DIETARY CONSIDERATIONS IN RENAL

FAILURE
Eileen Duff, Renal Dietitian
Fiona Chawke, Renal Dietitian
7th Aug 2015
  AIMS

 1. To highlight the risk of malnutrition in patients with

renal disease.
 2. To outline the different dietary requirements of patients
at each stage of renal failure.
 3. To provide practical tips about how to meet the different
nutritional requirements of these patients.
 AIMS OF DIETETIC INTERVENTION…
(WHAT WE DO!)

1. To optimise nutritional status

2. To keep renal biochemistry within safe limits
• K+
• PO4-
3. To prevent fluid overload & aid BP control
4. To make dietary advice as practical as possible to
aid compliance
 DIET AND RENAL DISEASE
Nutritional Assessment
•1. Anthropometry
Body weight/Dry weight
Diet will vary with:
Weight history • Biochemistry
•2. Biochemistry • Nutritional status
•3. Clinical condition • RRT
• Stage or RRT
• Symptoms affecting dietary intake
•4. Diet & diet history
•5. Social aspects
Diet is important throughout the

‘patient journey’
 :
MALNUTRITION

ESTIMATES OF 20-70% IN CKD/HD/PD

WHY… ?
Restrictions to diet Co-morbidities: Nutrient losses
•Cancer (Dialysis)
Catabolism •Diabetes •Protein
(Dialysis & acidosis,
(gastroparesis) •Vits & mins
AKI)
Travel time = Anaemia &
missed meals Factors fatigue
Frequent hosp contributing to risk
admission Infection
of malnutrition e.g. peritonitis
Mood &
depression
Uraemia:
Socio-economic factors: •Sickness
• Lack of food prep. skills •Taste changes
•Low budget ?employment •Reduced appetite
 ORAL NUTRITIONAL SUPPLEMENTS
Milk-style:
 Fresubin Energy = 300kcal, 11g protein
 Fresubin Protein Energy = 300 kcal, 20g protein
 Fresubin 2Kcal = 400Kcal, 20g protein
 While in hospital – various ‘homemade’ milkshakes

Juice-style:
 Fresubin Jucy = 300kcal, 8g protein

Dessert-style:
 Fresubin Crème/FresYocreme = 225kcal, 12.5g protein

Shot-style:
 Fresubin 5kcal 30 ml tds – 450kcal, 0 protein
 ProCal 40 ml tds – 400 kcal, 8 g protein

Also, powders & liquid energy modular supplements

 ENTERAL & PARENTERAL NUTRITION

Enteral tube feeding –

often require low electrolyte, fluid restricted feeds for dialysis
patients e.g. Nutrison Concentrate.

Parenteral feeding –
 often require ‘scratch or tailored’ bags for electrolyte
flexibility and low volume. Ordered by dietitian and pharmacist
with Medical approval.
Energy Renal Minerals
(calories) (potassium & phosphate)

Diet in Kidney Disease

Protein Micronutrients:
Fluid & salt vitamins &
(sodium) minerals
 FOCUS ON PROTEIN
Pre-Dx (LCC)
Protein 0.75g/kg IBW
required:
~53g protein/day =
For 70kg  ~30g HBV protein =
~5oz/125g meat or
equivalent daily
Example Bk = Cereal & toast (1/3
pint milk/d only - ?rice milk
meal plan: on cereal)
L = S/w (1 thin slice meat
or ¼ tin tuna/salmon)
EM = Pasta with vegetables
in tomato sauce (3 rasher
bacon) OR 4oz chicken
breast (if cream cheese at
lunch) No milk pudds
HD
≥1.1g/kg IBW
≥77g protein/day =
~54g HBV protein =
~9oz/225g meat or
equivalent daily
Bk = Cereal & Toast
(1/2 milk/d if low K+ diet)
L = S/w (2-3 slice meat
or ½ tin tuna/salmon)
EM = Pasta with
vegetables in tomato
sauce 5oz chicken
breast OR ¼ 500g beef
mince pack in bolognese
+/- cheese on top, or
milk pud (if po4- & fluid
allows)
PD
≥1.2g/kg IBW
≥84g protein/day =
~59g/day HBV protein =
~10oz/250g meat or
equivalent daily
Bk = 2 Grilled bacon or
sausage on toast
(1/2 milk/d if low K+ diet)
L = S/w (2-3 slice meat or
½ tin tuna/salmon)
EM = Pasta with
vegetables in tomato
sauce 5oz chicken breast
OR ¼ 500g beef mince
pack in bolognese
+/- cheese on top, or milk
pud (if po4- & fluid allows)
 QUIZ…IDENTIFY THE HIGH K FOODS
 Carrot  Apples
 Tomatoes  Milk

