CKD CHRONIC KIDNEY DISEASE, DEFINITION, STAGE AND MNT.ppt

CHRONIC KIDNEY DISEASE

1. Kidney
Eman Ahmad Sultan
NNI

2. Agenda
•Definitions
•GFR
•Stages of CKD
•Individuals at risk
•MNT
A.Goals
B.Macronutrients
C.Micronutrients
D.Exchange list
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3. Definition
•Chronic kidney disease (CKD) is a syndrome of
progressive and irreversible loss of the
excretory, endocrine, and metabolic
functions of the kidney secondary to kidney
damage.
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4. •CKD progresses slowly over time, and there may
be intervals during which kidney functions
remain stable.
•The onset of renal failure is not usually apparent
until 50% to 70% of renal function is lost.
•Once the disease progresses to end stage,
maintenance dialysis or kidney transplantation
is necessary.
•Dialysis only partially replaces the excretory and
regulatory functions of the kidney.
•Absence of other functions requires
medications and a special diet to
maintain homeostasis
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5. •Renal function is measured by the GFR,
which is reflected in clearance tests that
measure the rate at which substances are
cleared from the plasma by the glomeruli.
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6. •Plasma creatinine concentration varies
inversely with GFR.
The normal range of serum creatinine is
1. 0.8 to 1.2 mg/dL for males and
2. 0.6 to 1.0 for females.
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8. Estimating Glomerular Filtration Rate (GFR)
•The most widely used method for estimating GFR is
the Cockcroft-Gault equation.
•This equation considers the effects of age, sex, and
body weight on creatinine generation, thereby
adjusting serum creatinine values to accurately reflect
creatinine clearance:
GFR = ((140 - age) X body weight (kg) X 1.23 0.85 if
female] /[72 X serum creatinine (mg/dL)]
MDRD (Modification of Diet in Renal Disease)
www.renal.org/eGFRcalc/GFR.pl
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11. Stages of Chronic Kidney
Disease

12. Stages of Chronic Kidney Disease
StageGFR
(ml/min/1.73m
2
)Description
1>90Normal or increased GFR, with other evidence
of kidney damage
260–89Slight decrease in GFR, with other evidence of
kidney damage
3a45–59Moderate decrease in GFR, with or without
other evidence of kidney damage
3b30–44
415–29Severe decrease in GFR, with or without other
evidence of kidney damage
5<15Established renal failure
Diagnosis should be on the basis of evidence of CKD for ≥3
months.
Stages of Chronic Kidney Disease
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13. Stage of CKD and Symptoms
CKD
Stage
Symptoms
1HTN is more common
2HTN frequent, mild elevation of PTH
3HTN frequent,  Ca absorption,  phosphate
excretion, PTH, Altered metabolism, Renal
anaemia, LVH,  spontaneous protein intake
4As above but more pronounced plus, metabolic
acidosis, K
+
, decreased libido
5All of the above (severity),plus salt and water
retention, anorexia, vomiting, pruritis
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14. End-stage renal disease (ESRD)
•kidney disease in which kidney function declines
to 10% to 15% of normal; an old term that is no
longer used; CKD is now used instead; ESRD is
equivalent to CKD Stage 5 or when a patient
requires renal replacement therapy
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15. •Some individuals without kidney damage and with normal
or elevated GFR are at increased risk for development of
chronic kidney disease.
•All individuals should be assessed, as part of routine health
encounters, to determine whether they are at increased risk
of developing chronic kidney disease, based on clinical and
sociodemographic factors.
•Individuals at increased risk of developing chronic kidney
disease should undergo testing for markers of kidney
damage, and to estimate the level of GFR.
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16. INDIVIDUALS AT INCREASED RISK
OF CHRONIC KIDNEY DISEASE
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19. Risk Factors for
Progression of Renal Disease
Ca•P0
4
Anemia
Smoking
Hemoglobin A
1C
GenderDyslipidemia
EthnicityAlbuminuria/Proteinuria
AgeHypertension
Cannot be modifiedCan be modified
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20. •There is growing evidence that obesity is a
risk factor for CKD, but this hypothesis
requires additional study( National Kidney
Foundation 2005)
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21. •Individuals found to have chronic kidney
disease should be evaluated and treated as
specified
•Individuals at increased risk, but found not
to have chronic kidney disease, should be
advised to
1.Follow a program of risk factor reduction, if
appropriate,
2.Undergo repeat periodic evaluation.
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23. Risk factors that have been identified for CKD include (Llach
2005):
•Proteinuria one of the strongest predictors of renal disease
progression and response to antihypertensive therapy
•Ethnicity African-American males with diabetes have a 2-3
X higher risk of end-stage renal disease compared to white
patients
•Gender the incidence is greater in males than females
•Smoking associated with proteinuria, IgA nephropathy,
polycystic kidney disease, lupus nephritis, and pro­gression
in type 1 and 2 diabetes
•Heavy consumption of non-narcotic analgesics,
particularly phenacetin
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24. Diabetes
50%
Hypertension
27%
Glomerulonephritis
13%
Other
10%
Primary Diagnoses for
Patients Who Start Dialysis
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25. MNT

