Renal Exchange List - prototype-for-Research Through Design

Page | 1
Front cover
MEDICAL NUTRITION THERAPY FOR KIDNEY DISEASES

Page | 2
Medical Nutrition Therapy for Kidney Disease
Published by:
Food and Nutrition Research Institute
Department of Science and Technology
DOST Compound, General Santos Avenue
Bicutan, Taguig City 1631
Metro Manila, Philippines
Telephone: +63288378113 to 14 local
Fax:+632 837 2934
Website: www.fnri.dost.gov.ph
ISBN XXX-XXX-XXXX-XX-X
Copyright © 2020 by the Department of Science and Technology - Food and Nutrition Research Institute
ALL RIGHTS RESERVED.
No part of this book may be reproduced in any form or manner, without prior permission in writing from the Department of Science
and Technology- Food and Nutrition Research Institute, Bicutan, Taguig City.
Suggested Citation
Department of Science and Technology - Food and Nutrition Research Institute. Medical Nutrition Therapy for Kidney Disease.
Taguig City: Philippines: DOST-FNRI, 2020
Cover design by:
Layout by:

Page | 3
FOREWORD
The Department of Science and Technology -Food and Nutrition Research Institute (DOST-FNRI) presents The
Medical Nutrition Therapy for Kidney Diseases. This handbook is the revised version of the previous Handbook for
Nutritional Management of Renal Diseases, 1995 Edition. This comprehensive publication aims to guide registered
nutritionist-dietitians (RNDs) in their clinical practice in the nutritional management of renal diseases using the steps of
the Nutrition Care Process, a systematic approach in providing a high quality and personalized nutrition care to
patients. The clinical practice guidelines by the Kidney Disease Improving Global Outcomes (KDIGO) in 2012 and
Kidney Disease Outcomes Quality Initiative (KDOQI) in 2020, the other experts in the field and nutrition
recommendations from various societies like the Academy of Nutrition and Dietetics were used as reference in this
handbook. Nutritional goals of selected kidney diseases, application of Nutrition Care Process (NCP) in disease
management, writing a diet prescription, including a diet plan during emergency and disaster to reflect the current
need at this present time are discussed in this handbook.
With the advent of the new and harmonized food composition databases or Food Composition Tables (FCTs) – both
local and international, updated Food Exchange Lists (FEL) and practice guidelines, this paves the way to revise the
REL handbook. Both the Philippine FCT and FEL were revised and expanded in consideration of the emerging foods
and food products in the market brought about by new food technologies and processes as well as changing food
habits and practices of Filipinos. In the KDIGO Clinical Practice Guidelines for Acute Kidney Injury (AKI), definition,
and staging of AKI were based on a combination of the Risk, Injury, Failure; Loss, End-Stage Renal Disease (RIFLE)
and Acute Kidney Injury Network (AKIN) criteria which establish a solid ground for standardized Acute Kidney Injury
(AKI) assessment and classification. Likewise, the KDOQI for Chronic Kidney Disease (CKD) with the newest update
in 2020. The updated guideline recommendations have demonstrated the association of appropriate nutrition with
improved clinical outcomes of patients suffering from kidney diseases. This revised handbook is a valuable resource
for RNDs who aim to advance and apply this knowledge in close collaboration with the physician to make a positive
improvement in patient’s health outcomes.
Director
Department of Science and Technology
Food and Nutrition Research Institute

Page | 4
ACKNOWLEDGEMENTS
Grateful acknowledgement and appreciation go to the individuals whose expertise, time and insights contributed to the
publication of the handbook.
Expert consultant
Project assistants
Technical reviewers
Participants of survey, round table discussions/pre- and pilot test for their invaluable insights in refinements of the
technical contents including layout and design of handbook
FRDG - Alex and Tin B
TDSTSD – Dr. MG, Ms. IGG, Ms Maja, Ms Faye
Layout and design
Editing

Page | 5
TECHNICAL WORKING GROUP
Marilou L. Madrid, RND, MSc
Senior Science Research Specialist
NFRDD, DOST-FNRI
Ruby D. Frane, RND, MSc
Senior Science Research Specialist
NFRDD, DOST-FNRI
Hazel T. Lat, RND, MSc
Science Research Specialist I
NFRDD, DOST-FNRI
David Kenneth C. Mendoza, RND, MSc
Science Research Specialist I
NFRDD, DOST-FNRI
Merlyn G. Tajan, MPS-FNP
Science Research Specialist II
NFRDD, DOST-FNRI
CELESTE C. TANCHOCO, Dr. PH
Scientific Country Coordinator
International Life Science Institute
South-East Asia Region (ILSI-SEAR)

Page | 6
Contents
Page Page
Foreword Part 3: Application of Nutrition Care Process in Management
of Kidney Diseases
Acknowledgement Nutrition Care Process
Renal Exchange Lists Committee Nutrition Assessment
Technical Committee/Consultant Nutrition Diagnosis
External Reviewers Nutrition Intervention
Table of Contents Nutrition Monitoring and Evaluation
List of Tables Application of NCP in the Management of Kidney Diseases
List of Figures How to Use the Food Exchange List for Kidney Diseases
List of Abbreviation Part 4: Renal Food Exchange Lists
List of Acronyms Introduction of Renal Food Exchange Lists
List of Appendices The Food Exchange List for Kidney Disease
Glossary Composition of the Renal Food Exchanges
Part 1: Introduction Meat Exchange
Overview of the Kidneys and Renal Diseases Milk Exchange
Goals and Principles of Nutritional Management Rice Exchange
Part 2: Dietary Management of Kidney Disease Vegetable Exchange
Acute Kidney Injury Fruit Exchange
Nephrotic Syndrome Fat Exchange
Chronic Kidney Disease Sugar Exchange
Kidney Transplantation Free Foods
Selected Food List
Part 5: Dietary Guide for Kidney Patients during Emergency
and Disaster
LIST OF TABLES
Table Title Page Table Title Page
Table 1.1 The KDIGO, AKIN and ADQI (RIFLE)
Classification System of AKI
Table 4.2 Composition of Milk Exchanges
Table 1.2 Prognosis of CKD (GFR and Albuminuria
Categories: KDIGO 2012)
Table 4.2.1 Milk
Table 2.1 Classification of AKI and their specific
causes and nutrition relevance
Table 4.3 Composition of Rice Exchanges
Table 2.2 Nutrient Recommendations per day for AKI Table 4.3.1 Rice A
Table 2.3 Nutrient Recommendations per day for NS Table 4.3.2 Rice B
Table 2.4 Nutrient Recommendations per day for
CKD
Table 4.3.3 Rice C
Acute Post-Transplant Period
Table 4.4 Composition of Rice Exchanges

Page | 7
Chronic Post-Transplant Period
Table 4.4.1 Vegetable A
Table 2.7 Summary Dietary Recommendations for
Selected Renal Diseases
Table 4.4.2 Vegetable B
Table 3 Nutrition Assessment, Domains and
Sample Data
Table 4.5 Composition of Fruit Exchanges
Table 3.1 Nutrition Diagnosis, Domains and
Description
Table 4.5.1 Fruit A
Table 3.2 Nutrition Intervention Strategies Table 4.5.2 Fruit B
Table 3.3 Nutrition Monitoring and Evaluation Table 4.6 Composition of Fat Exchanges
Table 3.4 Distribution of exchanges per meal Table 4.6.1 Fat A
Table 3.5 Sample Meal Plan Table 4.6.2 Fat B
Table 3.6 Dietary Evaluation Sheet Table 4.7 Composition of Sugar Exchanges
Table 4 Composition of the Food Exchange Lists in
Kidney Disease
Table 4.7.1 Sugar
Table 4.1 Composition of Meat Exchanges Table 4.8 Free Foods
Table 4.1.1 Meat A Table 4.9 Selected Food Lists
Table 4.1.2 Meat B Other Forms of sodium
Table 4.1.3 Meat C
LIST OF FIGURES
Figure Title Page
Figure 1 The Kidneys
Figure 1.1 Illustration of Functions of the Kidneys
Figure 1.2 Etiology of PEW
Figure 2 Decision tree for nutritional support
Figure 2.1 Consequences of Nephrotic Syndrome

Page | 8
LIST OF ABBREVIATIONS
aBWef Adjusted edema free body weight
Ca Calcium
CHO Carbohydrate
Fl oz Fluid ounce
g/day Gram per day
Hct Hematocrit
g/L Gram per liter
Hgb Hemoglobin
Ht Height
Hx History
K Potassium
kcal Kilocalorie
kg Kilogram
mg/dL Milligram per deciliter
mmol/L Millimoles/liter
Na Sodium
n/a Not applicable
Oz Ounce
P Phosphorus
pc/pcs Piece/pieces
RBS Random Blood Sugar
SCrea Serum creatinine
Tbsp Tablespoon
Tsp teaspoon
Wt Weight
LIST OF ACRONYMS
ABW Actual Body Weight
Adj BW Adjusted Body Weight
ADQI Acute Dialysis Quality Initiative
AKI Acute Kidney Injury
AKIN Acute Kidney Injury Network
BMI Body Mass Index
BUN Blood Urea Nitrogen
CBW Corrected Body Weight
CDRR Chronic Disease Risk Reduction
CHF Congestive Heart Failure
CKD Chronic Kidney Disease
CRRT Continuous Renal Replacement Therapy

Page | 9
CT Computed Tomography
DBW Desirable Body Weight
DM Diabetes Mellitus
EDTNA/ERCA European Dialysis and Transplant Nurses Association/European Renal Care Association
EN Enteral Nutrition
EAA Essential Amino Acids
ESA Erythropoiesis- Stimulating Agents
ESPEN European Society for Parenteral and Enteral Nutrition
ESRD End-Stage Renal Disease
FSGS Focal segmental glomerulosclerosis
GFR Glomerular Filtration Rate
HBV High Biologic Value
HD Hemodialysis
IBW Ideal Body Weight
IHD Intermittent Hemodialysis
KA Keto-analogues
KDIGO Kidney Disease: Improving Global Outcomes
KDOQI Kidney Disease Outcomes Quality Initiative
LBV Low Biologic Value
LDL Low Density Lipoprotein
MNT Medical Nutrition Therapy
MRI Magnetic Resonance Imaging
MUAC Mid-Upper Arm Circumference
NCP Nutritional Care Process
NNS National Nutrition Survey
NODAT New Onset Diabetes After Transplantation
NPC Non- Protein Calories
NS Nephrotic Syndrome
ONS Oral Nutrition Supplement
PD Peritoneal dialysis
PDRI Philippine Dietary Reference Intakes
PEM Protein Energy Malnutrition
PEW Protein Energy Wasting
PKD Polycystic Kidney Disease
PN Parenteral Nutrition
PTH Parathyroid Hormone
RBC Red Blood Cell
RIFLE Risk, Injury, Failure, Loss, End-Stage Renal Disease
RND Registered Nutritionist-Dietitian
RRT Renal Replacement Therapy
SLE Systemic lupus erythematosus
TER Total Energy Requirement
VLDL Very Low-Density Lipoprotein

Page | 10
VLDP Very Low Protein Diet
WHO World Health Organization
GLOSSARY
Acute kidney injury (AKI) Any sudden severe impairment of kidney function or short duration of kidney dysfunction.
Acidosis A build-up of acid in the bloodstream.
Albuminuria Presence of albumin in the urine
Amyloidosis
The name for a group of rare, serious conditions caused by a build-up of an abnormal
protein called amyloid in organs and tissues throughout the body. The build-up of amyloid
proteins (deposits) can make it difficult for the organs and tissues to work properly.
Amino acid The building blocks of proteins.
Anthropometry The science of obtaining systematic measurements of the human body.
Ascites
It refers to accumulation of fluid in the peritoneal cavity, causing abdominal swelling.
Atherosclerosis
A disease in which plaque builds up inside your arteries.
Atherogenic lipoproteins
It is characterized by a predominance of atherogenic lipoproteins, namely very low density
(VLDL), intermediate density IDL1, and IDL2, and particularly by the presence of small
dense lipoproteins with low density (LDL).
Artificial Nutrition The delivery of nutrition via enteral feeding or parenteral feeding.
Anuria Characterized by reduced urine output (<100 mL urine per day), reflecting renal injury.
Atherogenic lipoprotein Lipoproteins that have the tendency to promote the formation of fatty plaques in the arteries.
Autoimmune disease
It is an illness that causes the immune system to produce antibodies that attack normal body
tissues.
Blood Urea Nitrogen
(BUN)
A test measures the amount of nitrogen in the blood that comes from the waste
product urea.
Bladder rupture
It is most commonly due to abdominal and/or pelvic trauma but may be spontaneous or
iatrogenic in association with surgical or endoscopic procedures.
Bone disease It is a condition that damages the skeleton and makes bones weak and prone to fractures.
Bone resorption A process whereby osteoclasts destroy an area of bone as the first step in bone remodeling
Calcitriol The active form of vitamin D, normally made in the kidney.
Cancer
Genetic disease—that is, it is caused by changes to genes that control the way our cells
function, especially how they grow and divide.
Catabolism
A metabolic pathway that breaks down molecules into smaller units that are either oxidized
to release energy or used in other anabolic reactions. It is the breaking down aspect of
metabolism.
Cardiac arrhythmias
It refers to a group of conditions that cause the heart to beat irregular, too slowly, or too
quickly.
Cardiovascular disease
It generally referring to conditions that involve narrowed or blocked blood vessels that can
lead to heart attack, chest pain or stroke.

