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Nutrition for Renal Patients

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A highly selective and complicated process.

The formulation of the renal diet is relatively

complex compared to planning of other modifieddiets.

Diets for renal patients must be carefully and

simultaneously regulated 6 components must be regulated:

Protein

Sodium

Potassium

Phosphorus

Calcium

Fluid

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Three major functions of the kidneys are:

1. To excretethe waste products of protein

breakdown

2. Toregulatethe blood levels of electrolytes and

maintain fluid balance in the body3. Toproducerenin and erythropoietin which

affects blood pressure and stimulates the

production of red blood cells

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When kidney are diseased,

less able to get rid the body of waste products of

protein metabolism, excess electrolytes and fluid. The waste products accumulate in the:

tissues and blood;

uremia

the final common pathway of chronic progressive kidneydisease develops.

To avoid such accumulation of more waste

products from the food and liquids in the diet

proper dietary control must be exercised.

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Dietary modifications for patients with

impaired or absent renal function aim to:

1. Maintain or improve nutritional status

2. Minimize uremic toxicity

3. Retard progression of renal failure

4. Promote patients well-being

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PROTEIN

The major end products protein metabolism arenon-protein nitrogen urea, urea acid, organic acids, carbon dioxide and

water normally eliminated through the kidneys.

When kidneys are not functioning normally, thesewaste products are not excreted properly Thus, nitrogen accumulates in the blood and tissues

Causing anorexia, nausea and vomiting, drowsiness and ageneral feeling of ill health

Thus in renal patient : Protein intake must beRESTRICTED

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The level of protein intake is determined by

the patients symptoms as well as the degreeof impairment of renal function as shown by

creatinine clearance.

Creatinine Clearance Daily Protein Intake

Ml/min g/Kg

30 to 20 0.60

19 to 5 0.45

5 0.30

the higherthe creatinine clearance, the greaterthe level of protein allowed

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For children, protein intake should not be lessthan 1.0 to 1.3 g/kg per dayto assure

adequate protein supply for growth.

If there is loss of protein in the urine

the diet should provide an equal quantityto

replace this.

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Sources of protein:

Egg whites (best soure of high quality protein)

Meat, fish, Milk and whole eggs are other good

sources.

The amount of rice and high proteinvegetables need to be regulated as the

proteins in these foods are oflower biological

value.

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Minerals

Excess and deficiencies of certain electrolytes

as a consequence of kidney malfunction are

common features of renal disease

These can lead to disruption of other body

processes

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SODIUM

Hypernatremia

May lead to:

High blood pressure

Edema Weight gain

Hyponatremia

May lead to:

Low blood pressure

Depletion of extracellularfluid volume

Rapid weight loss

Further deterioration in

excretory capacity

It is therefore important to control and regulate the sodium intake of patients with renal disease.

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The level of sodium intakes should be specific

to the patients need

When there is edema and HPN

Na intake of 60 to 90 mEq (1380-2070mg)/day isindicated

In extremelyedematous patients (stricter control)

Intake of less than 60 mEq (1380mg)/day

table salt- greatest source of sodiumSodium is naturally present in nearly all foods and

beverages but it differs in various foods.

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POTASSIUM

Potassium accumulates in the body if the

kidneys are not functioning properly

Too much potassium intake will cause:

headache, vomiting, bradycardia and cardiac arrest.

Daily intake: should notexceed 70mEq

(2370mg)/day

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Careful food selection is important to controlpotassium levels in renal patients.

Sources of Potassium:

Fruits ideal for low soduim and protein content

Vegetables vary in their potassium content

Instant coffee- provide significant amounts of

potassium

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Phosphorus and Calcium

Phosphate retention occurs with decline in

renal function

As a result serum Calcium goes down

A lower serum Calcium concentration

stimulates an increase in the secretion of PTH w/c

results to withdrawal of calcium from the bones.

Thus, bones may develop abnormalities too.

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Level of Phosphorus restriction may range

from 45 to 65 mEq (700-1000mg) daily Use of phosphate bunders

Aluminum hydroxide

Renders Phosphate unabsorbablein the intestine

Increase in calcium needs are often best met

by calcium supplements

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FLUIDS

Impairment of kidney function Reduced ability to conserve to or eliminate excess

fluid.

