NUTRITIONAL

MANAGEMNT IN CHRONIC
KIDNEY DISEASES
Nani Shova Shakya , Sr. Dietitian ,
TUTH
Kidney Function
 Regulate the composition and volume of
blood
 Remove metabolic waste in the urine
 Help control the acid/base and balance
in the body
 It activates vitamin d needed for
calcium absorption
 Produce erythropoietin needed for red
blood cells synthesis.
Common Kidney diseases
 Polycystic Kidney disease
 Hypertension induced Kidney disease
 Diabetic nephropathy
 Renal Failure : Acute kidney Injury or
chronic Kidney disease
 Glomerular Disease :
Nephrotic syndrome Nephritic
Syndrome
Nephrolithiasis
What is chronic Kidney disease (CKD)?

 CKD is a progressive kidney disease.

 CKD is defined as either
 Evidence of kidney damage including persistent
albuminuria as > 30 mg of urine albumin per
gram of urine creatinine with or without
decreased GFR for > 3 months
or
 Reduction of kidney function - defined as
estimated glomerular filteration rate (eGFR) <
60mL/min/ for
< 3 months with or without kidney damage
What is glomerulo
filteration rate ?

 It is sum of the filtration rates in all of

the functioning nephrons.
 Estimation of the GFR (eGFR) gives a
rough measure of the number of
functioning nephrons.
What is eGFR ?

 It is the estimation of glomerulo

filteration rate.
 It provides an estimation of how much
blood is filtered by the kidney each
minute.
Glomerular Filtration Rate
(Cockraft-Gault Equation)

 GFR = (140-age) X body weight (kg) X

0.85 if female
[72 X serum creatinine (mg/dL)]

 GFR of 100 approximates 100% kidney

function

 Normal GFR = 120 to 130 mL/min

Stages of Chronic Kidney Disease

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
CKD detection and
monitoring
Estimated glomerulo Normal > 60 ml/min/1.73
Filteration Rate m2
Kidney disease : 15 – 59
ml/min/1.73 m2
Kidney failure : < 15
ml/min/1.73 m2

Urine Albumin to creatinine Normal : 0 – 30

Ratio Albuminuria : > 30
( Preferred measure for
screening, assessing and
monitoring kidney damage
CKD Risk Factors*
Modifiable Non-Modifiable
 Diabetes
• Family history of
 Hypertension kidney disease,
 History of AKI diabetes, or
 Frequent NSAID use hypertension
 Glomerulonephrites
• Age 60 or older (GFR
 Chronic pylonephrites
declines normally
 Small Kidney
with age)
 Renovascular disease

 Obstructive uropathy
• Race/U.S. ethnic
minority status
 Immunological

Diseases
*Partial list
AKI, acute kidney injury
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
Treatment of Kidney
diseases
 Life style modification
 Medical Nutrition therapy
 Drug
 Regular monitoring
 Renal Replacement therapy :
Dialysis or kidney Transplantation
 Medical Nutrition Therapy
Why ?
 Delay the onset or progression of kidney impairment

 Prevent malnutrition by maintaining good nutritional

status
 Prevent breakdown of tissues by providing adequate

non-protein calories
 Stop accumulation of toxic products like urea,

creatinine by limiting protein intake

 Correct electrolytes losses and avoid excesses

 Avoid over hydration or dehydration

 Treat other complications

Problems and challenge

Acceptance :
Uremia diminishes taste acuity, making food
bland and unappealing, low acceptance of
food

Knowledge :
Kidney patients and the family members
does not have enough information
concerning their food and the importance of
good nutrition
Problems and challenge

Counseling :
 Unnecessary restriction due to lack

of proper counseling ,

 No proper counseling on how to

make food appetizing, importance of
including non-protein foods to
increase the calorie.
Factors that influence dietary
advice

 Stage of CKD
 Biochemistry levels (trends)
 Medications
 Treatments e.g. Conservative, Dialysis
 Other medical conditions e.g. Diabetes
 Lifestyle (social, psychological aspects)
Common complications
 Malnutrition
 Diabetes
 Hypertension
 Metabolic acidosis due to reduced acid
excretion
 Hyperkalemia
 Mineral imbalance and bone disorder
( calcium,phosphorous and vitamin D
 Anemia due to impaired erythropoiesis
and low iron stores
 Cardiovascular diseases
How to slow or delay the progression

