The document discusses the major roles of the kidney in metabolic regulation including water-electrolyte homeostasis, calcium-phosphate balance, waste product removal, acid-base balance, erythropoietin production, and blood pressure regulation. It then summarizes the goals of nutritional therapy in renal failure and discusses nutritional problems patients with renal failure often experience like anorexia and metabolic abnormalities. Guidelines for protein intake, energy intake, fluid intake, sodium intake, and potassium intake are provided for non-dialysis patients, patients undergoing hemodialysis, and patients undergoing peritoneal dialysis.

1. Presented by Wajid Hussain
Dietetic Intern at Ram Manohar Lohia Hospital

2. Major roles of the kidney in metabolic regulation
Water-electrolyte homeostasis
• Retention of fluid and electrolytes
• Hyperkalemia
• Fluid overload
• Left ventricular hypertrophy
Calcium-phosphate balance
• Vitamin D deficiency
• Hyperphoshatemia
• Bone and mineral disorders
• Vascular calcification
Waste products
removal
• Uremia
• Anorexia
• Metabolic disturbances
Acid-base balance
• Metabolic acidosis
• Protein catabolism
Erythropoietin
production
• Anemia
• Fatigue/Tiredness
• Physical inactivity
Degradation of peptides
• Hormonal alterations
• Insulin resistance
• ↑ serum β2-microglobulin
• Hypercytokinemia
Blood pressure regulation
• Hypertension
• Cardiovascular disease

3. Goals of Nutritional therapy in Renal Failure
 Ensuring adequate nourishment, energy, vitamin, and minerals.
 Minimising the burden of uraemia, by optimizing and limiting the protein
intake.
 Alleviating the fluid overload and the electrolyte and acid-base imbalance, by
controlling the intake of sodium and potassium ions and fluid.
 Preventing and retarding the metabolic derangements of renal
osteodystrophy, by maintaining calcium, phosphorus, and vitamin D
homeostasis.
 Delaying the progression of renal failure. This goal specifically applies to
patients in the pre-dialysis phase, who have a diminishing glomerular
filtration rate (GFR) between 25 mL/min and 5- 10 mL/min, and are being
conservatively managed.

4. Nutritional problems in Uraemic patients
Anorexia
Due to rise in blood urea, patients of chronic renal failure lose their appetite and have
no desire to eat. The taste acuity is also affected, and patients find the best of foods
seem quite bland and unappealing.
loss of nutrition into the dialysate
With the glomerular filtration rate (GFR) falling to 5 mL/min, uraemic patients require
dialysis on a regular basis. This leads to a persistent loss of nutrients into the
dialysate, and is a major cause of protein energy malnutrition.
metabolic abnormalities
Due to a poor protein and energy intake, altered protein metabolism, and the
development of hyperthyroidism and insulin resistance which pan out secondarily to
renal failure, patients of chronic renal failure develop features of wasting.

5. PROTEIN INTAKE
 During pre-dialysis phase
In individuals with a glomerular filtration rate (GFR) in the range of 25 -70 mL/min, protein intake should be reduced to 0.55
to 0.7 g/kg body wt/day. Of this , at least 0.35 g/kg body wt/day protein should be of high biological value.
 In patients undergoing maintenance dialysis
when the GFR falls below 5 ml/min, patients during this process lost significant amount of amino acids pool in the dialysate
so they consume regular diet with a higher intake of protein ( in the range of 1.0 -1.5 g/kg per day). This high protein
regimen is essential for averting the protein energy malnutrition.
 in patients undergoing haemodialysis
In patients undergoing haemodialysis losses can be as high as 1 g of amino acids per hour. A standard four hour session of
haemodailysis results in loses equivalent to 5 – 12 g of protein, of which large proportion are essential amino acids .
 in patients undergoing peritoneal dialysis
in patients regularly passing through peritoneal dialysis, the protein requirements are greater than in patients enduring
haemodialysis. on average 10 -14 g of protein loses in the dialysate. the protein intake is best maintained in the range of
1.3- 1.5 g/kg body weight /day.
 in patients of nephrotic syndrome
the protein intake should be kept around 0.7g/kg body wt/day. in addition, to compensate for the protein lost in the urine
the patient should receive 1g of high biological value for each gram of protein lost.

