This document provides an overview of integrated renal care and the role of renal diet and nutritional counseling. It discusses the stages of chronic kidney disease and care processes. Key points include: - Nutritional assessment and counseling are important parts of renal care provided by a renal dietitian. - Diet must be individualized based on a patient's kidney disease stage, lab results, nutrition status and other factors. - Diet focuses on managing calories, protein, carbohydrates, fat, sodium, fluids, phosphorus and other minerals. - Malnutrition is common in kidney disease and dialysis, so nutritional monitoring and counseling are essential.

1. Dr. Doaa Hamed Elsabakhawi
Lecture of Clinical Nutrition
National Nutrition Institute –Cairo (Egypt)
Instructor in Egyptian Fellowship of Clinical Nutrition

2. Objective
 Integrated renal care .
 Importance of renal diet .
 Nutritional counseling
 How to assess nutritional
state?
 Diet Planning In CKD & HD
 Conclusion

3. Stages of Chronic Kidney Disease
Stage CKD I CKD II CKD III CKD IV CKDV
Description Kidney Damage
with Normal or
↑GFR
Mild ↓GFR Moderate ↓ GFR Severe ↓ GFR Kidney Failure
GFR
(ml/min/1.73 m2 )
> 90 60 -89 30 -59 15 -29 < 15 or Dialysis
Stage
dependent
Actions
Prevent complications
Mineral metabolism
Nutritional monitoring
Anemia prevention

4. Care process Requires
A psychotherapist / motivation speaker
A diabetes educator
A renal specialist dietitian
A combination of:-
 Nephrologist
 Nurse
 pharmacist
 Social Worker
 patient's best friend

5. ‫إيــــــــه‬ ‫آكـــــل‬

6. What is the role of ?
 Trained & experienced in Renal nutrition
 Implementation of many guidelines concerning
nutritional assessment
Anthropometry, SGA, dietary interviews
 Plan for nutritional management & therapy
 Counseling the patient & the family
 Educational activities

7. Why there are for ?
All patients should receive nutritional counselling based
on an individualized plane of care.(Evidence Level C)
Nutrition in peritoneal dialysis Guidelines 2005
Nephrol DialTransplant (2005) 20 ( Suppl 9) : ix28-ix33
Clinicians use several strategies, but there are barriers to
nutritional counseling which include:-
skepticism about the effectiveness of nutritional interventions
lack of specific knowledge and training about therapeutic
nutrition
 lack of specialty clinics, absence of guidelines, and an
inadequate number of dietitians

8. screening
CKD
 We recommend that screening should be performed (1D)
o for inpatients
o for outpatients with eGFR <20 but not on dialysis
o of commencement of dialysis then 6-8 weeks
later
 Screening may need to occur more frequently if risk of
undernutrition is increased (for example by intercurrent illness)

9. screening
HD
 Stable and well-nourished haemodialysis patients should be
interviewed by a qualified dietitian every 6–12 months or
every 3 months if they are over 50 years of age or on
haemodialysis for more than 5 years (Evidence level III).
 Malnourished haemodialysis patients should undergo at
least a 24-h dietary recall more frequently until improved
(Opinion).
UK Renal Association, March 2010

10. CKD HD
 Clinical studies have shown that renal patients may
have inadequate dietary intakes during early stages
 40 - 70 % of patients with end-stage renal disease are
malnourished
 Protein–energy malnutrition should be avoided in
maintenance hemodialysis because of poor patient
outcome (Evidence III).
 Tow types of malnutrition I & II has been described
in CKD patients
(ESPEN 2008)

11. PEW
Kidney International (2013) 84, 1096–1107

12. Beto’s PAGE System
Pediatrics • Growth / development
Adults • Promote health ( Prevention)
Geriatric • Maintain health ( Holding pattern)
End of Life • Minimaze aging effects
CKD Key Focus on…
Quality of life

13.  Maintain optimal nutritional status
 Prevent protein energy malnutrition
 Slow the rate of disease progression
 Prevention/treatment of complications
and other medical conditions
 DM
 HTN
 Dyslipidemias and CVD
 Anemia
 Metabolic acidosis
 Secondary hyperparathyroidism

14. Renal diet minimizes the amount of wastes
A good meal plan choices can:
 Minimize build-up of waste products &
fluid between treatments
 Improve nutritional and functional status
 Conserve muscle mass

