FMSHK Certificate Course on Renal Medicine 2021

Nutritional management in kidney diseases

Cherry Law
Dietitian
 Chronic kidney diseases
n Excretion of metabolic waste products, water, electrolytes, inorganic
ions, foreign chemicals, …
n Production of erythropoietin, 1,25-dihydroxyvitamin D, renin-
angiotensin
n Acid-base control
Dialysis
X Transplant
Partial removal

Side effects of
Diet
modification
immunosuppressant
n Uremic, edema, hyperkalemia, hyperphosphatemia,…
n Anemia
n Mineral & bone disorders
n High blood pressure
n Metabolic acidosis
 Nutritional assessment
*Anthropometrics (actual - desirable)x25% + desirable
body weight = adjusted

Body weight (? dry, usual), body height, BMI, desirable/adjusted

for central obesity

body weight, weight change, waist circumference, body

composition, …
*Biochemical for DM case

RFT, LFT, Ca, PO4, urate, eGFR, 24-hour urine protein, lipids, A1C,
glucose, Hb, PTH, iron status, WBC, ESR, CRP,…
*Clinical
* Diagnosis, stage of CKD, medical history, medication, urine
output, blood pressure, …
* Treatment of CKD
* Conservative, palliative care
 Nutritional assessment
*Clinical
* Renal replacement therapy
* PD: Dextrose/ icodextrin/ amino acid based, concentration &
volume of dialysate, duration of dwell, types & adequacy of
dialysis, …
* HD: Type, frequency & duration of HD, adequacy of dialysis,…
* Transplant: Nutrition-related problems, side effects of
immunosuppressant
*Dietary
Current/usual dietary intake, estimated nutrient intake &
requirement, activity level, GI problems, ADL dependency, social
history, …
 Nutritional management

* Chronic kidney diseases

* Renal replacement therapy: PD & HD

* Transplant
 Chronic kidney diseases
Risk factors for kidney disease progression
* Diabetes Mellitus
* Hypertension
* Hyperlipidemia
* Proteinuria
* Obesity
* Smoking
* Male
* Family history of kidney diseases (e.g. polycystic kidney)
 Chronic kidney diseases
Goals of nutritional management
* Slow the progression of CKD through
* Optimization of glycemic, serum lipids, proteinuria & blood
pressure control
* Achieving a healthy body weight
* Provision of a nutritionally adequate, palatable & attractive diet
* Prevention of protein-energy malnutrition
* Control of edema & serum electrolytes
* Management of hyperphosphatemia & anemia
 No star fruit
urotoxin in star fruit

* Limb numbness
* Muscle weakness
* Intractable hiccups
* Consciousness disturbance
* Seizure
* Death

(Chang et al, Am J Kidney Dis, 2000, 189-93)

 Healthy balanced diet

KDIGO 2020 Clinical Practice Guideline for Diabetes Management

in Chronic Kidney Disease
Patients with diabetes & CKD should consume an individualized
diet
* High in vegetables, fruits, whole grains, fiber, legumes, plant-
based proteins, unsaturated fats & nuts
* Lower in processed meats, refined carbohydrate & sweetened
beverages
 Individualized meal plan

* Patient-centered
* Recognize the differences in individuals
* Meet patient goals
* Align conflicting comorbid nutrition requirements
 Protein
* ñ Accumulation of metabolic waste products (suppress
appetite & stimulate muscle protein wasting)
* ñ Acid load (precipitate or worsen metabolic acidosis)
* ñ Glomerular hyperfiltration (lead to glomerulosclerosis &
tubulointerstitial injury)
Low protein intake
ðMay slow down progression of CKD
ðMay reduce clinical symptoms & postpone the need to start
dialysis treatment
 Protein
* KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020
Update
Adults with CKD 3-5 who are metabolically stable: 0.55-0.6g
protein/kg body weight/day
Adults with CKD 3-5 & who has diabetes: 0.6-0.8g protein/kg
body weight/day
* KDIGO 2020 Clinical Practice Guideline for Diabetes
CKD without DM— 0.6
with DM —0.8

Management in Chronic Kidney Disease

0.8g protein/kg body weight/day for those with diabetes &
CKD not treated with dialysis
* No specific recommendation for type of protein
 Protein

Very low protein intake

* Limit carbohydrate, fat, alcohol & protein intake
ð ò Caloric content of diet
ð Weight loss
ð Malnutrition
* May make hypoglycemia more common
 Protein

where the meat contain all 9amino acid the human body needs

1 exchange high biological value protein = 7g protein

* Pork, beef, lamb, poultry, fish, seafood, milk, dairy products,
egg, soy products

