Renal Diet
ABC’s of Nephrology
Sobha Malla RD,CSR
9/17/11
Objectives
 Nursing staff will understand the basic premise of a
renal diet
 Understand the nutritional needs Hemo and
Peritoneal Dialysis patients
CHRONIC KIDNEY DISEASE
 One in nine Americans has Chronic Kidney Disease.
 Early detection can help prevent the progression of
kidney disease to kidney failure.
 High risk groups for CKD include those with diabetes,
hypertension and family history of kidney disease.
 Groups with increased risk include African Americans,
Hispanics, Pacific Islanders, Native Americans and the
elderly.
CHRONIC RENAL FAILURE
 Progressive and irreversible loss of function that
occurs over many months or years
 Causes include diabetes, hypertension and
glomerular diseases
 Some form of renal replacement therapy is
needed for life
STAGES OF CHRONIC
KIDNEY DISEASE
STAGE
GFR (mL/min/1.73m2)
EFFECT ON HOMEOSTASIS
1
≥ 90
2
60 - 89
Usually no symptoms, but may have
high BP, anemia & disturbance in Ca+ &
Phos+ metabolism.
3
30 - 59
May have fatigue, anemia, swelling,
high BP &/or Ca+ & Phos+ disturbance.
4
15 - 29
Usually symptomatic. Prepare for renal
replacement therapy.
5
< 15
Minimal; excretory and secretory
functions intact.
Unable to maintain homeostasis
without dialysis or transplant.
Goals of the
Patient Specific Renal Diet
 Improve/preserve nutritional status
 Optimize functional status
 Maintain patient safety
 Prepare for transplant
 Compensate/adjust diet for illness, catabolic
events
Subjective Global Assessment
Recognized by KDOQI as a useful measure of PEM
 Provides a nutritional score based on 2 components
 Medical history: history of wt. loss (6 months), eating
habits, GI symptoms, physiological functions and
metabolic stress
 Physical assessment: visual assessment of loss of
subcutaneous fat and muscle mass
 Patient is scored on a 7–point scale
 6-7 well nourished
 3,4,5 mild to moderately nourished
 1 or 2 severely malnourished
(1)
Renal diet for Dialysis patients
consists of individualized
modifications
 Calories
 Protein
 Sodium
 Potassium
 Phosphorus
 Calcium
 Fluid
 Carbohydrates
 Fat/Cholesterol
CALORIES
 Adults on Hemo Dialysis and Peritoneal Dialysis
 < 60 years old
30-35Kcals / Kg SBW
 > 60 years old or obese
30 Kcals / Kg SBW
KDOQI recommends NHANES II Data
for assessing SBW
Protein
• 1.2 grams of protein per Kg SBW for Hemo
Dialysis
• 1.2 - 1.3 grams of protein per Kg SBW with for
PD
Protein
 Important for growth and maintenance of body tissue
 Provides energy and fights infection
 Keep fluid balance in the blood
 2 types of Protein
 High Biological Value (HBV) or animal protein-meat,
fish, poultry, eggs, tofu, soy milk, and dairy
 Low Biological Value (LBV) or plant protein – breads,
gains, vegetables, dried beans and peas and fruits
Protein
 The following list contains foods and their
protein content:
 ▪ 1 egg=7 g protein
▪ 1-2 ounce (oz) chicken thigh=14 g protein
▪ 8 oz skim milk=8 g protein
▪ 1 slice of bread=2 g protein
▪ 1 cup (C) cooked rice=4 g protein
▪ ½ C corn=2 g protein
Phosphorus
• A mineral found in almost all foods.
• Normal kidneys will balance the amount of
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•
•
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phosphorus in our bodies. When the kidneys fail the
phosphorus increases in the blood.
It is necessary to limit and/or avoid high-phosphorus
foods.
Control of phosphorus is often difficult for kidney
failure patients.
Dietary goal is 1-1.5gms/day
Normal range <5.5
Phosphorus
 Foods high in
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phosphorus include:
Dairy products
Dried beans and peas
Nuts
Peanut butter
Bran cereals
Whole wheat bread
Meats
Food Additives
Potassium
• Dietary Goal is usually 2 - 3 gms/day
• Potassium is a mineral , plays a role in regulating your
heartbeat; so, too much can result in heart problems.
• Explore with patient high or low serum potassium
levels
• Monitor residual renal function, changes in appetite for
dietary adjustments
Low Potassium foods
 Apples
 Grapes
 Berries
 Pineapple
 Tangerine
 Cabbage
 Green Beans
 Cauliflower
 Eggplant
Potassium
 Common high K+ foods include many fruits
and vegetables:
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Prunes and Prune juice
Orange and Orange juice
Bananas
Dried fruits
Potatoes
Tomatoes
Brussels sprouts
Spinach
Beets
Milk
Sodium
 HD 2-4 gm/d
 PD usually more liberal
 Too much sodium in the blood is related to high blood pressure
and congestive heart failure.
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•
•
•
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Foods high in sodium include:
Processed meats
Canned soups
Salty snack foods
Deli meats
Sodium
 1 Tsp salt = 2000mg
sodium
 Most of us eat 3,0006,000mg of sodium /day
 Low sodium =
≤140mg/serving
 Do not buy a food that
has 150-350mg
sodium/serving
Fluids
 Hemo Dialysis: Fluid individualized to accommodate fluid
gains, blood pressure control, residual renal function.
