Pocket Guide to Nutrition Assessment

of the Patient with Kidney Disease

6th Edition

Author: Linda McCann, RDN, CSR

Thank you to the following people who provided secondary review of individual chapters:
Deborah Brommage, MS, RDN, LDN
Eileen Moore, RDN, CNSC, LD
Brad Warady, MD

© 2021 National Kidney Foundation, Inc. All Rights Reserved.

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 FOREWORD
Every effort was made to obtain and provide the most up-to-date, accurate information for this 6th edition of the Pocket Guide.
Older references are typically for classic information that is unchanged. Websites have been included where pertinent and other
references have been updated.
For those who are unfamiliar with this resource, the primary goal is to compile CKD nutrition information in a concise, abbreviated
format. Achieving a balance between too much and too little information is challenging because of the wide variation in practice
and knowledge within the target audience. For experienced clinicians, this book provides concentrated information that is known
and used on a regular basis. For less experienced clinicians, it provides a foundation on which to build expertise. Overall, the goal
is to help nephrology dietitians provide consistent, high-quality nutrition care for all patients with kidney disease.
This book is not all-inclusive. The information is a compilation of many sources and input from experienced nephrology dietitians.
It is not intended to dictate clinical practice but to provide practical information. It is the responsibility of each individual clinician
to keep his or her knowledge base current. Additionally, clinicians may need to update or modify this information in line with new
evidence-based recommendations, oversight mandates, and/or the policies and procedures of their employers.
I truly appreciate the secondary reviewers for their conscientious reviews and suggestions.
Linda McCann, RDN, CSR

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No portion of this publication may be reproduced without prior written permission from the National Kidney Foundation, Inc.

© 1993, National Kidney Foundation, New York, NY

© 1998, Second Edition, National Kidney Foundation, New York, NY
© 2002, Third Edition, National Kidney Foundation, New York, NY
© 2005, Third Edition Online, National Kidney Foundation, New York, NY
© 2009, Fourth Edition, National Kidney Foundation, New York, NY
© 2015, Fifth Edition, National Kidney Foundation, New York, NY
© 2021, Sixth Edition, National Kidney Foundation, New York, NY

30 East 33rd Street

New York, NY 10016
800.622.9010
www.kidney.org

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 TABLE OF CONTENTS
1 Contributors
2 Foreword
3 Copyright
A-1 Acronyms and Abbreviations
N-1 Nomenclature for KDIGO and KDOQI Guidelines
I-1 Introduction
I-2 Clinical Practice Guideline for Nutrition in Chronic Kidney Disease: 2020 Update

Chapter 1: Nutrition Assessment Charts, Tables, and Formulas

1-2 Author Note
1-3 Practical Steps to Nutrition Assessment – Adult CKD Patients
1-4 Centers for Medicare & Medicaid Services (CMS) Conditions for Coverage (CfC)
1-7 Nutrition Care Process Model (NCPM)
1-8 NCP Process and Terminology
1-11 NCP: Nutrition Diagnostic Statements Problem/Etiology/Signs and Symptoms (PES)
1-12 Common Nutrition Diagnostic Terms for CKD
1-14 NCP Example - CKD
1-15 Medical Nutrition Therapy (MNT)
1-16 Examples of Diagnostic Codes for MNT
1-17 Clinical Practice Guideline for Nutrition in CKD: 2020 Update Nutrition Assessment Recommendations
1-21 General Tips for Effective Assessment, Interviewing, and Teaching
1-22 Motivational Interviewing and Patient Activation Measure
1-23 Motivational Interviewing
1-24 Determination of Patient Height
1-25 Height Estimation From Knee Height
1-25 Height Estimation From Arm Span
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1-26 Height Estimation From Demi-Span
1-26 Height Estimation From Forearm
1-27 Determination of Frame Size
1-28 Body Frame Size Based on Wrist Circumference in Relation to Height
1-29 Determination of Frame Size by Wrist Circumference
1-30 Methods to Determine Body Weights
1-31 Standard Body Weight
1-32 Desirable Body Weight Based on Body Mass Index
1-33 Adjusted Body Weight for the Obese or Underweight Patient
1-34 Waist Circumference (WC) and Waist-to-Hip Ratio (WHR)
1-35 Clinical Signs of Fluid Status in Dialysis Patients
1-35 Usual Fluid Intake and Output in Adults Without Kidney Disease
1-36 Weight Comparison Formulas
1-37 Weight Estimation in Amputees
1-38 Body Mass Index (BMI)
1-39 BMI Classifications
1-39 Gender-Specific Weight of Limb Segments as a Percentage of Total Body Weight
1-40 Creatinine Index (estimates edema-free lean body mass)
1-41 Body Surface Area
1-42 Total Body Water
1-43 Skinfold Measurements/Arm Anthropometrics
1-44 Reference Values for the Triceps Skinfold Thickness (cm) – Male
1-45 Reference Values for the Triceps Skinfold Thickness (cm) – Female
1-46 Reference Values for Mid-Arm Muscle Circumference (cm)
1-47 Reference Values for Mid-Upper Arm Muscle Area (cm) – Male
1-48 Reference Values for Mid-Upper Arm Muscle Area (cm) – Female
1-49 Other Measures of Body Composition
1-50 Composite Nutrition Indices: Subjective Global Assessment (SGA)
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1-51 Author’s Note on SGA
1-52 SGA Weight/Medical/Nutrition History
1-53 Schematic of Muscle to Guide Assessment of Wasting
1-54 SGA Part I
1-55 SGA Part II
1-57 Estimation of Performance or Functional Status
1-58 PG-SGA Ratings
1-59 Malnutrition Inflammation Score (MIS)
1-60 Comprehensive Malnutrition Inflammation Score
1-62 Methods to Assessment of Dietary Intake
1-64 Assessing for PICA
1-65 Common Signs of Nutrient Deficiency in Physical Exam

Chapter 2: Biochemical
2-2 General Information
2-3 Stages of CKD
2-4 Prognosis of CKD by GFR and Albuminuria Category
2-5 Conversion Formulas
2-6 Metric and International System (SI)
2-7 Laboratory Tests
2-19 Possible Non-dietary Causes of Hyperkalemia in Kidney Disease
2-20 Potential Signs and Symptoms of Abnormal Blood K+ Levels
2-21 Acid Load
2-23 Potential Consequences of Acidosis in CKD
2-24 Na+/K+ Content of Salt and Salt Substitutes

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 Chapter 3: Medications
3-2 Medications in CKD
3-3 Common Drug Categories Used in CKD
3-5 Treatments for Hyperkalemia – Potassium Binders
3-7 Medications to Avoid or Use With Caution in CKD
3-8 Drug/Nutrient and Nutrient/Drug Interactions
3-9 Common Food-Drug Interactions
3-10 Drug Actions on Nutrition
3-11 Interactions/Instructions by Drug Category
3-16 KDIGO/KDOQI: Over-the-Counter and Herbal Remedies in CKD
3-17 CKD-Limited Nutrients Contained in Herbal Remedies
3-18 Review of Herbal Remedies
3-27 Pre-, Pro-, and Synbiotics

