Nutrition for Renal Patients

A highly selective and complicated process. The formulation of the renal diet is relatively complex compared to planning of other modified diets. Diets for renal patients must be carefully and simultaneously regulated
6 components must be regulated:
Protein Sodium Potassium Phosphorus Calcium Fluid

Three major functions of the kidneys are:

1. To excrete the waste products of protein breakdown 2. To regulate the blood levels of electrolytes and maintain fluid balance in the body 3. To produce renin and erythropoietin which affects blood pressure and stimulates the production of red blood cells

 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 kidney disease develops.

To avoid such accumulation of more waste products from the food and liquids in the diet
proper dietary control must be exercised.

Dietary modifications for patients with impaired or absent renal function aim to:
1. 2. 3. 4. Maintain or improve nutritional status Minimize uremic toxicity Retard progression of renal failure Promote patients well-being

PROTEIN
The major end products protein metabolism are non-protein nitrogen
urea, urea acid, organic acids, carbon dioxide and water
normally eliminated through the kidneys.

When kidneys are not functioning normally, these waste products are not excreted properly
Thus, nitrogen accumulates in the blood and tissues
Causing anorexia, nausea and vomiting, drowsiness and a general feeling of ill health

Thus in renal patient : Protein intake must be RESTRICTED

 The level of protein intake is determined by the patients symptoms as well as the degree of impairment of renal function as shown by creatinine clearance.
Creatinine Clearance Ml/min
30 to 20 19 to 5 5

Daily Protein Intake g/Kg

0.60 0.45 0.30

the higher the creatinine clearance, the greater the level of protein allowed

 For children, protein intake should not be less than 1.0 to 1.3 g/kg per day to assure adequate protein supply for growth.
If there is loss of protein in the urine
the diet should provide an equal quantity to replace this.

 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 protein vegetables need to be regulated as the proteins in these foods are of lower biological value.

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

SODIUM
Hypernatremia
May lead to:

Hyponatremia
May lead to:

High blood pressure Edema

Weight gain

Low blood pressure Depletion of extracellular fluid 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.

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 is indicated

In extremely edematous patients (stricter control)

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

table salt- greatest source of sodium

Sodium is naturally present in nearly all foods and beverages but it differs in various foods.

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 not exceed 70mEq (2370mg)/day

Careful food selection is important to control potassium 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 potassium

of

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.

 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

FLUIDS
Impairment of kidney function
Reduced ability to conserve to or eliminate excess fluid.

Advised to consume 500-600ml fluid more than their 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

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

Mechanic for Prescription Writing for Protein, sodium, Potassium, Phosphorus, Calcium and Fluid Controlled Diet

 1. Consider the laboratory results and clinical findings of the patient. e.g. a hypothetical weight with the following data 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

2. Calculate the protein level.. Grams protein = 0.60g/kg x 62kg = 40 g

Creatinine clearance(ml/min) 30-20 19-5 5 Daily CHON intake(g/kg) 0.60 0.45 0.30

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

4. Calculate non-CHON calories by subtracting CHON calories fro TER. CHON calories = 40gx 4kcal = 160 kcal Non CHON Calories = 2500kcal- 160 kcal = 2340kcal

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

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

To convert mg to meq:
mg/ atomic weight x valence = meq Na: mg Na/ 23 x 1 K : mg K/ 39 x 1 P: mg P/ 31 x 2 Ca: mg Ca/ 40 x 2

PEDIATRIC Case

CASE:
Hypothetical pediatric patient:
Age: 5 y/o Gender: Male Ht.: 98 cm Present weight: 16 Kg DBW: 18 Kg Creatinine clearance: 20 ml/min Serum creatinine: 1.5mg/dl Potassium: 5.5 mEq/L Phosphorus: 4.0 mg/dL Calcium: 6.0 mg/dL

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

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

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

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

Non-Protein Calories
Kcal CHON = 23g x 4 kcal/g CHON = 92 kcal = 1440 kcal 92 kcal = 1348 kcal

NPC

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

CHO AND FATS

g CHO = 60% (1348) / 4 = 202 g

g fats

= 40% (1348) / 9 = 60 g

Recommended
Na: 2-4 meq/kg/day K: 1-2 meq/kg/day Ca: 20-30 mg/kg/day

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 Mg (Na) = 32 x 23 1 = 736 mg Na = 750mg Na

valence

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 Mg (K) = 16 x 39 1 = 624 mg K = 650mg K

valence

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 mEq = 320 x 2 40 = 16 mEq Ca

Atomic wt.

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 mEq = 320 x 2 31 = 21 mEq Ca

Atomic wt.

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

Protein Biological Value

HBV protein = 2/3 x 23g = 15 g
LBV protein = 1/3 x 23g =8g

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 = 4g 1 exchange of meat =12g

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

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 = 6g 6 exchanges of fruits = 60g 3 exchanges of rice = 69g
141 g 202 141 = 61g 61 / 5 = 12 exchanges of sugar

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

TOTAL
CHON: CHO: Fats: Na: K: Ca: P: Fluids: 24g 201g 60g 703mg 651mg 298mg 320mg 250mL

PRESCRIBED
CHON: CHO: Fats: Na: K: Ca: P: Fluids: 23g 202g 60g 750mg 650mg 320mg 320mg 700mL

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

Additional oral Fluid

Fluid prescription Inherent fluid = 700 mL 250mL = 450mL

Additional sodium required

=Sodium prescription Inherent sodium =750 mg 703 mg =47 mg

Additional Calcium
Calcium prescriptionInherent Calcium = 320 mg 298 mg = 22 mg

SAMPLE MEAL PLAN

# 0f exchanges
Veg B Milk Meat B Rice Fruits Sugar Fat 2

Breakfast

Lunch
1

Snacks

Dinner
1

1
3 6 12 9

1 2 3 3

1 2 3 3 1 3 3

1 1 3

BREAKFAST
1 cup buttered Rice Hard Boiled egg glass powdered milk 3 candies 2 medium slice mango 1 rice, 3 fat meat
milk