15. Nutrition Care Process Steps
ADIME
Nutrition
Care
Process

16. assessment
History and physical examination looking for loss
of weight and muscle wasting
Dietary history
SGA (Subjective Global Assessment)
Anthropometry
Biochemical / laboratory tests

17. Subjective Global Assessment Rating Form

18. How can we monitor and Follow-up
nutritional status?
Severely underweight Lessthan 16.0
Underweight From16.0 to 18.5
Normal From18.5 to 24.9
Overweight From 25 to 29.9
Obese Class I From30 to 34.9
Obese Class II From35 to 39.9
Obese Class III Over40
Haemodialysis patients should maintain a BMI >23.0
BMI = Weight (kg) / (height [m]2)

19. Reverse epidemiology of obesity in dialysis
patients compared with the general population
Kalantar-Zadeh K et al. Am J Clin Nutr 2005;81:543-554

20. Ideal Body Weight (IBW)
For men = [ (height(cm) – 152.4) x 0.91) ] + 50
For women= [ (height(cm) – 152.4) x 0.91) ] + 45.5
Adjusted Body Weight (ABW)
For men: Adjusted weight = [( actual weight- IB weight) x 0.38] + IB weight
For women: Adjusted wt = [(actual weight- IB weight) x 0.32 ] + IB weight
If Actual BW > 30% IBW
use

21. Is albumin can predicts mortality at
onset of dialysis?
Strong predictor of morbidity and mortality
(CANUSA study)
However,
Albumin is affected by non-nutritional
factors
 Infection
 Inflammation
 Co-morbidities
 Fluid overload
 Inadequate dialysis
 Blood loss
 Metabolic acidosis
Albumin may not increase in response to
nutritional intervention
There is No Single Magic Nutritional Index

22. HD CAPD
Loss of amino
acids
6-10 g/dialysis 2-4 g/bag
Loss of glucose
~25 g/dialysis
(glucose free dialysate)
uptake
Loss of protein
0 5-15 g/day
(higher with peritonitis)
Inflammatory stimuli
Blood membrane contact
Cytokine release
Low grade inflammation
(particles chemicals)
Cytokine release
Is Dialysis has effect on Nutrition?

23. Is Dialysis has effect on Nutrition?
Daily HD or 6 HD sessions/ week
(Schulman G. Am J Kidney Dis 41:S112-S115,2003)
Improve appetite & food intake
General feeling of well being,↑ed physical activity
Fewer dietetic restrictions
↓ ed dose of medications → Phosphate & K binders,
antihypertensive drugs
↑es clearance of potential anorexic factors
Improves serum albumin levels

24. Dietary Recommendations

25. Dietary Recommendations

26. Diet Focus on…
Important
Nutrients
Individual
Differences
CKD
Diet Goals
HD
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Phosphorus (stage 3)
• Size
• Stage of CKD
• Nutrition
• Lab results
• Size
• Nutrition
• Lab results
• Calories
• Protein
• Carbohydrates
• Fat/Cholesterol
• Na & Fluids
• Potassium
• Phosphorus
• Calcium
• Management of
• Blood pressure
• Glucose
• Minerals
• Fluid
• Weight
• Good nutrition
• Management of
• Blood pressure
• Glucose

27. Adequate energy intake essential to optimize nutritional
status
 Present in (Carbohydrates – Fats - Protein)
 Calculated based on your
 current weight,
 weight loss goals
 age and gender
 physical activity and metabolic stress
35 kcal/kg/d < 60 yrs
30–35 kcal/kg/d ≥ 60 yrs
Regular physical activity should be encouraged, and energy intake should be
increased according to the level of physical activity (Opinion).
Calories

28. To increase the energy content of meals:
 Add extra oil to rice, noodles, breads, crackers, and
cooked vegetables.
 Add extra salad dressing.
 Non-protein calorie (NPC) supplement can be
added
(J Ren Nutr. Nov. 2012 )

29. Protein
 Essential for ❖ building muscles ❖ repairing tissue
❖ fighting infection ❖Keeping fluid balance in the blood
There are two kinds of proteins
◦ (HBV) or animal protein-meat, fish, poultry, eggs and dairy
◦ (LBV) or plant protein – breads, grains, vegetables, dried beans and peas
and fruits
50 -70% should be of HBV.
A well balanced diet for kidney patients should include
both kinds of proteins every day.
Protein Alternatives
protein bars, protein powders, supplement drinks