Chapter 4: Nutrient Prescription

4-2 General Information
4-2 Nutrient Recommendations for Metabolically Stable CKD Patients
4-3 Micronutrient Recommendations
4-4 Dietary Patterns
4-4 Nutritional Supplementation
4-6 Keto Acid/Amino Acid Analogs
4-8 Amino Acid Supplement (IV)
4-9 Dialysis-Specific Vitamin Formulations
4-10 Estimates of Calories Absorbed From Peritoneal Dialysate
4-13 Nutrition Education Resources
4-14 Composition of Common High-Fiber Cereals
4-15 Composition of Milk, Cream, and Substitutes

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4-16 L-Carnitine Supplementation in Hemodialysis Patients
4-17 Considerations for a Kosher Diet
4-18 Disease-Specific Formulas for Determination of Energy Requirements
4-19 Harris-Benedict Formulas for Resting Energy Expenditure
4-20 Suggested Adjustment Factors for Energy Needs During Illness
4-21 Estimated Energy Needs in Spinal Cord Injury Patients

Chapter 5: Diabetes Mellitus and CKD

5-2 Classifications of Diabetes Mellitus
5-3 KDIGO Clinical Practice Guidelines for DM and CKD
5-4 Comprehensive Care in Patients With DM and CKD
5-5 Glycemic Monitoring
5-6 Correlation Between A1C Level and Mean Plasma Glucose
5-7 Nutrition Intake for Those With DM an CKD
5-7 Physical Activity
5-8 Anti-hyperglycemic Therapies for Those With Type 2 DM and CKD
5-9 Self-Management and Education Programs
5-9 Team-Based Integrated Care
5-10 Screening for Kidney Disease in Diabetics
5-11 Insulin
5-12 Hypoglycemia in CKD
5-13 Classification of Hypoglycemia in DM
5-14 Recommendations for Glycemic Control During Hospitalization
5-15 Recommendations for Prevention of Hypoglycemia
5-17 Modifications for Acute Illness in Insulin-Dependent DM
5-18 DM Management With Intercurrent Issues
5-19 Other Nutrition Issues for Diabetics

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5-20 Sugar Alcohol and Non-Nutritive Sweeteners
5-21 Gastroparesis
5-23 Pancreas Transplant

Chapter 6: Protein-Energy Wasting/Malnutrition/Inflammation

6-2 Prevalence of Malnutrition/Protein-Energy Wasting in CKD
6-3 The Renal Association Clinical Practice Guideline on Undernutrition in CKD
6-5 Descriptive Terms Relating to Abnormal Nutrition/Metabolism
6-7 Malnutrition Versus Cachexia
6-8 Visceral Proteins/Acute Phase Reactants
6-9 Common Positive Acute Phase Reactants
6-10 Diagnostic Criteria for General Malnutrition Syndromes
6-12 GLIM Criteria for the Diagnosis of Malnutrition
6-13 ISRNM Diagnostic Criteria for AKI/CKD Malnutrition Syndrome (PEW)
6-14 Probable Multifactorial Causes of PEW
6-15 Indications and Steps for Implementation of Nutrition Support
6-16 Proposed Algorithm for Enteral Nutrition Support Intervention for CKD Stage 5
6-17 Meals and Enteral Support During Dialytic Therapy
6-18 Enteral Nutrition
6-20 Oral Amino Acid Therapy
6-21 Common Oral Nutrition Supplements
6-22 Specialty Nutrition Bars/Cookies
6-23 Specialty Nutrition Products
6-24 Modular/Single Nutrient Products
6-25 Enteral Tube Feeding
6-26 Tube Feedings in CKD
6-28 Tube Feeding Administration
6-29 Tube Feeding Formulas
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6-30 Common Tube Feeding Products/1000 mL
6-31 Intradialytic Parenteral Nutrition (IDPN)/Intraperitoneal Nutrition (IPN)
6-32 General Recommendations and International Guidelines for Utilization of IDPN/IPN in CKD 5D
6-34 Further Considerations for IDPN
6-35 Advantages and Disadvantages of IDPN/IPN
6-36 IDPN Nutrients/Formulations
6-37 Other Considerations for IDPN
6-38 IPN Solutions
6-39 Nutrition Support Monitoring Guidelines in the Stable Dialysis Patient
6-40 Nitrogen Balance

Chapter 7: Cardiovascular Disease, Dyslipidemia, and Hypertension

7-2 Cardiovascular Disease in CKD
7-3 Effects of Risk Factors in CKD
7-4 Left Ventricular Hypertrophy
7-5 Volume Control
7-6 KDIGO Summary: Lipid-Lowering in Adults With CKD
7-6 Secondary Causes of Dyslipidemia
7-7 Lipid Management in Adults With CKD
7-8 Nutritional Treatment of Dyslipidemia
7-9 Common Patterns of Dyslipidemia in CKD
7-10 Common Food Sources of Fat
7-11 Approximate Cholesterol Content of Common Foods
7-12 Hypertension in CKD (not dialysis dependent)
7-13 Blood Pressure Guidelines for Adult CKD (not dialysis dependent)
7-14 Blood Pressure Management for Those Being Treated With Hemodialysis

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 Chapter 8: CKD Mineral and Bone Disorder (CKD-MBD)
8-2 Bone and Mineral Metabolism Abnormalities in CKD
8-3 KDIGO Definitions of Mineral and Bone Abnormalities in CKD
8-4 Manifestations of Abnormal Mineral and Bone Metabolism
8-5 Abnormal Mineral and Bone States in CKD
8-6 Suggested Target Ranges for Biochemical Markers of CKD-MBD
8-8 Phosphorus in CKD Stage 5D
8-9 Phosphorus Density of Common Foods
8-11 Phosphorus Food Additives
8-13 Phosphate Binding and Calcium Supplementation
8-14 Common Calcium Compounds
8-15 Common Phosphate Binders
8-17 KDIGO-Proposed Nomenclature for Vitamin D
8-18 Vitamin D2, D3, and Their Derivatives
8-19 Repletion of Nutritional Vitamin D
8-20 KDIGO Recommendations for PTH-Lowering Therapy
8-21 PTH-Lowering Therapies
8-23 Actions of Pharmacologic Agents Used to Treat SHPT
8-23 Potential Effects of PTH-Lowering Therapies on Biomarkers
8-24 Active Vitamin D and Analogs (US)
8-25 Potential Effects of Vitamin D Supplementation in CKD
8-26 Potential Contraindications for the Use of Vitamin D/Analogs
8-27 Calcimimetics
8-30 Symptoms of Abnormal Serum Calcium Levels
8-30 Etiology of Hypercalcemia
8-31 Soft Tissue/Vascular Calcification in CKD

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8-32 Potential Indications for Parathyroidectomy
8-33 General Tips for Management of CKD-MBD
8-34 Osteoporosis

Chapter 9: Anemia
9-2 Anemia
9-3 Terminology Used to Describe Cell Alterations in Anemia
9-4 Laboratory Values Used to Evaluate Anemia in CKD: Clinical Practice Recommendations (CPRs)
9-5 Hemoglobin Levels Requiring Further Evaluation in CKD
9-5 Anemia in CKD-T (Transplant)
9-6 Interpretation of Iron Status Parameters
9-7 CKD Anemia: Monitoring Parameters and ESA/Iron Recommendations
9-8 ESAs
9-9 Epoetin and Biosimilars
9-10 FDA Labeling for ESA
9-11 Hypoxia Inducible Factor-Prolyl Hydroxylase Inhibitors (HIF-PHIs)
9-12 Iron Supplementation in CKD Patients
9-13 Oral Iron Supplements
9-14 IV Iron Preparations
9-15 Factors Most Commonly Associated With Hyporesponse to ESA Therapy

