Medical Nutrition Therapy for a Chronic Kidney Failure Patient on Hemodialysis
Medical Nutrition Therapy for a Chronic Kidney Failure Patient on Hemodialysis
MH is was diagnosed with End Stage Renal Disease (ESRD) secondary to
hypertension (HTN). Her secondary diagnosis include HTN, hypothyroidism,
hypercholesterolemia, coronary artery disease (CAD), anemia (blood loss), atrial
fistution, distolyic dysfunction, and congestive heart failure (CHF) secondary to volume
MH currently resides at an assisted living facility where she eats most of her
meals. Her son grocery shops for her. MH is physically inactive except for walking to
the dining room every day. She wears glasses and has some hearing loss. MH is a
nonsmoker and nondrinker. She is planning to undergo a root canal in January.
Significant Medical History
MH was hospitalized in 2002 to undergo cataract surgery for glaucoma and
cataracts. She was hospitalized again in 2003 for coronary angioplasty and pacemaker
due to bradyarrhythmia. MH was diagnosed with renal failure in 2003. She was
hospitalized at this time for left upperarm fistula and catheter placement. In 2003, MH
started hemodialysis. MH’s list of current medications are listed in the table below.
Medication List for MH
Medication Amount Use Nutritional implications
Synthroid 1 PO QAM hypothyroidism take on empty stomach
Amiodarone 200mg 1 QD antiarrhythmic agent no grapefruit juice
Docusate 100mg 1 PO TID stool softener take with fluids
Coumadin as directed, anticoagulant control Vit. K intake
Celebrex 200mg 1 BID NSAID (arthritis) take with food
Nephrocap 1 QD renal vitamin take with food
Nexium 40mg 1 30 min before breakfast GERD/esophagitis
Altace 10mg 1 PO QHS ACE inhibitor no grapefruit juice
Zocor 40mg 1 QHS antilipemic agent no grapefruit juice
Diltiazem calcium channel
CD 240mg 1 QAM blocker
Emla Cream as directed local anesthetic
Renagel 800mL 2 with meals phosphorus binder take with meals
Dulcolax 1 PO QHS PRN laxative do not take with milk
Zofran 4mg 1 tab Q8o PRN antiemetic monitor potassium
Restril 30mg 1 QHS PRN
Aranesp 5mcg IV Q Monday anemia tx avoid ethanol
Zemplar 3 mL with tx hyperparathyroidism tx
MH has had a history of low albumin. The table below indicates her albumin
levels for the past year. Over the past 11 months, MH has also had a weight loss of 3.5kg
or 5%. Her most recent weight change was an increase of 0.5kg in December. MH has
had some problems with high phosphorus in the past year, as shown in the table.
Currently, her phosphorus is being controlled through diet and phosphorus binders. Her
potassium level has been WNL each month for the past year. MH is taking a renal
vitamin to make up for the water soluble vitamins that are lost during dialysis. She has a
history of anemia, which is currently being treated with Aranesp.
K+ URR Kt/V Alb Hgb Ca PO4 Prod PTH Iron Dry Wt. Ave gain Wt. %
January 4.9 0.84 2.15 3.5 11.8 10.3 5.3 55 72.5 2.0 2.8
February 4.0 0.84 2.11 3.7 10.9 10.6 3.9 41 50 71.5 2.0 2.7
March 4.4 0.84 2.14 3.8 12.9 10.8 5.3 57 173 71.5 2.0 2.8
April 4.4 0.82 1.98 3.5 13.5 10.4 3.9 41 45 71.5 2.1 2.9
May 4.6 0.79 1.79 3.6 13.6 10.0 5.2 52 381 71.5 2.2 3.1
June 4.5 0.82 2.04 3.7 11.4 10.3 5.9 61 271 52 70.0 2.3 3.3
July 4.4 0.83 2.13 3.7 12.9 11.0 4.3 47 176 70.0 2.2 3.2
August 4.7 0.79 1.82 4.0 13.8 10.3 6.1 63 357 43 69.5 2.3 3.4
September 4.6 0.80 1.90 3.8 14.0 12.0 4.0 48 57 69.0 2.2 3.1
October 4.7 0.79 1.82 3.7 13.8 10.7 5.2 56 54 68.5 2.1 3.0
November 4.4 0.82 2.01 3.5 13.1 10.4 5.4 56 68.5 2.4 3.5
December 4.5 0.84 2.19 3.5 12.2 10.5 4.6 48 343 42 69.0 2.1 3.1
MH’s diet order is 100mEq potassium and 1500mL fluid. In November 2004, MH
stated that she eats 3 meals a day with a light noon meal on non-dialysis days and 2 meals a
day on dialysis days. She states that she knows she is not eating as much protein as she
should. She usually eats 6 eggs a week and 2-3oz meat with her evening meal. She has
been encouraged to use protein powder in the past, but currently only uses it 1-2 times a
week because she gets tired of eating applesauce. MH has been experiencing some
constipation due to the dialysis treatments and fluid restrictions and some gas. She has no
known food allergies or intolerances. In January 2005 MH stated that she is now using
protein powder 3 times a week in her oatmeal. She has started bringing the protein powder
to the dining room with her. MH has also added shaved deli turkey as a snack, and she is
consuming 8 eggs a week.