Page | 11
Cholecalciferol
It is also known as vitamin D3 and a type of vitamin D which is made by the skin when
exposed to sunlight.
Chronic Kidney Disease
(CKD)
Abnormalities of kidney structure or function with an estimated GFR of less than 60
mL/min/1.73 m2 for longer than 3 months.
Chronic Kidney Disease
(CKD – MBD)
A systemic disorder of mineral and bone metabolism due to CKD manifested or the
combination of the abnormalities of calcium, phosphorus, PTH or vitamin D metabolism.
Clinical outcomes It is a measurable change in health, function or quality of life that results from medical care.
Clotting Disorder
There is an increased tendency for excessive blood clotting. It can be due to inherited
genetic abnormalities that are associated with a life-long increased tendency to clot.
Comorbidities A state of having multiple medical conditions at the same time.
Congenital
diseases/disorder
An abnormality of structure or function in a person that is present at or before birth. Also
referred to as birth defects and can be acquired during the fetal stage of development or
from the genetic make-up of the parents (e.g. neural tube defects).
Continuous renal
replacement therapy
(CRRT)
A dialysis treatment modality that is provided continuously 24 hours per day at a slow and
steady rate.
Convulsions
A medical condition where body muscles contract and relax rapidly and repeatedly, resulting
in uncontrolled actions of the body.
Corticosteroids
A group of steroid hormones used to treat inflammation.
Creatinine
The waste product of creatine. A nitrogen-containing compound in muscle cells that supplies
energy for muscle contraction.
Critical illness A life-threatening condition.
Cyclosporine
Immunosuppression
It is an immunosuppressive drug that was first used to help prevent rejection in organ
transplant patients.
Cystic Disease/Renal
cystic disease
Multiple diseases and conditions that deal with cysts that develops around the kidneys.
Deceased donor
A person who has been declared dead and whose organs/or tissues have been donated for
transplantation.
Dehydration The condition when the amount of water in the body has dropped too low.
Diabetes Mellitus
A metabolic disease characterized by elevated blood glucose and inadequate or ineffective
insulin, which impair a person's ability to regulate blood glucose.
Dialysate
The fluid that is used during dialysis procedure to assist in the removal of metabolic by-
products, wastes, and toxins; composition is determined by individual patient requirements.
Dialysis
Renal replacement procedure that removes excess and toxic by-products of metabolism
from the blood, thus replacing the filtering function of healthy kidneys.
Diuretics
An agent that act on the kidneys to increase the excretion of water and sodium, thereby
diminishing blood pressure by reducing the volume of fluid in the vascular system.

Page | 12
Dry weight Weight after a hemodialysis session has removed all extra fluid from the body
Dyslipidemia
An abnormal amount of lipids (e.g. triglycerides, cholesterol and/or fat phospholipids) in the
blood.
Edema
Medical term for soft-tissue swelling that results from the abnormal accumulation of
interstitial fluid.
Electrolytes
Are minerals and compounds (such as sodium, potassium, chloride, and calcium) present on
the blood that helps regulates the proper balance of the body fluids.
Encephalopathy A term that means brain disease, damage, or malfunction.
End-stage renal disease
(ESRD)
The last stage of CKD requiring renal replacement therapy.
Enteral Feeding The delivery of nutrition via nasogastric or gastrostomy feeding
Etiology The cause, set of causes, or manner of causation of a disease or condition.
Essential Amino Acids
(EAA)
An amino acid that cannot be synthesized de novo (from scratch) by the organism at a rate
commensurate with its demand, and thus must be supplied in its diet.
Fasting Blood Sugar
(FBS)
A test to determine how much glucose (sugar) is in a blood sample after an overnight fast.
The fasting blood glucose test is commonly used to detect diabetes mellitus.
Fluid retention
A condition when there is a problem with one or more of the body’s mechanisms for
maintaining fluid levels.
Focal segmental
glomerulosclerosis
(FSGS)
A disease in which scar tissue develops on the parts of the kidneys that filter waste from the
blood (glomeruli).
Food -borne infection An infection caused by consuming contaminated food and drink
Genetic Disease It is a health problem caused by one or more abnormalities in the genome.
Glomerular Filtration
Rate (GFR)
A measure that estimates how much blood passes through the glomeruli each minute.
Glomeruli/
Glomerulus
A network of thin-walled capillaries closely surrounded by a pear-shaped epithelial
membrane called the Bowman’s capsule (within the kidney) where filtration occurs.
Glomerulonephritis
Inflammation of the glomeruli, which are structures in the kidneys that are made up of tiny
blood vessels. These knots of vessels help filter your blood and remove excess fluids.
Glomerulosclerosis
Refers to scarring or hardening of the glomeruli -- blood vessels located in the kidneys.
Glycemic Index
The ranking of carbohydrate in foods according to how they affect blood glucose levels.
Carbohydrates with a low GI value (55 or less) are more slowly digested, absorbed and
metabolized and cause a lower and slower rise in blood glucose and, therefore usually,
insulin levels.

Page | 13
Graft function Refers to the function of the transplanted kidney
Hematuria The presence of blood in the urine.
Hematocrit The ratio of the volume of red blood cells to the total volume of blood.
Hemodialysis Treatment to filter wastes and extra water from your blood. A machine pumps your blood
through a filter outside of your body and returns filtered blood to your body.
Hemoglobin
A protein in your red blood cells that carries oxygen to your body's organs and tissues and
transports carbon dioxide from your organs and tissues back to your lungs.
Hemorrhage An acute loss of blood from a damaged blood vessel.
Hyperaldosteronism
A disease in which the adrenal gland(s) make too much aldosterone which leads to
hypertension (high blood pressure) and low blood potassium levels.
Hypercalcemia Elevated serum calcium levels.
Hyperglycemia High levels of sugar/glucose in the blood.
Hyperkalemia Elevated serum potassium levels
Hyperlipidemia Higher than normal fat and cholesterol levels in the blood
Hypermagnesemia
An electrolyte disorder in which there is a high level of magnesium in the blood. Symptoms
include weakness, confusion, decreased breathing rate, and decreased reflexes.
Hyperparathyroidism
A condition in which one or more of the parathyroid glands become overactive and secrete
too much parathyroid hormone (PTH).
Hyperphosphatemia Elevated serum phosphate levels
Hypertension
It is also known as high or raised blood pressure, is a condition in which the blood vessels
have persistently raised pressure.
Hypertriglyceridemia
Elevated levels of triglycerides are associated with atherosclerosis, even in the absence of
hypercholesterolemia (high cholesterol levels), and predispose to cardiovascular disease.
Hypervolemia
Also known as fluid overload, is the medical condition where there is too much fluid in the
blood.
Hypoalbuminemia Low levels of albumin in the blood
Hypocalcemia
A condition in which there are lower-than-average levels of calcium in the liquid part of the
blood, or the plasma.
Hypoglycemia A condition in which your blood sugar (glucose) level is lower than normal.
Hypokalemia Low serum potassium levels.
Hypophosphatemia An electrolyte disorder in which there is a low level of phosphate in the blood.
Hypotension The term for low blood pressure (less than 90/60)
Immune-suppressive
medications/therapy
A drug treatment used to overcome immunologic barriers to transplantation and prevent
allograft rejection.
Insulin Resistance The diminished ability of cells to respond to the action of insulin in transporting glucose from
the bloodstream into muscle and other tissues.
Intermittent hemodialysis
(IHD) A dialysis treatment modality that removes large amounts of water and wastes on intervals,

Page | 14
usually 2-3 times per week.
Kidney Transplantation
A surgical procedure to place a healthy kidney from a living or deceased donor into a person
with ESRD or whose kidneys no longer function properly.
Living donor A person who is alive who donated an organ for transplantation.
Minimal Change Disease
(MCD)
A disease characterized by intense proteinuria leading to edema and intravascular volume
depletion. It Is a major cause of idiopathic nephrotic syndrome.
Macronutrients
Nutrients that provide calories or energy and are required in large amounts to maintain body
functions and carry out the activities of daily life (e.g CHO. Protein and Fats)
Medical Nutrition Therapy
(MNT)
An evidence-based medical approach to treating certain chronic conditions through the use
of and individually-tailored nutrition plan.
Membranous
Nephropathy
A disorder where the body's immune system attacks the filtering membranes in the kidney.
Metabolic Acidosis
A serious electrolyte disorder characterized by an imbalance in the body’s acid-base
balance.
Micronutrients
Vitamins and minerals that are required in minute amounts which are essential for a number
of different functions, including growth and development.
Nausea It is a feeling of sickness or discomfort in the stomach that may come with an urge to vomit.
Negative nitrogen
balance
It occurs when nitrogen losses are greater than nitrogen intake. It reflects a catabolic state.
Nephron
Basic functional unit of the normal kidney. Each nephron has two main parts: the glomerulus
and the tubule
Nephrotic Syndrome A syndrome that is caused by significant urinary protein loss (proteinuria) that results from
severe damage to the glomerular or filtering unit in the kidneys.
New Onset Diabetes
After Transplantation
(NODAT)
The occurrence of diabetes mellitus (DM) in a previously non-diabetic person after solid
organ transplantation.
Nutritional status The status of a person’s health in term of the nutrients in his or her diet.
Oliguria
Daily urine output of <500 mL, which is the minimum amount of normal urine that can carry
away the daily load of metabolic waste products.
Oral Nutrition Support
(ONS)
Are sterile liquids, semi-solids or powders, which provide macro and micro nutrients. They
are widely used within the acute and community health settings for individuals who are
unable to meet their nutritional requirements through oral diet alone.
Organ transplantation
A definitive treatment options for patient with end-organ dysfunction. Organs for
transplantation include heart, kidney, lung, liver, and pancreas.
Osteoporosis A medical condition in which the bones become brittle and fragile.

Page | 15
Oxidative stress
An imbalance of free radicals and antioxidants in the body, which can lead to cell and tissue
damage.
Parenteral Nutrition The delivery of nutrition via intravenous feeding.
Pericarditis
Inflammation of the pericardium, two thin layers of a sac-like tissue that surround the heart,
hold it in place and help it work.
Peritoneal dialysis
A type of dialysis that use the lining of your belly to filter wastes and extra fluid from your
body. This dialysis treatment that can be done at home.
Peritonitis An inflammation of the peritoneal membrane
Platelet count
A lab test to measure how many platelets you have in your blood. Platelets are parts of the
blood that helps the blood clot. They are smaller than red or white blood cells.
Polycystic kidney disease
(PKD)
An inherited disorder in which clusters of cysts develop primarily within your kidneys,
causing your kidneys to enlarge and lose function over time.
Positive nitrogen balance The nitrogen intake is more than nitrogen loss. It reflects an anabolic state.
Post-renal (obstructive)
acute kidney injury
Kidney injury related to obstruction of urine flow.
Potassium sparing
diuretics
It refers to drugs that cause diuresis without causing potassium loss in the urine and leading
to hyperkalemia.
Pre-renal acute kidney
injury
Kidney injury resulting from decreased blood flow to the kidney (i.e. ischemic damage)
Proteinuria The presence of protein in the urine.
Protein Energy Wasting
(PEW)
Defined as reduced somatic and/or circulating body protein mass, decreased fat mass, and
usually reduced protein and energy intake.
Refeeding Syndrome
It is defined as the potentially fatal shifts in fluids and electrolytes that may occur in
malnourished patients when feeding (oral, enteral or parenteral nutrition) is begun too
aggressively after a period of inadequate nutrition.
Renal Replacement
Therapy (RRT)
Therapy that replaces the normal blood-filtering function of the kidneys.
Renal Osteodystrophy
A term used to describe the many different patterns of the skeletal abnormalities that occur
in patients with kidney disease.
Renin
An enzyme secreted by and stored in the kidneys which promotes the production of the
protein angiotensin.
Saturated Fat
A fat that contains only saturated fatty acids, is solid at room temperature, and comes chiefly
from animal food products.