Chapter 10: Adequacy of Dialysis

10-2 Current Nomenclature Used by KDOQI in Reference to CKD
10-3 History of Hemodialysis (HD) Adequacy
10-4 Glossary for Discussion of Dialysis Adequacy
10-9 NKF KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy: 2015 Update
10-12 Criteria for Initiation of Dialysis

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10-13 Nomenclature/Parameters for Various HD Therapies
10-14 Methods of Measuring Hemodialysis Adequacy
10-15 Components of Kt/V
10-15 Parameters That Affect HD Adequacy Results
10-16 Per Treatment spKt/V Required to Achieve Standard Kt/V of Approximately 2.0
10-17 Other Considerations for HD Adequacy
10-18 CMS Quality Incentive Program (QIP) Targets for Adequacy of Dialysis
10-19 Types of Hemodialysis/Ultrafiltration
10-20 Incremental Dialysis
10-21 Total Body Water (Volume)
10-22 Volume from Surface Area (VSA) Formulas
10-23 Differences Between Single Pool and Double Pool (Equilibrated) Kt/V
10-24 Other Adequacy Parameters
10-25 Estimates of Protein Intake From Urea Kinetics
10-26 Estimates of PCRn (nPCR) Using Formulas That Employ Kt/V
10-27 Common Causes of Delivered Kt/V ≠ Prescribed
10-28 Evaluation of Adequacy Measures
10-29 Helpful Information for Analysis of Adequacy Results
10-30 Formulas for Other Measures of HD Adequacy
10-31 Formulas to Estimate Equilibrated Kt/V (eKt/V)
10-32 Daily Hemodialysis
10-33 Dialysis Dose With NxStage® Technology
10-34 Expanded Options for Home Dialysis
10-35 Peritoneal Dialysis (PD)
10-36 Management of Patients on PD
10-37 Peritoneal Dialysis Adequacy Targets
10-38 Aspects of Peritoneal Dialysis Adequacy
10-39 Achieving Peritoneal Dialysis Adequacy Targets
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10-40 Peritoneal Dialysis Adequacy Calculations – Kt/V
10-41 Peritoneal Dialysis Adequacy Calculation – PNA
10-42 Summary of KDOQI PD Adequacy Guideline
10-43 Urea Kinetic Modeling for CKD Not on Dialysis
10-44 Nutrition Intervention Based on nPNA for Those on Dialysis
10-45 Glomerular Filtration Rate

Chapter 11: Special Populations With CKD: Acute Kidney Injury, Gout, HIV/AIDS, Nephrolithiasis,
Nephrotic Syndrome, Obesity, Older Adults, Pediatrics, Pregnancy, Transplantation
11-2 Acute Kidney Injury (AKI)
11-2 AKI Staging
11-3 General Recommendations for AKI
11-3 Management Recommendations Based on AKI Stage
11-4 Understanding Continuous Replacement Therapy (CRRT) in AKI
11-5 Nutrition Assessment of the AKI Patient
11-6 CRRT in the Critically Ill
11-7 Nutrition Support Goals for AKI
11-8 Nutrition Recommendations for AKI Patients Receiving KRT
11-10 Gout
11-10 Indications for Pharmacologic ULT
11-11 Management of Lifestyle Factors
11-12 Gout Medications in CKD
11-13 Nutritional Effects of HIV/AIDS
11-14 Nutrient Recommendations for HIV/AIDS and Dialysis
11-15 Practical Tips for Nutrition in HIV/AIDS
11-16 Nephrolithiasis (Urinary Stones)
11-17 Common Nutrition Factors and Recommendations for Nephrolithiasis
11-19 Oxalates
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11-20 Nephrotic Syndrome
11-21 Obesity in CKD
11-22 Risks and Benefits of Intentional Weight Loss in CKD
11-23 Special Issues for the Older Adult CKD Patient
11-25 Potential Influences on Nutrition Status in the Older Adult
11-26 CKD Therapy Options in the Older Adult
11-27 Limitations of Common Nutrition Assessment Parameters in Older Adult CKD Patients
11-28 Considerations for Educating Older Adults
11-29 Pediatric Renal Nutrition Task Force
11-30 Evaluation of Nutritional Status in Pediatric CKD Patients
11-31 PRNT Recommendations for Nutrition Assessment of Children With Kidney Diseases
11-33 Pediatric Clinical Growth Resources
11-34 Indications for Nutrition Intervention in Pediatric CKD
11-35 Energy Needs for Children With CKD Stages 2-5D
11-36 Protein Recommendations for Children With CKD Stages 3-5D
11-37 PRNT Energy and Protein Requirements for Infants, Children, and Adolescents With CKD Stages 2-5D
Aged 0-18 Years
11-38 Macronutrient Distribution Ranges for Children With CKD Stages 2-5D
11-39 PRNT Recommendations for Dietary Management of Calcium and Phosphate in Children With CKD
11-41 Elemental Calcium Recommendations for Children
11-41 Phosphorus Recommendations for Children With CKD Stages 3-5D
11-42 PRNT Recommendations for Delivery of a Nutrition Prescription by Enteral Tube Feeding
in Children With CKD
11-44 Correcting Growth and Metabolic Deficits in Children With CKD Stages 2-5D
11-45 Lipid Management in Children With CKD
11-46 Recommendations for the Pregnant Patient With CKD
11-47 Other Recommendations for the Pregnant Dialysis Patient
11-48 Special Issues for the Kidney Transplant Recipient
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11-49 Concerns in the Acute Care Setting Posttransplantation
11-51 Nutrient Recommendations for the Kidney Transplant Recipient
11-53 Common Nutritional Effects of Immunosuppressant Drugs

