Nutrition Therapy:
Chronic Kidney Disease
Sheryl Rosenberg Thouin, MPH, RD, CDE
Chronic Kidney Disease
CKD is defined as either kidney damage or
GFR < 60mL/min for < 3 months
Kidney damage is defined as pathologic
abnormalities or markers of damage, including
abnormalities in blood or urine tests, or
imaging studies.
20 million Americans have CKD and 20 million
more (1 out of every 9) are at risk.
Approx 50% of dialysis patients have diabetes
– Note: Insulin requirements decrease with progressive CKD
due to inefficient excretion of insulin
Functions of the Kidney
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
Consequences of Kidney Disease
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
Uremic Syndrome
Nausea
Vomiting
Metallic taste
Itching
Lack of energy
Protein-energy wasting syndrome
Kidney Int. 2008;73(4):391-398
Goals of CKD Management
 Achieve/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 CVD
Anemia
Metabolic acidosis
Secondary hyperparathyroidism
Evidenced based clinical practice guidelines
– For all stages of kidney disease
– For related complications
Glomerular Filtration Rate
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
Stages of Chronic Kidney Disease
Stage 1
CVD risk reduction
Treat co-morbidities
GFR > 90 ml/min
Stage 2
Monitor progression
GFR = 60-89 ml/min
Stage 3
Evaluate
Test complications
Preparation for renal
replacement therapy
Renal replacement
therapy (RRT)
GFR = 30-59 ml/min
Stage 4
Stage 5
GFR = 15-29 ml/min
GFR < 15ml/min
or on dialysis
Deterioration of Nutritional Status Begins Early
 GFR 28 – 35 mL/min or greater
 Protein Energy Malnutrition (PEM) is often present at
the time patients begin dialysis.
 Malnutrition in pts beginning dialysis is a strong
predictor of poor clinical outcome
Medical Nutrition Therapy
Recommendations (Stages 3 to 5)
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
Optimal Nutritional Status
 Albumin > 4.0
 Stable, desirable dry weight
 Adequate fat stores and muscle mass
 Appropriate appetite and intake
Reverse epidemiology of obesity in dialysis
patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554
Assessing Anemia in CDK
TEST
K/DOQI Goal
Hgb
11 to 12 mg/dL
Iron SAT > 20%
Ferritin
200-500 ng/mL
Hct can be falsely low
due to fluid overload
Monthly test
Reflects tissue iron
stores
Low Albumin
 Non-nutritional factors
 Infection
 Inflammation
 Co-morbidities
 Fluid overload
 Inadequate dialysis
 Blood loss
 Metabolic acidosis
Calories
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
PROTEIN
Dietary Protein Restriction…
Reduces nitrogenous waste
Reduces inorganic ions
Reduces metabolic/ clinical disturbance
(uremia)
Slows rate of decline in GFR
K/DOQI protein guidelines
(Average American Intake = 1.2 g per kg/day)
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
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
1 fruit
5
15
2
0
0
0
1 teaspoon
fat/ oil
0
0
5
Food
Food Portion Estimations
1 tsp
3 oz
1 cup
&
½ cup
¼ cup
1 oz
Protein in Foods
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
Challenges with High Protein Foods
Also high in phosphorus and potassium
Milk
Cheese
Beans
Peanut butter
How much protein?
Lunch A
–
–
–
–
–
–
2 slices bread
Chicken breast (3 oz)
Lettuce, tomato
Mayonnaise
16 oz milk
banana
Lunch B
–
–
–
–
–
–
2 slices bread
1 oz chicken
Lettuce
Mayonnaise
Iced tea
apple
Nutritional Interventions
Encourage patients to eat
– Adjust or liberalize diet as appropriate
– Frequent small meals/snacks
High protein foods first if they get full
quickly
Calorie dense foods
Consider use of nutritional supplements
Supplements
Protein Powder
– Procel, Egg/Pro
Liquid Protein
– Pro-Stat, ProSource, Liquicel
Liquid Nutritional
– Ensure, Boost, Enlive
Calorie Dense
– Ensure Plus, Boost Plus
Renal Specific
– Nepro with Carb Steady, Re/Gen
– Novasource Renal, NutriRenal
SODIUM
Sodium
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
Sources of dietary sodium
Pre-prepared foods
Processed foods
Canned, bottled, packaged foods.