Advised to consume 500-600ml fluid more thantheir 24 hour urine output Provide for insensible daily loose of water via:

Lungs, skin and the water in the feces

Excessive fluid intake: edema( swelling of the hands and feet with body

weight gain)

HPN, and

shortness of breath

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CALORIES

To maintain the desirable body weight

Adults usually needs at least 35 kcal/kg desirable

body weight per day

Children should be no less than 80% of their

recommended allowance for age (60-80 kcal/kg)

to prevent growth retardation

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Mechanic for Prescription Writing

for Protein, sodium, Potassium,

Phosphorus, Calcium and FluidControlled Diet

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1. Consider the laboratory results and clinical

findings of the patient.

e.g. a hypothetical weight with the followingdata

Desirable body weight - 62kg

Present weight -58 kg(wet weight)

Creatinine Clearance -20 ml/min

Potassium(serum) - 6 mg/dl

Phosphorus -5.5mg/dl

Calcium -7.0mg/dl

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2. Calculate the protein level..

Grams protein = 0.60g/kg x 62kg

= 40 g

Creatinine clearance(ml/min) Daily CHON intake(g/kg)

30-20 0.60

19-5 0.455 0.30

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3. Calculate the total energy requirement (TER).Since the patient is underwieight,allow atleast

40 kca/kg desirable body weight. Thus,

TER= 40 kcal x 62kg

= 2500 kcal

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4. Calculate non-CHON calories by subtracting

CHON calories fro TER.

CHON calories = 40gx 4kcal

= 160 kcal

Non CHON

Calories = 2500kcal- 160 kcal

= 2340kcal

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5. Divide non- CHON calories into

CHO : 55-80%

Fat : 20-45%Compute for grams CHO and fat by dividing the calories

from CHO and fat by their respective fuel value.

Calories from CHO = 70% (2340) = 1638 kcal

= 1638 kcal/ 4 kcal/g

= 410 g

Calories from fat = 30% (2340)= 702kcal

= 702 kcal/ 9 kcal

= 78 g

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6. Specify the level of Sodium, potassium,

calcium, phosphorus, and fluid based on the

clinical symptoms and biochemical findings.e.g.

Rx diet= 2500 C410P40F75

= 2000mg Na (87 meq)1

= 1600 mg K (41 meq) 1

= 500 mg Phosphorus (39meq)1

= 1200 mg Calcium (60 meq)1

= 1500 ml fluid

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To convert mg to meq:

mg/ atomic weight x valence = meq

Na: mg Na/ 23 x 1K : mg K/ 39 x 1

P: mg P/ 31 x 2

Ca: mg Ca/ 40 x 2

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PEDIATRIC Case

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CASE:

Hypothetical pediatric

patient:

Age: 5 y/o

Gender: Male Ht.: 98 cm

Present weight: 16 Kg

DBW: 18 Kg

Creatinine clearance: 20ml/min

Serum creatinine:1.5mg/dl

Potassium: 5.5 mEq/L

Phosphorus: 4.0 mg/dL

Calcium: 6.0 mg/dL

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Computation of DBW in Pedia

< 6 months = Age (mos) x 600 + BW (grams)

6-12 months= Age (mos) x 500 + BW (grams)

Average BW of Filipino is 3000 g (3 Kg)

1-6 y/o = Age (yrs) x 2 + 8

7- 12 y/o= Age (yrs) x 7 5

2

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Creatinine clearance:

CC = (140-age) x BW

serum crea (mg/dL) x 72

= (140-5) x 16kg

1.5mg/dL x 72= 2160 kg

108 mg/dL

= 20 mL/min

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PROTEIN LEVEL

Daily protein intake = 1.0-1.3 g/Kg/Day

g CHON = daily protein intake x DBW

= 1.3 g/kg x 18 kg

= 23.4 = 23 g

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CALORIE INTAKE

60-80 kcal/kg/day

patient is underweight = allow 80kcal/kg

(TER)kcal = 80kcal/kg x DBW

= 80 kcal/kg x 18 kg

= 1440 kcal

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Non-Protein Calories

Kcal CHON = 23g x 4 kcal/g CHON

= 92 kcal

NPC = 1440 kcal 92 kcal

= 1348 kcal

1348 kcal will be distributed to CHO (55-80%)and fats (20-45%)

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CHO AND FATS

g CHO = 60% (1348) / 4

= 202 g

g fats = 40% (1348) / 9

= 60 g

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Na:

2-4 meq/kg/dayK:1-2 meq/kg/day

Ca:20-30 mg/kg/day

Recommended

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Computations (lower limit x actual wt.)

Na = 2meq/kg/day x 16 kg

= 32 meq/day

Milligrams to milliequivalent: (page 99)

mEq = mg x valence

Atomic wt.

Milliequivalent to milligrams:

mg = mEq x atomic wt

valence

Mg (Na) = 32 x 23

1= 736 mg Na = 750mg Na

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Computations (lower limit x actual wt.)

K = 1meq/kg/day x 16 kg

= 16 meq/day

Milligrams to milliequivalent: (page 99)

mEq = mg x valence

Atomic wt.

Milliequivalent to milligrams:

mg = mEq x atomic wt

valence

Mg (K) = 16 x 39

1= 624 mg K = 650mg K

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Computations (lower limit x actual wt.)