11-44 Common Nutritional Effects of Immunosuppressant Drugs

I-1 Index

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 ACRONYMS AND ABBREVIATIONS
A1C – Glycosylated or glycated hemoglobin Ave – Average
AA/aa – Amino acid AVF – Arteriovenous fistula
ABW – Adjusted body weight AVG – Arteriovenous graft
ACE – Angiotensin-converting enzyme BCG – Bromocresol green
ACEi – Angiotensin-converting enzyme inhibitor BEE – Basal energy expenditure
ACR – Albumin-to-creatinine ratio BFR – Blood flow rate
ADAG – A1C-derived average glucose BG – Blood glucose
ADHD – Attention-deficit/hyperactivity disorder BIA – Bioelectrical impedance analysis
ADI – Acceptable daily intake BID – Twice a day
Adj – Adjusted BK – Below the knee
AEB – As evidenced by BKA – Below the knee amputation
AHA – American Heart Association BMD – Bone and mineral disorder
AI – Adequate intake BMI – Body mass index
AIDS – Acquired immune deficiency syndrome BP – Blood pressure
AKI – Acute kidney injury BRAT – Bananas, rice, applesauce, toast (diet)
AKIN – Acute Kidney Injury Network BSA – Body surface area
ALP – Alkaline phosphatase BUN – blood urea nitrogen
AND – Academy of Nutrition and Dietetics BW – Body weight
ANDHII – Academy of Nutrition and Dietetics Health Ca++ – Calcium
Information Infrastructure CAD – Coronary artery disease
APD – Automated peritoneal dialysis CaOx – Calcium oxalate
APP – Acute phase protein CAPD – Continuous ambulatory peritoneal dialysis
APR – Acute phase reactant CaSR – Calcium-sensing receptor
ARB – Angiotensin receptor blocker CAVH – Continuous arteriovenous hemofiltration
ARF – Acute renal failure CAVHD – Continuous arteriovenous hemodialysis
Art – Arterial CBC – Complete blood count
ASN – American Society of Nephrology CCPD – Continuous cyclic peritoneal dialysis
ASPEN – American Society of Parenteral and Enteral Nutrition CDR – Commission on Dietetic Registration
A-1
CERA – Continuous erythropoietin receptor activator CVVH – Continuous veno-venous hemofiltration
CfC – Conditions for Coverage CVVHD – Continuous veno-venous hemodialysis
CGM – Continuous glucose monitoring CVVHDF – Continuous veno-venous hemodiafiltration
CGMI – Continuous glucose management indicator d – Day
C-HD – Continuous hemodialysis D2 – Ergocalciferol
C-HDF – Continuous hemodiafiltration D3 – Cholecalciferol
C-HF – Continuous hemofiltration (also called CVVH or CRRT) DASH – Dietary Approached to Stop Hypertension (diet)
CHF – Congestive heart failure DBP – Diastolic blood pressure
CHO – Carbohydrate DBW – Desirable body weight
CHOL – Cholesterol D/C – Discontinue
CHr – Content of hemoglobin in reticulocytes DCCT – Diabetes Control and Complications Trial
CI – Creatinine index Decr – Decreased (also signified by ↓)
CKD – Chronic kidney disease DEI – Dietary energy intake
CKD-MBD – Chronic kidney disease mineral and bone disorder DFR – Dialysate flow rate
Cmax – maximum plasma concentration DM – Diabetes mellitus
CMS – Centers for Medicare & Medicaid Services DOPPS – Dialysis Outcomes and Practice Patterns Study
COPD – Chronic obstructive pulmonary disease DPI – Dietary protein intake
Cp – Ceruloplasmin DPP-4 – Dipeptidyl peptidase-4
CPG – Clinical practice guideline DPVV – Double pool, variable volume
CPR – Clinical practice recommendation DRI – Dietary reference intake
CPT – Current procedural terminology DSMT – Diabetes Self-Management Training
Cr - Creatinine D/T – Due to
CrCl – Creatinine clearance DTR – Registered dietetic technician
CRP – C-reactive protein DUN – Dialysis urea nitrogen
CRRT – Continuous renal replacement therapy DW – Dry weight
CUA – Calcific uremic arteriolopathy DXA – Dual energy X-ray absorptiometry
CV – Cardiovascular EAA – Essential amino acid
CVA – Cerebrovascular accident eAG – Estimated average glucose
CVC – Central venous catheter ECG – Electrocardiogram
CVD – Cardiovascular disease EDW – Estimated dry weight A-2
EER – Estimated energy requirement GLP-1RA – glucagon-like peptide 1 receptor agonist
EFA – Essential fatty acid GRAS – Generally recognized as safe
eKt/V – Equilibrated Kt/V (see Kt/V) GU – Urea generation rate
EMA – European Medicines Agency HA – Headache
EN – Enteral nutrition HAART – highly active antiretroviral therapy
eNCPT – Electronic nutrition care process terminology Hb – Hemoglobin
EPO – Erythropoietin HbA1C – Glycosylated or glycated hemoglobin
Eq – Equivalent HBV – High biological value
ESA – Erythropoiesis-stimulating agent Hct – Hematocrit
ESKD – End-stage kidney disease HD – Hemodialysis
ESPEN – European Society for Clinical Nutrition and Metabolism HDL – High-density lipoprotein
ESR – Erythrocyte sedimentation rate HDL-C – High-density lipoprotein cholesterol
ESRD QIP – End-Stage Renal Disease Quality Incentive Program HFC – High-fructose corn syrup
ETOH – Alcohol HIF-PHI – Hypoxia inducible factor-prolyl hydroxylase inhibitors
EU – European Union HIV – Human immunodeficiency virus
Exch – Peritoneal dialysis exchange HMG-CoA reductase – Hydroxy-methyl-glutaryl
F – Female coenzyme A reductase
FA – Fatty acid; folic acid HN – High nitrogen
FDA – United States Food and Drug Administration HP – High protein
Fe – Iron HPT – Hyperparathyroidism
FF – Flow fraction hr – Hour
FFA – Free fatty acid %HRC – Percentage of hypochromic red blood cells
FFQ – Food frequency questionnaire hsCRP – Highly sensitive C-reactive protein
FGF – Fibroblast growth factor ht – Height
FPG – Fasting plasma glucose HTN – Hypertension
g – Gram IBW – Ideal body weight
GDM – Gestational diabetes mellitus IBS – Inflammatory bowel syndrome
GFR – Glomerular filtration rate ICU – Intensive care unit
GI – Gastrointestinal ID – Interdialytic
GLIM – Global Leadership Initiative on Malnutrition IDPN – Intradialytic parenteral nutrition A-3
IDT – Interdisciplinary team LDL – Low-density lipoprotein
IDWG – Interdialytic weight gain LDL-C – Low-density lipoprotein cholesterol
IFG – Impaired fasting glucose Ln – Natural log
IGF – Insulin-like growth factor LOS – Length of stay
IGT – Impaired glucose tolerance LP – Low protein
IHD – Intermittent hemodialysis Lp-a – Lipoprotein a
IL – interleukin LPS – Lipopolysaccharide
IM – Intramuscular LV – Left ventricular
Incr – Increased (also signified by ↑) LVH – Left ventricular hypertrophy
IPAA – Intraperitoneal amino acids M – Male
IPD – Intermittent peritoneal dialysis MAC – Mid-arm circumference
IPN – Intraperitoneal nutrition MAMA – Mid-arm muscle area
iPTH - Intact parathyroid hormone MAMC – Mid-arm muscle circumference
IS – Indoxyl sulfate MAO – Monoamine oxidase