3 sugar 2 fruits

LUNCH
Ginataang Tilapia with Malunggay 1 cup Rice 1 glass soft drink 8 pcs Lychees
meat, 1 veg B, 3 fat

1 rice, 3 sugar 2 fruits

SNACK
Half glass pineapple juice cup banana cracker with latik 100 ml water 1 fruit 3 sugar, 3fats

DINNER
1 cup plain rice 1 rice Porkchop w/ 2talong meat, 1 veg B 1 med. Pears 1 fruit 1 pc Pulburon 3 sugar

Chronic Renal Insufficiency Diet = Pre- dialysis Diet

Aim:
1.
2. 3. 4. 5.

Reduce the workload of diseased kidney by reducing urea, uric acid, creatinine and electrolytes (esp. Phosphates) that must be excreted; Prevent acceleration of nephrotic damage resulting from excessive protein intake; Prevent calcification secondary to renal dystrophy; Prevent renal osteodystrophy; and at the same time, Promote a feeling of well-being and postpone the need for dialysis

Diet Prescription
The diet order should state the level of calories, protein and electrolytes desired.
Dietary factor Protein (g/kg IBW) Energy (kcal/kg IBW) Recommendation 0.6-0.8 NW: 35 kcal/ kg IBW Obese: 20-30 Catabolic: 50 8-12 1000-3000 Typically not restricted Typically restricted Typically not restricted 20-25 g/d

Phosphorus (mg/kg IBW) Sodium (mg/day) Potassium Fluid Calcium (mg/day) Fiber

Food Selection Guide

Food Group Vegetable Fruit Milk Rice Meat or Substitute Fat Sugar and sweet dessert Allow All fresh All except on avoided list Evaporated, whole Rice, bread, bihon, corn, spaghetti All except nuts Cooking fats, salad oils Low protein-dessert as pudding, nata de coco, kondol Avoid or Restrict Legumes, pickled, fermented, canned or frozen Marachino cherries, candied/dried fruits In excess of milk mixes, sherbet, cocoa Commercially prepared dessert, mixes, pastries In excess nuts, beans, seeds Coconuts, other nuts Those with chocolates or nuts, milk and eggs

Chronic Renal Failure

Aim:
1. 2. 3. 4. Meet nutritional requirement; Minimize uremic complications; Maintain acceptable blood chemistries, BP and fluid status; 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.

Diet Prescription
Dietary Factor Protein (g/kg IBW) Energy (kcal/kg IBW) Hemodialysis 1.1-1.4 at least 30-35 wt. maintenance 25-30 for reduction 40-50 for wt. gain 800-1200 mg/d Peritoneal Dialysis 1.2-1.5 25-35 maintenance 35-50 for repletion 20-25 reduction 35 id with Diabetes 1200 mg/d

Phosphorus

Sodium
Potassium Fluid Calcium Fat Fiber

2000-3000 mg/d
40 mg/ kg IBW 500-750 ml/d + daily u.o. 1000-8000 mg/d <300 mg/d 20-25 g/d

Individualized based on BP
Gen. unrestricted In CAPD &CCPD 2000-3000 ml/d Same as for hemodialysis Same as for hemodialysis Same as for hemodialysis

Dietary Modifications
Multiply vol. of each dialysate exchange in L by its glucose concentration/L (g of glucose) to obtain grams of glucose in dialysate exchange to determine total grams of glucose. Multiply total grams of glucose by approximate absorption rate of 80%. Multiply total grams of glucose absorbed by the calories/ gram of glucose (3.7 kcal/g) to determine total calories absorbed 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

Acute Renal Failure

Aim:
1. 2. 3. 4. Reduce the accumulation of uremic toxins; Control electrolyte abnormalities; Correct fluid retention; Maintain nutritional status

Note: Control CHON, Na, K, P and fuids. Diet order should state the calorie, protein, electrolyte levels desired.

Dietary Modification
Dietary factor Protein Energy Phosphorus Sodium Potassium Fluid Calcium I Fat Recommendation 0.5-0.6 g/kg 35-50 kcal/kg individualized Anuric-oliguric phase: 500-1000 mg/d Anuric-oliguric phase: 1000 mg/d Assess on daily basis individualized No modification needed

Post Kidney Transplantation

Aim:
1. Provide adequate calories and protein to counteract the catabolic effects of surgery 2. Manage nutritional side effects of immunosuppressive drugs

Dietary Modifications
Dietary factor First month after transplant & during treatment for acute rejection 1.3-1.5 g/kg/d sufficient Encourage complex type <35% of calories Variable, based on serum level 2-4 g/d 1200 mg/d 1200 mg/d Ad libitum unless fl. retention After first month

Protein Calories 30-35 kcal/kg/d Carbohydrates Fats Potassium Sodium Calcium Phosphorus Fluids

1.0 g/kg/d mantain same same same <3g/d same same same

Nephrotic Syndrome
Aim:
1. 2. 3. 4. Minimize edema and proteinuria Control hypertension Retard the progression of renal disease Prevent muscle catabolism and protein malnutrition 5. Supply adequate energy

Dietary Modifications
Dietary factor Protein Recommendation Adult: 0.6-1.0 g/kg IBW + replacement of urinary CHON losses Children: RDA for age + replacement of urinary CHON losses 1-3 g/day Generally unrestricted <30% of total cal/d <300 mg/d Sufficient to achieve and mantain edema Necessary if CHON intake is 60g or less/d

Sodium Fluids Fats Cholesterol Energy Vitamins and Minerals