Ca = 20mg/kg/day x 16 kg

= 320 mg/day

Milligrams to milliequivalent: (page 99)

mEq = mg x valence

Atomic wt.

mEq = 320 x 2

40

= 16 mEq Ca

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Computations (lower limit x actual wt.)

P = 20mg/kg/day x 16 kg

= 320 mg/day

Milligrams to milliequivalent: (page 99)

mEq = mg x valence

Atomic wt.

mEq = 320 x 2

31

= 21 mEq Ca

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DIET RX

1440 CHO 202 CHON 23 Fats 60

750 mg (32 mEq) Na

650 mg (16 mEq) K

320 mg (21 mEq) P

320 mg (16 mEq) Ca

700 ml fluid

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Protein Biological Value

HBV protein = 2/3 x 23g

= 15 g

LBV protein = 1/3 x 23g

= 8 g

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2. Distribute HBV protein into foods.

allocate milk allowance

after that divide remaining HBV protein by 8

to determine meat exchange.

HBV=15g

In this patient: exchange of milk = 4g1 exchange of meat =12g

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3. Distribute LBV protein into foods.

Determine exchange of vegetables Then divide the remaining LBV protein by 2 to

determine rice exchange.

LBV=8g

in this patient:

2 exchanges of vegetables B = 2g

3 exchanges of rice = 6g

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4. Distribute CHO to fruits considering K prescription .

Compute the amount of CHO coming from milk,

vegetables and rice and fruits.

Subtract this from prescribed CHO.

Divide the answer by 5 to determine exchange of

sugar.Total CHO: 202

exchange of milk = 6g

2 exchanges of Vegetable B = 6g6 exchanges of fruits = 60g

3 exchanges of rice = 69g

141 g

202 141 = 61g

61 / 5 = 12 exchanges of

sugar

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5. Compute the amount of fat coming from

milk and meat.

Subtract this from prescribed fat and divide it

by 5 to determine fat exchange.

Total fat: 60g

In this patient: exchange of milk = 5g

1 exchange of meat =3g

8g

60 8 = 52g / 5 = 10 exchanges of fat

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TOTAL PRESCRIBEDCHON: 24gCHO: 201g

Fats: 60g

Na: 703mgK: 651mg

Ca: 298mg

P: 320mgFluids: 250mL

CHON: 23gCHO: 202g

Fats: 60g

Na: 750mgK: 650mg

Ca: 320mg

P: 320mgFluids: 700mL

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Fluid Prescription

Use the formula:

Fluid Requirement= BSA x IWL + 24 hr UO

2

Legend:

IWL (Insensible Water Loss)

= 400-600 ml/m2/day

UO = 600-1000ml/m2/day

BSA= Kg (actual BW) x ht (cm)

3600

= 16 kg x 98 cm

3600

= 0.66 m2

FR = 0.66 x 600ml + 1000ml

2

= 698 ml = 700ml

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Additional oral Fluid

Fluid prescription Inherent fluid

= 700 mL 250mL

= 450mL

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Additional sodium required

=Sodium prescription Inherent sodium

=750 mg 703 mg

=47 mg

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Additional Calcium

Calcium prescriptionInherent

Calcium= 320 mg 298 mg

= 22 mg

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SAMPLE MEAL PLAN

# 0f

exchanges

Breakfast Lunch Snacks Dinner

Veg B 2 1 1

Milk

Meat B 1 Rice 3 1 1 1

Fruits 6 2 2 1 1

Sugar 12 3 3 3 3

Fat 9 3 3 3

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BREAKFAST

1 cup buttered Rice 1 rice, 3 fat

Hard Boiled egg meat

glass powdered milk milk

3 candies 3 sugar

2 medium slice mango 2 fruits

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LUNCH

Ginataang Tilapia meat, 1 veg B, 3 fat

with Malunggay

1 cup Rice 1 rice,

1 glass soft drink 3 sugar

8 pcs Lychees 2 fruits

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SNACK

Half glass pineapple juice 1 fruit

cup banana cracker

with latik 3 sugar, 3fats

100 ml water

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DINNER

1 cup plain rice 1 rice

Porkchop w/ 2talong meat, 1 veg B

1 med. Pears 1 fruit

1 pc Pulburon 3 sugar

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Chronic Renal Insufficiency Diet = Pre- dialysis Diet

Aim:

1. Reduce the workload of diseased kidney by reducing urea, uric acid,

creatinine and electrolytes (esp. Phosphates) that must be excreted;

2. Prevent acceleration of nephrotic damage resulting from excessive

protein intake;3. Prevent calcification secondary to renal dystrophy;

4. Prevent renal osteodystrophy; and at the same time,

5. Promote a feeling of well-being and postpone the need for dialysis

Diet Prescription

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Diet Prescription The diet order should state the level of calories, protein and

electrolytes desired.