1 exchange low biological value protein = 2g protein

* Starchy food
1 exchange high biological value protein = 7g protein

* 1 ounce cooked pork/beef/ * 1½ slices cheese

lamb/poultry/fish * 150ml yoghurt
* 4 pieces prawn/scallop * ⅓ piece bean curd
(medium)
* 4 level tablespoons cooked
* 1 egg soy bean
* 250ml milk/soy milk
1 exchange low biological value protein = 2g protein

* ½ bowl rice/noodle
* 1 bowl congee
* 1 slice bread
* 4 pieces cream/soda crackers
 Energy
* To spare/preserve dietary protein for tissue protein synthesis
* To attain or maintain ideal body weight
* KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020
Update: 25-35kcal/kg body weight/day
Based on age, sex, level of physical activity, body composition,
weight status goals, CKD stage, and concurrent illness or
presence of inflammation to maintain normal nutritional status
* Sources of energy
Protein: 4 kcal/g; Carbohydrate: 4 kcal/g; Fat: 9 kcal/g; alcohol: 7kcal/g
Sugar ð Good energy source
Food low in protein & high in sugar

Limit intake of food high in sugar in case of

* Diabetes Mellitus
* Overweight
* Hypertriglyceridemia
Control carbohydrate portion ð DM control
* Moderate carbohydrate intake (depend on individual need &
glycemic control)
* Choose food low in glycemic index lower effect over bld glucose

* Small, frequent & regular meals

* Follow prescribed meal plan
 Fibre

* Relieve constipation
* Control serum lipids & glucose
* Recommendation: 25–30g/day
* Adequate intake of high fibre bread/ cereals/ grains, dried
beans, fruits & vegetables
 Fat

* Good energy source

* Taste of food

Overweight

Underweight
 Management of hyperlipidemia

from animal fat

* 5-6% energy from saturated fat

* ò trans fat

(2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk)

 Sodium

Excessive intake
[Proteinuria
[Hypertension
[Edema
[ò anti-proteinuric effect of ACE inhibitors
 Sodium

KDIGO 2020 Clinical Practice Guideline

for Diabetes Management in Chronic
Kidney Disease
* <2g sodium/day (90mmol, 5g or ~1
teaspoon salt)
Except those with sodium-wasting
nephropathy, excessive sodium sweat
losses during high temperatures & high
levels of physical activity
How much sodium in 1 salted egg?

1 serving = 1990mg sodium

~1 day allowance
 How much sodium in 1 tablespoon
preserved vegetable?

100g = 10100mg sodium

1 tablespoon (10g) = 1010mg sodium

~½ day allowance
Healthy choice ?
Contain sodium &
potassium

ò36% sodium

5g = 1960mg sodium 5g = 1250mg sodium

1 serving sodium-containing seasoning = 250mg sodium
6 servings per day

* 1/8 茶匙鹽 * ½ 茶匙雞粉

* ½ 茶匙生/老抽 * ¾ 茶匙磨豉/柱侯醬
* ¾ 茶匙日本豉油/魚露 * 1 茶匙豆豉/腐乳
* 1¼ 茶匙南乳/蠔油 * 2¼ 茶匙甜麵豉醬
* 2½ 茶匙沙爹醬 * 3 茶匙蝦膏
* 3¾ 茶匙茄汁 * 5 茶匙喼汁
* 6 茶匙茄膏
 Sodium in pre-packed food

100g = 581mg 100g = 541mg 270g = 18 pieces 1 pack = 1936mg

sodium sodium 100g = 7 pieces = sodium
1 pack (25.5g) = 20 pieces (~ 23g) 410mg sodium
148mg sodium = 124mg sodium