Page | 16
Sepsis A potentially life-threatening condition caused by the body's response to an infection. The
body normally releases chemicals into the bloodstream to fight an infection.
Strictures An abnormal narrowing of a body passage, especially a tube or a canal.
Systemic Inflammation
The presence of systemic proinflammatory cell stress products—cytokines and other
inflammatory mediators in plasma. It can contribute to the development or progression of
certain conditions.
Systemic lupus
erythematosus (SLE)
An autoimmune disease. In this disease, the immune system of the body mistakenly attacks
healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs.
Tubulointerstitial
diseases
Disorders that are clinically heterogeneous that share similar features of tubular and
interstitial injury. In severe and prolonged cases, the entire kidney may become involved,
with glomerular dysfunction and even renal failure.
Trauma An emotional response to a terrible event (e.g. accident)
Tumor
An abnormal mass of tissue that forms when cells grow and divide more than they should or
do not die when they should. Tumors may be benign (not cancer) or malignant (cancer).
Uremia (uremic
syndrome)
A general term used to encompass a cluster of symptoms resulting from disordered
biochemical processes as chronic kidney disease progresses; early symptoms include
fatigue, delayed thinking, and pruritis
Urinary tract obstruction
The blockage that inhibits the flow of urine through its normal path (urinary tract), including
the kidneys, ureters, bladder, and urethra.
Vascular Disease
Any abnormal condition of the blood vessels caused by inflammation and weakness of the
veins and arteries, usually due to the build-up of fatty deposits in the blood vessels.
Ventilator failure
The inability of the respiratory system to function effectively as a pump normally able to
oxygenate arterial blood and eliminate carbon dioxide from the body.
Volume overload
The expansion of the extracellular fluid (ECF) volume. ECF volume expansion typically
occurs in heart failure, kidney failure, nephrotic syndrome, and cirrhosis.
Vomiting
It is clinically defined as the oral eviction of gastrointestinal contents due to contractions of
the gut and the muscles of the thoracoabdominal wall.

Page | 18
INTRODUCTION
Overview of the kidneys
The kidneys are a pair of two bean-shaped organs. Its size is about 12.7-centimeter-long and 7.62-centimeter-
wide and one-inch thick located below the ribs at the back of each side of the spine. Each kidney has about 1 million
nephrons. The nephrons are basic units where the filtering of extra fluids and dissolved particles occurs. Aside from
filtering extra fluids, producing urine, and excreting waste products (e.g., urea, uric acid, creatinine, ammonia,
sulfates), the kidneys have other important functions in the body.
Functions of the kidneys
 Excretion of metabolic waste and toxicants in the
urine
 Regulation of fluid and electrolyte balance
 Regulation of acid-base balance
 Reabsorption of glucose and amino acid
 Synthesis and secretion of hormones such as:
- release of renin, that help regulates blood
pressure
- make erythropoietin which aids in the
formation of red blood cells (RBC)
- convert vitamin D (cholecalciferol) into
its active form (calcitriol also known as
1, 25-dihydroxycholecalciferol) to help regulate
calcium balance and bone formation
Figure 1.1. Illustration of kidney functions
Figure 1. The Kidneys

Page | 19
Causes of kidney failure
In most cases, kidney failure is caused by other health problems that have done permanent damage to the
kidneys slowly over time.
The kidneys may experience a sudden loss of kidney function which may last a few days or weeks. This type
of kidney failure is called acute kidney injury (AKI). AKI is often associated with acute illness caused by an event that
leads to kidney malfunctions, such as dehydration, blood loss from major surgery or injury, and some medications
particularly, the triple combination of non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme
inhibitors (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and diuretics by interfering with homeostatic
mechanisms (Fournier et al., 2012).
However, when the damage to the kidneys continues to get worse for extended period of time, for three (3)
months or longer, this kidney failure can lead to chronic kidney disease (CKD). Diabetes and high blood pressures are
the two most common causes of CKD.
Furthermore, as CKD reaches an advanced state where the kidneys lost their filtering capabilities, dangerous
levels of fluid, electrolytes and wastes accumulate in the tissues and blood, causing uremia– a term used to
encompass a cluster of symptoms resulting from disordered biochemical processes as CKD progresses. This type of
kidney failure is the end- stage renal disease (ESRD).
Other problems that can cause kidney failure include:
 Autoimmune diseases, such as lupus and IgA nephropathy
 Genetic diseases (a person is born with a disease), such as polycystic kidney disease
 Urinary tract problems
 Urinary tract obstruction

Page | 20
Stages of AKI and CKD
The stages of AKI are defined using any of the three (3) main classification systems based on urine output
and serum creatinine (Scr) concentration. However, most clinicians used KDIGO classification system to define
the AKI.
Table 1.1 Classification systems of AKI based on urine output and Serum Creatinine (Scr)
Source: 1
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group, 2012
2
Bellomo R, Ronco C, Kellum JA et al. Palevsky P and the workgroups Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care, 2004
3
Mehta RL, Kellum JA, Shah SV et al. Acute Kidney Injury Network, 2007.
AKI Stage Urine Output KDIGO 1
AKIN 2
RIFLE 3
1 <0.5 mL/kg/h for 6 h Scr : 1.5-1.9 x baseline over
7 d Or 0.3 mg/dL absolute
increase over 48 h
Scr :>1.5-2 x baseline
Or 0.3 mg/dL absolute Scr
increase within 48 h
Risk: Scr to 1.5 x increases
within 7 d, sustained for  24 h
UO >25% decrease in GFR
2 <0.5 mL/kg/h for 12 h Scr : 2.0-2.9 x baseline Scr : >2-3 x baseline Injury: Scr to 2 x increases in
sCr or
3 <0.3 mL/kg/h for 24 h
or anuria for  12 h
Scr to 3.0 x baseline, or
Scr increase to 4.0 mg/dL
Scr to >3.0 x baseline, or
Scr increase to 4.0 mg/dL (with
increase of 0.5 mg/dL) or initiation
of RRT
Failure: Scr to  3.0 x increase or
Scr increase to  4.0 mg/dL
(with increase of 0.5 mg/dL)
4 Loss: Complete loss of kidney
function for >4 wk
5 ESRD e
: ESRD for >3 mo

Page | 21
Moreover, the staging of CKD is defined using the classification framework based on GFR stages (G1-G5) and
albuminuria (A1-A3) as shown in Table 1.2.
Table 1.2 Prognosis of CKD (GFR and Albuminuria Categories)
GFR Categories
(ml/min/1.73 m2)
Persistent albuminuria categories
Description and range
A1 A2 A3
Normal to mildly increased Moderately increased Severely increased
Description and range GFR <30 mg/g
<3 mg/mmol
30-300 mg/g
3-30 mg/mmol
>300 mg/g
>30 mg/mmol
G1 Normal or high ≥ 90
G2 Mildly decreased 60 – 89
G3a Mildly to moderately
decreased
45 – 59
G3b Moderately to severely
decreased
30 – 44
G4 Severely decreased 15 – 29
G5 Kidney Failure < 15
Green: low risk, Yellow: moderately increased risk, Orange: high risk, Red: very high risk
Source: Levin, A. & Stevens, P.E. (2014). Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework
for moving forward. Kidney International 85(1):49-61.

Page | 22
Protein energy wasting (PEW)
The pathogenesis of PEW in patients with kidney disease is
brought about by multitude of factors such as metabolic and
hormonal derangements, systemic inflammation, co-morbid
conditions, loss of appetite, and catabolic effects of RRT. PEW
is common in patients with CKD and ESRD and is associated
with poor clinical outcomes (Ikizler et al., 2013; Sarav &
Kovesdy, 2018).
Figure 1.2 Etiology of PEW in CKD
Source: Carrero, et al. (2013). Etiology of the Protein-Energy Wasting
Syndrome in Chronic Kidney Disease: A Consensus Statement
from the International Society of Renal Nutrition and Metabolism
(ISRNM). J. Ren. Nutr. 23(2):77-90
https://doi.org/10.1053/j.jrn2013.01.001.

Page | 23
Protein Catabolism
Protein catabolism is the metabolic hallmark of AKI. The protein catabolic state of critically ill patients with AKI
is multifactorial. The effect of catabolism increases the protein turnover rate and negative nitrogen balance results. In
most cases, this catabolic state cannot simply overcome by increasing protein intake, although this may reduce
nitrogen losses (Druml, 2005; Patel et al., 2017). A positive nitrogen balance is achieved only until the patient’s
underlying illness is reversed and all acute inflammatory processes are controlled (Sarav & Kovesdy, 2018).
AKI in the non-catabolic state is commonly found in patients with following conditions:
 Dehydration
 Intake of certain medications
 Urinary obstruction
 AKI stages 1 and 2 and patients with a pre-renal and post-renal injury (pls. refer to page 39)
AKI in the catabolic state on the other hand, is commonly found in patients with:
 Sepsis, acidosis, trauma, multi-organ failure, and critical illness
 AKI stages 2 and 3 and patients with intrinsic renal injury (pls. refer to page 39)
 RRT treatment
 Usually requiring nutrition enteral (EN) or parenteral nutrition (PN).

Page | 24
Renal replacement therapy (RRT) is the process of supporting renal function through the application of
intermittent or continuous extracorporeal (hemodialysis) or paracorporeal (peritoneal dialysis) methods. RRT is a
modality treatment for patients requiring dialysis (Fleming, 2011).
In hemodialysis (HD), the patient’s blood is
cleansed through a machine that filters away
waste products. The clean blood is returned to
the body. Hemodialysis is usually performed at a
dialysis center three times per week for 3 to 4
hours.
During hemodialysis, there is 10-12 g amino
acid loss per dialysis session (Stegmayr, 2017;
Liu et al., 2016; Navarro et al., 2000; Cano et al.,
2009; Fouque 2003; Ikizler et al., 1994).
Diagram from Circle medical management, 2020.
In peritoneal dialysis (PD), a fluid (the dialysate) is infused from
a plastic container into the abdomen using a surgically implanted catheter.
It uses the inner lining of the belly (peritoneum) as filter to clean the blood.
There are two types of PD, the most common is the continuous
ambulatory peritoneal dialysis (CAPD), which change dialysate four times
a day. Another form of PD is the continuous cycling peritoneal dialysis
(CCPD) which can be performed at night with a machine that drains and
refills the abdomen automatically.
During peritoneal dialysis, there is 5-15 g amino acid loss per
dialysis session (Tjiong, et al., 2007; Unverdi, et al., 2014; Ikizler et
al., 1994).
Protein requirements in PD are higher than for HD due to increased
losses during dialysis (Wolfson,1999; Bukart, 2004). However, much
higher of protein is required during episodes of peritonitis because protein
losses can increase by 50% or more (Burkart, 2004).
Diagram from National Kidney and Urologic Diseases Information Clearinghouse, National
Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, USA.

Page | 25
GOALS AND PRINCIPLES OF NUTRITIONAL MANAGEMENT OF KIDNEY DISEASE
The nutritional management of kidney disease is intended to slowdown the build-up of metabolic
waste products in the bloodstream to help control symptoms of fluid retention, edema, nausea, and vomiting.
The recommended amounts of macronutrients and other dietary components depend on many factors. In
general, dietary modification aims to:
 Reduce workload of the kidneys
 Delay progression of the disease
 Minimize uremic symptoms
 Maintain or improve nutritional status
Most diseases have only one or two dietary components to be controlled, whereas in kidney disorder several
nutrients must be carefully examined, and simultaneously regulated when planning meals. The key nutrients that are
regulated include: protein, sodium, potassium, calcium, phosphorus as well as fluids.