ISRNM – International Society of Renal Nutrition and Metabolism MAOI – Monoamine oxidase inhibitor
IV – Intravenous MBD – Mineral and bone disorder
K – Clearance MCC – Major comorbid conditions
K+ – Potassium MCH – Mean corpuscular hemoglobin
KA – Ketoacid analog MCHC – Mean corpuscular hemoglobin concentration
kat – Katal MCV – Mean corpuscular volume
kcal – Kilocalories MD – Maintenance dialysis
KDIGO – Kidney Disease Improving Global Outcomes MDRD – Modification of Diet in Renal Disease study
KDOQI – Kidney Disease Outcomes Quality Initiative Mg – Magnesium
kj – Kilojoules MHD – Maintenance hemodialysis
KRT – kidney replacement therapy MI – Myocardial infarction; also motivational interviewing
KrU – Residual urea clearance min – Minute
Kt/V – Unitless measure of dialysis adequacy MIS – Malnutrition Inflammation Score
LBM – Lean body mass M/M – Morbidity/mortality
LBW – Lean body weight MNT – Medical nutrition therapy
LC n-3 PUFA - long-chain n-3 polyunsaturated fatty acids mo – Month A-4
MODY – Maturity-onset diabetes mellitus in the young ONS – Oral nutrition supplement
mol – Mole OTC – Over-the-counter
MRSA – Methicillin-resistant Staphylococcus aureus oz – Ounce
MSJE – Mifflin-St. Jeor Equation P – Phosphorus
MVT – Multivitamin PA – Physical activity
Na+ – Sodium PA – Pyrrolizidine alkaloid
NA – Not available PA – Plasma albumin, prealbumin
NAM – Nicotinamide PAL – Physical activity level
NB – Nitrogen balance PAM – Patient Activation Measure
NCDS – National Cooperative Dialysis Study PCC – People centered care
NCP – Nutrition care process PCR – Protein catabolic rate
NCPM – Nutrition care process model PCRn – Normalized protein catabolic rate
ND – Not on dialysis PCS – p-Cresyl sulfate
NEAP – Net estimated acid production PD – Peritoneal dialysis
Neg – Negligible P-E – Protein energy
NGT – Nasogastric tube Peds – Pediatric
NHANES – National Health and Nutrition Examination Survey PEG – Percutaneous endoscopic gastrostomy
NHD – Nocturnal hemodialysis Nia – Niacin PEM – Protein-energy malnutrition
NIH – National Institutes of Health PES – Problem/etiology/signs and symptoms
NIPD – Nocturnal intermittent peritoneal dialysis PET – Peritoneal equilibration test
NIR – Near infrared interactance radiation PEU – Protein/energy undernutrition
NKDEP – National Kidney Disease Education Program PEW – Protein-energy wasting
NKF – National Kidney Foundation PG – Patient-generated
NL – Normal limits PI – Package insert
NODAT – New-onset diabetes after transplantation PLAG – percutaneous laparoscopic-assisted gastrostomy
nPCR – Normalized protein catabolic rate PN – Parenteral nutrition
nPNA – Normalized protein nitrogen appearance PNA – Protein equivalent of total nitrogen appearance
NSAID - Non-steroidal anti-inflammatory drug POC – Plan of care
N&V or N/V – Nausea and vomiting Post BUN – Blood urea level at the end of HD treatment
OIG – Office of Inspector General PPS – Prospective Payment System A-5
PRCA – Pure red cell aplasia RMR – Resting metabolic rate
Pre BUN – Blood urea level prior to dialysis treatment R/O – Rule out
PRNT – Pediatric Renal Nutrition Task Force RO – Reverse osmosis, renal osteodystrophy
pro – Protein Rx – Prescription
pt – Patient SA – Serum albumin
PT – Parathyroid SBP – Systolic blood pressure
PTH – Parathyroid hormone SBW – Standard body weight
PUFA – Polyunsaturated fatty acid SC – Subcutaneous
PVD – Peripheral vascular disease SCr – Serum creatinine
Q – Each SCUF – Slow continuous ultrafiltration
QAPI – Quality Assurance and Performance Improvement SD – Standard deviation
Qb – Blood flow rate (also termed BFR) SDS – Standard deviation score
Qd – Dialysate flow rate (also termed DFR) SDHD – Short daily hemodialysis
QOL – Quality of life SDI – Suggested Dietary Intake
RAAS – Renin-angiotensin-aldosterone system SDS – Standard deviation scores
RA-UK – Renal Association, United Kingdom sec – Second
RBC – Red blood cell SGA – Subjective Global Assessment
RBP – Retinol binding protein SGLT2 – sodium-glucose cotransporter 2
RCT – Randomized controlled trial SGLT2i – sodium-glucose cotransporter 2 inhibitor
RDA – Recommended dietary allowance SHPT – Secondary hyperparathyroidism
RDI – Recommended dietary intake SI – International system of units
RDN – Registered dietitian nutritionist SL – Standardized language
Rec – Recommendation or recommend SLE – Systemic lupus erythematosus
REE – Resting energy expenditure SLED – Sustained, low-efficiency dialysis
Retic – Reticulocyte SMBG – self-monitoring blood glucose
rhGH – Recombinant human growth hormone SOB – Shortness of breath
RI – Reticulocyte index SOBP – Standardized office blood pressure
RIFLE – Risk, Injury, Failure, Loss, End-Stage Renal Disease spKt/V – Single pool Kt/V
RIG – Radiologically inserted gastrostomy SPS – Sodium polystyrene sulfonate
RKF – Residual kidney function spvv – Single pool variable volume A-6
SRI – Solute removal index
S/S – Signs and symptoms
SU – Serum urea
Suppl – Supplement
sx – Symptom
t – Time
Tbsp – Tablespoon
TB – Tuberculosis
TBD – To be determined
TBW – Total body water
TEE – Total energy expenditure
TFA – Trans-fatty acid
TG – Triglyceride
TIBC – Total iron-binding capacity
TID – Three times a day
TLC – Therapeutic lifestyle changes
TNA – Total nitrogen appearance
TNF – Tumor necrosis factor
TPD – Tidal peritoneal dialysis
TPN – Total parenteral nutrition
TSat – Transferrin saturation
TSF – Triceps skinfold
TSH – Thyroid stimulating hormone
tsp – Teaspoon
Tx – Treatment
TZD – Thiazolidinedione
UBW – Usual body weight
UF – Ultrafiltration
UFR – Ultrafiltration rate
UKM – Urea kinetic modeling
ULT – Urate lowering therapy
UNA – Urea nitrogen appearance
Unk – Unknown
URR – Urea reduction ratio
URS – Uremic retention solute
US – United States (as adjective only)
USDA – United States Department of Agriculture
USP – United States Pharmacopeia
USRDS – United States Renal Data System
UTI – Urinary tract infection
UUN – Urine urea nitrogen
V – Volume
VA – Vascular access
VDR – Vitamin D receptor
Ven – Venous
Vit – Vitamin
VLDL – Very low-density lipoprotein
VLPD – Very low protein diet
VSA – Volume from surface area
Vu – Volume of urine
WC – Waist circumference
WHR – Waist-to-hip ratio
wk – Week
WNL – Within normal limits
wt – Weight
× – Times (also signified by *)
yr – Year
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 NOMENCLATURE FOR KDIGO and KDOQI GUIDELINES
The strength of KDIGO and KDOQI recommendations are indicated as Level 1, Level 2, or not graded. The quality of the supporting evidence
is shown as A, B, C, or D.