5 crackers =
180mg sodium 100g (~2 pieces) = 0.3 can (100g) =
540mg sodium 640mg sodium 1 piece (200g)
= 620mg
sodium
Seasonings
 Eating out
早餐 晚餐
* 餐蛋即食麵 * 例湯
* 牛油多士 * 西炒飯
* 咖啡 * 凍檸茶
* 紅豆沙
午餐 Total: 7400mg sodium
* 乾炒牛河 ð Choose healthy eating out
* 凍奶茶 choices
ð Reduce frequency of eating out
 Potassium
* Blood pressure control
* Dietary Approaches to Stop Hypertension (DASH) diet:
Adequate intake of dietary potassium
* Chronic kidney diseases
òExcretion of potassium + Excessive intake of dietary
potassium
ðHyperkalemia: Ventricular arrhythmias, paralysis, respiratory
failure
ðRestrict dietary intake of potassium
 Food high in potassium
* Fruit & fruit juice
* Vegetable
* Nuts
* Beans & bean products
* Milk
* Soup
* Tea & coffee
* Low/reduced sodium salt
Soak & boil vegetable to reduce potassium content
 Low potassium vegetables & fruit
* Hairy/winter melon (節/冬瓜)
* Red/green/yellow sweet bell pepper (紅/青/黃甜椒)
* Lettuce/Yau Mak Choi (生菜/油麥菜)
* Choi sum/kale/mustard leaf (菜心/芥蘭/芥菜)
* Zucchini/chayote/luffa (翠玉瓜/合掌瓜/絲瓜)
* Cauliflower (椰菜花)
* Green/white long bean/French bean (青/白豆角/四季豆)
* Cabbage/Wong Nga Pak (椰菜/黃芽白/紹菜)
* Cucumber/yellow cucumber (青瓜/老黃瓜)
* Mung bean sprouts/Chinese parsley (芽菜/唐芫茜)
* Pear/blueberry/apple/rambutan (梨/藍莓 /蘋果/紅毛丹)
 Phosphorus
* Retention of phosphorus as renal function decreases
* Hyperphosphatemia: Renal osteodystrophy, parathyroid gland
hyperplasia, myocardial fibrosis, heart & valve calcification,
cardiovascular sudden death
* Phosphate binders: Take with meals
* Calcium carbonate: Chew well
* Sevelamer: No need to chew
* Aluminum hydroxide: Not recommended for long term use to
prevent aluminum intoxication
 Food high in phosphorus
* Fish, seafood, internal organ meat & bone
* Beans & bean products
* Nuts
* Mushrooms
* Wholegrain cereals
* Chocolate
* Milk & dairy products
* Phosphorus containing food additives
Simmer in water for 30 min, ò P
Beef: 58% ; Chicken: 37%
(Cupisti A, et al, Journal of Renal Nutrition, 2006, 36-40)
 Phosphorus density of common foods
Food Actual phosphorus(mg) Adjusted phosphorus (mg)
Protein(g) Protein (g)
Poultry 6.6 - 7.6 4.8 - 5.4
Red meat 8.1 - 8.6 6 - 6.3
Fish 10.2 - 12.3 7.5 - 9
Tofu 12.7 - 13.6 7.5 - 7.6
Soy beans 14.5 8.5
Dried beans 14.9 - 15.7 8 - 12
Nuts 18.4 - 24.5 10.9 - 14.4
Cheddar cheese 20.7 15.3
Milk 26.1 - 30.9 19 - 26
Yoghurt 27 - 29.5 19.8
Adjusted for digestibility & absorption: Animal > 70%; Plant 50%; Mixed meals 50-70%
National Kidney Foundation, Pocket guide to nutrition assessment of the patient with kidney disease, 5th edition, 2015
Phosphorus in snacks & drinks
Soy milk
Food additives
* Inorganic phosphorus Luncheon
* Highly absorbable Biscuit
* Color, antioxidant, acidity regulator, acid,
emulsifier, stabilizer, raising/firming/anti-
caking agent
Chocolate drink Cup noodle
Instant coffee drink

E339 Sodium phosphate

E340 Potassium phosphate
Roll cake
Lemon water Cola drink

E338 Phosphoric acid E341 Calcium phosphate

 Alcohol
Blood pressure control
* Male: No more than 2 servings/day
* Female: No more than 1 serving/day

1 serving
= 360ml beer
= 150ml white/red wine
= 45ml whisky
 Fluid

Depend on clinical status

* Degree of impaired renal function
* ñ fluid requirement: Nephrolithiasis, UTI, salt-losing
nephropathy, diarrhea, vomiting, excessive perspiration,
pressure ulcers (Stage II, III, IV), fever
* ò fluid requirement: Dilutional hyponatremia, congestive heart
failure, edema, ascites
 Fluid restriction

