Topic: Renal nutrition Faculty: Medicine Course: BSc RDT - 2nd year Subtopics: - Protein-Energy Wasting(PEW) - Nutritional requirements in dialysis - Special diets - Supplementation of vitamins and minerals - Routes of nutrition - Nutrition after kidney transplantation

1. Renal Nutrition
Dr. Salman Ansari
Kanachur Institute of Medical Sciences

2. Contents
- Protein-Energy Wasting(PEW)
- Nutritional requirements in dialysis
- Special diets
- Supplementation of vitamins and minerals
- Routes of nutrition
- Nutrition after kidney transplantation

3. Protein-Energy Wasting(PEW)
- Decline in body stores of protein, with or without fat
depletion, due to inadequate nutrient intake and can
be improved by nutritional replacement
- 40% of ESKD patients have PEW
- Poor nutritional status before starting dialysis leads to
poor outcomes in dialysis

4. Causes of PEW in ESKD
● Increased requirement: due to comorbid conditions,
sepsis
● Dialysis: leads to loss of nutrients through dialysis, protein
catabolism
● Decreased intake: due to nausea
● Metabolic acidosis
● Insulin resistance: leads to increased breakdown of
protein

5. Nutritional requirements in HD and PD
- Appetite and food intake gradually improve as uremia comes
down with dialysis
- Initially, there may be loss of protein through dialysis

8. How to achieve nutritional aims?
Energy:
In PD:
- Avoid higher dextrose concentration dialysate in obese
and diabetic patients
- Energy restriction in PD patients to compensate for
additional calories absorbed from dialysate patient
- Higher glucose dialysate is hypertonic, which can cause
damage to peritoneal membrane, leading to
hyperpermeability and weight gain

9. Energy(...continuation):
In HD:
- They have more difficulty reaching recommended energy
intake and need advice to increase intake, using energy-
rich foods or energy supplements

10. Protein:
- High protein requirement is difficult to reach with diet alone
- Increase intake of protein-rich foods and snacks
- Protein supplements

11. Potassium:
- In PD, potassium restriction is rarely needed in PD due to
continuous clearance
- In HD, dietary potassium restriction depending upon residual
renal function
- Limit potassium-rich foods such as:
- Fruits: banana, avocado, dried fruits
- Vegetables: spinach, mushroom, beetroot, unboiled
potatoes
- Drinks: fresh fruit juices, coffee, drinking chocolate, milky
drinks
- Others: chocolate, condensed milk, nuts

13. - Advice on cooking with water(as potassium is water
soluble):
- Use large volumes of water for boiling vegetables and
discard this cooking water
- Boil potatoes
- Avoid pressure cookers

14. Phosphate:
- PD and HD are both not effective at clearing phosphate
- Dietary restriction of phosphate rich foods is necessary
- Phosphate binders need to be taken with or immediately
after food
- Some phosphate-rich foods are:
- Milk
- Cheese
- Dairy products
- Chocolate
- Dried fruit
- Eggs
- Fish
- Nuts
- Meat and poultry

16. Special diets:
Vegetarian or vegan diet:
- Less in protein - protein supplementation
- Higher in potassium and phosphate
- Vitamin B12 deficiency
Fasting
Cooking methods:
- Curries, stir-fries

17. Foods rich in sodium:
- Soy sauce
- Pickles
- Chevda
- Salted fish
- MSG(monosodium glutamate)

18. Chevda

20. - Star fruit-induced nephrotoxicity: it is toxic in renal
failure
- Leads to intractable hiccoughs, agitation, muscle
weakness, confusion and fits
- It can be fatal
- Rich in oxalates

21. Supplementation of vitamins and trace elements
Vitamins:
- Water soluble vitamins like vitamin B group, vitamin C and folic
acid(vitamin B9)
- Vitamin A: not routinely given
- Vitamin E: protective effect in coronary heart disease
Trace elements(minerals):
- Deficiencies in zinc, copper, manganese, chromium and
selenium

23. Intradialytic nutrition
- Intradialytic parenteral nutrition(IDPN)
- Used for supplementing energy and protein intake during
each HD session
- Provides nutrients
- Up to 1100 kcal and 50 g protein per session

24. Routes for nutritional support
- Feed orally wherever possible
- Enteral tube feeding: if requirements cannot be met through
oral means alone and gut is functioning
- Parenteral nutrition: in patients with impaired GI function

25. Fluid requirements
- Management depends upon residual renal function and mode of dialysis
- If patient has a urine output of >1L/day, they do not need strict fluid
restriction
- Sodium intake: ‘no added salt’ diet, which is 5-6 g of salt per day
Fluid restriction in PD:
- Fluid loss by UF depending on dextrose concentration of dialysate(up to
2L/day)
- Volume of UF together with volume of urine passed in previous 24 hours
and 500 mL of insensible losses per day will give the recommended fluid
intake per day

26. Fluid restriction in HD:
- They are usually anuric, hence require severe fluid restriction
- Volume of urine passed in previous 24 hours and 500 mL daily
for insensible losses
- Sodium restriction

27. Diet after renal transplant
- After kidney transplantation, follow a diet low in salt, high in fiber
- Take high calorie foods, more dairy products
- Balanced diet including a variety of fresh fruits and vegetables,
lean meats, low-fat dairy products, whole grains and plenty of
water
- Sugar-free drinks, unsweetened tea, coffee
- Avoid raw or undercooked meats, undercooked eggs
- Avoid grapefruit and pomegranate juice(interactions with
immunosuppressive medicines)
- Avoid unwashed raw fruits and damaged fruits, unwashed raw

28. Questions:
LE: -
SE:
- Nutrition in CKD patients on dialysis
- Renal diet during peritoneal dialysis
SA:
- Mention any 3 foods rich in potassium
- Is potassium good for hemodialysis patients? Give reasons for your answer.
- Recommended protein intake in PD patient.
- What are the types of food the patient has to include in their diet post renal
transplantation?

29. References:
● Oxford Handbook of Dialysis, 4th Ed.
● Foods to Avoid After Transplantation -
National Kidney Foundation
Questions:
salman.s.ansari92@gmail.com
For PPT, scan: