2. Goals of MNT
● Prevent and treat protein-energy malnutrition and mineral and electrolyte
disorders
● Minimize impact of other conditions on prognosis of kidney disease
○ Caloric intake
○ Protein
○ Anemia
○ Diabetes
○ Obesity
○ Hypertension
○ Disorders of lipid metabolism
○ etc.
Nephrologynews.com
3. Phosphorus and Nutrition in Chronic Kidney Disease
● Protein foods often rich in phosphorus
● Low protein diet: slows progression of disease and decreases supply of
phosphorus
● Protein balance is key
● Advanced CKD (non-dialysis): 0.6-0.8 g/kg BW
● HD: 1.2-1.4 g/kg BW and no more than 800mg phos
○ Alternative solution: nutrition supplements - low in phos but high in kcal and pro
■ Educate patient on phosphorus amounts per protein food
■ Early use of phos binders
(Gonzalez-Parra E, 2012)
4. CKD Non-Dialysis
● NN:
○ Stages 1, 2, 3: may not need to limit protein
○ Stage 4: 0.8g/kg protein (50% HBV)
● KDOQI
○ GFR<25mL/min
■ Low-protein providing 0.60g/kg (50% HBV)
■ Those unwilling or unable to maintain adequate intake, intake of up to 0.75g/kg prescribed
■ 35kcal/kg for those under 60, 30-35kcal/kg for those 60+
(Nephrologynews.com), (www.kidney.org)
5. CKD Non-Dialysis
● NCM
○ Without diabetes
■ 0.6-0.8 g protein/kg body weight
○ With diabetic nephropathy: 0.8-0.9g/kg
■ Intakes at 0.7g/kg or less may result in hypoalbuminemia
○ Kidney transplant: 0.8-1.0 g pro/kg before, 1.4 g pro/kg after (ACMC)
■ Energy: 23-35kcal/kg
● Davita
○ Stages 1, 2, 3 (GFR 30+): 12-15% of calories from protein
○ Stage 4 (GFR 15-29): 10% of calories from protein
(Nutritioncaremanual.org), (www.davita.com)
6. CKD Non-Dialysis
● Cleveland Clinic
○ Protein: 0.6g/kg.day
○ Na: <2gm/day
○ K: 40-70 mEq/day
○ P: 600-800 mg/day
○ Ca: 1400-1600 mg/day
● International Society of Renal Nutrition and Metabolism (Ikizler TA, et al, 2013)
○ CKD 3-5 (clinically stable)
■ 0.6-0.8g/kg IBW
■ 30-35kcal/kg
■ Adjust for hypermetabolic conditions
● Illness: 1g/kg
(my.clevelandclinic..org), (www.renal-nutrition.com)
7. CKD Non-Dialysis
● Elderly Study: Light and shadows of dietary protein restriction in elderly with
Chronic Kidney Disease (Giordano M, et al., 2013)
○ CKD 3: 0.8g/kg/day
○ CKD 4: greater protein reduction
○ In combination with reduction in sodium and phosphorus
8. CKD Non-Dialysis
● Vegetarian, low-protein diet supplemented with ketoanalogues (Piccoli GB, et al,
2013)
○ Ketoanalogue: nitrogen-free analogues of essential amino acids
○ Randomized to ketoanalogue-supplemented diet with 0.3g/kg vegetable protein OR mixed
low-protein diet of 0.6g/kg for 15 months
○ Results: 5 pts with stage 4 or higher CKD could avoid a 50% reduction in kidney function; 1 pt to
avoid dialysis
9. Plant Protein
● The Associations of Plant Protein Intake With All-Cause Mortality in CKD (Chen
X, et al, 2016)
○ Higher proporition of protein from plant sources is associated with lower mortality in those with
eGFR<60mL/min/1.73m2
● The effects of soy protein on chronic kidney disease: a meta-analysis of
randomized controlled trials (Zhang J, et al, 2014)
○ Limited evidence: small amount of trials and subjects
○ Protective effect of soy protein consumption on creatinine and phosphorus concentrations
10. Fiber
● Dietary fiber and protein: nutritional therapy in chronic kidney disease and
beyond. (Evenepoel P, Meijers BK, 2012)
○ CKD is a microinflammatory state with increased proteolytic fermentation
■ Exacerbated by dietary protein, reversed by dietary fiber
○ Increase consumption of fiber or K-free alternatives (ex: prebiotics)
11. Maintenance Hemodialysis
● KDOQI
○ Clinically stable
○ 1.2g/kg body weight (50% HBV)
○ 35 kcal/kg body weight for those under 60
○ 30-35 kcal/kg body weight for those 60+
● NCM
○ Protein: ≥ 1.2 g/kg of body weight; ≥50% HBV
■ Choose high protein foods (many also tend to be higher in phosphorus) to maintain
adequate protein stores (will increase need for phosphate binders)
○ Energy: <60 years: 35kcal/kg; >60 years: 30-35 kcal/kg
● International Society of Renal Nutrition and Metabolism (Ikizler TA, 2013)
○ 1.2 g/kg IBW (50% HBV)
○ 30-35kcal/kg IBW
(kidney.org), (Nutritioncaremanual.org), (www.renal-nutrition.com)
12. Peritoneal Dialysis
● KDOQI
○ Clinically stable: 1.2-1.3g/kg body weight (50% HBV)
○ No less than 1.2 g/kg/day
○ Unless demonstrated adequate protein nutritional status on 1.2g/kg diet, 1.3 should be prescribed
● NCM:
○ Protein: ≥ 1.2 g/kg-1.3 g/kg, ≥50% HBV
○ Energy: <60 years: 35kcal/kg; >60 years: 30-35 kcal/kg, including dialysate calories
● International Society of Renal Nutrition and Metabolism (Ikizler TA, et al, 2013)
○ 1.2 g/kg IBW (50% HBV)
○ 30-35kcal/kg IBW
(kidney.org), (Nutritioncaremanual.org), (www.renal-nutrition.com)
13. AKI
● NCM
○ None/mild renal catabolism: 0.6-1.0 g/kg – 30 kcal/kg RBW
○ Moderate, dialysis as needed: 1.0-1.2 g/kg – 35 kcal/kg RBW
○ Severe, hemodialysis/peritoneal dialysis: 1.2-1.8g/kg – 35-50 kcal/kg RBW
○ Burn/sepsis, CRRT: 1.5-2.0 g/kg – 35-50 kcal/kg RBW
● Official Journal of the International Society of Nephrology (2012)
○ Noncatabolic, non-dialysis: 0.8-1g/kg/day
○ RRT: 1-1.5g/kg
○ Hypercatabolic, CRRT: 1.7g/kg
((Nutritioncaremanual.org), (www.theisn.org)
14. CRRT
● ASPEN
○ Protein: 2.5 g/kg
● Review: Nutritional and metabolic alterations during continuous renal
replacement therapy (Honore PM, et al, 2013)
○ Average energy: 25-35kcal/kg
○ Average protein: 1.5-1.8g/kg
● SCCM
○ Scheinkestel et al: 2.5g/kg
○ Journal of Parenteral and Enteral Nutrition (Klein et al): 2.5g/kg
○ Conclusion: 2-2.5g/kg
● NCM
○ 1.5-2g/kg, 35-50 kcal/kg RBW
● Official Journal of the International Society of Nephrology (2012)
○ 1.7g/kg
15. Fluid
● Weight gain of 1-2 kg is appropriate, any more is excessive (1 L fluid ~ 1kg)
● Fluid restriction in combination with salt restriction
● Cleveland Clinic: urine output + 1-1.5L/day free water
● Edema? - what to do?
my.clevelandclinic.org