* Use smaller cup

* Suck ice cube or rinse mouth to relieve thirst

* Decrease intake of sodium

 Vitamins
* Recommended Daily Intake (RDI)
* Vitamin D: 1,25-dihydroxyvitamin D3 (active form) may be
required for treatment of secondary hyperparathyroidism
* Vitamin C : Excreted by kidney
* Excessive intake ð # blood oxalate level
* Deposition of oxalate in heart, kidney & blood vessels
* Precipitation of acute pseudogout
* Vitamin A: Excreted by kidney, Excessive intake [ Toxicity
ð Avoid over-the-counter supplement
 Minerals

Iron
* Dietary restriction, impaired absorption
* $ absorption: Tea, coffee, milk, high fibre food
* # absorption: Vitamin C rich food
* Supplement may be required
Zinc
* Dietary restriction, impaired absorption
* Erythropoietin resistance, anxiety, depression, poor wound healing ð
Supplement may be required
 Renal replacement therapy
Goals of nutritional management
* Provision of a nutritionally adequate, palatable & attractive diet
* Prevention of protein-energy malnutrition
* Control of edema & serum electrolytes
* Management of hyperphosphatemia, anemia & hyperlipidemia
 Protein

* KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update:

Adults with CKD stage 5 on HD/PD & metabolically stable: 1.0-1.2g
protein/kg body weight/day
* Peritoneal loss: 2-15g protein/day (average 6-8g)
* Amino acid based dialysate (per bag)
* 1.1% x 2L = 22g amino acids (64% essential & 36% non-essential)
* 70-80% ð 15-18g amino acids absorbed
* Peritonitis: Peritoneal inflammation ð ñ Vascular permeability ð ñ
“Effective peritoneal surface area” ð ñ Protein loss: 10-25g per day ð
ñ Protein requirement + ò Nutrient intake ð ñ Risk of malnutrition
 Energy

* KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020

Update: 25-35kcal/kg body weight/day
* PD: Include dialysate calories
10-180g dextrose absorbed x 3.4kcal = 34-612kcal/day
(depend on concentration & volume of dialysate, duration of
dwell, permeability of peritoneum)
ð Limit intake of food high in simple sugar
 Sodium
Excessive intake
[Hypertension
[PD: Edema
[HD: Excessive intra-dialysis weight gain

Monitor body weight & blood pressure regularly

 Potassium

* Remove from dialysis

* PD: May need a diet rich in potassium
Hypokalemia: Muscle weakness, paralysis, respiratory failure,
ventricular arrhythmias, diabetes inspidus, rhabdomyolysis
] Relax potassium restriction
* HD: May need a low potassium diet
 Phosphorus
PD
* Remove ~400mg phosphorus/day
* Limit to 800-1000mg phosphorus/day
HD
* Remove ~250mg phosphorus/session
* Limit to 10-17mg phosphorus/kg body weight/day
 Fluid – Daily allowance

PD
* 500ml + Urine output + Fluid loss in dialysis
HD
* 500ml + Urine output + (2L ÷ 2-4 days)
 Water soluble vitamins

* Dialysate loss (especially vitamin C & folate), dietary restriction

& reduced oral intake
* Recommended Daily Intake (RDI)
* Supplement may be required
Transplant – Nutrition related problems

* Diabetes Mellitus
* Hyperlipidemia
* Hypertension
* Overweight
* Bone disease
* Hypophosphatemia
* Food safety
* Malnutrition
 Transplant
Early Long-term
Energy 30-35kcal/kg/day 25-35kcal/kg/day
Protein 1.4g/kg/day 0.75-1g/kg/day
Fat < 30% of energy from total fat
Reduce intake of saturated & trans fat
Carbohydrate High dietary fibre, limit simple sugar
Calcium Recommended Daily Intake
Phosphorus Recommended Daily Intake
Sodium 2300mg/day
Potassium Restricted if persistent hyperkalemia
Fluid Depend on fluid balance
 Summary

* Healthy balanced diet ð Provide adequate nutrients

* Adequate energy & protein intake ð Avoid malnutrition
* Avoid excessive energy ð Maintain ideal body weight
* Avoid excessive protein intake ð ò Accumulation of metabolic
waste products, acid load & glomerular hyperfiltration
* Control carbohydrate portion, choose food low in GI, regular
meal pattern & limit sugary food intake ð Better DM control
* Limit saturated & trans fat intake ð Control serum lipid level
 Summary
* Limit salt intake ð Control blood pressure, proteinuria & edema
* Use natural seasoning to enhance flavor of food
* Potassium & phosphorus intake depend on serum level
* Fluid intake depend on clinical status
* Adequate intake of minerals & vitamins
* No star fruit
* Food safety
* Individualized meal plan
* Relax diet restriction if appropriate