Page | 26
Proteins are substances found in all living cells, which are essential to proper growth and maintenance.
Proteins are an important part of the human diet with an essential role as a major structural and functional component
of living systems. Proteins are composed of amino acids linked together by peptide bonds. There are two types of
amino acids:
 Essential amino acids - are amino acids that cannot be synthesized by the body and therefore must be
supplied in the diet. Good dietary sources include meat, eggs, milk, dairy products, soybean, tofu.
 Non-essential amino acids – are amino acids that can be synthesized by the body from carbon and nitrogen
donors.
Amount of dietary protein needed
The specific amount of dietary protein requirement is determined by several factors such as body composition,
weight, physical activity level, presence of illness/injury, by the extent of hypercatabolism and losses during dialysis.
The protein requirement may be as follows:
 Very low protein (0.3 -0.4 g/kg/BW) (KDOQI, 2020)
 Low protein (0.6 g/kg/BW) (Kalantar-Zadeh, 2017)
 Normal protein (0.8 - 1.0 g/kg/BW) (Byham-Gray, et al., 2013)
 High protein (1.2 - 2.8 g/kg/BW) (Ikizler, 2013)

Page | 27
End-products of protein metabolism
The primary end products of protein metabolism
include nitrogenous compounds, such as urea, uric acid as
well as sulfate, creatinine, organic acids, carbon dioxide, and
water, which is usually excreted by the kidneys in the urine.
Protein Quality
Biological value refers to how well and how quickly the
body can use the protein. High biological value
(HBV) ensure better utilization of protein in the body as
compared to Low biological value (LBV) proteins.
At least >50% HBV must be consumed for an adequate
supply of essential amino acids (National Kidney
Foundation KDOQI, 2000).
However, since the dietary pattern of Filipinos is largely
derived from rice-based diet and that the average
consumption of protein of Filipinos is only around 12.5% of the
total calories (NNS, 2013), local nutrition expert recommends,
>60-70% protein of HBV should be consumed in the diet.
In addition, rice has lower limiting amino acids.
Among the cereals, the quality of protein in rice is at 7%
(Hoogenkamp et al., 2016).
HBV LBV
 With complete
protein as they
contain all the
essential amino acids
Example:
Animal sources like
meat, seafood, fish,
poultry, eggs and
milk.
 With incomplete or
partially complete
proteins
Example:
Legumes, nuts, seeds,
and cereal grains are
good sources of plant
proteins

Page | 28
Sodium is the main mineral outside of the cell. Sodium is vital in the maintenance of extracellular volume and blood
pressure. When kidneys are impaired, there is a reduction in the amount of sodium that can be excreted; thus, it starts to
build up in the blood. Since sodium attracts and holds water, the blood volume increases, which makes the heart work harder
and increases the pressure in the arteries (Grillo et al., 2019).
Why there is a need to reduce dietary sodium intake?
 To prevent and control edema and hypertension (Byham-Gray, 2008).
 To prevent worsening of proteinuria (Kopple et al., 2013).
 To avoid too much fluid to be removed in dialysis (Sanders, 2007).
The recommended amount of sodium in the diet
The World Health Organization (WHO) recommends daily sodium intake of less than 2000 mg, or equivalent to 5 g or
½ Tbsp of table salt per day. Evidence has shown the relationship between sodium intake and blood pressure and its
potential adverse effects on renal functions.

Page | 29
Table Salt
“Table salt" is the term commonly used
for sodium chloride (NaCl). Table salt is 40%
sodium and 60% chloride. One teaspoon of
table salt contains about 2,000 mg of sodium.
Sodium-containing compounds in processed
foods
*Monosodium glutamate (MSG)
*Baking soda (also called sodium bicarbonate)
*Baking powder
*Disodium phosphate
*Sodium alginate
*Sodium citrate
*Sodium nitrite
Common sodium claims and what they really mean:
Sodium-free or salt-
free
Each serving in this product
contains less than 5 mg of
sodium.
Very low sodium
Each serving contains 35 mg
of sodium or less.
Low sodium
Each serving contains 140
mg of sodium or less.
Reduced or less
sodium
The product contains at least
25% less sodium than the
regular version.
Lite or light in sodium
The sodium content has been
reduced by at least 50% from
the regular version.
Unsalted or no salt
added
No salt is added during
processing of a food that
normally contains salt.
However, some foods with
these labels may still be high
in sodium because some of
the ingredients may be high
in sodium

Page | 30
Potassium is an essential constituent of all living cells. It is a mineral that controls nerve and muscle function and
maintains the normal rhythm of the heart. Potassium is also necessary for maintaining fluid and electrolyte balance and pH
levels.
Healthy kidneys help keep potassium at a normal level by removing excess potassium in the urine. However, when
kidneys are not functioning properly or impaired, potassium levels in the blood may rise. Among the effects of high levels of
potassium in the blood are nausea, headache, weakness and numbness and, slow pulse.
Patients with AKI commonly develop hyperkalemia because of reduced kidney clearance, acidosis, and
gastrointestinal losses (Gervasio et al, 2011). While those receiving RRT often experienced hypokalemia, which can
increase the risk of heart diseases. Hypokalemia can be managed by adjustment of the dialysis prescription by the physician
or administration of oral potassium supplement or through intravenous replacement.
For CKD patients on dialysis, the potassium levels may rise in between dialysis treatments. Likewise, serum
potassium levels may also be elevated in transplanted patients. This is due to poor graft function, as well as impaired
potassium excretion associated with cyclosporine immunosuppression and potassium-sparing diuretics (Byham-Gray,
2014).
In the case of nephrotic syndrome, potassium level should be monitored because it may increase potassium and
magnesium losses due to secondary hyperaldosteronism, potassium-wasting diuretics and steroids may require
replacement. In such cases, dietary potassium may be needed. Though, generally, there is no modification for potassium
(NKF, 2009).
A low potassium diet is recommended if serum potassium levels are high. For patients in need of additional
potassium, exogenous sources of potassium (e.g. high potassium-rich foods, in tablet form or IV infusion) can correct serum
potassium levels (Pistolesi et al., 2019).

Page | 31
Phosphorus is the second most abundant mineral with the majority found in the skeleton where it plays a structural
role. The rest is found in the extracellular fluids.
Phosphate retention occurs with a decline in renal function. The phosphate builds up in the body and binds the
calcium, which in turn lowers the calcium levels in the body. When the calcium levels get too low, the parathyroid glands pull
the extra calcium out of the bones, thus making the bones weak. The bound phosphate and calcium then get deposited in
the blood vessels causing an increase in the risk of developing heart disease and stroke (Kidney Health Australia, 2020).
Among patients with AKI on prolonged RRT, hypophosphatemia and hypomagnesemia can frequently be observed
and should be anticipated (Pistolesi et al., 2019). These can lead to respiratory muscle weakness and phosphate depletion,
ventilator failure, myocardial dysfunction, and encephalopathy (Downs, 2014).
CKD patients not requiring dialysis may need to restrict phosphate intake. In the later stages of CKD, the level of
phosphate in the blood may reach higher than 5 mg/dL. In such cases, the use of phosphate binder is recommended.
Phosphate binders are used to reduce positive phosphate balance to lower serum phosphate levels preventing the
progression to chronic kidney disease-mineral bone disorder (CKD-MBD) (Ruospo et al., 2018).
For patients with elevated serum phosphate levels, a low phosphorus diet may be warranted. However, when
kidney function recovers, serum phosphate level normalizes hence any restrictions can be lifted.

Page | 32
Use of phosphate binder
Phosphate binders such as calcium acetate act like sponges, trapping the phosphate before it is absorbed by the
body. This means that less of the phosphate from food will go into the bloodstream.
All foods contain a significant amount of phosphorus, but phosphorus in food from animal origin is more bioavailable
than that in plant food. Unfortunately, dietary phosphorus and calcium are difficult to control. Increasing the calcium intake
and at the same reducing the phosphorus intake may be difficult since those nutrients usually occur together in foods, e.g.,
milk and milk products are high in both minerals.
_____________________________________________________________________________________

Page | 33
Calcium is mostly found in the bones (99%), while the remainder (1%) is found in soft tissues, extracellular, and
plasma, where it performs many metabolic and regulatory roles.
Both negative and positive calcium balance has important implications in patients with kidney disease. A negative
balance may increase the risk of osteoporosis and fracture, while a positive balance may increase the risk of vascular
calcification and cardiovascular events.
Hypocalcemia should be managed to prevent having hypotension and clotting disorders (Gervasio et al., 2011). This
usually occur when the patient started receiving RRT and on long-term use of corticosteroids. There is an approximately
42% decrease in elemental calcium absorption with the use of corticosteroids. The amount of calcium excreted in the urine
is also increased with corticosteroid therapy (Byham- Gray et al., 2008).
Moreover, hypocalcemia can occur when hyperphosphatemia is simultaneously present. Patients who are
hypocalcemic because of vitamin D deficiency should receive oral vitamin D and calcium supplements.
Impaired kidney function reduced the body’s ability to conserve or to eliminate excess fluid. Fluid control is very
important in patients receiving HD. Excessive fluid intake between treatments can result in fluid overload leading to
hypertension and cardiac problems such as congestive heart failure (CHF) (NFK, 2020).
Likewise, excessive fluid intake can significantly impact weight status thus, caution is needed with the use of body
weight for computing for the nutrient requirements. Volume overload setting is associated with adverse outcomes, so
attention should be given to overall fluid balance (Moore et al., 2018).
For kidney transplants, hydration must be monitored closely after transplantation to avoid both extreme dehydration
and over-hydration. Generally, fluid is not restricted in the long-term. To optimize graft function, sufficient hydration is

Page | 34
necessary, especially in hot climates. In case graft function losses functionality, fluid intake should follow guidelines for CKD
(EDTNA/ERCA, 2012).
Other dietary components:
The energy requirement should be tailored to the individual needs, nutritional status, co-morbid conditions, and type
of RRT received. Adequate energy intake will make the body to:
 utilize protein more efficiently;
 prevent the breakdown of protein and
 preserve protein stores
If the energy supply is not sufficient, there will be muscle breakdown. Protein from muscle will be metabolized as
energy sources, which may aggravate the existing uremia. Proper energy intake will benefit NS patients by maintaining a
positive energy balance rather than increasing protein in the diet (Tracey, 2002). On the contrary, excessive energy intake
may cause other complications such as hyperglycemia, hypertriglyceridemia, and hypervolemia (Fiaccadori & Cremaschi,
2009).
In a kidney transplant, the nutrient requirements including energy are generally increased during this acute phase.
This is due to the metabolic demand of the transplantation and high-dose immunosuppressive therapy and for wound healing
(Kopple et al., 2013; Byham-Gray et al., 2008; EDTNA/ERCA, 2012). However, it is essential for a patient who has
inadequate intake for more than 4-7 days regardless of the BMI category, to start at low calorie, about 10–20 kcal/kg for the
first 24 hours; advance by 33% of goal every 1 to 2 days to prevent refeeding syndrome (Da Silva et al., 2020).

Page | 35
What is Refeeding syndrome?
It is defined as intracellular shift in electrolytes that may occur
in malnourished patients when feeding (oral, enteral or parenteral
nutrition) is begun too aggressively after a period of inadequate nutrition.
This may cause serious clinical complications and may potentially be
fatal.
The hallmark biochemical feature of refeeding syndrome is
hypophosphatemia, hypokalemia and hypomagnesemia.
The subsequent change from fat to carbohydrate metabolism causes
alteration in electrolyte levels.
Calories in dialysate
In HD, the standard dialysate solution
contains glucose but does not significantly
contribute to energy intake even thrice-weekly
dialysis.
For patients receiving PD, energy
requirement should include calories from both
diet and the dialysate since calories absorbed
during dialysis can be significant and lead to
weight gain (Byham-Gray et al., 2014).
For the computation of glucose in
dialysate, see Appendix 2.