26. •Nutritional management of CKD is an integral
component of the medical care of early,
progressive, and end-stage disease.
• Malnutrition, cardiovascular disease, bone
and mineral disorders, and anemia are the
most common complications
•Each of these complications requires both
medical and nutritional intervention.
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27. EFFECT OF NUTRIENT

28. •Each nutrient component has a specific
purpose
•All components function in an organized
supportive manner
•Every diet needs to be individualized to the
patient
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29. Nutrition therapy for CKD
•can slow progression of the disease and
compensate for impaired renal function and/or
limitations of treatment modalities.
•Therapeutic lifestyle changes (TLC) that include
following nutrition recommendations
•serve a proactive role by addressing risk factors
for CKD.
• Nutrition intervention is a fundamental
component of the medical
management
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30. GOALS OF MNT

31. •To maintain Optimum nutrition
•Keep build up of wastes between
treatments to a minimum
•Decrease complications and malnutrition
•Individualized
•Can be changed based on patient needs
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32. CKD Long-Term Goal
•Prevent or retard progression
•Institute renal replacement therapy, when
necessary
•Actively seek transplant as appropriate
•Support end-of-life initiatives
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33. IndexExpected OutcomeGoal
AlbuminMaintained within the normal
range or stabilized with
proteinuria (Nephrotic Syndrome)
Alb 3.5-5.0 g/dL;
may be lower with
significant proteinuria
BUN& CreatinineStabilizedStabilized
PotassiumMaintained within normal rangeK 3.5-5.5 mEq/L
Ph & CaProgressing toward goal rangePh 2.5-5.0 mg/dL
Ca 8.5-10.5 mg/dL
Cholesterol &TGProgressing toward goal rangeCholesterol < 200
TG < 200
Hematocrit and HbMaintain adequate erythropoiesisHct 33%-36%
Hb 11-12 g/dL
FerritinMaintain adequate iron stores for
erythropoiesis
Fe 100-800 ng/mL
Transferrin
Saturation
Maintain adequate erythropoiesis 20%-50%
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34. Albumin as a Predictor
Strong predictor of morbidity and mortality
(CANUSA study)
Albumin may be affected by protein intake
Albumin is affected by non-nutritional factors
Albumin may not increase in response to
nutritional intervention
However,

35. Non-Nutritional Factors
Affecting Albumin
•Fluid balance
•Infection/inflammation
•Urinary losses
•High dialysate losses

36. Non-Nutritional Factors
Affecting Albumin
Analytical method
Gender
Age
Pregnancy
Fluid balance
Infection/inflammation
Cardiac disease
Malignancy
Protein losses
(urine, dialysate)
•Infection/inflammation related
albumin is like an ‘negative’ acute phase protein
•Association between cardiac disease and
hypoalbuminaemia (Foley 1996)

37. Serum albumin alone is
neither necessary nor
sufficient to indicate
malnutrition

38. Screening
•All patients should undergo regular screening
for undernutrition using as a minimum SGA,
height weight and albumin
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39. Screening
•Weekly for inpatients
•2-3 monthly for outpatients with eGFR <20 but not
on dialysis
•Within one month of commencement of dialysis
then 6-8 weeks later
•4-6 monthly for stable haemodialysis patients
•4-6 monthly for stable peritoneal dialysis patients
•Screening may need to occur more frequently if risk
of undernutrition is increased (for example by
intercurrent illness)
- See more at: http://www.renal.org/guidelines/modules/nutrition-in-
ckd#sthash.hBbH7EGn.dpuf
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40. •Diagnosis of under-nutrition should be
considered if any of following are met:
–a BMI <18.5 kg/m
2
–an unintentional weight loss of oedema free
weight >10% in 3-6 months
–BMI <20 kg/m
2
 
