This document provides information on medical nutrition therapy for a patient with end-stage renal disease undergoing hemodialysis. The patient has a GFR of 12 mL/min and receives hemodialysis twice a week. The goals of medical nutrition therapy are to prevent deficiencies, control fluid balance and electrolytes, and prevent complications related to calcium and phosphorus levels. The dietitian provides calculations to determine the patient's energy, protein, fluid and electrolyte needs and prescribes an appropriate diet.

1. Medical Nutrition Therapy
for ESRD - Hemodialysis
Dietitian - Jake Brandon M. Andal

2. Case 3: ESRD Hemodialysis
• GFR = 12 mL/min
• Kidney not immediately available, hemodialysis was
recommended
• Arteriovenous fistula was created on his left forearm
• BP na d serum potassium level has risen and BUN is 110 mg/dL
• HD is twice a week
• Instructed to continue phosphate binders and calcium
supplements
• Post-dialysis weight gain is 54 kg

3. Pathophysiology
• End Stage Renal Disease can result from a wide variety of
different kidney diseases
– Diabetes Mellitus
– Hypertension
– Glomerulonephritis or Acute Kidney Failure
– Chronic Kidney Failure
• Diagnosis: Stage 5 CKD, BUN 100 mg/dL, Cr 10-12 mg/dL

4. Medical Treatment
• Options include
– Dialysis <3
– Transplantation
– Medical management progressing to death 

5. Dialysis
• Px may choose if he/she prefers:
– Outpatient dialysis facility
– Hemodialysis at home
– Peritoneal Dialysis
• Continuous Ambulatory Peritoneal Dialysis (CAPD)
• Continuous Cyclic Peritoneal Dialysis (CCPD)

6. Factors to consider in type of Dialysis Treatment
• Availability of family/friends/caretaker to assist therapy
• Type of water supply ate home
• Previous abdominal surgeries
• Membrane characteristics of Peritoneal Membrane
• Body size, cardiac status, presence of vascular access
• Desire to travel

7. What is Hemodialysis?
• Hemodialysis requires permanent access to blood stream
through a FISTULA
– If the patient’s blood vessels are fragile, a GRAFT is necessary
• Large needles are inserted into the fistula or graft each
dialysis and removed when dialysis is complete
• HD’s fluid is similar to that of a Human’s Plasma
• Waste Products and Electrolytes are removed by diffusion,
ultrafiltration, and osmosis from the dialysate
• Usually 3 to 5 hours ; newer treatments are shorter

9. What is Peritoneal Dialysis
• Uses the body’s PERITONEUM
• Dialysate containing High-dextrose solution is installed in the
peritoneum
– Diffusion ; blood  dialysate (wastes)
– Osmosis (water)
• Advantage compared to HD: avoids large fluctuations in blood
chemistry, longer residual renal function and ability of the
patient to live a normal lifestyle
• Complications: Peritonitis, Hypotension and WEIGHT GAIN
• Icodextrin – superior fluid removal without dextrose absorption

11. Evaluation of Dialysis Frequency
• Kinetic Modeling
– Measures the removal of urea from the patient’s blood over a given
period
– Kt/V
• K – Urea Clearance
• t – Length of time of dialysis
• V – Total Body Water Volume
• Urea Reduction Ratio
– Looks ate the reduction of urea after dialysis

12. GOALS?????

13. Medical Nutrition Therapy Goals
• Prevent deficiency and maintain good nutrition status
through adequate protein, energy, vitamin and mineral
intake
• Control edema and electrolyte imbalance by controlling
sodium, potassium and fluid intake
• Prevent or retard development of renal osteodystrophy by
controlling calcium, phosphorus, Vitamin D and PTH

14. Medical Nutrition Therapy Goals
• Enable the patient to eat a palatable, attractive diet that fits
his or her lifestyle as much as possible
• Coordinate with the Healthcare Team
• Provide initial nutrition education, periodic counseling and
long term monitoring of patients

15. PROTEIN NEEDS
• Dialysis drains body protein
• 1.2 g of Pro for patients who receive HD three times a week
• Albumin is a limited factor of protein nutriture, but is
routinely used in evaluating ESRD’s NS
• Patients with Uremia have greater chances of lowered
protein intake
• Patients may tolerate other sources of meats better
• Phosphate restriction may be lifted to allow dairy products

16. Energy
• SHOULD BE ADEQUATE TO SPARE PROTEIN
• 25 kcal – 40 kcal/g of body weight
• Higher needs for patients in PD

17. Fluid and Sodium Balance
• Thirst may indicate excessive sodium intake, increased fluid
gain and resultant hypertension
• Allowed weight gain (fluid gain) for HD patients – 2 to 4
kilograms
• Restriction on fluid: 750 ml + urine output
• Some patients may have salt wasting tendencies which maye
require extra sodium
• Frequent dialyses, daily PD, daily nocturnal dialysis – higher
allowance for sodium and fluid