Page | 36
The kidneys play an important role in insulin metabolism and clearance. Abnormalities of carbohydrate metabolism
are encountered with impaired renal functions (Kopple et al., 2013). Hyperglycemia is common in patients with AKI, in the
early stages of CKD, in dialysis patients, and even in transplanted patients. In transplanted patients, hyperglycemia is due to
the effect of immunosuppressive therapy, corticosteroids, and insulin resistance due to the elevated weight (EDTNA/ERCA,
2012).
Moreover, uremia-induced insulin resistance can be due to reduced glucose uptake in the peripheral tissues. The
insulin resistance is related to the accumulation of uremia toxins, markers of inflammation, increased visceral fats, oxidative
stress, and vitamin D deficiency (Pecoits-Filho et al., 2016; Hill, et al., 2016; Iglesias & Diez, 2008; Sampanis, 2008; Mak,
2000).
The recommendation should emphasize on consuming complex carbohydrates, low in glycemic index, high dietary
fiber, and limit simple sugars to achieve better blood glucose (Teger, 2019).
New-onset diabetes mellitus (NODAT)
New-onset diabetes mellitus after transplantation (NODAT)
is the occurrence of diabetes mellitus in a previously
non-diabetic person after solid organ transplantation. NODAT
frequently appears after organ transplantation as a result
of corticosteroid therapy.
Organ transplantation is a practical definitive
treatment options for patient with end-organ
dysfunction. Organs for transplantation
include heart, kidney, lung, liver, and
pancreas.
1
Solid organ transplantation

Page | 37
Kidney disorder is associated with the derangement of lipid metabolism. This is due to reduced activity of both
peripheral lipoprotein lipase and hepatic triglyceride lipase (HTGL) by about 50 % (Druml et al., 1992; Leverve et al., 1998).
Moreover, if acidosis coexists, total inhibition of the lipoprotein lipase activity may form (Marin & Hardy, 2001).
Patients with AKI often have elevated plasma levels of triglycerides and very-low-density lipoprotein (VLDL)
(Fiaccadori, 2018). Similarly, increased serum concentrations of total cholesterol, low-density lipoprotein (LDL), and VLDL
are a feature of the NS (Vaziri, 2016; Agrawal, et al., 2018).
Dyslipidemia becomes more pronounced as renal failure progresses, and persists even when patients are on
dialysis. The changes in the lipid profile lead to the accumulation of atherogenic lipoproteins, and thus contribute to
accelerated atherosclerosis, the progression of renal failure and worsening of proteinuria (Gupta & Misra, 2011). This lipid
derangement puts people with CKD at greater risk of having a heart attack or stroke.
Likewise, dyslipidemia in adult renal transplant patients is related to immunosuppressant therapy within one month of
initiation and may continue indefinitely unless treated (Ramani et al., 2014).
Of note, lowering dietary lipids alone will not correct the observed hyperlipidemia. A low-fat diet can only improve
hyperlipidemia by 25% in adults (Agrawal et al., 2018). Treating the underlying causes of the kidney problem will improve or
resolve dyslipidemia (Hull, 2008).
Despite this observation, limiting the overall intake of fats such as saturated fats, trans-fats, and monounsaturated
fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) are still emphasized (Teger, 2019).

Page | 39
ACUTE KIDNEY INJURY
Acute Kidney Injury (AKI), is a sudden impairment of kidney function the accumulation of waste products (i.e.,
creatinine, urea, ammonia, sulfate, and uric acid) after an abrupt decrease in kidney function due to a wide spectrum of injury
(Rahman et al., 2012; Koore et al., 2018). Although in many cases, with a prompt evaluation of the cause of AKI, the kidneys
can recover completely.
The rapid reduction of kidney function can result in the following:
 Fluid and electrolyte imbalances
 Uremic toxicity
 Protein-energy wasting (PEW)
 Death
Causes of AKI
AKI is classified into three categories according to underlying cause of kidney dysfunction - prerenal, intrinsic, and post renal.
Table 2.1 Classification of AKI and their specific causes and nutrition relevance
Classification Examples of Specific Causes Nutritional Relevance
Prerenal – It refers to any injury that
decreases the blood flow to the kidneys
resulting in a low GFR.
Heart disorders:
Heart failure, heart attack
Low blood volume or pressure:
Hemorrhage, burns, sepsis or shock, nephrotic
syndrome, diuretics, antihypertensive medication
Renal artery disorders:
Blood clots or emboli, trauma
There is typically no change in the
nutritional requirements of patients with a
pre-renal AKI.
Intrinsic – Any injury that damages part of
the kidneys such as the tubule, interstitium,
glomerulus or vasculature.
Renal injury:
Infections, environmental contaminants, drugs,
medications, food poisoning
This is a more severe form of injury and
is likely to alter the nutritional
requirements of the patient.
Post renal – Any injury that block the urine
flow from the kidneys caused by crystals,
protein deposits or malignant tumor
infiltration.
Bladder disorders:
neurological conditions, bladder rupture
Obstruction (ureter or bladder):
Strictures, stones, tumors, trauma
Obstructions (within kidneys):
Inflammation, tumors, scar tissue
Prostate disorders:
Cancer
There is typically no change in the
nutritional requirements of patients with a
post-renal AKI.
Source: Rahman M, Shad F, Smith MC. (2012) Acute kidney injury: a guide to diagnosis and management. American family physician. 1;86 (7) 631-639

Page | 40
NUTRIENT RECOMMENDATION
Table 2.2 Nutrient Recommendations and Rationale for AKI
Nutrients AKI Condition Recommendation Rationale
Protein (g)
No RRT
Non-Catabolic
(No RRT)
0.8 - 1.0 g/kg/IBW
(KDIGO, 2012; Fiaccadori, 2018;
Gervasio et al, 2011)
To supply sufficient protein to
maintain metabolic balance
(KDIGO, 2012)
Catabolic
(no RRT)
At least 1.0 g/kg/IBW To prevent further protein
breakdown, compensate for the
losses, achieve positive nitrogen
balance, and prevent PEW.
(KDIGO, 2012; McClave et al., 2016; Patel et
al 2017; Gervasio et al., 2011; Brown &
Compher, 2010; Cano et al., 2006).
On IHD
Non-Catabolic 1.0 - 1.5 g/kg/IBW
(KDIGO, 2012; Naylor,et al., 2013; Cano et al., 2006).
Catabolic
On CRRT
Non-Catabolic 1.2 - 1.5 g/kg/IBW
Up to 1.7 g/kg/IBW
(KDIGO, 2012; Cano et al., 2006)
Catabolic 1.5 – 2 g/kg/IBW up to max of 2.5
g/kg/IBW
in critically ill patients
(McClave, 2016; Patel et al., 2017; Brown & Compher,
2010)

Page | 41
Table 2.2 Nutrient Recommendations for AKI (cont’d.)
Nutrient Recommendation Rationale
Sodium
(mg)
< 2000 mg
(KDIGO, 2012)
To maintain healthy sodium levels and prevent fluid
retention, hypertension, and edema (KDIGO, 2012).
Potassium
(mg)
2000 mg
(PDRI, 2015)
To maintain normal potassium levels and prevent
hyperkalemia, and cardiac arrhythmias
Calcium
(mg)
800 mg – 1000 g
(KDOQI, 2020)
To maintain calcium levels unless laboratory test show
abnormalities; to be adjusted according to the physician's
recommendation.
To be increased by 1000 mg due to risk of renal
osteodystrophy.
Phosphorus
(mg)
700 mg
(PDRI, 2015)
To maintain normal levels of phosphorus unless laboratory
tests show some abnormalities; to be adjusted according to
the physician's recommendation
Fluid
(mL)
24 hr Urine output + 500 mL
(Debruyne, 2016)
To account for water lost from skin, lungs and perspiration
(Debruyne, 2016).
Energy
(kcal)
Any stage of AKI patients:
20 - 30 kcal/kgBW
(KDIGO, 2012; Cano et al., 2006)
To provide adequate energy from carbohydrates and fat.
To make the body utilize protein more efficiently.
For critically ill patients:
25 - 35 kcal
(KDIGO, 2012; Downs, 2014)
To compensate for the significant increase in the metabolic
rate and to help prevent PEW (Gervasio, 2011).
Carbohydrate
(g)
50 - 60% of TER To maintain normoglycemia.
To make the body utilize protein more efficiently.
Fat (g)
30 - 35% of TER
or remainder of TER
(Fiaccadori, 2018)
To prevent the elevation of plasma triglycerides (TGs) and
very low density lipoproteins (LDL) levels (Fiaccadori, 2018).

Page | 42
RRT for AKI
The traditional indications for RRT in critically ill patients with AKI include (Negi et al., 2016):
 Volume overload (resistant to diuretic agents)
 Hyperkalemia not responsive to medical management
 Severe metabolic acidosis
 Caused by certain poisonings, and intoxications, e.g., ethylene glycol, lithium (Joannidis & Forni, 2011).
 Uremic manifestations including encephalopathy, pericarditis and convulsions
This can be assessed through physical examination and biochemical parameters.
Nutritional support in AKI patients with PEW
The European Society for Parenteral and Enteral
Nutrition (ESPEN) has proposed a decision tree for
nutritional support in patients with AKI who developed
PEW (Fig. 2). It is essential to assess first the
gastrointestinal function because it will determine the
route of feeding i.e., whether enteral or intravenous
feeding will be initiated. The artificial nutrition is to prevent
deterioration in the nutritional state of the patients brought
about by the disease condition and its complications.
When enteral feeding cannot be optimized for whatever
reason, it can be supplemented with parenteral nutrition.
Parenteral nutrition for short-term period up to 14 days is
given through peripheral veins while for long -term
therapy via central line. Figure 2. Decision tree for nutritional support
Source: Fiaccadori E. (2013). Module 12.1 Acute Kidney Injury.
Lifelong Learning (LLL) Course in Clinical Nutrition and Metabolism:
Nutrition Support in Renal Diseases. ESPEN, 2013.

Page | 43
Key Points:
 Protein requirements vary depending on the patient's clinical condition, the severity of AKI, catabolism,
and form of RRT received.
 High protein intake should be provided when on RRT to compensate for the protein and
amino acid losses during the dialysis protein/amino acid losses during the dialysis and achieve
positive nitrogen balance.
 Patients with AKI need optimal energy intake for the body to utilize protein efficiently.
 AKI patients with PEW frequently require nutritional support to prevent deterioration of nutritional status.
 Electrolyte intake should be adjusted according to blood biochemistry and recommendation of the physicians

Page | 44
NEPHROTIC SYNDROME
Nephrotic Syndrome (NS) – is a syndrome and not a diagnosis of a particular renal disease but it can occur in
several conditions including minimal change disease (MCD), membranous nephropathy, focal segmental glomerulosclerosis
(FSGS), diabetes mellitus, systemic lupus erythematosus (SLE), and amyloidosis (NIDDK, 2014).
Definition of Nephrotic Syndrome
This refers to a syndrome that is caused by significant urinary protein loss (proteinuria) that results from severe
damage to the glomerular or filtering unit in the kidneys. There is an increase in permeability to plasma proteins, allowing the
proteins to escape into the urine.
Consequences of the Nephrotic Syndrome
The loss of proteins may cause serious consequences such as edema, blood lipid abnormalities, blood coagulation
disorders, and infections. In some cases, nephrotic syndrome can progress to renal failure (DeBruyne et al., 2016) (Figure
2.1).
Figure 2.1 Consequences of Nephrotic Syndrome
Source: DeBruyne, L.K., Pinna, K., & Whitney, E. (2016). Nutrition and Diet Therapy, 9th
Edition. USA: Cengage Learning

Page | 45
NUTRIENT RECOMMENDATIONS
The diet for nephrotic syndrome is modified primarily in protein and sodium.
Table 2.3 Nutrient Recommendations for Nephrotic Syndrome
Nutrients Recommendations Rationale
Protein
(g)
0.8-1.0 g/kgBW
(EDTNA/ERCA, 2012; Kaysen & Odabei, 2013)
To prevent occurrence of proteinuria (EDTNA/ERCA,
2012).
To prevent muscle wasting (Hull & Goldsmith,
2008)
To prevent further deterioration of renal function.
Sodium
(mg)
< 2000 mg
(EDTNA/ERCA, 2012)
To minimize edema and hypertension.
Potassium
(mg)
Generally unrestricted
(EDTNA/ERCA, 2012)
To maintain serum potassium within the normal
range.
Phosphorus
(mg)
700 mg
(PDRI, 2015)
Calcium
(mg)
800 – 1000 mg
2000 mg, if vitamin D deficient
(Dinesh et al., 2008)
To preserve bone density.
Fluid
(mL)
< 1500 mL
(Hull and Goldsmith, 2008)
To reverse the edema slowly (Hull and Goldsmith, 2008)
Energy
(kcal)
30 - 35 kcal/kg BW
(EDTNA/ERCA, 2012; Andolino & Reid-Adam,
2015; Tracey, 2002)
To achieve and maintain a desirable dry body
weight (EDTNA/ERCA, 2012)
Maintain a positive nitrogen balance.
Carbohydrate
(g)
50 - 60% of TER To make the body utilize protein more efficiently.
Fat
(g)
25 – 30% of TER
Limit < 200 mg/day
To control dyslipidemia and CVD
(EDTNA/ERCA, 2012; Andolino & Reid-Adam, 2015)