6. Nutritional surveillance in patients in chronic Renal Failure
Biochemical parameters Normal blood levels Dietary /metabolic sources Therapeutic measures ,
including dietary management ,
incase of abnormal levels
MINERALS
Sodium 135-145 mEq/L Table salt, high protein foods,
salted and processed foods.
High: check fluid status. If high
fluid, tell the patient to take fewer
salty foods
Low: if high fluid gains, tell the
patient to reduce water and salt
intake
Potassium 3.5-4.5 mEq/L Fruits, vegetables and high protein
foods like milk, meat and egg
High: evaluate for any complicating
factor which may be responsible for
the rise. Limit intake to 40mEq/L
Low: add one high potassium
food/day. Recheck blood level.
Calcium 8.5-10.5 mg/dL Milk products, millet , some green
veg, custard apple ,dates
High: discontinue calcium
supplements
Low: add calcium and vit D3
supplements
Phosphorus 2.5-4.8 mg/dl Milk products ,dried beans,
nuts and meat
High: limit milk and its
products to one serving per day
. Ask patient to take phosphate
binders.
Low: Add one serving of milk
products. Decrease the dose of
phosphate binders
Magnesium 1.5- 2.4 mg/dL Whole grains, legumes, ground
water, dark green leafy veg,
nuts, and fish also antacids
High: discontinue antacids and
laxatives which contain
aluminum hydroxide

7. Nutritional surveillance in patients in chronic Renal Failure (continued)
Metabolites and others
BUN (blood urea nitrogen) 15-4:0 mg/dL Waste product of protein
breakdown
High: under dialysis
Creatinine 0.6-1.5mg/dL Waste product of muscle
breakdown
High: if accompanied by
weight loss, the product may
need to eat more calories
and food.
Albumin 3.5-5.0 g/dL Protein produced in the liver,
a good measure of the
nutritional status
Low: consider increasing the
intake of protein- rich foods
. Protein supplements may
help
I-PTH (parathyroid
hormone)
10-65 pg/mL Produced by the parathyroid
glands, governs calcium and
phosphorus metabolism
High : the patient may need
calcium and vitamin D3
supplements

8. 30g protein Renal diet (1600Kcal)
Excha
nges
No. Amou
nt
(gm)
CAL PRO CHO FAT VIT A (µg/day) Thiam
in
Ribofl
avin
Niacin
Eq
(mg/d
ay)
Dietar
y
VIT C Calciu
m
Iron
(kcal) (g) (g) (g) (mg/d
ay)
(mg/d
ay)
Folate (mg/d
ay)
(mg/d
ay)
(mg/d
ay)
retinol Β-caro (µg/da
y)
Milk
(cow/s
kim)
1 250 170 8 12 10 132.5 0.12 0.47 0.25 21.25 5 300 0.5
Meat
/lean/
egg
1 1 80 7 6 420 0.1 0.4 0.1 78.3 0 60 2.1
Cereal
s
6 120 420 12 90 - - 30 0.14 0.08 2.88 27 3.24
Pulses 1 30 100 7 17 14.7 0.14 0.6 0.72 42 22.5 1.17
Veg A
(GLV)
2 variabl
e
40 2 7 - - 3510 0.06 0.46 1.2 246 78 592 2.89
Veg B
(oth)
1 variabl
e
40 2 7 - - - 0.03 - 0.02 14.66 7 97.33 1.52
Root/t
ubers
2 130 128 2 30 31.2 0.13 0.01 1.56 9.1 22.1 13 0.62
Fruits 2 100 90 20 15 0.06 0.02 0.4 64 5 0.7
Sugar 4 20 80
Fat 6 30 270 30
Sago 3 51 180 45
Total 1598 40 228 46 517 4153.
4
0.78 2.04 7.13 411.3
1
176.1 1116.
83
12.74
RDA 1600 60 - 25 600 4800 1.2 1.4 16 200 40 600 17