Implications
Grade For Patients For Clinicians For Policy Makers
Level 1 Most people in your situation would Most patients should receive the The recommendation can be evaluated
“Recommend” want the recommended course of recommended course of action. as a candidate for developing a policy
action and only a small proportion or performance measure.
would not.
Level 2 The majority of people in your situation Different choices will be appropriate The recommendation is likely to require
“Suggest” would want the recommended course for different patients; each needs help substantial debate and involvement
of action but many would not. to arrive at a management decision of stakeholders before policy can
consistent with his/her values/ be determined.
preferences.
Not Graded Provides guidance based on common sense or when the topic does not allow adequate application of evidence. This category
is most commonly used for monitoring intervals, counseling, and referral to other clinical specialists and written as simple
declarative statements. They are not meant to be stronger than level 1 or 2 recommendations.

Grade Quality of Evidence Meaning

A High We are confident that the true effect lies close to the estimate of the effect.
B Moderate The true effect is likely to be close to the estimate of the effect, but there is a possibility
that it is substantially different.
C Low The true effect may be substantially different from the estimate of the effect.
D Very Low The estimate of effect is very uncertain and often will be far from the truth.

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 INTRODUCTION
While this is not a typical introduction, I felt that the Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease (CKD) 2020 Update,
should be included first and foremost to allow readers a concise review prior to delving into the chapters in the Pocket Guide (PG). These
evidence-based guidelines were developed through a rigorous process that was applied by well-respected, high-level nutrition, research, and
analytic experts. Information throughout the PG has been updated as appropriate to reflect the published guidelines. Due to the lack of quality
evidence in many areas of CKD nutrition care, many recommendations are based on opinion or they advise clinicians to use their professional
judgement. Previous editions of the PG included practical information that was based on historical nutrition care, common clinical practices,
expert opinions, and reasonable expectations. Much of the information is considered helpful by nephrology clinicians, thus will continue to be
included. It was decided to not to remove the original content unless it was contraindicated or redefined by the guidelines. This allows the reader
to review and use methods, procedures, techniques, recommendations from the past when the evidence-based guideline is not definitive.
It also provides written documentation for performing various nutrition assessment methods or techniques that may already be a part of dialysis
providers nutrition care standards. Continuation of those standards has the potential to enhance the value of data collection from the past where
serial measurements have been recorded to assess status of the population or demonstrate the efficacy of treatment.
For example, the guidelines suggest using clinical judgment to determine the method for measuring BW (actual, wt history, serial wt measures,
adjustments for edema, ascites, polycystic kidney disease) due to absence of standard reference norms. The descriptions of various BW measures
included in Chapter 1 may help determine which method to use or precisely define a method that is already established within your clinical
practice setting.
None of the information in the PG is meant to undermine or contradict the guidelines. We have made every effort to align the content with the
guidelines, but also continue to provide other information that may be of value to nephrology clinicians, especially where guideline information
is lacking or not definitive. The brief overview in the following pages provide all the guideline statements. Each individual chapter has been
reviewed and updated as appropriate in relation to the published guidelines with italicized text. It is strongly recommended that you read the entire
published guideline document to avail yourself of the extensive evidence and expert opinions. The detail in the document is extremely informative
and helpful as you make your clinical decisions and guide your employers if they may choose to revise their nutrition standards of practice.

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 CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CHRONIC KIDNEY DISEASE: 2020 UPDATE
These guidelines are designed to provide information and assist decision making, but not designed to define a standard of care and should not
be construed as a standard or be interpreted as prescribing an exclusive course of management. Delivery of nutrition care for those with CKD
must consider individual patient needs, available resources, and limitations that are unique to an institution or type of practice. Each health-care
professional using the recommendations is responsible for evaluating the appropriateness of applying them in the specific clinical situations.
The guideline is for adults, age 18 or older.
GUIDELINE 1: NUTRITIONAL ASSESSMENT

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

1.0 General Statements
Screening 3-5D, 1.01 reasonable to consider routine nutrition O
posttransplantation screening at least biannually with intent of
identifying risk for PEW
Tools Same as above 1.0.2 limited evidence to the use of one tool over 2D
another to identify risk of PEW
Routine Same as above 1.0.3 reasonable to conduct a comprehensive O Completed by RDN or international
assessment nutritional assessment including but not equivalent
limited to appetite, diet history, BW and BMI,
biochemical data, anthropometric measures, and
nutrition focused physical exam within the first
90 days of dialysis, annually, or when indicated
by nutrition screening or provider referral

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 GUIDELINE 1: NUTRITIONAL ASSESSMENT (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

1.1 Technical Devices & Anthropometrics
Bioimpedance MHD 1.1.1 suggest using BIA, preferable multi-frequency 2C
BIA to assess body composition if available;
perform > 30 min after end of HD session
CKD, PD 1.1.2 insufficient evidence to suggest BIA 2D
DXA 1-5D, 1.1.3 reasonable to use DXA when feasible O
posttransplantation (gold standard for measuring body composition)
BW/BMI Same as above 1.1.4 reasonable to consider assessing body O
composition in combination with BW/BMI
at 1st visit and periodically over time
Frequency of Same as above 1.1.5 for clinically stable measure/monitor O
BW/BMI changes at least:
Monthly (MHD, PD)
Every 3 mo (CKD 4-5, posttransplantation)
Every 6 mo (CKD 1-3)
Body Weight Same as above 1.1.6 reasonable to use clinical judgement to O Completed by RDN/international
determine method for measuring BW (actual, equivalent or physician
wt history, serial wt measures, adjustments for
edema, ascites, and polycystic kidney disease)
due to absence of standard reference norms
BMI as predictor PD 1.1.7 suggest underweight status based on BMI 2C
of mortality be used to predict higher mortality

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 GUIDELINE 1: NUTRITIONAL ASSESSMENT (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

1.1 Technical Devices & Anthropometrics (cont.)
MHD 1.1.8 suggest use overweight/obese BMI as 2B
predictor of ↓ mortality; underweight/ morbid
obesity as predictor of ↑ mortality
CKD 1-5, 1.1.9 reasonable to consider underweight BMI O
as predictor of ↑ mortality, but overweight/
obesity risk is unclear
Posttransplantation 1.1.10 reasonable to consider underweight and O
overweight/obesity as predictor of ↑ mortality
BMI/PEW CKD 1-5D, 1.1.11 BMI alone not sufficient to establish PEW O (<18 kg/m2)
posttransplantation unless very low (<18 kg/m2)
Skinfold Same as above 1.1.12 in absence of edema suggest use of O Lack of reference standards, need for
Thickness skinfold thickness measures to assess body fat training/accuracy
Waist 5D 1.1.13 suggest that waist circumference may be 2C Reliability over time is low
Circumference used to assess abdominal obesity
Conicity Index MHD 1.1.14 may be used to assess nutritional status 2C Risk indicator of for hyperlipidemia
(of abdominal and as predictor of mortality in Western populations
obesity)
Creatinine 5D 1.1.15 suggest it may be used to estimate 2C Diet and/or creatine supplements will
Kinetics muscle mass influence accuracy; requires urine collection

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 GUIDELINE 1: NUTRITIONAL ASSESSMENT (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

1.2 Laboratory Measures
Biomarkers 1-5 D, 1.2.1 may be considered as complimentary tools O
(nPCR, albumin, posttransplantation to assess nutritional status, but not in isolation
PAB) because of non-nutritional factors
Serum Albumin 5D 1.2.2 may be used as a predictor of 1A Note: BCG method is recommended
hospitalization/mortality; lower levels associated for use in those with ESKD
with ↑ risk
1.3 Handgrip Strength
Handgrip 1-5D 1.3.1 suggest using handgrip strength as an 2B Requires special equipment but simple
strength indicator of protein-energy and functional to perform
status when baseline data (prior measures)
are available for comparison
1.4 Assessing Energy Requirements
Assessing REE 1-5D, 1.4.1 reasonable to use indirect calorimetry O Gold standard, use when feasible
posttransplantation to measure REE and indicated
Resting Energy CKD5 1.4.2 in metabolically stable, suggest using 2C Some studies suggest CKD
Equations disease-specific predictive energy equations requirements may be like healthy adults
(if indirect calorimetry not possible)

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 GUIDELINE 1: NUTRITIONAL ASSESSMENT (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