Page | 46
Gram to gram replacement in
Nephrotic Syndrome (NS)
Prolonged and massive proteinuria in NS leads to muscle wasting. If NS
patient is losing more than 5 g of protein through urine, then the protein
intake should be decreased to 0.7 g/kg and provide an additional 1 g/day for
every gram of urinary protein lost above 5 g/day (De Mutsert et al., 2009).
In the study of Maroni et al. (1997) this gram to gram replacement has been
shown to maintain protein stores. Although this may be enough for patients
with levels of urinary protein excretion of less than 10 g/day, the dietary
requirements have not been established for those with more severe
proteinuria.
Keto-analogue (KA) KA is a nitrogen-free analog of essential amino acids.
A recent study showed that the very low protein diet (VLPD) supplemented
with KA amino acid delays the progression of kidney disease when compared
to a low protein diet (LPD) (Garneata et al., 2016). This in effect reduced the
intake of nitrogen while avoiding the deleterious consequences of inadequate
dietary protein intake and malnourishment (Khan et al., 2014).
KA prescription usually given by physician:
tablet/5 kg/BW/day (Cupisti et al., 2018) - tablet/10 kg/BW/day (Wu et al.,
2017)
Sample Computations:
Case Scenario
Patient JJ is a female, 60 years old, 5’4’’ tall and weighs 60 kg.
The doctor prescribed a keto-analogue of 1 tablet/10 kg/BW.
𝟏
𝟏𝟎 𝒌𝒈/𝑩𝑾
𝒙
?
𝟔𝟎 𝒌𝒈
= 6 tablets

Page | 47
Key Points:
 Moderate amount of protein is recommended i.e. 0.8-1.0 g/kg/ dry BW per day. HBV protein should contribute at
least 50% of protein intake.
 Patients with NS should have adequate energy intake to maintain positive nitrogen balance.
 A sodium-restricted diet is recommended to control edema and hypertension.
 Vitamin D and calcium supplement may be needed to preserve bone density in NS.
 Patient with NS may benefit from low saturated fat and low cholesterol diet in combination 
with drug therapy.

Page | 48
CHRONIC KIDNEY DISEASE
Chronic Kidney Disease (CKD) or chronic renal failure, as previously termed, is the decline in renal function from
damage that may lead to kidney failure. Patients with CKD display a variety of metabolic and nutritional abnormalities. This
disease condition is typically progressive and irreversible, which may require dialysis or a kidney transplant to maintain life.
Definition
KDIGO defines CKD as abnormalities of kidney structure or function estimated GFR of less than 60 mL/min/1.73
m2 that is present for longer than 3 months
The stages of kidney function provide insight into the changes that might be necessary for altering dietary intake. As
CKD progresses, the management becomes more complex, thus a multidisciplinary team approach which includes
physicians, dietitians, nurses, and pharmacists are involved in the care of these patients.
NUTRIENT RECOMMENDATIONS
MNT plays an integral role in the health of the patient especially those in the latter stages of CKD receiving
maintenance dialysis. The registered nutritionist-dietitian should be knowledgeable on the factors affecting assessment and
maintenance of adequate nutritional status, and the nutritional implications associated with the different types of RRT.
The dietary management of CKD aims to:
 prevent protein-energy wasting (PEW)
 reduce metabolic complications
 delay the progression of the disease condition
 maintain fluid and electrolyte balance
 maintain optimal body composition

Page | 49
Table 2.4 Nutrient Recommendation for CKD
Nutrients Recommendations Rationale
Protein
(g)
Conservative Nutritional Treatment in CKD
Patients
(Non-dialyzed)
Stage 1-3:
0.6 - 0.8 g/kg BW
(Kalantar-zadeh & Foque, 2017)
Stages 3-5:
LPD: 0.55-0.6 g/kg BW
(KDOQI,2020; Kalantar-zadeh & Foque,
2017)
In more advanced CKD Stages 4-5:
VLPD supplemented with KA
0.3 – 0.4 g/kg BW + KA
(KDOQI, 2020)
KA prescription:
1 tablet/10 kg/BW/day
(Wu et al., 2017)
To maintain a stable nutritional status and optimize
glycemic control (KDOQI, 2020)
To reduce risk for end-stage kidney disease
(ESKD)/death and improve quality of life (KDOQI,
2020)
To ensure a sufficient balance of the essential amino
acids (EAAs) normally brought by animal proteins,
which are basically absent in these low-protein vegan-
like diet (KDOQI, 2020)
To better control uremia symptoms, the intake of more
vegetable protein and the use of keto-analogues are
allowed by some physician (Fouque, 2018)
CKD Patients with Maintenance
Hemodialysis and Peritoneal Dialysis
1.0-1.2 g/kg BW To maintain a stable nutritional status and optimize
glycemic control (KDOQI, 2020)

Page | 50
Table 2.4 Dietary Recommendations per day for CKD (continued)
Sodium
(mg)
<2000 mg
(WHO)
To reduce blood pressure and improve volume control
(KDOQI, 2020)
Potassium
(mg)
Stage 1-2
Usually not restricted
Stage 3-5D
Based on patient’s individual need and
clinician judgement (KDOQI, 2020)
Patient on Dialysis
HD: < 2400 mg
PD: Should be individualized
(AND, 2012)
To prevent risk of hyperkalemia (AND, 2012)
To maintain serum potassium within the normal range
(KDOQI, 2020)
Phosphorus
(mg)
<800 mg
(Kalantar-zadeh and Foque 2017)
Stage 1-2
800 to 900 mg/day
(KDOQI, 2020)
Stage 3-5D
adjust dietary phosphorus intake
individually
(KDOQI, 2020)
To minimize added inorganic phosphorus and
encourage consumption of more plant-based food
To maintain serum phosphate levels in the normal
range and restriction is required if elevated serum
phosphate occurs (KDOQI, 2020).
Calcium
(mg)
800 to 1,000 mg/d
(KDOQI, 2020, Kalantar-zadeh and
Foque 2017)
Stage 5D
Adjust calcium intake individually
(KDOQI, 2020)
To maintain calcium balance in patients who are not
receiving active vitamin D analogues, at least at short
term (KDOQI, 2020); close to EAR and RDA proposed
by IOM (Kalantar-zadeh and Foque 2017)
To give consideration of concurrent use of vitamin D
analogs and calcimimetics in order to avoid
hypercalcemia or calcium overload (KDOQI, 2020)

Page | 51
Fluid
(mL)
Stages 1 – 5: Usually not restricted or
2000mL + 500mL
(Haddad et al, 2013)
HD: 600 mL + urine output +
extrarenal water loss
PD: Individualized or advised “drink
less liquid”
Recommendations of the nephrologists
To maintain proper fluid intake in these stages is
important because CKD patients are taking diuretics to
control blood pressure and need to maintain as much
kidney function as possible (Haddad et al, 2013)
To prevent fluid overload and avoid serious
perturbations of water balance (Haddad et al, 2013)
Energy
(kcal)
30 - 35 kcal/kg BW
(KDOQI,2020; Kalantar-zadeh &
Foque, 2017)
To avoid protein–energy wasting
To maintain neutral nitrogen balance and nutritional
status
(KDOQI, 2020)
Carbohydrate
(g)
40-60% of TER
should be natural and complex with a
high-fiber content
(Kalantar-zadeh & Foque, 2017)
To control weight and for glucose control
Fat
(g)
< 30- 35% of TER
or remainder of calories
To prevent dyslipidemia (Sabbatini, 2019, Kopple, et
al., 2013; EDTNA/ERCA, 2012)
Key Points:
 Protein intake varies between dialyzed and non-dialyzed patients.
 Keto-analog may be prescribed by physician in conjunction with VLPD.
 Adequate energy is needed to maintain neutral nitrogen balance and body composition.
 Low sodium diet to prevent hypertension and fluid overload.
 Electrolytes and fluids intake should be adjusted based on serum laboratory test

Page | 52
FOOD SELECTION GUIDE IN CKD
Food Group Allow Limit
Meat All except nuts, seeds, beans and
anchovies
In excess of allowance
Nuts, seeds and beans
Salted egg, dried fish, cheese and products
Canned foods, frozen dinners, processed meats like
ham, bacon, hot dogs, sausage and deli meats
restaurant/fast food meats
Milk All but limit intake to half exchange In excess of allowances
Commercial foods made with milk, malted milk, milk
mixes, sherbet, ice cream, chocolate, coco
Rice Rice
Breads
Bihon
Pasta
Corn
All of these and their products in
allowed amounts.
Commercially prepared products like:
 desserts, breads, pastries, potato chips, cereals
or crackers containing baking soda, salt or other
sodium compounds
 bran cereals, boxed, frozen or canned meals,
whole wheat/grain breads and cereals, quinoa
 mami, miki, miswa, instant noodles
 Flavored rice such as java, kimchi, paella
Vegetable All fresh in allowed amounts Pickled vegetables
Salt fermented vegetables like burong mustasa, kimchi
Processed, canned and frozen vegetables
Fruit All fresh fruits in allowed amounts Maraschino cherries
Candied fruits
Dried fruits
Fat Butter, Margarine, salad oils and
dressing
Coconuts
other nuts in allowed amounts
Sugar and sweets All Sweets containing chocolates and nuts
Carbonated drinks (soft drinks)
Dessert Made with allowed foods only; low-
protein desserts as plain arrowroot or
cornstarch and pudding, nata de coco,
matamis na bao, lohwa (puffed rice
only), kundol, sago or kaong with syrup
Those with milk, eggs and cereals in allowed amounts
such as ice cream, custard, pudding; cakes, cookies,
bibingka. Etc; cocoa, chocolate, nuts
*Note: always read and check the food labels and watch portion sizes

Page | 53
KIDNEY TRANSPLANTATION

Patient's nutrition after kidney transplantation is influenced by several different factors, such as the time after
transplantation, kidney function (chronic kidney disease stages 1-5), side effects of immunosuppressive and other drugs,
possible food-drug interactions and possible immunomodulatory effects of some food additives (Mlinšek, 2014).
Definition
The removal of a healthy kidney from a living donor or recently deceased person and transferred into a person with
ESRD. Kidney transplantation is a preferred alternative to dialysis treatment.
Complications of post transplantation
1. increased risk for weight gain and obesity
2. higher new onset of diabetes after transplantation (NODAT)
3. hypertension
4. hyperkalemia
5. cardiovascular disease,
6. bone disease
7. food-borne infection (related to immune-suppressing medication)
In all these cases, nutrition (along with adequate physical activity) can be a first-line modifiable intervention for
management or prevention of complications post transplantation.
A. The Acute Post- Transplant Period - the first 3 months after transplantation or until medication are stabilized to a
maintenance dose.
During this period, nutrition intervention focuses on recovery, especially for the patient who enters transplant surgery
in a malnourished state. A higher nutrient requirement is needed immediately to gain adequate nutrition to successfully
counteract postoperative catabolism, recover muscle mass and fat losses (Anderson et al., 2016, McCann, 2015), and
promote wound healing (Teger, 2019; McCarthy, 2014; Kopple et al., 2013).