 Control Blood pressure by reducing

sodium intake
 Reduce protein intake, if excessive
 Manage diabetes
 Reduce or treat albuminuria
 Common problems and dietary
Intervention

Problems Dietary Intervention

Decreased GFR Restrict Total protein with high
energy
Hypertension, Limit sodium intake
Weight reduction ,if overweight
Hyperkalemia Restrict dietary potassium
when serum K+ level is > 5.0
mEq/dl
Avoid potassium containing
salt substitutes
Apply Leaching process to
decrease potassium from
vegetables
 Common problems and dietary
Intervention

Poor appetite, Prescribe varieties of

nausea, food
High phosphorous level Dietary phosphorous
restriction
Phosphorous binders to
lower phosphorous level
Counsel patients to
take binder with meal to
help limit absorption of
phosphorous from food
and beverages
Nutritional factors to be considered

Macro-nutrients Energy
Protein
Fat
Carbohydrate
Minerals Sodium
Potassium
Phosphorous
calcium
Fluid
Vitamins Water soluble
Fat soluble
Optimum energy Intake
 Why ???
 Prevent breakdown of tissues to fulfill
days requirement
 To spare protein
 To maintain ideal body weight/weight
gain/slow weight loss
 Challenges
 Decreased appetite from uremia
 Various CKD dietary restrictions
 Finding food sources for added
calories
Energy Requirement
 Adult 30- 35 kcal /kg/IBW
 Children 80 – 110 kcal
 Infant 100- 120 kcal
Energy sources
 Carbohydrates : Different types of
cereals
 Oils and fats
 Proteins
 Low protein food sources
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
 Protein Exchange List
Food Amount Energy Protein( Na (mg) K ( mg)
stuff g)
Foods of High Biological value Protein
Milk 200 116 6.4 32 280
Curd 206 127 6.4 66 268
Egg 48 78 6.4 5 13
Mutton 35 63 6.4 11 94
Liver 32 60 6.4 15 59
Chicken 24 43 6.4 23 53
Fish 32 6.4 16 48
Food of Low Biological Value

Rice 100 345 6.4 10 117

Wheat 53 183 6.4 11 167
Flour
Bread 53 138 6.4 11 167
Calcium in CKD

 Maintain serum calcium 8.4 – 10.2 mg/dL

 Optimal < 9.6 mg/dL
 Calcium
CKD Stages 1 – 4 CKD Stage 5

 1200 – 1500  Not to exceed

mg/day based on 2000 mg/day,
DRI* including calcium-
 May need vitamin based binders
D3  Activated vitamin
D
 PTH control
important

30 *DRI = Dietary Reference

CALCIUM
 Hypercalcemia (Ca > 10.2):
 nausea

 confusion

 coma

 risk for heart disease

 Hypocalcemia:
 numbness

 seizures

 confusion

 painfulmuscle spasms
 osteoporosis
 What to do if calcium levels are too high
or too low?

Hypercalcemia ( calcium)
Patient should decrease calcium intake

Hypocalcemia ( calcium)
Patient may need additional dietary or
supplemental calcium
May be due to low albumin levels
 Potassium and CKD
CKD Stages 1 – 3 CKD Stages 4 and 5

 Usually not  Changes in medications

restricted that increase potassium
 Stop using salt substitute
and products that have
potassium chloride added
(check labels)
 Learn about highest
potassium fruits and
vegetables—have these
less frequently and in
smaller portions
33  Learn about other high
Potassium-Function

 It is essential for nerves and

muscles (including the heart) to work
properly
 Too much or too little can cause
sudden death
 Hyperkalemia (Elevated Potassium)
Goal : 3.5 – 5.5 mEq/L

 Hyperkalemia (high
potassium level) can cause
muscle weakness
the heart to stop
What to do?
 Alert doctor immediately if > 7.0
 Review symptoms with patient
 Review diet with patient
 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
Potassium

Requirement :
1500 to 2000 mg/day

Requirement of potassium varies

according
 24 hour urine output

 Number of dialysis in a week

 Laboratory potassium value

 List of High Potassium Foods
Foods High Potassium foods
Fruits All types of dried fruits ( raisins, apricots
etc)
Fresh fruits and fruit juices ( sp. Banana,
sweet lime, Mango
Dals and legumes all types of dals and legumes ( can be
taken in recommended amount)
Spices and condiments All types ( can be used in small quantity)
Nuts and oilseeds All types ( rich in protein , so better not to
use)
Milk & milk products All types of powdered milk ( Fresh milk can
be taken in recommended amounts)
Sweets Chocolates, cocoa,
Miscellaneous Salt substitutes, too many cups of tea,
coffee, green tea
 List of vegetables rich in Potassium