30. Stage 5 -
On dialysis
All stages – if
malnourished
Protein Intake
Example:
A 150 lb
(68kg)
• 82 grams
• ½ cup milk
• 2 eggs or 4
egg whites
• 5-6 oz meat
• 3 vegetables
• 8 servings of
grains
• 41 – 48 grams
• ½ cup milk
• 1 egg or 2 egg
whites
• 2 oz meat
• 2 – 3
vegetables
• 5 – 6 servings
of grains
Stage 4 or 5 -
Not on dialysis
Stages 1 - 3
• 55 grams
• ½ cup milk
• 1 egg or 2 egg
whites
• 3 oz meat
• 3 vegetables
• 6 servings of
grains
0.75 gm/kg/d 1.2-1.3 gm/kg/d0.6 gm/kg/d
• Eat additional protein

31. Potential beneficial effect of
low-protein diet in CKD
 Uremic symptoms diminish or disappear
 (especially nausea, vomiting)
 Reduce the burden of uremic toxins
 (urea, H+, K+, phosphate, other)
 Slow progression of renal failure ?
Reduce proteinuria
 Improve nutritional status
Increases insulin sensitivity and glucose tolerance
Antioxidant effect
No Protein Restriction for Dialysis Patients10-12 grams lost per HD treatment
Aparicio M et al J Renal Nutr, 19, No 5S (September), 2009: pp S33–S35

32. Lipids
 Patients considered at highest risk for cardiovascular disease
 Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile and
individualized treatment goals
requirement of fat
( 30 % total cal ) Minimize the ↑ in TG & Cholesterol
< 10% of calories → SFAc Ratio of USFAc to SFAc l fats = 2 : 1
8% SFAc l :10 % PUSFAc : 12% , MUFAc
250–300 mg cholesterol/day
Omega 3 fatty acid ↓ TG & Chol. as well as phospholipids may be tried

33. Fish Oil Could Protect Hemodialysis Patients
Patients receiving hemodialysis are significantly more
likely to die of sudden cardiac death in their first year of
treatment if they have lower serum levels of omega 3 fatty
acids compared with those who have higher levels
Kidney International (2013) 83, 1130–1135; doi:10.1038/ki.2013.4;

34. Lipid disorders
Hypertriglyceridemia, often normal cholesterol but low HDL cholesterol
Chmielewski M et al. J Nephrol 21: 635-44, 2008

35. Carbohydrates
65-70% total kcal
70% complex sugar
(reduceTG synthesis and improve glucose tolerance)
30% simple sugar
Carbohydrate intake may need to be modified for Patients
with Diabetes to achieve the goal of HgAIC < 7 %
Carbohydrate Counting

36. Fiber Intake
Optimum fiber intake 20-25 g/day

37. Fiber Intake

38. Sodium
 Plays vital role in regulation of fluid balance and blood
pressure
In CKD& HD:-
 May result in :-
high blood pressure,
fluid retention/swelling (edema)
 lead to shortness of breath
Excessive thirst
CHF
Serum Sodium (nl 133-145 mEq/L)

39. Sources of Dietary Sodium

40. Eat out less (especially Fast Food)
Cook at home with low-sodium ingredients
Read labels
1,000- 4,000mg/d
for
CKD&HD
patient
diets
Cut out: • Salt
• High-sodium condiments
• Processed, cured foods
Add: • Herbs
• Spices
• Lemon
• Vinegar
No Added Salt (NAS)

41. Fluids
“any food that is liquid at room temp”
Soup, gelatin, ice cream, ect.
HD
Urine Output + 1000 ml
Limit IDWG (2-5% Estimated Dry weight )
 Excess fluid buildup
Edema, HTN, CHF and
Breathlessness
Delays wound healing
 Fluid restriction estimations
are based upon:-
Urinary output
Disease state
Treatment modality (dialysis, etc.)