Chronic Kidney Failure (CKF)
MH’s high BUN and Creatinine are clear indicators that she has chronic kidney
failure (8). MH’s renal failure was caused by her history of hypertension. A large
number of problems can result from the kidney’s inability to excrete nitrogenous wastes.
Therefore, the CKF patient must be treated through dialysis or a kidney transplant to
Fluid and Electrolyte Balance
Renal failure can result in fluid and electrolyte imbalance because the kidneys are
responsible for regulating water and solute balance. Fluids and electrolytes are
monitored through edema, between treatment fluid gains, blood pressure, dietary intake,
and serum Na levels (4). A fluid gain of 2-3 kg or 2-5% of body weight is expected to
occur between dialysis treatments (4). Restricting dietary intake of fluids and sodium can
help control edema and high fluid gains. Fluids should be restricted to 1L a day and
sodium should be restricted to 2g a day in patients who are anuric (9).
Potassium and Vitamins
Potassium is responsible for controlling muscle contractions, including the heart
muscle. Consequently, hyperkalemia or hypokalemia in CKD patients can rapidly lead to
death from arrhymthia (2). This is a concern for MH, who has a history of
bradyarrhythmia. Abnormal potassium lab values can be controlled through the choice of
dialysate and by restricting or increasing the dietary intake of high potassium foods. Salt
substitutes, which have a large amount of potassium, should be avoided in patients with
Loss of water soluble vitamins occurs during dialysis, thus a supplement is
recommended for dialysis patients (10). Multivitamins should be chosen carefully so
they do not contain Vitamin A or high doses of Vitamin C. Renal vitamins are suggested
over multivitamins to prevent vitamin deficiency (10).
Protein-calorie malnutrition can occur in CKD patients who do not consume
adequate protein or calories to spare protein use as energy (6). Malnutrition in CKD
patients increases risk of death and hospitalization (10). Malnutrition is assessed through
weight, BMI, anthropometrics, skinfold measurements, and albumin. Serum albumin is
the most significant predictor of risk of mortality and morbidity. Risk of death and
hospitalization increases as serum albumin decreases (10).
Anemia is a common result of CKF since the kidneys are responsible for secreting
erythropoietin, which acts on stem cells in bone marrow to stimulate RBC production. A
deficiency of erythropoietin in CKD causes anemia (5). Currently Aranesp is being used
to treat MH’s anemia. Aranesp stimulates red blood cell production to correct anemia.
MH’s anemia is under control as determined by her normal Hct, Hgb, MCV, MCHC, and
MCH lab values (5). Anemia, as indicated by low serum ferritin and low TSAT, may
require IV iron or EPO (5). In studies, ferritin and transferrin saturation increased
significantly and iron deficiency decreased after supplementation (2).
Renal Bone Disease
MH is currently being monitored for renal bone disease. In patients with CKD,
the kidneys are unable to maintain calcium-phosphorus homeostasis, thus potentially
resulting in osteoporosis, osteodystrophy, or osteitis fibrosis. This is evident in the
calcium, phosphorus, and Parathyroid Hormone (PTH) lab values (4).
Hyperphosphatemia, elevated CaXP product, excess calcium intake, and elevated PTH
are all risk factors for calcification of the cardiac tissues, which can lead to death (8).
MH has had problems with elevated PTH, calcium, and phosphorus in the past thus
putting her at risk for renal bone disease. Her December lab values indicate high PTH
(343) and adjusted calcium (10.9); therefore, in December, MH was started on Zemplar
to control renal bone disease. PTH labs were ordered again in January, and the value was
still high at 512.
Cardiovascular disease is the leading cause of death in patients with CKD (8).
Chronic kidney disease is an independent risk factor for cardiovascular events (1). The
risk is progressive. Each 10-unit reduction in GFR below 81 mL/min/1.73m2 is
associated with a 10% increase in the relative risk of death or nonfatal cardiovascular
complication (1). Renal dysfunction is a powerful independent predictor of fatal and
nonfatal adverse cardiovascular outcomes (1). MH has an increased risk for
cardiovascular disease due to established CAD. She does not have a cholesterol profile
available to assess; however, she will be at greater risk if her LDL cholesterol > 160
mg/dL and triglycerides > 500 mg/dL (5). The usual pattern of hyperlipidemia in
hemodialysis patients is mild to moderate hypertriglyceridemia, low to mildly elevated
cholesterol/LDL, and low HDL (5). Hyperlipidemia in CKD patients is caused by
increased hepatic production of cholesterol and impaired removal of circulating LDL and
VLDL (5). All CKD patients should be screened for hyperlipidemia. If hyperlipidemia
is an issue, weight control, reduced carbohydrate intake, and exercise can all improve
high cholesterol. However, the renal diet takes priority over hyperlipidemia (5).