Page | 54
Table 2.5 Nutrient Recommendations for Acute Post-Transplant Period
Protein
(g)
Up to 1.4 g/kg/day
(Chadban, et al., 2010 as cited by
Sabbatini, 2019; Paul, et al., 2019;
Byham-Gray, et al., 2013 as cited by
Hong, et al., 2019; Kopple, et al., 2013)
To match protein catabolism that follows steroid administration and surgical
stress
To prevent or cure a pre-existing under-nutrition that may lead to poor wound
healing or greater susceptibility to infections.
To prevent loss of lean body mass (Chadban, et al., 2010)
To achieve neutral or positive nitrogen balance (Chadban, et al., 2010)
Sodium
(mg)
<2000 mg
(PDRI/WHO)
To minimize fluid retention and helps to control blood pressure
Potassium
(mg)
2000 mg
(Cochran & Kent, 2004 as cited by
Byham-Gray, 2014; Mahan & Raymond,
2017)
To prevent hyperkalemia (Cochran & Kent, 2004 as cited by Byham-Gray,
2014)
Phosphorus
(mg)
1000-1300 mg/d (RDI)
(Kopple, et al., 2013; Mlinsek, 2016)
To maintain normal levels (Mlinsek, 2016)
To prevent decrease with administration of corticosteroid (McCarthy, 2014)
Calcium
(mg)
800- 1000 mg
(KDOQI, 2020)
To achieve calcium balance ((PDRI, 2015)
To prevent secondary hyperparathyroidism and its metabolic and clinical
consequences (Fouque, 2018)
Fluid
(mL)
Individualized, according to
graft functionality
(EDTNA/ERCA, 2012)
Typically encouraged to drink
2000-2500 mL/day
(Minsek, 2016)
Individualized; may need to be limited if patient requires dialysis or if edema is
present.
(Cochran & Kent, 2004 as cited by Byham-Gray, 2014; EDTNA/ERCA, 2012)

Page | 55
Energy
(kcal)
30 - 35 kcal/kg BW
(EDTNA/ERCA, 2012)
To prevent negative nitrogen balance (Martins, 2004 as cited by Chitra, 2013)
To minimize protein catabolism and malnutrition to minimize side effects
associated with immunosuppression therapy (Kopple et al., 2013)
To replenish energy losses (Toigo, et al., 2000; EDTNA/ERCA, 2012)
To achieve and maintain a healthy body weight
(McCarthy, 2014 in Byham-Gray, 2014)
Carbohydrate
(g)
50 - 70% of TER
or non-protein calories
(Cochran & Kent, 2004 as cited by
Byham-Gray, 2014, McCann, 2015 as
cited by Teger, 2019)
Note: emphasis on high dietary
fiber (20 - 30 g) and complex
carbohydrates
To control lipid levels, and reduce risk of posttransplant DM (McCann, 2015 as
cited by Teger, 2019)
To treat post-transplant hyperglycemia (Toigo, et al., 2000).
Fat
(g)
25 - 30% of TER
or remainder of calories
(Toigo et al., 2000; EDTNA/ERCA,
2012; Terger, 2019)
To prevent dyslipidemia (Sabbatini, 2019, Kopple, et al., 2013;
EDTNA/ERCA, 2012)

Page | 56
B. The Chronic Post-Transplant Maintenance Phase (beyond the first 6 months)
During this phase, caloric requirements are less than in acute phase. Kidney transplant recipients may follow a diet
regimen consistent with guidelines for the healthy population for as long as no other underlying issues, and with emphasis on
disease prevention (McCann, 2015).
Table 2.6 Nutrient Recommendations for Chronic Post-Transplant Period
Nutrient Recommendations Rationale
Protein
(g)
0.8-1.0 g/kg
(Byham-Gray, et al., 2013 as cited by
Hong, et al.,2019; EDTNA/ERCA, 2012)
To maintain or achieve an appropriate weight for height (Toigo, et al.,
2000; Mahan & Raymond, 2017)
To stabilize and prevent deterioration of renal function (Toigo, et al.,
2000; Chitra, 2013; EDTNA/ERCA, 2012)
Sodium
(mg)
<2000 mg
(PDRI, 2019)
To prevent edema (Cochran & Kent, 2004; EDTNA/ERCA, 2012)
Potassium
(mg)
Usually unrestricted, unless
there is hyperkalemia
(Cochran & Kent, 2004)
Phosphorus
(mg)
1500 - 2000 mg
(Fouque, 2018)
Calcium
(mg)
800 - 1500 mg
(EDTNA/ERCA, 2012)
To maintain bone mineral metabolism (Byham-Gray, 2014); to optimize
bone density (EDTNA/ERCA, 2012), and to treat osteoporosis (if
present).
Fluid
(mL)
Individualized
(Byham-Gray et al., 2014)
To optimize graft function, sufficient hydration is necessary, especially in
hot climates. In case graft function losses functionality, fluid intake should
follow guidelines for CKD (EDTNA/ERCA, 2012).
Energy
(kcal)
25 - 35 kcal
(McCann, 2015)
To attain or maintain a healthy weight.
Carbohydrates
(g)
45 - 50% of TER
(McCann, 2015)
Note: emphasis on high dietary fiber (20
- 30 g) and complex carbohydrates
To achieve a better blood glucose and triglyceride control
Fat
(g)
< 30% of TER
(EDTNA/ERCA, 2012; Teger, 2019)
To achieve a better blood glucose and triglyceride control

Page | 57
Food Selection Guide in Kidney Transplantation
Food Group Allow Limit
Meat Consumption of white
meat (chicken, fish) and
eggs is better than the
intake of red meat (pork
and beef).
Concentrated foods like organ meats
Packaged, frozen, microwaveable meals, processed
meats (like bacon, hot dogs, ham, sausage and deli
meats).
Milk All in allowed amounts Commercial foods made with milk.
Rice All noodles, root crops,
bakery products rice and
other products, all of
these in allowed amounts
Commercially prepared products like instant noodles,
mac and cheese, flavored rice, or pasta side dishes,
desserts, mixes and pastries, salted snack foods like
crackers, canned meals
Vegetable All fresh in allowed
amounts
Canned and frozen vegetables with added salt like
pickled and salt fermented vegetables.
Fruit All fresh in allowed
amounts
Limit bananas, melons, oranges, prunes, grapes and
other dried fruits, canned and bottled juices with added
sugar.
Fat All in allowed amounts Animal oil sources.
Fat can be eaten in allowed amount, through frying and
sautéing of foods.
Sugar and sweets All in allowed amounts Simple sugars and sweets (cakes, candies, chocolate
bars etc.)
*Note: always read and check the food labels and watch portion sizes.

Page | 58
Complications of Post-Kidney Transplantation
1. increased risk for weight gain and obesity
2. high chance of new onset of diabetes after
transplantation (NODAT)
3. hypertension
4. hyperkalemia
5. cardiovascular disease
6. bone disease
7. food-borne infection (related to immune-
suppressing medication)
Key Points:
 A higher nutrient requirement is needed in the acute phase rather than in chronic postoperatively.
 During acute phase, nutrition intervention is focused on recovery.
 Estimated protein needs in the chronic post-transplant stage can vary based on diabetes status.
 Protein recommendations of long-term kidney graft recipients do not differ from the healthy population.
 Total carbohydrate intake, sodium, saturated fats should be limited because of increased risk of weight
gain, obesity, NODAT, dyslipidemia after transplantation.
Kidney transplantation is a surgical procedure to place a
healthy kidney from a living or deceased donor into a person
with ESRD or whose kidneys no longer function properly.
Nutritional care of the kidney transplant recipient is a dynamic
process as the procedures have sets of critical nutritional challenges
related to:
a. recovery from major surgery
b. immune-suppressive pharmacotherapy
c. preexisting comorbidities
(Mlinšek, 2014; Veroux et al., 2013)

Page | 59
Table 2.7 Summary of Nutrient Recommendations for Selected Kidney Diseases and Kidney Transplantation
Dietary
Component
Recommendation for Kidney Disease/Condition Per Day
Acute Kidney Injury Nephrotic Syndrome Chronic Kidney
Disease
Protein
(g)
Non-catabolic
(No RRT):
0.8 – 1.0 g/kg/IBW
Catabolic (no RRT):
At least 1.0 g/kg/IBW
0.8 – 1.0 g/kg/IBW
Stage 1-3:
0.6 - 0.8 g/kg/BW
Stages 3-5:
LPD: 0.55-0.6 g/kg/IBW
In more advanced CKD:
Stages 4-5:
VLPD supplemented
with KA
0.3 – 0.4 g/kg/IBW + KA
KA prescription:
1 tablet/10 kg/BW/day
CKD patients on
Dialysis Treatment
1.0-1.2 g/kg BW
Acute post-transplant period:
1 up to 1.4 g/kg BW
On IHD (Non
Catabolic/Catabolic):
1.0-1.5g/kg IBW
Chronic post-transplant
period:
0.8-1.0 g/kg BW
Non-catabolic (on CRRT:
1.2 – 1.5 g/kg/day
Catabolic (on CRRT):
1.5 – 2 g/kg/IBW up to max
of 2.5 g/kg/IBW in critical
patients
Sodium
(mg)
< 2000 mg < 2000 mg < 2000 mg
Acute post-transplant
period:
<2000 mg
period:
2000 mg
Potassium
(mg)
2000 mg
Generally
unrestricted
Stages 1 & 2
Usually not restricted
Acute post-transplant period:
2000 mg

Page | 60
Table 2.7 Summary of Nutrient Recommendations for Selected Renal Diseases (continued)
Nutrients Selected Renal Diseases
Acute Kidney Injury Nephrotic Syndrome Chronic Kidney Disease Kidney Transplantation
Potassium
(mg)
(cont.)
Stages 3 – 5 D
Based on patient’s individual
need and clinician
judgement
Patient on dialysis
HD: < 2400 mg
PD: Should be
Individualized
period:
Usually unrestricted,
unless there is
hyperkalemia
Calcium
(mg)
800-1000 mg
800-1000 mg
2000 mg, if vitamin D
deficient
800 to 1000 mg/day
Stage 5D
Adjust calcium intake
individually
period:
800-1000 mg
period:
800 - 1500 mg
Phosphorus
(mg)
700 mg 700 mg
<800 mg
Stage 1 & 2
800 – 900 mg/day
Stage 3-5
Adjust dietary phosphorus
intake individually
period:
1000 - 1300 mg
period:
1500 - 2000 mg
Fluid
(mL)
24 hr Urine output + 500
mL
< 1500 mL
Stages 1-5: Usually not
restricted or 2000 mL + 500
mL
HD: 600 mL + urine output +
extrarenal water loss
PD: Individualized or
advised “drink less liquid”
Restriction may be required
to optimize glucose control
period:
Individualized, according
to graft functionality
Typically encouraged to
drink 2000 mL
period:
Should be individualized

Page | 61
Table 2.7 Summary of Nutrient Recommendations for Selected Renal Diseases (continued)
Nutrients Selected Renal Diseases
Acute Kidney Injury (AKI) Nephrotic Syndrome Chronic Kidney Disease Kidney Transplantation
Energy
(kcal)
Any stage of AKI patients:
20 – 30 kcal
For critically Ill
25-35 kcal
30 - 35 kcal
30 - 35 kcal
period:
30 – 35 kcal
period:
25 – 35 kcal
Carbohydrates
(g)
50 – 60% of TER
50 - 60% of TER
40 – 60% of TER
should be natural and
complex with a high- fiber
content
period:
50-70%
period:
45 – 50%
Note: emphasis on high
dietary fiber (20 - 30 g),
whole grain and complex
carbohydrates.
Fat
(g)
30 – 35% of TER or
remainder of TER
25 – 30% of TER < 30 – 35% of TER
period:
Remainder of calories
period:
Remainder of calories
Cholesterol
(mg)
Limit <200 mg/day
<300 mg/day

Page | 62
PART III – APPLICATION OF NUTRITION CARE PROCESS IN THE
NUTRITIONAL MANAGEMENT OF KIDNEY DISEASE
Nutrition Care Process
Mechanics of Prescription Writing
How to use the Food Exchange List for Kidney Disease

Page | 63
The Nutrition Care Process (NCP) is the systematic problem-solving method that dietetics professionals utilize to critically
think and make decisions to address nutrition-related health problems and provide safe and effective quality nutrition care.
The NCP includes nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.
Purpose: The purpose of the nutrition assessment is to obtain, verify, and interpret data needed to identify nutrition-related
health problems, their causes, and their significance.
The nutritional assessment of renal patient is carried out in the same way as routine nutrition assessment of normal
individuals. The collection of data for the five domains can be done either through patient/client interview or direct
observation and measurements by RNDs during routine ward rounds or may be abstracted from the medical records.
Table 3.1 Nutritional Assessment Domains and Sample Data
Domains
Personal History Anthropometry Biochemical Data,
Medical Tests and
Procedures
Dietary and
Food/Nutrition-related
Clinical assessment/
Nutrition-focused
Physical Findings
 Medical/Health
 Medications
 Treatments
 Social history
 Family health
history
 Height
 Weight
 Body mass
index (BMI)
 Weight History
 Laboratory Data:
CBC, creatinine, BUN,
Na, K, calcium, lipid
profile, FBS, albumin,
C-reactive protein
 Tests:
Renal ultrasound,
computed tomography
(CT), MRI, renal
scintigraphy, biopsy,
gastric residual volume,
type of dialysis
 Nutrient intake
 Food preferences
 Food allergies
 Nutritional
supplements
 Herbal medicines
 Knowledge/beliefs
 Food and supplies
availability
 Physical
appearance
showing clinical
signs associated
with malnutrition
 Signs of muscle
and fat wasting
 Presence of
edema, ascites