1 tsp salt = 2,300 mg sodium
2 gram Sodium Diet…
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
POTASSIUM
Potassium
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
Potassium in the Diet
High (> 400 mg/serving)
– Banana
– Potato
– Avocado
– Orange juice
Moderate (>200 mg/serving)
– Berries
– Broccoli
– Tomato
Low Potassium Fruit & Vegetables
>100 mg/serving
– Cranberries
– Apple
– Corn
– Lettuce
– Pineapple
– String beans
How much potassium?
Lunch A
–
–
–
–
–
–
2 slices bread
Chicken breast (3 oz)
Lettuce, tomato
Mayonnaise
16 oz milk
banana
Lunch B
–
–
–
–
–
–
2 slices bread
1 oz chicken
Lettuce
Mayonnaise
Iced tea
apple
MANAGING BONE HEALTH
Altered Bone Turnover in CKD
Kidney Failure leads to…
Decreased production of active Vit D
Low serum calcium
Phosphorus retention
Elevated PTH
Secondary Hyperparathyroidism
Mineral and Bone Disorder
Prevalence of Abnormal Mineral Metabolism in CKD
>4.6
KI (2007) 71, 31-38. Levin et. al.
PHOSPHORUS
Phosphorus
 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)
Phosphorus is not
found on the
Nutrition Facts Label
High Phosphorous Foods
DAIRY
Cheese
Milk
1 oz
½ cup
150 mg
120 mg
PROTEIN
Egg
Liver
Peanut butter
Salmon or tuna
Nuts
1 large
1 oz
2 Tbsp
1 oz
1 oz
100 mg
150 mg
120 mg
75 mg
100 mg
VEGETABLES
Baked beans
Soybeans
½ cup
½ cup
130 mg
160 mg
BREADS
Bran
Cornbread
Whole-grain bread
½ cup
2 inch square
1 slice
350 mg
200 mg
60 mg
BEVERAGES
Beer
Cola
12 oz can
12 oz can
50 mg
50 mg
CALCIUM
Calcium in CKD
Maintain serum calcium 8.4 – 10.2 mg/dL
Optimal < 9.6 mg/dL
Dietary Calcium
1200 – 1500 mg/day (stages 3 and 4)
Calcimimetics: A new family of drugs
(Sensipar)
Binds to calcium receptor
Decreases PTH
Active orally
Advantageous: Suppression of PTH
without risk of hypercalcemia or
hyperphosphatemia
FDA approved
FLUID
RESTRICTION
Fluid Restriction
CKD Stage 4 or 5
Fluid: “any food that is liquid at room temp”
Soup, gelatin, ice cream, popsicles
Excess fluid buildup
– Edema, SOB, HTN, CHF
– Delays wound healing
Fluid restriction estimations are based upon
– Urinary output
– Disease state
– Treatment modality (dialysis, etc.)
Fluid Allowance Tips
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 & Mineral Supplements
Dietary restrictions result in a diet deficient in nutrients
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]
Procrit and iron supplementation
Suggestion: Nephrocaps
Herbal Supplements
Use may be unsafe for CKD patients
– Poor clearance
– Purity, safety, effectiveness unknown
– No regulation, no testing requirements
– Subject to contamination
Lead
mercury
Herbs can interact with medications
– Renal patients take > 10 meds/day
Renal toxicity
– Wormwood
– Horse chestnut
– Sassafras
Herbs with diuretic properties that
may cause renal inflammation
 Bucha leaves
 Juniper berries
 Uva ursi
 Parsley capsules
Making Meals Appetizing
Lunch:
Two slices white bread
Two Tbsp mayonnaise with lettuce and onion
1 ounce chicken or one hard boiled egg
Two canned peach halves
7 Up or Lemonade
CKD Nutrition Resources
www.dietconsultpro.com
– Relevant and easy-to-understand nutrition
education guides by Medi-Diets™
Renal Nutrition Principles (non-dialysis)
You Potassium Intake
Lowering Your Sodium Intake
www.davita.org
– Complete CKD education site