AND unintentional weight loss >5%
in 3-6 months
- plasma albumin below normal (value depends on
assay)
- Low SGA scores
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National Institute of Clinical Excellence (National Collaborating Centre for Acute Care 2006)
2
Nutrition: Guidelines 2002

41. Nutrition: Guidelines 2002
If undernutrition suspected
- refer to dietitian to assess dietary intake
-measure CRP, plasma bicarbonate, dialysis adequacy
and residual renal function
Correct low dietary intake
If intake adequate, look for infection if CRP high,
and other catabolic factors such as acidosis,
thyrotoxicosis and poorly controlled diabetes

42. Patients at Risk of Developing
Malnutrition
•Elderly
•Socially isolated
•Diabetes mellitus
•Recurrent peritonitis
•Active comorbid conditions
•Loss of RRF
•Inadequate solute removal
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43. Risk Factors for Poor Nutrition
•Late start of dialysis
•Use of low protein diet
•Poor appetite
•Social factors
•Protein loss through peritoneum
•Increased with peritonitis
•Catabolic state
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44. CAPDHD
Loss of amino acids2-4 g/day
14-28 g/week
9-13 g/dialysis
27-39 g/week
Loss of glucoseuptake~25 g/dialysis
(glucose free dialysate)
Loss of protein5-15 g/day
(higher with peritonitis)
0
Inflammatory stimuli
Low grade
inflammation (particles
chemicals)
Cytokine release
Blood membrane
contact
Cytokine release
Catabolic Effects of Dialysis
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45. How to change diet
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46. MEAL PLAN
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47. Calories
•Minimum 25 kcal/kg/d and titrate upward
to achieve body weight goal
•Adequate calories needed to spare protein
•Body weight can mask protein malnutrition
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48. Calorie Challenges
•Diabetics present special challenge
•Calculate peritoneal dialysis solution
calories into daily intake
•Controversy: what weight to use?
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49. Energy
kcal/kg
•30-35 kcal/kg IBW/day for all patients
depending upon age and physical activity
(2B) –
•high complex carbohydrates,low cholesterol; <30%
fat
Calories provided in the dialysate should be included in
total intake (may absorb as much as 1/3 of daily energy
needs)
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50. Protein
(g/kg)
Recommended nutrient intakes are designed to ensure that 97.5% of a population
take in enough protein and energy to maintain their body composition .
There is variation in actual nutrient requirement between individuals. This means that some patients will
be well maintained with lower nutrient intakes. Regular screening will help to identify when the dietary
prescription needs to be amended- .
Protein Energy
(g/kg BW/day) (kcal/kg BW/day)
CRF patients (non-dialyzed) 0.60-0.75 (high quality) >35
HD patients > 1.2 >35
CAPD patients > 1.2:1.3 >35
CRF patients with GFR 30-20 ml/min reduce protein and energy intake
(MDRD study) Protein and energy intake lower than recommended in a
large proportion (20-60%?) of HD and CAPD patients
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51. Protein
•0.6-0.75 g/kg IBW(50% HBV) to retard or
delay in adults (non-growth)
•High biological value (50-70%)
•Keep serum albumin in normal ranges
•Don’t overload kidney by replacing urinary
protein losses
•Match diet to kidney
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52. Heamo-Dialysis( HD )Treatment
•10-12 g free amino acids lost
•Losses increase with glucose free dialysate
• So, patients who are receiving dialysis, need to
increase protein intake
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53. •Although a neutral or positive nitrogen balance
can be achieved in HD patients at an intake of
0.9-1.0 g protein/kg/day
•A higher protein intake, from 1.1 to 1.4 g/kg/day,