 Avocado  Cake

 Oranges  Nuts

 Spinach  Pear

 Coconut  Fresh beetroot

 Dried fruit  Cheese

 Beef  Blackcurrant

 Pate  Toffee
 LOW POTASSIUM DIET
1. Potatoes 4oz/100g boiled per day
AVOID: jackets, chips, crisps, instant mash
2. 3 -6 x 80g portions fruit and/or (boiled) vegetables /day
AVOID: avocados, bananas, blackcurrants, coconut, all dried
fruits (inc. apricots, figs, raisins)
3. Limit milk to ½ pint /day (inc. milk pudding etc)
4. Avoid/limit other high K+ foods:
•E.g. coffee, chocolate, toffee, liquorice, bran, nuts, fruit juices,
salt-substitues(Lo-salt), marmite, ketchup, brown sauce

Written low potassium advice on the intranet:

http://pht/Departments/NutritionDietetics/default.aspx
 PHOSPHATE MANAGEMENT
High phosphate foods:
 Milk allowance (½ pint daily)
 Cheese allowance (e.g. 100g/week)
 Eggs allowance (e.g. 2-3/week)
 Others include: nuts, chocolate, products
with baking powder (e.g. scones), shellfish,
bony fish, offal/pate.
Phosphate restriction often not necessary
in hospital due to reduced intake.
No low phosphate menu while in-pt –
choose appropriately from ‘normal’ menu
as required.
PHOSPHATE BINDERS
 FLUID ALLOWANCE IN DIALYSIS
1. Reduce salt in the diet =  thirst
2. Effective control of BMs in diabetes =  thirst

3. Include fluid from foods “liquid at room temperature”:

 Milk on cereal, soups, gravy, ice cream etc.

4. Use small or half cups

5. Plan a routine for drinks through the day

6. Suck (sugar-free) sweets / chew gum

7. Rinse mouth or clean teeth

8. Suck ice cubes

9. Minimise fluid with meds

 RENAL TRANSPLANT
Immediately post transplant:
1. High protein diet & boil drinking water
2. Food hygiene – food storage/ handling/ preparation & high
risk foods
Long term:
1. Healthy eating & weight maintenance
 5-a-day Fruit & veg
 Reduce fats/sugars
 Minimise saturated fats (choose MUFA)
 Physical activity

2. Occ. low K+ needed

3. Occ. steroid-induced diabetes

N.B. Failing transplant as per CKD/Low clearance

RE-FEEDING SYNDROME
 Re-introduce food slowly
 Thiamine and multivitamins for 10 days (pabrinex)

 Monitor po4, k and mg daily for 10 days

 Re-feeding guidelines on the intranet

http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Refeeding
%20Syndrome%20Guideline.doc
 Prolonged vomitting, diarrhoea, alcoholism, neglect etc
are high risk patients.
 REASONS TO REFER TO US
 New starter HD/ PD
 New ‘Crash-lander’ / Catabolic AKI
 K+/po4-/fluid modification
 Poor intake/Dry weight loss/malnutrition
 Nephrotic syndrome
 Weight reduction
 New transplant advice
 NODAT (New onset diabetes after transplant)
CONTACT DETAILS
 Bleep 1479, 1480, 1481
 Phone 02392 286000 ext. 1016 or 1014

 Location: beside the registrars office at QA

 Eileen, Sarah, Caroline, Fiona, Clare, Miriam

 We cover G9, G7, G6 acute wards,

HD units at QA , Havant, Totton, Salisbury,

IOW, Bognor, Milford, Basingstoke and
low clearance clinic at these locations also.
ANY QUESTIONS?