18. Potassium
• Restriction would be based on the frequency of
Hemodialysis
• Be careful: Low sodium foods contain potassium chloride as
a salt substitute

19. Phosphorus
• As GFR decreases, phosphorus excretion also decreases
• High-protein diet may also be equated to high phosphorus
intake
• Phosphate binders
– May cause GI distress, diarrhea or gas
– Severe constipation  intestinal impaction

20. Calcium and Parathyroid Hormone
• ESRD patients  Impaired Calcium and PTH balance
• As GFR decreases, serum calcium declines because
– Decreased ability to convert Vit. D
– Increased need due to high phosphorus intake
– Hypertrophy of the Parathyroid gland
• Over secretion of PTH
• Secondary hyperparathyroidism
• Calciphylaxis
– Deposition in wound tissues with resultant vascular calcification,
thrombosis, non-healing wounds and gangrene

21. Lipids
• Risk of atherosclerotic cardiovascular diseases
• Elevated TG without increase in cholesterol
• Low cholesterol levels may lead to mortality of ESRD

22. Iron and EPO
• ESRD  inability of the kidney to produce EPO
• EPO – stimulates bone marrow to produce red blood cells
• There is also a destruction of red blood cells
• Lost blood in dialysis
 RISK FOR ANEMIA

23. Vitamins
• Water soluble vitamins -> lost during dialysis
• Emphasis on Folate
• Vitamin B12 is protein bound, thus, losses are minimal
• High Phosphorus foods -> High water soluble vitamins
• Niacin -> helpful in lowering phosphate levels in ESRD
patients

24. Case Study: Dietary Computations
• Desirable Body Weight
– (172.27 cm – 100) x .90
– 65 kg
• Dry Body Weight
– NTBW = 54 kg x .50
– =27
– ATBW = (142 mEq/L / 140 mEqL x NTBW)
– =27.38

25. Dietary Computations
• EBW = 27.38 – 27 kg
• EBW = 0.38 L
• Estimated Dry Weight – 53.62 kg
• Estimated BMI = 18.0 (Underweight)

26. Total Energy Requirement
• = DBW x 35 kcal/DBW
• =65 kg x 35 kg
• = 2275 kcal ῀ 2250 kcal

27. Protein Requirement
• = DBW x 1.2 g/KDBW
• = 78 g Pro ῀ 80 g Pro
• NPC = 2250 – (80 g Pro x 4 kcal/g)
• NPC = 1930 kcal
Based on the Diet Manual

28. Non-Protein Calories Distribution
Carbohydrates
• 1930 kcal x .70
• = 1351 kcal / (4 kcal/g)
• = 337.75 g CHO
• = 340 g CHO
Fat
• 1930 kcal x .30
• = 579 kcal / (9 kcal/g)
• = 64.5 g Fat
• = 65 g Fat

29. Phosphorus, Potassium and Sodium Restriction
• Potassium
– DBW X 40 mg/KgIBW
– =2600 mg or 2 g - 3 g Potassium
• Phosphorus
– DBW x < 17 mg / Kg DBW
– = < 1105 mg
• Sodium
– 2 – 3 g

30. Fluid and Restriction
• Fluid
– 750 mL – 1000 ml / Day
• Calcium
– 1000 mg – 1800 mg (supplements as needed)

31. Final Diet Prescription
• 2250 kcal ; 340 g CHO ; 80 g Pro ; 65 g Fat
– 2 – 3 g Potassium
– < 1105 Phosphorus
– 750 mL – 1000 mL Fluid
– 2 – 3 g Sodium
– 1000 mg – 1800 mg Calcium

32. Distribution to Exchanges
Food Group
Ex CHO (g) PRO (g) FAT (g) KCAL Na K Ca P Moisture
Veg A 2 3 1.2 32 4 120 30 30 60
Veg A.1 2 3 1.2 32 4 240 80 30 60
Fruit B (Processed) 3 30 0.6 120 6 180 15 15 126
Sugar A 5 25 100 35 100 75 100 10
Sugar (Free Foods) 10 50 200 0 0 0 0 0
Rice A 8 184 16 800 16 480 120 280 600
Rice B 2 46 8 200 460 120 40 70 20
Meat (Lean) A 6 48 6 246 180 1200 90 420 186
Fat A 2 10 90 80 4 2 2 2
Fat (Free Foods) 9 45 405 0 0 0 0 0
TOTAL 341 75 61 2225 785 2444 452 947 1064

33. Calcium and Sodium Supplement Computation
• Calcium Restriction – 1400 mg
• Less: Inherent Calcium – 467 mg
• Remaining = 933 mg Ca
– Equivalent to (2) 500 mg tablets
• Sodium Restriction – 2000 mg (Lower limit)
• Inherent Sodium – 815 mg
• Remaining = 1185 mg = 2 ¼ tablespoon Salt Solution