is needed in HD patients
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54. •1.2-1.3 g protein/kg IBW
–Average patient: 80 g Protein
•50% HBV protein foods
•HBV Proteins
–Beef, poultry, fish, shell fish, fresh pork,
turkey, eggs, cottage cheese, soy
–6 to 10 ounces daily
•Protein Alternatives
–protein bars, protein powders,
supplement drinks
NB
•The average healthy American consumes the amount of
protein equivalent to 1.2 g/kg/d.
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55. •Milk/Yogurt/Cheese
•Limit milk, yogurt, and cheese to
½-cup milk or ½-cup yogurt or 1-ounce cheese
per day.
• Most dairy foods are very high in phosphorus.
•The phosphorus content is the same for all
types of milk
• Milk contain 2 types of protein
1.Casine (contain phosphprus)
2.Whey
Dairy foods “low” in phosphorus !
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56. Can Renal Nutrition Education
Improve Adherence to a Low-
Protein Diet in Patients With
Stages 3 to 5 Chronic Kidney
Disease? 
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57. •Nutritional education programs are
effective in increasing patient
adherence to protein intake
recommendations.
•Juliana et al., Journal of Renal Nutrition. published online 29
November 2012
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59. Sodium
(g/day.)
Varies from 1 -3 g to no added salt
Potassium
( g/day)
Usually unrestricted unless se level is high
40mg/kg/IBW
is easily cleared by PD; some patients may need K+
supplementation
Phosphorus
mg/g of
protein
or (mg/day)
10-12 mg/g protein or 10 (8-12)mg/kg/IBW
Calcium
(g/day)
• 1.0-1.5 g/day dietary calcium
<2-2.5 g/day including binder load
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60. Fluid (mL/day)•individualized
Vitamins/Minerals
(daily)
•RDA for B complex and C
vitamins;
•individualize VD, Fe, Zn •
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61. Fluid &Sodium
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62. SODIUM
•≥ 1 L fluid output: 2-3 g Na and 2 L fluid
•< 1 L fluid output: 2 g Na and 1-1.5 L fluid
•Anuria: 2 g Na and 1 L fluid
– Limit IDWG 2-5% Estimated Dry weight
•Individualize
•IDWG, blood pressure, residual renal functions
•can be adjusted by varying the dextrose concentrations of
the dialysate
•May need to be restricted if pts cannot achieve fluid balance
without frequent hypertonic exchanges
•Increased Restrictions if ↑ IDWG, CHF, edema, HTN
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63. SODIUM
•Found in almost all foods
in kidney failure, sodium is
retained and excess sodium
causes fluid retention
Salt = sodium chloride
1 teaspoon of salt contains
2000 mg of sodium
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64. Salty Foods
Fast Foods
Preserved meats
Cheese
Seasonings &
sauces
Snacks
Others
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66. Spices You May Use
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69. POTASSIUM
•Excess potassium is dangerous –
cause heart to stop without warning
•Too little is harmful
•Potassium levels are monitored 2 / 3
monthly
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70. POTASSIUM
•Major source of potassium are : milk,
potatoes, certain fruits (especially
dried fruits), nuts, salt substitute
and chocolate.
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71. Fruit/Juice
•All fruits have some potassium, but
certain fruits have more than others
and should be limited or totally
avoided.
•Eat 2-3 servings of low potassium
fruits each day. Choose:
•Apple (1)
•Pear, fresh or canned, drained (1
halve)
•Watermelon (1 small wedge)
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72. Vegetables/Salads
All vegetables have some potassium, but
certain vegetables have more than
others and should be limited or totally
avoided.
•Eat 2-3 servings of low-potassium
vegetables each day.One serving = ½-
cup.
•Carrots
•Cucumber
•Lettuce-all types (1 cup)
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73. Calcium

