Professional Refresher

Nutrition Care for Patients With Chronic Renal Failure

Medical nutrition therapy for management of renal disease is sometimes complex. Comorbidities, such as obesity, hypertension, and diabetes, can make nutrition recommendations more complicated.

The presence of kidney disease is established by level of glomerular function, or glomerular filtration rate (GFR). GFR is estimated from predictive equations using serum creatinine levels. The National Kidney Foundation has an online GFR calculator at http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm.

Scientific consensus defines the 5 stages of chronic kidney disease as follows:

Stage	Description	GFR (mL/min/1.73m^2)
1	Kidney damage, but normal to increased kidney function	90-130
2	Mild decrease in kidney function	60-89
3	Moderate decrease in kidney function	30-59
4	Severe decrease in kidney function	15-29
5	Kidney failure, defined as end-stage renal disease, dialysis usually initiated	<15

Source: National Kidney Foundation

A summary of the current nutrition guidelines for management of adults with kidney disease is below.

Stages 1-4 chronic kidney disease (impaired renal function, predialysis)

â–ª Energy: 30 kcal/kg body weight for those < 60 years of age, 30-35 kcal/kg for those >60 years of age

▪ Protein: 0.6-0.75 g/kg body weight, ≥50% of HBV

â–ª Fluid: No restriction

â–ª Sodium: 1-3 g/day

â–ª Phosphorus: 800-1000 mg/day if serum phosphorus is >4.6 mg/dL or parathyroid hormone is elevated

â–ª Potassium: May need to increase to cover losses with diuretics; may need to restrict if serum potassium is elevated

Stage 5 chronic kidney disease (hemodialysis)

▪ Energy: 35 kcal/kg body weight for those <60 years, 30-35 kcal/kg body weight for those ≥60 years

▪ Protein: ≥1.2 g/kg body weight

â–ª Fluid: Urine output plus 1000 cc

â–ª Sodium: 1-3 g/day

â–ª Phosphorus: 800-1000 mg/day when serum phosphorous is >5.5 mg/dL or parathyroid hormone is elevated

â–ª Potassium: 2-3 g/day, adjust as needed based on serum K levels

Stage 5 chronic kidney disease (peritoneal dialysis)

▪ Energy: 35 kcal/kg for those <60 years, 30-35 kcal/kg for those ≥60 years

▪ Protein: ≥1.2-1.3 g/kg of body weight

â–ª Fluid: Maintain fluid balance

â–ª Sodium: 2-4 g/day

â–ª Phosphorus: 800-1000 mg/day when serum phosphorous is >5.5 mg/dL or parathyroid hormone is elevated

â–ª Potassium: 3-4 g/day, adjust as needed based on serum K levels

Kidney transplant

â–ª Energy: 30-35 kcal/kg body weight

â–ª Protein: 1.3-2 g/kg body weight

â–ª Fluid: No restriction

â–ª Sodium: Varies depending on comorbidities

â–ª Phosphorus: 1.2 g/day

â–ª Potassium: Varies depending on serum levels; may need to restrict with cyclosporine-induced hyperkalemia

Vitamins and minerals in end-stage renal disease

Vitamin and mineral supplements are sometimes indicated, particularly for those receiving hemodialysis or peritoneal dialysis. The American Dietetic Association Nutrition Care Manual recommends the following daily intake of vitamins and minerals for dialysis patients. Supplements are sometimes recommended based on dietary intake of foods and fortified foods.

â–ª Vitamin C: 60-100 mg/day

â–ª Vitamin B₆: 2 mg/day

â–ª Folate: 1 mg/day

â–ª Vitamin B₁₂: 3 mcg/day

â–ª Vitamin E: 15 IU/day

â–ª Zinc: 15 mg/day

â–ª Iron and Vitamin D: Individualize based on medical condition and serum levels

â–ª B vitamins:

- Hemodialysis: Dietary Reference Intakes

- Peritoneal dialysis: May need 1.5-2 mg/day of B₁ because of dialysis losses

Implications for dietetics practitioners

It is important to weigh the potential benefits of protein restriction in predialysis patients with the potential risk for malnutrition. Before prescribing medical nutrition therapy for patients with renal disease, consider the patient's ability and willingness to adhere to strict dietary restrictions.

References

American Dietetic Association. ADA Nutrition Care Manual. Available online to subscribers at: www.nutritioncaremanual.org. Accessed March 6, 2008.

Mahan KL, Escott-Stump S. Krause's Food and Nutrition Therapy. 12th ed. St Louis, MO: WB Saunders; 2008.

National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Available at: http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqi_nut.html.

Accessed March 6, 2008.

Review Date 5/08

R-0525

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