MH has had a history of high blood pressure, which eventually resulted in her
impaired renal function. The kidneys regulate blood pressure through the rennin-
angiotensin mechanism. When blood volume is low, rennin is secreted from the
glomerulus. This rennin forms angiotensin. Angiotensin causes vasoconstriction and
stimulates aldosterone secretion causing sodium to be reabsorbed and blood pressure to
return to normal (4). High blood pressure is a major risk factor for CVD in patients with
CKD (8). Hypertension is treated by dietary sodium reduction and fluid control (5,8).
Weight control, physical activity, and moderation in alcohol can also benefit CKD
patients with HTN (8).
MH’s treatment for CKD is dialysis. She is not a good candidate for transplant,
which is the only cure for kidney failure. During dialysis, blood passes through the
semipermeable membrane of the artificial kidney. Waste products are then removed by
diffusion and fluids are removed by ultrafiltration (4). MH has been on dialysis since
2003. Access was obtained through a fistula in her left upper arm. Her current dialysate
is 2K 2.5Ca. Her dialysis is effective as determined by her KT/V value, which measures
the removal of urea from the patient’s blood over a given period of time. The URR is the
reduction in urea before and after dialysis, and this also indicates that MH’s dialysis is
Role of Medical Nutrition Therapy
Diet plays a large role in the health status of CKD patients on dialysis. The goals
of MNT for CKD patients include: to maintain good nutritional status through adequate
protein, energy, vitamin, and mineral intake; control edema and electrolyte imbalance by
controlling Na, K, and fluid intake; prevent or slow growth of renal osteodystrophy by
controlling Ca, Ph, and Vit. D; enable the patient to consume a palatable diet that fits his/
her lifestyle (4). These goals can be achieved by counseling the patient on making
appropriate food choices, taking medications as prescribed, maintaining adequate protein
intake, maintaining lab values within acceptable limits, and maintaining an exercise
Regular dietary counseling based on the individual’s needs is essential for dialysis
patients, especially those with low albumin values. Subjects that received dietary
counseling had a higher rate of increase in serum albumin levels than subjects who took
an oral supplement (3).
MH’s lab values and the desired ranges are indicated below (6,8). MH is at high
nutritional risk because of her low albumin labs. Dialysis drains body protein, so more
protein is needed in her diet to improve albumin levels (4). MH improved her efforts to
increase p.o. intake of protein and protein powder since receiving dietary counseling in
November. In November, MH’s pertinent nutritional labs were mostly WNL, with the
exception of albumin. Her phosphorus was getting a little high at 5.4, but was still WNL.
High phosphorus levels can pose many problems. Hyperphosphatemia can result in
osteodystrophy, decrease in the effectiveness of calcitriol, increase PTH production, and
contribute to metastatic calcifications (5). MH’s high phosphorus labs have been
associated with high PTH labs, as expected. Hyperparathyroid bone disease may cause
phosphorus to be released from the bones, which may be a contributor to MH’s high
phosphorus labs (5). Previously the phosphorus binder, PhosLo was being used, which
increased MH’s calcium levels. In December, her phosphorus binder was changed to
Renagel to control calcium levels. Calcium must continue to be monitored closely as her
adjusted calcium is high.
MH is 62”/157.48cm tall. Her dry weight is 69kg. Overall energy intake may
need to be increased if a downward trend in weight continues (5). The average fluid
gains from the last 3 tx in January was 2.4kg. Her desired body weight according to
HANES II is 64kg. Her BMI is 27. Weight was not adjusted. Anthropometric labs taken
in August of 2004 indicate that her AMA is 75-90%ile, which is a 4.6% decrease from
the previous year. Her AFA is in the 90-95%ile, which is a 14% decrease from the
previous year. Although her arm mass is decreasing, she is not at risk for malnutrition
since she is still in a high percentile (9). The right arm was used for measurements, and a
medium frame was used.