74. Use corrected calcium
(adjusted calcium)for albumin <4 Calculation:
[ (4-albumin) x 0.8] + Ca++
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75. In CKD patients, a positive calcium balance
arises because the intestinal absorption is
greater than the kidney’s capacity to excrete
calcium.
 Not all calcium sources are the same:
1. dietary calcium (especially dairy) co-exists
with phosphorus, protein, and fat, is absorbed
more slowly than inorganic calcium
supplements, and thus may be associated with
less hypercalcemia and CV risk.
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76. calcium intake within the Institute of Medicine
(IOM) recommendations is important for health.
<2000 mg/d for the general population;
1200 mg/d is the recommended daily allowance
for seniors (women age >50 years and men age
>70 years) and
1000 mg/d for all other adults
total elemental calcium intake should be
between 800 and 1200 mg/d to prevent calcium
deficiency or calcium loading
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77. •Hypercalcemia
–Ca++ based binders, supplements
–Vitamin D analogs/treatment
–Diet, fortified foods
–Dialysate calcium levels
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78. In patients with CKD stages 3 to 5 and
hyperphosphatemia, KDIGO advises
restricting the dose of calcium-based
phosphorus binders in the presence of
hypercalcemia (persistent or recurrent),
arterial calcification,
adynamic bone disease, or
persistently low
Studies have shown that calcium-free binders
such as sevelamer is better
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79. •Hypocalcemia
–Vitamin D, Calcium
–Supplement between meals
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80. Phosphorus

81. •In CKD patients, phosphorus retention occurs
as a result of higher dietary phosphorus
intake relative to renal excretion or dialysis
removal
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82. As phosphorus and protein are combined in
nutrients with a ratio of 12-15mg
phosphorus/g protein,
most HD patients who have an adequate
protein intake will need phosphate binders to
prevent an increase in serum phosphorus
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83. •Dietary intake ~800 to 1000 mg/day
<17 mg/kg IBW
•HD removes ~500-1000 mg/treatment
•50% dietary phosphorus removed by binders
•Control = Binders + Diet + Adequate dialysis
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84. Phosphate Binders
Generic NameBrand Name Estimated
Binding Capacity
Calcium acetate
667 mg
PhosLo30 mg
Sevelamer HCL
800 mg
Renagel, Renvela64 mg
Calcium carbonate
500-600 mg
TUMS, Os-Cal, Calci-
Chew, Caltrate
20-24 mg
Lanthanum carbonate
1000 mg
Fosrenol 320 mg
It is impossible to eat a phosphate free diet and it is necessary to take a phosphate binder
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86. •Phosphate binder therapy
•should be taken with the meal or
immediately after the meal and not on an
empty stomach
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87. Phosphorus Balance
Phos Intake
+1000 mg/day
+7000 mg/wk
Absorption
~60%
+600 mg/day
+4200 mg/wk
Binding
~50%
-300 mg/day
(10 Phoslo)
-2100 mg/wk
Dialysis
Removal
HD
-700 x 3 =
-2100 mg/wk
PD
-400 x 7 =
-2800 mg/wk
Weekly Phosphorus Balance
4200(