1.5 Composite Nutritional Indices
7-point SGA 5D 1.5.1 recommend the use of 7-point SGA as a valid 1B 11 studies
and reliable tool for assessing nutritional status
MIS 5D, 1.5.2 may be used to assess nutritional status 2C 8 studies
posttransplantation
Note: a comprehensive nutrition assessment, using a composite nutritional index should be conducted at the initial visit and completed
whenever there is a change in health status or as directed by institutional or regulatory policies.
1.6 Tools/Methods Used to Assess Protein and Calorie Intake
Considerations 3-5D, 1.6.1 reasonable to assess factors beyond DI O
when assessing posttransplantation (medication use, knowledge, beliefs, attitudes,
Dietary Intake behaviors, access to food, depression, cognitive
(DI) function, etc.) to plan nutrition interventions
3-day Food 3-5D 1.6.2 suggest the use of 3-day food record as 2C Conduct during both dialysis and
Records the preferred method to assess dietary intake non-dialysis day (as applicable)
Alternative 3-5 1.6.3 24-hr food recalls, food frequency O
Methods for questionnaires, and
Assessing DI 5D nPCR may be considered as alternative methods 2D nPCR requires 24-hr urine collection
of assessing dietary intake for accuracy

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 GUIDELINE 2: MEDICAL NUTRITION THERAPY

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

2.0 Medical Nutrition Therapy
MNT to Improve 1-5D 2.0.1 recommend providing MNT to optimize 1C RDN or international equivalent,
Outcomes nutritional status, and minimize risks of O in close collaboration with a physician
comorbid conditions and alterations in the or other provider (NP or PA)
metabolism on the progression of kidney
disease and on adverse clinical outcomes
MNT Content 1-5D, 2.0.2 reasonable to prescribe MNT that is O
posttransplantation tailored to the individuals’ needs, nutritional
status, and comorbid conditions
MNT 3-5D, 2.0.3 reasonable to monitor and evaluate O RDN or international equivalent
Monitoring and posttransplantation appetite, dietary intake BW changes,
Evaluation biochemical data, anthropometric measures,
and nutrition-focused physical findings to assess
efficacy of MNT

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 GUIDELINE 3: PROTEIN AND ENERGY INTAKE

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

3.0 Protein Amount
Protein 3-5 3.0.1 in metabolically stable, recommend 1A Restriction should be closely supervised
Restriction, protein restriction with or without keto-acid by an RDN or international equivalent
Non-dialysis, analogs to reduce risk of ESKD death and in collaboration with a physician
Without DM improve quality of life
Low protein 0.55 to 0.6 g/kg BW/d 2C
Very-low protein diet 0.28-0.43 g/kg BW/d with
additional keto analogs to meet the 0.55-0.6 g/
kg requirement
Protein 3-5 3.0.2 reasonable to prescribe a dietary protein O Supervised by an RDN or international
Restriction, intake of 0.6-0.8 g/kg BW/d to maintain stable equivalent in collaboration with
Non-dialysis, nutritional status and optimize glycemic control a physician
With DM
Protein Intake, 5D (MHD) 3.0.3 in metabolically stable recommend 1C
MHD, PD prescribing DPI of 1.0-1.2 g/kg BW/d to
Without DM maintain stable nutritional status
5D (PD) Same as above O
Protein Intake 5D 3.0.4 reasonable to prescribe DPI of 1.0-1.2 g/kg O Consider ↑ if at risk for hyper/
MHD, PD BW/d to maintain stable nutritional status hypoglycemia
With DM

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 GUIDELINE 3: PROTEIN AND ENERGY INTAKE (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

3.1 Energy Intake
Energy Intake 1-5D 3.1.1 in metabolically stable, recommend 1C
prescribing an energy intake of 25-35 kcal/kg/
BW/d to maintain normal nutritional status
(based on age, sex, physical activity, body
composition, weight status goals, CKD stage,
concurrent illnesses, inflammation)
Posttransplantation Same as above O
3.2 Protein Type
Protein Type 1-5D 3.2.1 there is insufficient evidence to recommend 1B There is increasing interest in vegetable-
a particular protein type (plant or animal) based diets, but evidence is limited
in terms of effects on nutritional status,
Ca or P levels, or blood lipid levels
Posttransplantation Same as above O
3.3 Dietary Patterns
Mediterranean 1-5, non-dialysis, 3.3.1 with or without dyslipidemia suggest that 2C
Diet posttransplantation prescribing a Mediterranean Diet may improve
lipid profiles
Fruits and 1-4 3.3.2 suggest prescribing increased fruit 2C
Vegetables and vegetable intake may decrease BW, BP,
and NEAP

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 GUIDELINE 4: NUTRITIONAL SUPPLEMENTATION

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

4.1 Oral Protein-Energy Supplementation
Oral Protein- 3-5D 4.1.1 in those at risk for or with PEW suggest 2D To improve nutritional status
Energy a minimum 3-mo trial of oral nutrition
Supplements supplements if dietary counseling alone does
not achieve sufficient energy and protein intake
to meet nutritional requirements
Posttransplantation As above O
Enteral Nutrition Supplementation
Enteral Nutrition 1-5D 4.1.2 in those with chronically inadequate O
intake and whose pro/energy needs cannot be
met by dietary counseling and oral nutritional
supplements, it is reasonable to consider a trial
of enteral tube feeding
TPN and IDPN 1-5D 4.1.3 in those with PEW, suggest a trial of TPN 2C To improve nutritional status if
for CKD and IDPN for MHD nutrition requirements cannot be met
with existing oral and enteral intake

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 GUIDELINE 4: NUTRITIONAL SUPPLEMENTATION (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

4.2 Nutrition Supplementation – Dialysate
Dialysate 5D (PD) 4.2.1 PD with PEW suggest not substituting O Variable study results on different
conventional dextrose dialysate with aa dialysate outcomes, long-term effects remain
to improve nutritional status, although it is unclear
reasonable to consider a trial of aa dialysate
to improve and maintain nutritional status if
nutritional needs cannot be met with existing
oral and enteral intake
4.3 Long Chain Omega-3 Polyunsaturated Fatty Acids
LC n-3 PUFA Nutritional Supplements: Mortality and CV Disease
LC n-3 PUFA for MHD, 4.3.1 suggest not routinely prescribing LC n3 2C
Mortality and posttransplantation PUFA (including those from fish, flaxseed, 2B
CV disease or other oils to ↓ risk for mortality or CV events
As above PD 4.3.2 Same as above O
LC n-3 PUFA Nutritional Supplements: Lipid Profiles
LC n-3 PUFA for 5D (MHD) 4.3.3 suggest 1.3-4 g/d LC n-3 PUFA may be
Lipid Profile prescribed to ↓ TG and LDL cholesterol and
↑ HDL levels

5D (PD) 4.3.4 reasonable to consider prescribing 1.3-4 O

g/d LC n-3 PUFA to improve lipid profile
3-5 4.3.5 suggest prescribing ~2 g/d LC n-3 PUFA 2C
to ↓ serum TG
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 GUIDELINE 4: NUTRITIONAL SUPPLEMENTATION (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

LC n-3 PUFA Nutritional Supplements: AV Graft and Fistula Patency
5D (MHD) 4.3.6 suggest not routinely prescribing fish oil 2B
to improve primary patency rates in patients 2A
with AV grafts or fistulas
LC n-3 PUFA Nutritional Supplements: Kidney Allograft Survival
Posttransplantation 4.3.7 suggest not routinely prescribing LC 2D
with kidney n-3 PUFA to reduce the number of rejection
allograft episodes or improve graft survival