Low Moderate High

Methi sag cabbage Coriander leaves
Lettuce Carrot Spinach
Beets Radish Colocasia
Bottlegourd Onion Potato
Cucumber Bittergourd Yam
Snakegourd Eggplant Sweet potato
Chyote cauliflower. Amaranth
Parwar French beans Asparagus
Broad beans Ladies finger Bamboo shoots
Ridgegourd Zucchini
Green Banana
 Phosphorus and CKD
CKD Stages 1 – 2 CKD Stages 3 – 5

 Usually not
 800 to 1000 mg/day for
most patients
restricted  Lower protein diets
decrease phosphorus
 Phosphate binders may be
needed
 Learn about and limit
highest phosphorus foods
 Processed foods and
phosphate additives—read
labels
 Early phosphorus control
may delay bone disease
40
Phosphorus (“P”) or Phosphate (PO4)

 Needed for
healthy bones & teeth
energy metabolism (ATP)
 When the kidneys fail, phosphorus

levels usually increases

 Hemodialysis does not remove

phosphorus from the blood very well

 Protein-rich foods are high in

Phosphorous
 Very challenging for patients to

maintain optimal Phosphorous levels

 Phosphorus
 Normal ranges currently are 2.5 –5.5
mg/dl
 Hyperphosphatemia ( phosphorus)
itching
bone damage
  risk for soft tissue calcification (including heart and

blood vessels)

 Hypophosphatemia ( phosphorus)
rare
muscle weakness
coma


What to do if Phosphorus too HIGH

 decrease intake of P-rich food

and/or

 take PO4 binders as prescribed(Binders

must be taken with meals)
 Phosphorus rich foods
Alldals and legumes
Nuts (peanut butter), seeds
Chocolate, cocoa
Cheese (pizza), milk, yogurt and their

products
Whole grains (whole wheat bread)
Bran cereals
Coke, Pepsi & other sodas with

“phosphoric acid”
Sodium ( Normal range : 133-145
mEq/l
 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
Sodium

Sources :
 Salt used in cooking

 Salty biscuits, Papad, dalmoth , bottle pickles

 Cheese

 Canned, bottled, packaged foods.

 Soybean sauce, Worcester sauce,
 Instant noodles, Readymade soups, meat cubes
 Smoked fish and meat
 Processed food as ham, sausage
 Salted nuts, salty butter etc
 Tips to Decrease Sodium Intake

Cook at home with low-sodium 1000-3000

ingredients mg

48
• Salt
Cut out:
• High-sodium condiments sodium/day
• Processed, cured foods
for ALL
Add: • Herbs • Lemon
• Spices • Vinegar kidney diets

Eat out less (especially Fast Food)

Read labels
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, Shortness of breath SOB, HTN, CHF
 Delays wound healing
 Fluid restriction estimations are based
upon
 Urinaryoutput
 Disease state
 Treatment modality (dialysis, etc.)
Fluid Allowance Tips
 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

 Output + 500 ml
 Guidelines for fluid
allowance
Restriction Fluid with meal Fluid with medication

600 300 ml 300 ml

750 450 ml 300 ml

800 480 ml 320 ml

900 540 ml 360 ml

1000 ml 600 ml 400 ml

1200 ml 700 ml 500 ml

1500 ml 1000 ml 500 ml

2000 ml 1000 ml 1000 ml

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
 Dietary advice

1. Weight Management - activity/lifestyle,

current intake, food preferences, cooking
methods, food labelling, alcohol.
2. DM Control - meds, regular meals &
starchy CHOs, low sugar, fruit & veg.
3. Lipid Control – ↓saturated fats, ↑mono
fats, oily fish, fruit & veg.
4. Salt Intake - at table, in cooking,
convenience foods.
Dietary advice:
1. Low Appetite, Depressed & Symptomatic – small &
frequent meals, energy dense and high protein foods.
2. High Potassium Level – cooking methods, food
choices & frequencies of high K foods.
3. Hypertension – salt intake
4. Phosphate Level –Need to evaluate binders and when
they are taken. Binders need to be taken with meals

Factors Considered by Dietitian:

Family situation / recent loss of love one/other medical conditions
Culture – Asian diet & cooking methods
Future ‘life changing’ treatments – Hemodialysis