diet{ –
)
2100 (Binders) +2100(HD) = } Balance
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88. Nutritional knowledge in
hemodialysis patients and
nurses: focus on phosphorus
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89. nutritional knowledge of HD patients,
although higher than the general
population, is lower for phosphorus
with respect to the other nutrients,
such as protein, sodium, and
potassium. This occurs even in
patients with hyperphosphatemia or
those taking phosphate binder
medications
Cupisti et al, 2012 J Ren Nutr. 
Nov;22(6):541-6.
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90. •Phosphorus is found in almost every food
and is derived primarily from proteins,
phytates, and additives
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91. Two types exist
Inorganic phosphorus is present in
processed-food additives,which are highly
absorbable, and is highly abundant in the
diet of postmodern industrialized regions.
Organic phosphorus is found in animal-
derived and plant-derived protein-rich foods;
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92. •The naturally existing organic phosphorus is
only partially (60%-70%) absorbed in the
gastrointestinal tract; however, this
absorption varies widely and is lower for
plant-based phosphorus, including phytate
(<40%), and higher for foods enhanced with
inorganic phosphorus-containing
preservatives (>80%).
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93. TypeSourceExamplesGI
Absorption
Phosphorus/
Protein Ratio
Advantage
Organic
plants
Plant
proteins
Nuts, beans,
chocolate
20%-40%5-15 mg/gProtein
gain
Organic
animals
Animal
proteins
Fish, red
meat,
chicken
40%-60%10-20 mg/g
Egg whites
< 5 mg/g
Egg yolk
> 20 mg/g
High value
protein
and
animo
acids
InorganicAdditivesSoft drinks,
fast food
~100%Very high
(> 50 mg/g)
No gain
Dietary Phosphorus Types
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94. •Additives and preservatives are used in food processing and enhancement
for a variety of reasons:
• Extending shelflife
•Improving color
•Enhancing flavor
•Retaining moisture
Food manufacturers are not required to list phosphorus on food labels
•Inorganic phosphorus is often hidden by complex names in the ingredients
•Disodium monophosphate
•Monosodium dihydrogen orthophosphate
•Pentapotassium triphosphate
•Potassium tripolyphosphate
•Sodium hexametaphosphate
•Sodium tripolyphosphate
•Trisodium phosphate anhydrous
•Tetrasodium pyrophosphate
Inorganic Phosphates and Phosphorus Burden
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95. READ THE INGREDENTS
LABEL!!
•Phosphoric acid
•Sodium hexametaphosphate
•Calcium phosphate
•Disodium phosphate
•Trisodium triphosphate
•Monosodium phosphate
•Sodium tripolyphosphate
•Tetrasodium pyrophosphate
•Potassium tripolyphosphate
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96. <1 mg PhosphorusHigh Phosphorus
•7 Up
•Sprite
•Ginger ale
•Root beer
•Mountain Dew
•Aquafina essentials
•Nestea lemon
•Fanta
•Minute Maid fruit punch
•Coca-Cola Classic: 62 mg
•Diet Coke: 27 mg
•Dr Pepper: 45 mg
•Nestea Cool Iced Tea: 134 mg
•Nestea Diet Cool: 159 mg
•Tropicana Fruit Punch: 93 mg
•Fruitworks: 53-140 mg
•Hawaiian Punch: 173 mg
Phosphorus Content of Popular Beverages )12oz
Serving(
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97. •There is evidence that education on avoiding
foods with phosphorus additives does
contribute to better reduction in serum
phosphorus levels versus control
participants.
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98. •Restriction of poorly absorbed food born
organic phosphorus is unnecessary;
• overzealous restriction of protein-associated
phosphorus may even contribute to protein
malnutrition with an adverse impact on
survival.
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99. •The lowest amount of phosphorus in
proportion to protein comes from nondairy
products and animal-derived foods, including
egg whites
•Egg white is an unusually rich source of high
biological value protein and has one of the
lowest phosphorus-to-protein ratios, and is
devoid of cholesterol, making it an ideal
dietary choice for the CKD patient
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101. •In predialysis CKD patients who ate a
metabolic-laboratory vegetarian diet for just
1 week, serum phosphorus levels and
fibroblast growth factor-23 (FGF-23) levels
were lower compared with patients
consuming a meat diet with
the same protein, calories, and
phosphorus intake level
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102. Other Micronutrients
Vitamin C
–Limit total vitamin C 60-100 mg
↑ Vitamin C → ↑ oxalate → calcification of
soft tissues and kidney stones
Vitamin A
However, patients in renal failure have
decreased excretion of vitamin A, and
vitamin A toxicity has been reported in
some cases.
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103. VD
•If the patient's GFR is < 20 mL/min, or in
stage 5
•Standard vitamin D is no longer effective
and the active vitamin 1,25 (OH2)D3 is
needed.
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104. HD
•They are known to lose certain water-soluble
vitamins.
•Therefore, patients on dialysis should receive a
multivitamin supplement that avoids excessive
vitamin A
•Renal Multivitamin containing water soluble
vitamins
Dialyzable – take after dialysis