 Peritoneal Dialysis: Fluid individualized to patient tolerance.
Strive for minimal use of hypertonic solution to maintain fluid
balance.
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Everything that is liquid at room temperature
1500ml-2000ml
~6 c-8 c /day
4 cups=32 oz=1 qt=1000ml=1 liter
Fluids
 Choices include all drinks and foods that are liquid at
room temperature.
 Water
 Coffee
 Tea
 Sodas
 Soups
 Juices
 Jell-O
Fluids Cont..
Thirst Quenching Ideas :
 Suck on sour candies or chew gum
 Eat chilled fruit, frozen grapes and berries
 Add lemon or Lime juice to water
 Take pills with apple sauce instead of liquids
 Use smaller cups or glasses
 Keep track of all liquids
 Limit salty foods
 If diabetic, control blood sugars
CALCIUM
Hemo Dialysis Patients Balance is determined by:
 Dietary Calcium Intake
 Calcium Supplements and Calcium Based Binders
 Dialysate Calcium Levels
 Vitamin D Therapy
 Physician Monitoring of PTH
CARBOHYDRATE
 Carbohydrate intake may need to be modified for
Patients with Diabetes to achieve the goal of
HgAIC < 7 %
CAUTION !
HYPOGLYCEMIA
PD - HYPERGLYCEMIA / WEIGHT GAIN
FAT / CHOLESTEROL
• Cardiovascular Disease is the most frequent cause of
death among patients with Renal Disease regardless of
treatment modality.
• Nutrition therapy for Dyslipidemia is based on pt’s
metabolic profile and individualized treatment goals
• Consider nutritional status / protein, energy deficits
Supplements
 Multi Vitamins
 Water soluble
 Vitamin C
 Supplementation may improve Iron availability from
stores
 Limit to 60-100mg/d to avoid oxalate formation
 Iron and Zinc supplementation must be determined
individually based on labs
Monitoring
 Monthly QAPI report to review the labs and discuss plan of action
to correct the problem
 Monthly interdisciplinary Care plan meeting to review the patient
performance
 Albumin to monitor intake
 (Goal >3.5mg/dl)
 Potassium to determine dietary restriction
 (Goal 3.5-5.5mg/dl)
 Phosphorus to adjust binders & compliance
 (Goal <5.5 mg/dl)
Summary
 When a patient has a diagnosis of renal failure, their
nutritional needs are complex—Levels of Protein,
Calories, Fluid, Sodium, Potassium, Calcium
Phosphors need to be regularly monitored and make
changes based on pt’s needs.
 It is important to continuously monitor their labs , PO
intake , provide or offer nutritional supplements,
encourage dietary and medication compliance
Question and Answers
Which food is highest in Potassium?
 Apple
 Pineapple
 Broccoli
 Banana
 Potato
Q&A
Correct answer…
 Apple -1 medium(62 mg)
 Pineapple -1/2c(150mg)
 Broccoli -1/2c(127mg)
 Banana -medium(451mg)
 Potato- medium (926 mg)
Q&A
What are the foods high in Phosphorus?
Pizza (Cheese and meat)
Chicken
American Cheese
Yogurt
Cream Cheese
Cottage Cheese
Oatmeal
Q &A
Pizza (1-1/8 slice -131mg Po4, 1780mg K+, 382mg Na)
Chicken (1oz-60mg po4)
American Cheese (1oz- 211 mg Po4, 46 mg K+, 405 mg Na)
Yogurt (fruit 6 oz - 150 mg Po4, 310 mg K+, 100 mg Na)
Cream Cheese (1tbsp- 15 mg PO4, 17mg K+, 43 mg Na)
Cottage Cheese (4 oz- 152 mg Po4, 97 mg K+, 459 mg Na)
Oatmeal (instant, 1 cup - 176 mg PO4, 131 mg K+, 377 mg Na)
Q &A
 Why do dialysis patients need to limit dairy and high
phosphorus foods?
Q &A
 Healthy kidneys get rid of Phosphorus from the body,
but when kidneys fail, phosphorus builds in the blood.
 High levels cause calcium to come out of the bones
and make them brittle, weak and painful. It also gets
deposited in soft tissues like blood vessels and heart,
causing damage to them.
Q &A
 How does the diet for someone on peritoneal
dialysis differ from the one for hemodialysis?
 A. It requires more calories
 B. It requires more calcium
 C. It requires less protein
 D. None of the above
Q &A
 A. It requires more calories
 B. It requires more calcium
 C. It requires less protein
 D. None of the above
Q &A
 If you are on a renal diet, you most need to limit
your intake of what three things?
 a. Apples, oranges, grapes.
 b. Carrot cake, ice cream, Coke.
 c. Sodium, phosphorus, potassium
 d. Seafood, surf-and-turf Red Lobster entrees,
macaroni and cheese.
Q &A
 a. Apples, oranges, grapes.
 b. Carrot cake, ice cream, Coke.
 c. Sodium, phosphorus, potassium
 d. Seafood, surf-and-turf Red Lobster entrees,
macaroni and cheese.
References
 1) A Clinical Guide to Nutrition Care in Kidney Disease
American Dietetic Association, 2004
 2) Pocket Guide to Nutrition Assessment of the Patient with
Chronic Kidney Disease, 4 th Edition, National Kidney
Foundation, 2009
 3) Core Curriculum for Nephrology Nursing, Fifth Edition.
American Nephrology Nurses Association, 2008.