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 GUIDELINE 5: MICRONUTRIENTS

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

5.0 General Guidance
Dietary Intake 3-5D, 5.0.1 reasonable to encourage eating a diet that O RDN or international equivalent
posttransplantation meets RDA for AI of all vitamins and minerals
Assessment and 3-5D, 5.0.2 reasonable to assess dietary vitamin O RDN or international equivalent in
Supplementation posttransplantation intake periodically and to consider MVT collaboration with a physician (PA/NP)
supplementation if vitamin intake is inadequate
Supplementation, 5D 5.0.3 in those who exhibit inadequate dietary O
Dialysis intake for a sustained time it is reasonable
to consider MVT supplementation including
water-soluble and essential trace elements
to prevent or treat micronutrient deficiencies
5.1 Folic Acid
Folic Acid 3-5D, 5.1.1 for those with elevated CKD associated 1A No evidence demonstrating reduction
Supplementation posttransplantation homocysteine recommend to not routinely in adverse CV outcomes
for Hyperhomo- supplement FA with or without B complex
cysteinemia
Folic Acid 1-5D 5.1.2 suggest prescribing folate, B12, and/or 2B
Supplementation B-complex supplement to correct for deficiency/
for Deficiency or insufficiency based on clinical signs/symptoms
Insufficiency
Posttransplantation O

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 GUIDELINE 5: MICRONUTRIENTS (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

5.2 Vitamin C
Vitamin C 1-5D, 5.2.1 for those at risk of vitamin C deficiency, O
Supplementation posttransplantation reasonable to consider supplementation to meet
recommended intake of at least 90 mg/d for
men and 75 mg/d for women
5.3 Vitamin D
Supplementation 1-5D 5.3.1 suggest prescribing vitamin D 2C
for Deficiency or supplementation as cholecalciferol
Insufficiency or ergocalciferol to correct 25(OH)D
deficiency/insufficiency
Posttransplantation O
Supplementation 1-5, nephrotic 5.3.2 reasonable to consider supplementation O
With Proteinuria proteinuria of cholecalciferol, ergocalciferol, or other safe
and effective 25(OH)D precursors
5.4 Vitamins A and E
Supplementation 5D (MHD, PD) 5.4.1 reasonable to not routinely supplement O
and Toxicity vitamin A or E because of possible toxicity.
If warranted, use caution to avoid excessive
doses and monitor for toxicity

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 GUIDELINE 5: MICRONUTRIENTS (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

5.5 Vitamin K
Anticoagulant 1-5D, 5.5.1 reasonable for those on anti-coagulants O
Medication posttransplantation that are known to inhibit vitamin K activity
and Vitamin K (eg, warfarin) not to receive vitamin
Supplementation supplements
5.6 Trace Minerals – Selenium and Zinc
Selenium 1-5D 5.6.1 suggest not routinely supplementing 2C Little evidence that supplementation
and Zinc selenium or zinc improves nutritional, inflammatory,
Supplementation or micronutrient status

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 GUIDELINE 6: ELECTROLYTES

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

6.1 Acid Load
Dietary 1-4 6.1.1 suggest reducing NEAP through increased 2C To reduce the rate of decline of residual
Management dietary intake of fruits and vegetables kidney function
of NEAP
Bicarbonate 3-5D 6.1.2 recommend reducing NEAP through 1C Same as above
Maintenance increase bicarbonate or a citric acid/sodium
citrate solution supplementation
3-5D 6.1.3 reasonable to maintain serum bicarbonate O
levels at 24-26 mmol/L
6.2 Calcium
Total Intake 3-4 6.2.1 in those not taking active vitamin D 2B Including dietary calcium, calcium
analogs, suggest a total elemental Ca intake of supplementation, and calcium-based
800-1000 mg/d to maintain neutral Ca balance phosphate binder
5D 6.2.2 reasonable to adjust calcium intake with O Same as above. Author note: dialysate
consideration of concurrent use of vitamin D calcium may affect balance
analogs and calcimimetics in order to avoid
hypercalcemia or calcium overload

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 GUIDELINE 6: ELECTROLYTES (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

6.3 Phosphorus
Amount 3-5D 6.3.1 recommend adjusting dietary P intake to 1B Author note: Slightly different than
maintain serum P levels in the normal range KDIGO Bone and Mineral Guideline
Source 1-5D, 6.3.2 reasonable when making decisions O P sources include animal, vegetable,
posttransplantation about P restriction treatment to consider and additives; each have different
the bioavailability of P sources bioavailability
Hypophospha- posttransplantation 6.3.3 reasonable to consider prescribing high P O Due to increased phosphate excretion
temia intake (diet or supplements) to replace serum P by the kidneys
6.4 Potassium
Dietary Amount 3-5D, 6.4.1 reasonable to adjust dietary potassium O
posttransplantation intake to maintain serum K+ within the
normal range
Dietary and 3-5D 6.4.2 in those with either hyperkalemia or 2D
Supplemental hypokalemia, suggest dietary or supplemental
Intake for potassium intake based on individual needs
Hyperkalemia and clinician judgement
or Hypokalemia Posttransplantation Same as above O

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 GUIDELINE 6: ELECTROLYTES (cont.)

Guideline Topic CKD Stage Guideline Statement GRADE Rationale

6.5 Sodium
Intake and BP 3-5 6.5.1 recommended limiting Na intake to 1B To reduce BP and volume control
<100 mmol/d (or <2.3 g/d)
5D, Same as above 1C Same as above
posttransplantation
Intake and 3-5 6.5.2 suggest limiting Na intake to <100 mmol/d 2A To reduce proteinuria synergistically
Proteinuria (or <2.3 g/d) with available pharmacologic
interventions
Intake and 3-5D 6.5.3 suggest reduced sodium intake as an 2B To achieve better volume control
Dry BW adjunctive lifestyle modification strategy and a more desirable BW

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 Summary of Differences Between 2000 Guidelines and 2020 Guidelines
KDOQI Nutrition Guidelines 2000
Primarily addresses maintenance dialysis and advanced CKD
without dialysis
Stated “Evidence” or “Opinion” using Agency for Health Care
Research and Quality (AHCRQ) guidelines
Evaluation of nutrition status
Management of protein/energy status
Heavily focused on macronutrients
Included pediatric recommendations
Nutritional counseling/follow-up
Carnitine
Appendices to define measures, calculations, methodologies
Literature from 1966 to 1997
Updated KDOQI-Academy of Nutrition and Dietetics Guidelines 2020
Addresses CKD stages 1-5 including dialysis and posttransplantation
Use of highly regarded GRADE system for evaluating the evidence
More comprehensive and more evidence-based statements; more definitive
recommendations for specific measures in different stages of CKD
More comprehensive and more evidence-based statements
Includes macronutrients, micronutrients, electrolytes
Micronutrients including intake, assessment, supplementation
Pertinent dietary patterns are addressed
Pediatric guidelines were separated from adult guidelines and updated
in 2008
MNT, more comprehensive and more evidence-based statements
Not reviewed
Studies reviewed with citations of studies used for various measures,
calculations
Literature from 1985 to 2016 (Some earlier publications were cited
in the final document as appropriate.)
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Assessment