental and not to meet 100% of
anyone have experience with IDPN? Is there a separate formula for IDPN or can a nurse
use Clinimix for IDPN? Does anyone know why IDPN is indicated over Clinimix E via a PICC?
nutrition needs. It’s infused via the venous line of
I cannot find resources to see what parts of TPN gets filtered through the dialysis machine their dialysis access so when they need IDPN in the
if it is not being administered IDPN.
dialysis clinic setting, they don’t have a PICC line
What do you do with patients who are on hemodialysis and are receiving TPN? Do you placed. Usually the volume of the IDPN solution is
hold TPN for dialysis? calculated into the UF (or volume of water that must
be removed) to avoid excess fluid retention. I believe
IDPN only provides about 70% of the nutrients to the
patient because of the loss into the dialysate. These
dialysis clinics even so much as use albumin <3.5 as
an indicator for IDPN and most of those patients are
on an oral diet as well. With that information, IDPN
composition differs from TPN most often since it’s not
pro re nata intended to provide 100% of their needs, it would
(as necessary) also be hard to be comparable to TPN since the
infusion time would be a max of about 3-4 hours for
many of those dialysis patients
guidelines for using IDPN
• IDPN may be beneficial for malnourished patients or patients unable
to consume sufficient energy and protein to meet nutrient
requirements.
• Chronic GI problems ; N/V/D and anorexia.
• Weight loss of 10% to 15%over 6 months
• A trial of intensive nutrition counseling with oral supplements and/or
tube feeding should be attempted and/or considered before initiating
IDPN.
• The combination of IDPN and oral diet or tube feeding should meet
the patient’s energy and protein needs.
Decision tree for identifying IDPN candidates.
Intradialytic Parenteral Nutrition
• IDPN is an intravenous nutrition support therapy given to the malnourished patients during hemodialysis. It
is a supplement to the oral and /or enteral diet
• IDPN, a form of partial PN, is administered via a venous line during dialysis sessions.
• Each IDPN bag delivers a variable amount of dextrose that is based on weight, dialysis treatment time, and
glucose tolerance (e.g., diabetes mellitus). For example, the dextrose content range in the bag may vary
between 30–90 g
• or could be even higher. Reduction of dextrose from 125 mg to under 60 g helps prevent hyperglycemia in
the diabetic population.
How much protein in IDPN
1.2-1.34 g/kg dry body weight
1 g/kg for hepatic encephalopathy who are sensitive to protein
Insulin therapy with 5 units of regular insulin per 1000 ml of IDPN is recommended when serum glucose level
exceed 300 ml/dl
Infusion of glucose can promote intracellular shift of electrolytes. Serum level of K, Mg and PO4
Vitamins and trace elements are not usually added to IDPN because the additives could be lost in the dialysate. They can be added
durind the last 30 minutes of IDPN if the patient can not tolerate oral vitamin supplementation
Setting PN considerations
• Dextrose and lipid administration –hyperglycemia and hypertriglyceridemia should be avoided
• Overfeeding is a concern
- can result in hyperglycemia, azotemia, hypertriglyceridemia and steatosis
- also macronutrients may influence acid-base balance. Excessive CHO may elevate C02 levels
and precipitate respiratory acidosis
 Other point on PN considerations during AKI is the use of RRT

Conventional recommendation is to begin RRT

When disturbances are evident with ;
• Electrolyte balance
• Worsening azotemia
• Fluid overload
• Metabolic acidosis
• Symptoms of uremia observed

Cognitive dysfunction (problems with thinking and remembering), Fatigue, Shortness of breath from fluid accumulation,
Loss of appetite, Muscle cramps, Nausea and vomiting, Itching, Unexplained weight loss.
What are the signs and symptoms of prerenal azotemia?

• Diarrhea.
• vomiting.
• Profound heat exhaustion.
• Excessive sweat loss.
• Concurrent illness that impairs the ability to eat and drink adequately.
• Hemorrhage.
• Liver disease.
• Congestive heart failure.
• Uremia is a symptom of kidney failure.
When the kidneys cannot filter waste properly, it can enter the bloodstream.
Azotemia is a biochemical abnormality, defined as elevation, or buildup of, nitrogenous products (BUN-usually ranging 7 to
21 mg/dL), creatinine in the blood, and other secondary waste products within the body.
Renal transplantation- Goal
• Promote healing and prevent infections
• Prevent or control AMP
• Support immunity and prevent new infections
• Modify diet according to drug therapy
• Consider EN or PN
• Monitor
 Nutrient Recommendations by Transplant Phase
Nutrient Pre-Transplant Post-Transplant (1-3 Post-Transplant (> 3 months)
months)
Energy 30-35 kcal/kg 30-35 kcal/kg or adjusted BW 30 kcal/kg adjust to maintain stable weight