Lab values from
Lab values from 11/10/04 12/6/04
BUN 67 51
Post-Tx BUN 12 8
Creatinine 8.2 7.9
P 5.4 4.6
K 4.4 4.5
Cl 94 L 94 L
CO2 26 28
Ca 10.4 Adj. Ca 10.8 H 10.5 Adj. Ca 10.9 H
Albumin 3.5 L 3.5 L
Total Protein 7.2 6.6
LDH 213 219
Alk phos 62 72
RBC 3.87 L
Hgb 13.1 12.2
MCV 102 H
MCH 33.8 H
Determining Caloric Needs – (6,8)
Calories: 69 kg X 30 kcal/kg = 2,070 total kcals/day
Protein: 69 kg X 1.3 g/kg = 89.7 g protein/day = 359 kcal
Fat: 2,070 kcals X 30% = 621 kcal = 69 g fat
CHO: 2,070 – 359 – 621 = 1,090 kcal = 273 g CHO
Na: 2-3 g/day
K: 69 kg X 40 mg/kg = 2,760 mg/day
P: 800-1,000 mg/day
Fluid: 1,000 mL/day
Recommended Nutrition Therapies and Rationale
MH was encouraged to increase her intake of protein. Estimated protein needs were set
higher for MH than for most hemodialysis patients because MH’s albumin has been so low. A
low albumin has been associated with higher mortality rates in dialysis patients, so it is
essential to return the albumin level to 4.0 or greater. For MH, a lower albumin goal may be
more realistic given her history of low albumin levels. Protein intake will be increased through
the increased use of protein powder. MH was encouraged to use protein powder at breakfast or
the noon meal, since MH is typically not consuming meat then. Since MH is discouraged from
using protein powder because she is tired of eating applesauce, ideas of other foods that protein
powder could be mixed with (including hot cereal) were brainstormed. In addition, MH was
encouraged to add a snack once a day that includes meat such as lunch meat roll-ups or lunch
meat with low-sodium crackers to increase protein intake. The snack will also help improve
MH’s caloric intake to help maintain her weight. Other foods that are high in protein and
appropriate for the patient’s diet order include: eggs, egg substitutes, fish, chicken, beef, pork,
and other meats.
The phosphorus binder she was taking, PhosLo, consisted of calcium acetate, which
negatively impacted her calcium levels. In November, her adjusted calcium was 10.8.
Renagel was considered as an alternative phosphorus binder in November. In December,
MH’s adjusted calcium was 10.9, and a switch was made to Renagel for her phosphorus
MH was praised by the dietitian for her good lab values to encourage her to keep up the
good work with the potassium and fluid restrictions. A positive environment was created to
help prevent MH from becoming discouraged at all of the dietary requirements. MH was also
encouraged to continue to comply with all new medications.
Continued monitoring of MH’s labs, especially albumin, is essential to gauge how well
she is doing with her nutritional goals. Continue to monitor PTH to evaluate the effectiveness
of the new medication, Zemplar. Monitor weight for any changes, which will indicate nutrition
status. If a downward trend in weight continues, increase total energy intake to prevent further
weight loss. A lipid profile is recommended for MH to properly assess her risk for
Exercise could benefit MH in many ways and was encouraged for the patient.
Exercise could prevent further loss of muscle mass. It can also lower blood pressure and
improve lipid levels, if they prove to be a problem. Make a referral to the exercise
specialist to encourage MH to exercise while she is at dialysis.
MH seems to be a very motivated individual who is willing to work to meet her
nutritional goals. She has some barriers that get in the way of healthy eating habits (ex:
tired of applesauce, lacking ideas for protein sources), but once they were addressed by
the dietitian, her optimism and compliance improved. Her expected prognosis is fair,
depending largely on her albumin trends. Should they continue to decline, her risk of
morbidity and mortality will be greatly increased.
(1) Anavekar, N, et al. Relation between Renal Dysfunction and Cardiovascular
Outcomes after Myocardial Infarction. The New England Journal of Medicine, 2004; 351
(2) Kopple, J. and Massry, S. Nutritional Management of Renal Disease. Baltimore:
Williams & Wilkens, 997.
(3) Akpele, L. and Bailey, J. Nutrition Counseling Impacts Serum Albumin Levels.
Journal of Renal Nutrition, 2004; 14(3): 143-148.
(4) Mahan, LK, and Escott-Stump, S. Krause’s Food, Nutrition, and Diet Therapy.
Eleventh edition. Philadelphia: Elsevier, 2004.
(5) National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient
with Chronic Kidney Disease. Third Edition. 2002.
(6) Beto, J. and Bansal, V. Medical Nutrition Therapy in Chronic Kidney Failure:
Integrating Clinical Practice Guidelines. Journal of the American Dietetic Association,
2004; 104: 404-409.
(7) American Dietetic Association. Guidelines for Nutrition Care of Renal Patients.
Third edition. 2002.
(8) American Dietetic Association. Renal Care: Resources and Practical Application.
(9) Daugirdas, J., Blake, P., and Ing, T. Handbook of Dialysis. Third edition.
Philadelphia: Lippencott Williams & Wilkins, 2001.
(10) Ahmad, S. Manual of Clinical Dialysis. London: Science Press, 1999.