1. Nutrition Therapy: Chronic Kidney Disease
Sheryl Rosenberg Thouin, MPH, RD, CDE

2. 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

3. 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

4. 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

5. Uremic Syndrome
Nausea
Vomiting
Metallic taste
Itching
Lack of energy

6. Protein-energy wasting syndrome
Kidney Int. 2008;73(4):

7. 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

8. Evidenced based clinical practice guidelines
For all stages of kidney disease
For related complications

9. 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

10. Stages of Chronic Kidney Disease
CVD risk reduction
Treat co-morbidities
GFR > 90 ml/min
Stage 2
Monitor progression
GFR = ml/min
Stage 3
Evaluate
Test complications
GFR = ml/min
Stage 4
Preparation for renal replacement therapy
GFR = ml/min
Stage 5
Renal replacement therapy (RRT)
GFR < 15ml/min
or on dialysis

11. 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

12. Medical Nutrition Therapy Recommendations (Stages 3 to 5)
Calories
30-35 kcals/kg IBW
Protein
gm/kg IBW
Sodium mg
Fluids
Evaluate need to restrict
Potassium
Calcium
<2000mg
Phosphorus mg
Vitamins
Individualized

13. Optimal Nutritional Status
Albumin > 4.0
Stable, desirable dry weight
Adequate fat stores and muscle mass
Appropriate appetite and intake

14. Reverse epidemiology of obesity in dialysis patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:

15. Assessing Anemia in CDK
TEST
K/DOQI Goal
Hgb
11 to 12 mg/dL
Hct can be falsely low due to fluid overload
Iron SAT
> 20%
Monthly test
Ferritin
ng/mL
Reflects tissue iron stores

16. Low Albumin Non-nutritional factors Infection Inflammation
Co-morbidities
Fluid overload
Inadequate dialysis
Blood loss
Metabolic acidosis

17. 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

18. protein

19. Dietary Protein Restriction…
Reduces nitrogenous waste
Reduces inorganic ions
Reduces metabolic/ clinical disturbance (uremia)
Slows rate of decline in GFR

20. 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

21. Food Carbohydrate Protein Fat
4 kcals/g
Protein
Fat
9 kcals/g
1 cup milk 12 8
0 –10
1 oz meat 7
1 – 12
1 oz bread 15 3
1 cup veg 5 2
1 fruit
1 teaspoon fat/ oil

22. Food Portion Estimations
1 tsp
3 oz
1 cup
&
½ cup
¼ cup
1 oz

23. 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

24. Challenges with High Protein Foods Also high in phosphorus and potassium
Milk
Cheese
Beans
Peanut butter

25. How much protein? Lunch A Lunch B 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

26. 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

27. Supplements Protein Powder Liquid Protein Liquid Nutritional
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
Zone bar too!

28. Sodium

30. Sodium Dietary sodium restriction prevents: Edema Hypertension CHF
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

32. Sources of dietary sodium
Pre-prepared foods
Processed foods
Canned, bottled, packaged foods.

33. 1 tsp salt = 2,300 mg sodium

34. 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

35. Potassium

36. 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: mEq/L

37. Potassium in the Diet High (> 400 mg/serving) Banana Potato Avocado
Orange juice
Moderate (>200 mg/serving)
Berries
Broccoli
Tomato

38. Low Potassium Fruit & Vegetables
>100 mg/serving
Cranberries
Apple
Corn
Lettuce
Pineapple
String beans

39. How much potassium? Lunch A Lunch B 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

40. Managing Bone Health

41. 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

42. >4.6
This outpatient cohort cross-sectional study was conducted in 153 centers, (71% primary care practices). The 1814 patients had a mean age of 71.1 years old; 48% had diabetes mellitus (DM).

43. Phosphorus

45. 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)

46. Phosphorus is not found on the Nutrition Facts Label

47. 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
2 Tbsp
100 mg
75 mg
VEGETABLES
Baked beans
Soybeans
130 mg
160 mg
BREADS
Bran
Cornbread
Whole-grain bread
2 inch square
1 slice
350 mg
200 mg
60 mg
BEVERAGES
Beer
Cola
12 oz can
50 mg
Keep in mind restriction = 560 to 850 mg/day

48. calcium

49. 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)

50. 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

51. Fluid Restriction

52. 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 restriction is estimated based primarily on disease state, urine output, and treatment modality

53. 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

54. 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
CKD patients have depressed production of the hormone erythropoietin (needed to stimulate bone marrow to produce red blood cells)

55. 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

56. Herbs with diuretic properties that may cause renal inflammation
Bucha leaves
Juniper berries
Uva ursi
Parsley capsules

57. 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

58. CKD Nutrition Resources
Relevant and easy-to-understand nutrition education guides by Medi-Diets™
Renal Nutrition Principles (non-dialysis)
You Potassium Intake
Lowering Your Sodium Intake
Complete CKD education site