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105. anemia
Consider investigating and managing
anemia in people with chronic kidney
disease (CKD) if:
•Their Hb level falls to 11 g/dl or less (or
10.5 g/dl or less if younger than 2
years) or
•They develop symptoms attributable to
anaemia (such as tiredness, shortness of
breath, lethargy, and palpitations
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106. Diagnostic Role of GFR
•An estimated glomerular filtration rate (eGFR)
of less than 60 ml/min/1.73m
2
should trigger
investigation into whether anaemia is due to
CKD.
• When the eGFR is greater than or equal to 60
ml/min/1.73m
2
the anaemia is more likely to
be related to other causes. [2006]
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107. •Serum ferritin levels may be used to assess iron
deficiency in people with CKD.
• Because serum ferritin is an acute-phase reactant and
frequently raised in CKD, the diagnostic cut-off value
should be interpreted differently to non-CKD patients.
[2006]
Iron-deficiency anaemia should be:
•Diagnosed in stage 5 CKD with ferritin < 100 µg/l
•Considered in stage 3 and 4 CKD if the ferritin level is <
100 µg/l
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108. In people with CKD who have se ferritin levels >100
micrograms/l,
• functional iron deficiency (and hence, those patients
who are most likely to benefit from intravenous iron
therapy) should be defined by:
•Percentage of hypochromic red cells greater than 6%,
where the test is available or
•Transferrin saturation less than 20%, when the
measurement of the percentage of hypochromic red
cells is unavailable [2006]
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109. •Iron supplementation may be necessary for
patients receiving erythropoietin.
•
•There are also data to suggest that dialysis
results in increased risk for zinc deficiency;
patients taking zinc supplements reported
improvements in taste alterations and
sensitivity
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110. NUTRITIONAL SUPPLEMENTS
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111. •Oral supplements: Nepro, Ensure, Boost
•Powders: Beneprotein, ProSource, Eggpro
•Modular Protein: Pro-Stat, Promod
•Cookies: NutraBalance
•Protein Bars
–Meal replacements vs. snacks
–Over the counter
–Evaluate potassium, phosphorus
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112. Nutrition Support
Enteral
•Oral Supplements
–Barriers: compliance, fluid , palatability,
cost
•Tube feeding
–Renal Formulas
•Nepro and Novasource Renal
–Barriers: acceptance, intolerance, tube
placement, fluid intake, reimbursements,
assistance
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113. 10/13/25Eman sultan113

114. 10/13/25Eman sultan114

115. Can be added to all types of foods and
beverages
Each scoop contains 6 grams of protein
Flavor-free way to add high quality protein
Made from the highest quality whey protein
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116. 10/13/25Eman sultan116

117. Nutrition Extras Nutrition Extras
•Vitamin Vitamin EE//omegaomega fatty fatty
acids/graftsacids/grafts
•Growth hormoneGrowth hormone in children in children
•Daily dialysis modalityDaily dialysis modality
•Cyclic/nocturnal treatmentsCyclic/nocturnal treatments
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118. •Focus on cardiovascularFocus on cardiovascular
•Plant sterols/stanol estersPlant sterols/stanol esters
•Saturated fat awareness with Saturated fat awareness with
adequate caloriesadequate calories
•Fiber and fluid restrictionFiber and fluid restriction
•Physical activityPhysical activity
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119. Target Lipid Levels
BestBest Borderline Borderline
CholChol <200 gm/dl <200 gm/dl 200-239 200-239
LDLLDL <100 <100 100-159100-159
HDLHDL>40>40 <40<40
TGTG <150 <150 150-159150-159
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120. Modality changes lipid pattern
CKD-Proteinuria/nephrotic syndrome &
Hemodialysis
– LDL/HDL vs total cholesterol
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121. 10/13/25Eman sultan121

122. Food GroupsKcalCHO g.PRO g. FAT g. Na mg.K+ mg.PO4 mg.
Milk ( ½ c.)8564580185110
Meat650742510065
Starch801521803535
Vegetable255101515020
Fruit60150.50515015
Fat (1TB.)100001115005
Calorie
Boosters
60150015205
Beverages:
Coffee (1c.) tea
(1 bag) wine (4
oz.) beer (12
oz.)
000001000
RENAL EXCHANGES FOR MEAL PLANNING

123. Food Exchanges for The Day
Food
Exchange
12001500180020002200
Starch /bread
Meat
Vegetables
Fruits
Milk
Fat
6
6
2
3
1
3
8
6
2
3
1
5
10
7
2
3
1
5
12
8
2
3
1
5
14
8
2
3
1
7
Total daily energy intake (Calories)
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124. Distribution of food exchanges into meals
(for total of 1500 calories)
Meal
Number of food exchanges
Starch
/bread
MeatVegetablesFruit
Breakfast
Mid-morning
Snack
Lunch
Mid-afternoon
Snack
Dinner
Bedtime snack
MilkFat
Total
2
-
3
-
3
-
-
-
3
-
3
-
-
-
1
-
1
-
-
-
1
1
1
-
-
-
-
-
-
1
1
-
2
-
2
-
8 31 56 2
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125. Everyone is different…
•There is no one special diet for people with
renal disease.
•There is no need to avoid potassium or
phosphate foods unless your blood levels
are high.
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