Protein Base on 0.6-0.8 g/kg conservative management 1.3-2 g/kg dry or adjusted body weight 0.8-1.0 g/kg dry or adjusted body weight
50% from HBV sources; RRT therapy options 1.2
g/kg
Carbohydrate 50-60% of non-protein calories. Parallel 50-60% of non-protein calories, increase fiber to Controlled with 50-60% total calories, primarily
levels for healthy individuals assist in control of hyperglycemia complex carbohydrate; increase soluble fiber
control blood glucose especially in new onset
diabetes after transplantation
Fat As possible, within recommendations of As needed to provide adequate calories for Follow CEP-recommended levels of fat and
American Heart Association/ Cholesterol metabolic stress cholesterol intake to minimize risk of
Education Project cardiovascular disease, obesity and dyslipidemia
Phosphorus 2-4 g/d; to maintain labs within target Individualize based on serum levels, graft Individualize based on serum levels, graft
function and impact of immunosuppressive function, secondary hyperparathyroidism and
medications impact of immunosuppressive medications
Calcium Limit to < 2 g. Include binder load. Base on Individualize based on serum levels, graft Individualize based on serum levels, graft
serum levels and pre-transplant therapy. function and impact of immunosuppressive function and impact of immunosuppressive
Adjust for albumin medications. Adjust for albumin medications. Minimum 1000-1500 mg with
long term prednisone
Magnesium Monitor serum levels Supplement as needed to maintain levels Individualize based on serum levels, graft
>1.8 mg/dL function and impact of immunosuppressive
medications
Potassium Maintain serum levels < 5.0 mg based on pre- 2-4 g/d; maintain serum levels within normal Individualize based on serum levels, graft
transplant therapy limits function and impact of immunosuppressive
medications
Sodium 1-2 g/d to control fluid balance on pre- 2-4 g/d if blood pressure and fluid balance are 2-4 g/d, individualized to control blood pressure,
transplant therapy within normal limits parallel recommendations for healthy individuals
Ascorbic Acid Limit supplementation to < 100 mg Limit supplementation to < 100 mg Limit supplementation to < 100 mg

Pyridoxine (Vitamin B6) Potential peripheral neuropathy: avoid RDI supplement as indicated RDI supplement as indicated
megavitamin therapy
 Potential adverse effects of immunosupressants with nutritional
implications(antirejection medications)
Agent Adverse effects Interventions
Cyclosporine A Hyperkalemia Restrict potassium intake
Hyperglycemia Address CHO load
Gingival hyperplasia Good oral hygiene
HPTN Restrict Na intake
Hypomagnesemia Supplement magnesium
Gastrointestinal distress Provide C/L, oral supplementation
Hyperlipidemia Therapeutic life style changes
Azathioprine (Imuran) Infection Increased nutrient intake
Mouth ulcers Diet texture medications
Folate deficiency Folate supplementation
Gastrointestinal distress Provide C/L, oral supplementation
Corticosteroids Cushingold appearance Address CHO load and increase protein
Sodium retention Restrict sodium intake
Enhanced appetite Low-calorie snacks
Hyperlipidemia Therapeutic life style changes
Protein catabolism Increase protein provision
Gastrointestinal ulceration Limit/restrict caffeine, if sensitive
Vitamin and Mineral supplements needed for
HD.
• Most dialysis patients will need to supplement vitamin C and B vitamins to
replace what is lost in the dialysis solution
• The ASPEN Adult Nutrition Support Core Curriculum states : Additional
vitamins may be needed in dialysis patients because of loss in dialysate in
combination with poor intake and altered metabolism. water-soluble
vitamins include vitamin C and the B vitamins (folate, thiamine, riboflavin,
niacin, pantothenic acid, biotin, vitamin B6, vitamin B12).
• Vitamin A Levels are usually elevated; supplementation not recommended,
may cause toxic levels; if needed to treat deficiency, limit to the Daily
Reference Intake (DRI) 700-900 ug/day ((equivalent to 2,000 IU and 3,000
IU, respectively).
CKD not as an isolated disease that affects many organ systems

• Study shown that RBP4 and retinol levels were increased approximately
twofold in patients with CKD. Increases in circulating retinol, RBP4 may be
due to increased hepatic RBP4 synthesis, retinyl ester hydrolysis, and/or
hepatic secretion of RBP4-retinol
• Serum RBP4 levels are associated with CV outcomes in patients with CKD.
RBP4 may provide a pathway linking CKD to an increased risk of CV disease
• CKD is a chronic inflammatory disease. serum RBP4 levels were elevated in
inflammatory and insulin-resistant states in patients with obesity ,T2D,
metabolic syndrome, and CV diseases.
• The developing inflammation in patients with CKD promotes the formation
of vascular atherosclerosis and then causes prevalence of CV events.
Teach patients
• 3-5% BW between dialysis
• Calculation of fluid
• Calculation of protein
• Automatic calculators are now available that can directly calculate the
GFR.
• accounts for age, sex and muscle mass
• Physical examination
Quiz
• Normal GFR is 100-140 mls/min Y/N
• Functional part of kidney is glomerulus Y/N
• Pt on HD requires low protein Y/N
• IDPN is necessary for every dialysis pts Y/N
• AKI is reversible Y/N
• Main reason for CKD is DM and HPTN Y/N
• Post kidney transplantation pt requires low protein diet Y/N
• More protein is better in urine Y/N
Reading material
• KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD: 2020 UPDATE
• ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease 2021
• American Association of Kidney Patients www.aakp.org

• DaVita, Inc www.davita.com

• National Kidney Foundation www.kidney.org

• Renal Support Network www.renalnetwork.org