Dietary factor Recommendation

Protein (g/kg IBW) 0.6-0.8

Energy (kcal/kg IBW) NW: 35 kcal/ kg IBW

Obese: 20-30Catabolic: 50

Phosphorus (mg/kg IBW) 8-12

Sodium (mg/day) 1000-3000

Potassium Typically not restricted

Fluid Typically restricted

Calcium (mg/day) Typically not restricted

Fiber 20-25 g/d

Food Selection Guide

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Food Selection Guide

Food Group Allow Avoid or Restrict

Vegetable All fresh Legumes, pickled,

fermented, canned or frozen

Fruit All except on avoided list Marachino cherries,

candied/dried fruits

Milk Evaporated, whole In excess of milk mixes,

sherbet, cocoaRice Rice, bread, bihon, corn,

spaghetti

Commercially prepared

dessert, mixes, pastries

Meat or Substitute All except nuts In excess nuts, beans, seeds

Fat Cooking fats, salad oils Coconuts, other nuts

Sugar and sweet dessert Low protein-dessert as

pudding, nata de coco,

kondol

Those with chocolates or

nuts, milk and eggs

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Chronic Renal Failure

Aim:

1. Meet nutritional requirement;

2. Minimize uremic complications;

3. Maintain acceptable blood chemistries, BP and fluid status;

4. Promote well-being

Note: Diet has controlled amounts of CHON, K, Na, P and fluids.

Modification of fat, cholesterol, triglycerides and fiber depend

on individual requirements.

Di t P i ti

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Diet Prescription

Dietary Factor Hemodialysis Peritoneal Dialysis

Protein (g/kg IBW) 1.1-1.4 at least 1.2-1.5Energy (kcal/kg IBW) 30-35 wt. maintenance

25-30 for reduction

40-50 for wt. gain

25-35 maintenance

35-50 for repletion

20-25 reduction

35 id with Diabetes

Phosphorus 800-1200 mg/d 1200 mg/dSodium 2000-3000 mg/d Individualized based on BP

Potassium 40 mg/ kg IBW Gen. unrestricted

Fluid 500-750 ml/d + daily u.o. In CAPD &CCPD 2000-3000

ml/d

Calcium 1000-8000 mg/d Same as for hemodialysis

Fat

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Dietary Modifications

Multiply vol. of each dialysate exchange in L by its glucose

concentration/L (g of glucose) to obtain grams of glucose indialysate exchange to determine total grams of glucose.

Multiply total grams of glucose by approximate absorptionrate of 80%.

Multiply total grams of glucose absorbed by the calories/gram of glucose (3.7 kcal/g) to determine total caloriesabsorbed from dialysate solution.

Ex: 2 L of 2.5% soln 2L X 25g glucose

=50g total glucose

50 g glucose X 0.80= 40g glucose absorbed

40g X 3.7 kcal/g= 148 kcal from dialysate soln

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Acute Renal Failure

Aim:

1. Reduce the accumulation of uremic toxins;

2. Control electrolyte abnormalities;

3. Correct fluid retention;

4. Maintain nutritional status

Note: Control CHON, Na, K, P and fuids.

Diet order should state the calorie, protein, electrolyte

levels desired.

Di t M difi ti

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Dietary Modification

Dietary factor Recommendation

Protein 0.5-0.6 g/kg

Energy 35-50 kcal/kg

Phosphorus individualized

Sodium Anuric-oliguric phase: 500-1000 mg/d

Potassium Anuric-oliguric phase: 1000 mg/d

Fluid Assess on daily basis

Calcium I individualized

Fat No modification needed

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Post Kidney Transplantation

Aim:

1. Provide adequate calories and protein to

counteract the catabolic effects of surgery

2. Manage nutritional side effects ofimmunosuppressive drugs

Di t M difi ti

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Dietary ModificationsDietary factor First month after

transplant & duringtreatment for acute

rejection

After first month

Protein 1.3-1.5 g/kg/d 1.0 g/kg/d

Calories 30-35 kcal/kg/d sufficient mantain

Carbohydrates Encourage complex type same

Fats

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Nephrotic Syndrome

Aim:

1. Minimize edema and proteinuria

2. Control hypertension

3. Retard the progression of renal disease

4. Prevent muscle catabolism and protein

malnutrition

5. Supply adequate energy

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Dietary Modifications

Dietary factor Recommendation

Protein Adult: 0.6-1.0 g/kg IBW + replacement of

urinary CHON losses

Children: RDA for age + replacement of

urinary CHON losses

Sodium 1-3 g/day

Fluids Generally unrestricted

Fats