Nutrition Assessment for CKD

Stages of Chronic Kidney Disease (CKD)

Stage Description GFR (ml/min/1.73m2)

1 Kidney damage with normal or GFR ≥ 90

2 Kidney damage with mildly GFR 60 to 89
3 Moderately GFR 30 to 59
4 Severely GFR 15 to 29
5 Kidney failure < 15 or dialysis

Chronic Kidney Disease is defined as either kidney damage or GFR < 60

ml/min/1.73m2 for ≥ 3 months.

Kidney damage is defined as pathological abnormalities or markers of damage,

including abnormal blood, urine or imaging tests.

NKF KDOQI Clinical Practice Guidelines for CKD: Evaluation, Classification and Stratification. Am J Kidney Dis. 2002;
39:2 (suppl 1) S1 – S266.
Assessment and Monitoring of
Nutritional Status
 Requires multiple different parameters
 Panel of Assessment includes:
 Anthropometrics
 Biochemical measurements
 Nutrition Index Scores (Subjective Global Assessment (SGA) /
Malnutrition Inflammation Score (MIS) / Dialysis Malnutrition Score
(DMS)
 Dietary Intake
 International Society of Renal Nutrition and Metabolism
(ISRNM), 2013
CRITERIA
Serum Serum Albumin < 3.8 g / 100 ml
Chemistry Serum Pre-Albumin < 30 mg / 100 ml (for MHD only)

Body Mass BMI < 23 kg/m2

Unintentional Weight Loss over time:
5% in 3 months or 10% in 6 months
Total Body Fat percentage < 10%

Muscle Mass Muscle wasting:

Reduced muscle mass 5% in 3 months or 10% in 6 months
Reduced MAMC/area: (reduction > 10% in relation to 50 th percentile of
reference population)
Creatinine Appearance

Dietary Intake Unintentional DPI , 0.8 g/kg/day for at least 2 months (MD) or 0.6 g/kg
for patients with CKD stages 2 to 5
Unintentional DEI , 25 kcal/kg/day for at least 2 months
 KDOQI Assessment and Monitoring
Parameter Minimum Frequency
Serum albumin Monthly
nPNA Monthly-HD; every 4 months-PD
% Usual Dry Weight (post dialysis or post-drain) Monthly
% Standard body weight Every 4 months
Subjective Global Assessment (SGA) Biannually
Diet interview / diary Biannually
Anthropometrics, DEXA, prealbumin, creatinine As needed
index, creatinine, urea nitrogen, cholesterol

NKF KDOQI Clinical Practice Guidelines for Nutrition in CRF. Am J Kidney Dis. 2000; 35 (6) suppl 2: S1 – S140.
Anthropometric Measures
WEIGHT COMPARISON FORMULAS
Percent Standard Body Weight
(% SBW) Actual Body Weight x 100
Standard Body Weight

Percent Desirable Body Weight

(%DBW) Actual Body Weight x 100
Desirable Body Weight
Percent Usual Body Weight
(%UBW)
Actual Body Weight x 100
Usual Weight
Percent Weight Change
(% Wt Change)
Previous Weight - Actual Weight x 100

Previous Weight
Anthropometric Measures
Adjusted body weight (BW) = edema-free BW + [(standard BW – edema-free BW) x 0.25]

* Adjust when patient’s weight is <95% or >115% of standard body weight

Examples of adjustment:

Underweight patient: ABW=60 kg SBW=80 kg

Adjusted BW= 65 kg

Overweight patient:ABW=80 kg SBW=60 kg

Adjusted BW= 75 kg
Anthropometric Measures
 Arm Anthropometrics
 MAC
 TSF
 MAMC (MAMC = MAC – (TSF x 0.314)

 Height estimation
 Forearm – point of the elbow and the midpoint of the
prominent bone of the wrist
 Knee height
 Demi-span
Biochemical Measurements
Test Values
Albumin 3.5 to 5.0g/dL
BUN 10 to 20 mg/dL
Calcium 9.0 to 10.5 mg/dL
Cholesterol < 200 mg/dL
Creatinine 0.3 to 1.1 mg/dL
Hemoglobin 10 to 12 g/dL
Phosphorus 3.5 to 5.5 mg/dL
Potassium 3.5 to 6.0 mEq/L
Sodium 136 to 145 mEq/L
Uric Acid M: 2.1 to 8.5 mg/dL
F: 2.0 to 6.6 mg/dL
Nutrition Index Scores
 Subjective Global Assessment (SGA)
 Weight change – in 6 months / in the past 2 weeks
 Dietary Intake – duration and degree
 GI Symptoms – duration and frequency
 Functional Status – duration and degree of dysfunction
 Metabolic Stress / Co-morbidities
 Low to moderate function (infection, skeletal trauma, malignancy)
 High stress (ulcerative colitis with diarrhea)
Components of SGA
Medical History
Component Outcomes
Weight History Changes in dry weight – rate and pattern
of loss > 5 to 10 %
Diet Intake Review Comparison to usual intake – degree and
duration
Gastrointestinal Frequency and severity of symptoms that
Symptoms last more than 2 weeks

Functional Status Asses changes from baseline related to

nutrition
Acute Stresses Increased metabolic demands
Components of SGA
Physical Examination
Component Sites Outcomes
Subcutaneous Fat Biceps, triceps, fat pads Declining circumference,
Stores under eyes hollow under eyes
Muscle Wasting Temple, quadriceps, Prominent bone
deltoid, clavicle and structure, flat or hollow
shoulder, ribs, knee, calf, areas
interosseous muscle, ribs,
scapula
Edema Extremities and facial Swelling when at dry
features weight
Ascites Abdomen Swelling in abdominal
area after treatment
Dietary Intake
 Food and Nutrition History
 To identify nutrient intake and imbalances
 Potential food and nutrition problems
 Dietary factors related to nutrition diagnosis and intervention

 Data
 Food intake
 Eating habits and patterns
 Lifestyle patterns related to nutrition and health
SAMPLE REL AND NCP
Case:

 Case GG is a 58 year old female, single, a clerk from

Quezon City
 2 weeks PTA, Patient started to experience nausea, loss of
appetite; no abdominal pain
 3 days PTA, patient had difficulty sleeping, weakness and
noted a decrease in urine output
 Consult done and noted elevated creatinine
Case:
 Medical History:
(+) HPN
(+) DM - since 2011
(+) CKD sec. to DMN, not on RRT – since 2013
Height: 5’2”
Actual Body Weight: 66 kg
Usual Body Weight: 71 kg
BP: 120/70
Case:

Physical Assessment:

Bipedal edema
Body weakness

Diet History
No food allergies
Has poor appetite
Does not follow meal plan
Guide Questions:
 1.) Compute for the Total Energy Requirement for the
Patient

 2.) Formulate your NCP based with the provided data

 3.) Present your possible PES

IBW = 58 kg = 60 kg

BMI = 26.8 kg/m2

1.) 60 KG x 35 kcal = 2,100 kcal
2.) 2,100 kcal - 300 kcal (for weight loss) = 1,800 kcal

Diet Rx: 1,800 kcal, 2g Na, Low Protein

 PES:

 Limited adherence to nutrition-related recommendations

related to lack of knowledge on proper eating practices as
evidenced by poor food choices.