Page | 64
Use of nutrition assessment data: Nutrition assessment data, or indicators, are compared to criteria, or relevant norms
and standards. These norms and standards may be national, institutional, or regulatory. Nutrition assessment findings
become the basis in establishing the nutrition diagnosis and nutrition intervention goal setting.
Purpose: The nutrition diagnoses identify and describe a specific nutrition problem.
Labeling of nutrition diagnosis: The nutrition diagnosis is described using a standardized terminology for the diagnostic
label and organized in three major domains, namely: intake, clinical, and behavioral-environmental (Table 1.4).
Table 3.2 Nutrition Diagnosis, Domain and Description
Domain Description
Intake Too much or too little of a food or nutrient compared to actual or estimated needs
Clinical Nutrition problems that relate to medical or physical conditions
Behavioral-Environmental Knowledge, attitudes, beliefs, physical environment, access to food, or food safety
Documenting the nutrition diagnosis: Write using the PES format:
Problem _____________ related to
Etiology ______________as evidenced by
Signs/symptoms
Where:
Problem is the Diagnostic Label (see appendix 3)
Etiology - Cause/contributing risk factors
Signs/Symptoms - Defining characteristics
 Signs - objective data (observable,
measurable changes)
 Symptoms - subjective data (changes client
feels and expresses
Example 1
Problem Patient is morbidly obese related to
Etiology frequent consumption of processed foods as
evidenced by
Signs &
symptoms
BMI of 34 kg/m2 and foods recorded in the food
diary
Example 2
Problem Patient is moderately malnourished related to
Etiology loss of appetite due to dialysis treatment as
evidenced by
Signs &
symptoms
Reduced oral intake of 960 calories/day and
moderate fat and muscle wasting

Page | 65
Purpose: The nutrition intervention aims to resolve or improve the nutrition-related problem brought about by the medical
condition (e.g., renal disorder) through the development of a nutrition care plan. Nutrition intervention can be in the form of
actual delivery of food and nutrition provision of nutrition education, counseling, or meal plan tailored to individual needs and
coordination of nutrition care with the attending physician and other healthcare providers (Table 1.5)
Table 3.3 Intervention Strategies
Food and Nutrition
Delivery
Nutrition Education Nutrition Counseling Coordination of Nutrition
Care
 Modification of
consistency of food and
drink
 Provision of oral nutrition
supplement, enteral or
parenteral nutrition
support (artificial
nutrition).
 Conduct of lay forum
symposium or seminars
to impart basic
knowledge on food and
nutrition on how to
decipher food labels or
substitution of healthy
foods with not so healthy
food and drink.
 A supportive process
characterized by a
collaborative counselor-
patient relationship.
 To establish achievable
target goals for
behavioral change weight
management,
individualize meal
planning to promote
healthy well-being.
 Consultation with, referral
to, or coordination of
nutrition care with other
health care providers,
institutions or agencies
that can assist in treating
or managing nutrition-
related problems.

Page | 66
Purpose: Monitoring and evaluation aim to measure the amount of progress and the success of nutrition intervention
in achieving the set goals. This step includes the following:
1. Monitor nutrition intervention to see changes in the patient/client’s behavior or status.
2. Measure outcomes by comparing the current findings with previous status or nutrition intervention goals (e.g.,
adequacy of intake versus target goal requirement).
3. Evaluate the overall impact of nutrition intervention on the patient/client’s clinical outcomes.
Table 3.4 Items for Nutrition Monitoring and Evaluation
Changes in patient/client’s
behavior status Nutrition outcomes Clinical outcomes
 Improvement or
deterioration of appetite
 Tolerance to prescribed diet
 Tolerance to oral
supplement (ONS) given
 nutritional adequacy
 adequacy of intake vs target goal
requirement
 resolution of nutrient deficiencies
 Morbidity rate
 Mortality rate
 Length of hospital stay
 Days on mechanical ventilator
 Hospital cost

Page | 68
APPLICATION OF NCP IN MNT FOR KIDNEY DISEASE
Case Scenario: CKD Stage 4
 LABORATORY RESULTS
Test Patient’s Result Reference Interval
SI Units Conventional Units
Hematology
WBC count 11.5 × 109/L 4.0-11.0 x 109
/L 4000-11000/uL
RBC count
2.83 x 106/uL
Male: 4.4-5.9 x 106
/uL
Female: 3.8-5.2 x 106
/uL
Male: 4.4-5.9 x 106
/uL
Female: 3.8-5.2 x 106
/uL
Hemoglobin
79 g/L
Male: 133-177 g/L
Female: 117-157 g/L
Male: 13.3-17.7 g/dL
11.7-15.7 g/dL
Hematocrit
0.24
Male: 0.40-0.54
Female: 0.37-0.47
Male: 40-54%
Female: 37-40%
Platelet count 299 x 109/L 150-400 x 109
/L 150,000-400,000/mm3
Chemistry
Sodium 138 mmol/L 135-145 mmol/L 135-145 mEq/L
Potassium 4.9 mmol/L 3.5-5.1 mmol/L 3.5-5.1 mEq/L
Albumin 32 g/L 35-50 g/L 3.5-5.0 g/dL
BUN 12 mmol/L 2.9-7.1 mmol/L 8-20 mg/dL
Creatinine 200 umol/L 50-110 umol/L 0.6-1.2 mg/dL
eGFR 3 mL/min/1.73m3 >60mL/min/1.73m3
FBS 8.5 mmol/L 5.6 mmol/L <100 mg/dL
 CLINICAL HISTORY
Patient: XY is a 50 year-old female, housewife with 2 children.
Chief complaint: Dizziness, shortness of breath, lower extremity swelling, and decrease urine output
History of Present Illness: Patient presented to the emergency room with complaints of dizziness for 1 month,
shortness of breath for the last few days, worsening of lower extremity swelling and decrease urine output for 3 days.
Past Medical and Surgical History: Patient has a long standing history of hypertension and diabetes for about 6
years. No major accident or surgery has been reported.
Social History: No tobacco use, alcohol or drug abuse.
Physical exam Vital Signs: Temp of 36.5°C, respiratory rate of 20/minute and unlabored; pulse rate of 90 bpm
and BP of 140/90 mmHg. Pertinent physical findings were clinically dry, significant for lower extremity edema, weight
loss 3 kg in 2 weeks
s

Page | 69
Anthropometry
Ht- 160 cm
Wt- 86 kg
BMI= 33.6 kg/m2 (obese)
IBW = 54 kg
Since patient is obese, compute for the CBW dj BW/
CBW = [(ABW – IBW) × 0.25)] + IBW
= [(86 – 54) × 0.25] + 54
= 62 kg
Significant laboratory data
RBC = 2.83 × 1012/L ↓ , Hgb= 79 mg/dL ↓, Hct
= 0.24 ↓
Alb 32g/L ↓
FBS= 8.5 mmol/L ↑ , BUN = 12 mmol/L ↑ ,
Creatinine 200 umol/L ↑,
Clinical Hx
 Edema
 weight loss
Patient appears pale and with dry skin
Diet Hx
Her daily oral intake over the last 2 weeks has been
1 serving of milk powder or nutritional supplement
for breakfast, ½ cup rice with viand of 1 slice of meat
for lunch and dinner, and some biscuits (approx. 960
kcal/day; 20 gm protein).
 poor appetite
STEP 1
Nutritional Assessment
a. Compute for BMI, IBW/DBW and CBW.
b. Note all significant laboratory and clinical
findings
c. Conduct interview to determine diet history
d. Conduct nutrition-focused physical assessment

Page | 70
Patient is malnourished related to current medical
condition as evidenced by altered laboratory values and
inadequate intake of calorie and protein based on 24-
hour diet recall (approx. 960 kcal/day and 20 g protein
per day
Since the patient is obese, use at least 25 kcal/kg
CBW. Thus,
TER = weight (kg) × calorie factor
= 62 kg × 25 kcal/kg
= 1550 kcal
Since patient is non-dialyzed, 0.8 g of protein is
recommended.
Total Protein = weight (kg) × protein factor
= 62 kg × 0.8 g
= 49. 6 g or 50 g
Calculate for the non-protein calories. Initially, convert
gram of protein into calories. Then, subtract protein
calories from the TER.
Protein calories = 50 × 4 kcal/g
= 200 kcal
Non-Protein calories = 1550 - 200 kcal
= 1350 kcal
Determine the percent to be allocated for CHO and fat
This should total 100%.
Carbohydrate: 45 – 70 %
Fat: 30 – 55 %
STEP 2
Nutrition Diagnosis
a. Write the nutrition diagnosis using the PES
statement, considering the intake domain
and the clinical domain for this case.
STEP 3
Nutrition Intervention
Development of Care Plan
a. Compute for the energy and protein
requirements
b. Compute for the gram carbohydrates (CHO),
protein, and fat

Page | 71
Since the patient has Type 2 DM, carbohydrates intake
should be regulated. In our example, we use 55% CHO
and 45% Fat.
Multiply percent carbohydrates and fats with the non-
protein calories, and then divide by their respective
physiologic fuel value.
Calories from CHO = 55 % × 1350 kcal
= 742.5 kcal ÷ 4 kcal/g
= 185.63g or 185 g CHO
Calories from Fat = 45 % × 1350 kcal
= 607.5 kcal ÷ 9 kcal/g
= 67.5 g or 70 g Fat
Aside from the macronutrients, recommend also levels for
sodium, potassium, calcium phosphorus and fluid, and
other micronutrients based on current laboratory data.
Conduct nutrition monitoring through calorie counting (at least for
3 days or as necessary) to evaluate tolerance and adequacy of
intake.
 If diet is tolerated, continue present diet
 If diet is not tolerated, conduct re-assessment and revise the
nutrition care plan
 If intake is still inadequate, may consider ONS then monitor
tolerance and intake.
 May consider artificial nutrition (EN/PN) if oral intake does not
improve in 4-7 days (ASPEN, 2009)
STEP 4
Nutrition Monitoring & Evaluation
a. Monitor adequacy of intake
b. Evaluate diet tolerance
c. Document results of calorie counting in the
patient’s chart
d. Conduct re-assessment, if necessary
e. Monitor provision of ONS (if given)
f. Monitor provision of artificial nutrition (if
warranted)
Diet Rx: Full diabetic diet 1550 kcal CHO 185 g Protein 50 g
Fat 70 g , <2000 mg Na, <2000 mg K, 800 mg P, 750 mg Ca,
1500 mL fluid divided into 3 meals and 2 snacks
(Note: See p 71 for translation of dietary prescription into meal plan)
STEP 3 (cont’d.)
Nutrition Intervention
Development of Care Plan
c. Determine electrolytes, fluid and other
micronutrients requirement based on
clinical findings and guideline
recommendations
d. Write diet prescription to physician
e. Document diet prescription in the patient’s
chart
f. Consider ONS to augment for inadequate
intake
g. Consider artificial nutrition (when
necessary)

Page | 72
HOW TO USE THE FOOD EXCHANGE LIST IN KIDNEY DISEASE
After formulating the diet prescription, this is then translated into food items. Using the sample prescription, follow the
steps below:
Steps:
1. Determine the percentage to be allotted for HBV and LBV (i.e. 60-70% HBV and 30-40% LBV) then multiply
with the prescribed protein.
Example: HBV protein = 0.7 (50 g) = 35 g
LBV protein = 0.3 (50 g) = 15 g
2. Distribute HBV protein into foods. Consider patient’s preferences in distributing HBV into (optional) and
meat and milk exchange (optional).
3. Divide the HBV protein by 8 to determine number of meat exchanges (one meat exchange = 8g protein) and
the remaining for the milk exchange.
Protein (HBV) = 35 g ÷ 8 g protein
= 4.375 or 4 exchanges of HBV protein
Diet Rx : Full diabetic diet 1550 kcal Carbohydrate 185 g Protein 50 g Fat 70 g ,
<2000 mg Na, <2000 mg K, 800 mg P, 750 mg Ca, 1500 mL fluid divided into 3 meals and
2 snacks

Renal Exchange List - prototype-for-Research Through Design

Renal Exchange List - prototype-for-Research Through Design

Recommended

Recommended

More Related Content

Similar to Renal Exchange List - prototype-for-Research Through Design

Similar to Renal Exchange List - prototype-for-Research Through Design (20)

Recently uploaded

Recently uploaded (20)

Renal Exchange List - prototype-for-Research Through Design