9. 1800 KCAL 50 G PROTEIN RENAL DIET
Exchan
ges
No. Amount
(gm)
CAL PRO CHO FAT VIT A (µg/day) Thiamin Riboflav
in
Niacin
Eq
(mg/day
)
Dietary VIT C Calcium Iron
(kcal) (g) (g) (g) (mg/day) (mg/day) Folate (mg/day) (mg/day) (mg/day)
retinol Β-caro (µg/day)
Milk
(cow/ski
m)
1 320 93 8 14.7 10 0 0 0 0.32 0 3.2 384 0.64
Meat
/lean/eg
g
1 1 80 7 6 420 0.1 0.4 0.1 78.3 0 60 2.1
Cereals 8 160 560 16 120 40 0.18 0.1 3.84 36.8 4.32
Pulses 2 60 200 14 34 29.2 0.28 1.2 1.42 82 45 2.34
Veg A
(GLV)
2 variable 40 2 7 - - 3510 0.06 0.46 1.2 246 78 592 2.89
Veg B
(oth)
1 variable 40 2 7 - - - 0.03 - 0.02 14.66 7 97.33 1.52
Root/tu
bers
2 130 128 2 30 31.2 0.13 0.01 1.56 9.1 22.1 13 0.62
Fruits 2 100 90 20 15 0.06 0.02 0.4 64 5 0.7
Sugar 6 30 120
Fat 6 30 270 30
Sago 3 51 180 45
Total 1801 51 277.7 46 517 4045.4 0.84 2.19 8.86 430.06 174.3 1233.13 15.13
RDA 1800 50 - 25 600 4800 1.2 1.4 16 200 40 600 17

10. 30 g protein diet 1500 Kcal
Exchan
ges
No. Amount
(gm)
CAL PRO CHO FAT VIT A (µg/day) Thiami
n
Ribofla
vin
Niacin
Eq
(mg/da
y)
Dietary VIT C Calciu
m
Iron
(kcal) (g) (g) (g) (mg/day
)
(mg/day
)
Folate (mg/day
)
(mg/day
)
(mg/day
)
retinol Β-caro (µg/day)
Milk
(cow/sk
im)
1 320 93 8 14.7 10 0 0 0 0.32 0 3.2 384 0.64
Meat
/lean/e
gg
1 1 80 7 6 420 0.1 0.4 0.1 78.3 0 60 2.1
Cereals 6 120 420 12 120 40 0.18 0.1 3.84 36.8 4.32
Pulses
Veg A
(GLV)
1 variable 20 1 3.5 - - 3510 0.06 0.46 1.2 246 78 592 2.89
Veg B
(oth)
1 variable 40 1 3.5 - - - 0.03 - 0.02 14.66 7 97.33 1.52
Root/tu
bers
2 130 128 2 30 31.2 0.13 0.01 1.56 9.1 22.1 13 0.62
Fruits 2 200 180 40 15 0.06 0.02 0.4 64 5 0.7
Sugar 6 30 120
Fat 6 30 270 30
Sago 3 51 180 45
Total 1531 31 277.7 46 517 4045.4 0.84 2.19 8.86 430.06 174.3 1233.13 15.13
RDA 1500 40 - 25 600 4800 1.2 1.4 16 200 40 600 17

11. Guidelines in daily practice
Carry out a quick clinical and nutritional assessment.
Calculate the protein, energy, water, sodium, and potassium allowances
for the patient according to the clinical status. Prefer high biological value
protein. Use unsaturated fats. Make allowance for calorically dense, low
protein foods, which are palatable to the patient.
Monitor the nutritional status and dietary intake of the patient. Certain
clinical and laboratory tests like measuring the body weight, and serum
values of sodium, potassium, calcium, phosphorus, BUN, Creatinine, and
albumin should be done regularly.
Take immediate corrective steps if the patient losses weight, shows
derangements in laboratory parameters or develops any signs of
nutritional deficiency.
Choose a low –protein menu which suits best to patient’s requirements or
draw a new eating plan along the ongoing treatment.

12. Guide lines in daily practice
Non –dialysis patient in
CRF
Undergoing
haemodialysis
Undergoing
peritoneal dialysis
protein intake
0.55-0.7g/kg body wt/day
Protein intake
1.0- 1.2 g/kg body wt/day
Protein intake
1.2-1.3 g/kg body wt/day
Energy intake
30-35 Kcal/kg/wt/day
Energy intake
35 Kcal/kg body wt/day
Energy intake
30-35 Kcal/kg body wt/day
fluid intake
Up to 3,000mL/day, more if fluid loss is
high
Fluid intake
750-15,00 mL/day
Fluid intake
Ad libitum (minimum 2,000 mL/day +
urine output)
Sodium intake
2-4 g/day
Sodium intake
2-3 g/day
Sodium intake
2-4 g/day
Potassium intake
40-70 mEq/day
Potassium intake
40-70 mEq/day
Potassium intake
40-70 mEq/day

13. For valuable feedback, please connect on linkdln@Wajid
Rather or wajidrather@yahoo.com