42. Tips for thirst and fluid control!
 Track your fluids
 Avoid chewing lots of ice
 Avoid refills at restaurant
 Avoid super-sized beverages
 Limit salty foods
 Small glasses at meals & meds
 Add lemon or Lime juice to water
 Hot weather, temperature
Keep your skin cool: cold wash cloth,
mist-bottle
Keep your lips moist with a chap stick
Keep your mouth wet
◦ Keep your mouth clean
 toothpaste for dry mouth (biotene)
◦ Rinse your mouth with cold water, but
don’t swallow it
◦ Rinse your mouth with chilled
mouthwash
◦ Chew on gum: Quench gum
◦ Try lemon wedges or freeze grapes &
strawberries
If diabetic, control blood sugars

43. Sodium & Fluids
 The requirement for sodium and water varies markedly, and
each patient must be managed individually.
 Individualize
◦ IDWG, blood pressure, residual renal functions
 Increased Restrictions if
 ↑ IDWG, CHF, edema, HTN
fluid output Na fluid
≥ 1 L 2-3 g 2 L
≤ 1 L 2 g 1-1.5 L
Anuria 2 g 1 L

44. Phosphorus
 High serum phosphorus
 Bone decalcification
 Soft tissue calcifications
 Hyperparathyroidism
 Dietary intake ~800 to 1000 mg/day OR <17 mg/kg SBW
HD removes ~500-1000 mg/treatment
Binders removes 50% of dietary phosphorus
Control = Binders + Diet + Adequate dialysis

45. Organic phosphorus
40 – 60% absorbed
Phytates ↓ absorption
Dairy products
Meat, poultry, fish
Soy (soy milk, tofu)
Nuts and seeds
Dried beans and peas
Whole grains
Inorganic phosphorus
> 90% absorbed
Food additives
Dietary supplements
Calcium fortification
Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519-530
Phosphorus Types
Control Phosphorus
Diet
READ THE INGREDENTS LABEL!!
Phosphorus binders
ineffective

46. What are high and low phosphorus foods?

47. Control Phosphorus
Binders
Generic Name Brand Name Estimated Binding Capacity
Calcium acetate
667 mg
PhosLo 30 mg
Sevelamer HCL
800 mg
Renagel, Renvela 64 mg
Calcium carbonate
500-600 mg
TUMS, Os-Cal,
Calci-Chew, Caltrate
20-24 mg
Lanthanum carbonate
1000 mg
Fosrenol 320 mg
Binders are like a sponge. They “soak up” phosphorus from food! in the GI tract
Must take with meals

48. Control Phosphorus
Dialysis
 Among dialysis patients with persistent Hyperphosphatemia, we
suggest increasing phosphate removal via hemodialysis (Grade
2C)
 Phosphate clearance is effective only during the first 2 hours of
dialysis. Serum phosphorus levels do not change during the
second half of dialysis. Haemodialysis removes approximately 900
mg of phosphate three times weekly. (Mucsi et al., 1998; Block &
Port, 2000)
 Among patient with refractory Hyperphosphatemia, nocturnal HD
is an option among those who are welling to accept this form of
dialysis.

49. Ph Intake
Absorption
~60%
Binding
~50%
Dialysis
Removal HD
+1000 mg/day
+7000 mg/wk
+600 mg/day
+4200 mg/wk
-300 mg/day
(10 Phoslo)
-2100 mg/wk
-700 x 3 =
-2100 mg/wk
Weekly Phosphorus Balance
+ 4200 (diet) – 2100 (Binders) – 2100 (HD) = Balance
Diet + Binders + Adequate dialysis

50. Calcium
Renal diet is approximately 500-800 mg / day
Diet (low ----- many foods high in ca high in ph )
 1200 – 1500 mg/day based on DRI*
 May need vitamin D3
Not to exceed 2g/day, including calcium-
based binders
 Activated vitamin D
 PTH control important
CKD Stages 1 – 4
CKD Stage 5 & HD

51. Potassium
CKD Stages 1 – 3 Usually not restricted
CKD Stages 4 and 5 and HD Correct labs
 Dietary Goal is usually 2 - 3 gms/day
adjust per serum levels
Dialysis bath concentrations

52. Low Potassium foods Avoid Highest Foods
 Apples
 Grapes
 Berries
 Pineapple
 Tangerine
 Cabbage
 Green Beans
 Cauliflower
 Eggplant
◦ Oranges/Juice
◦ Banana
◦ Potato
◦ Mango
◦ Melon
◦ Avocado
◦ Tomato
◦ Nuts
Fruits & Vegetables
 Low: 20-150 mg
 Medium: 150-250 mg
 High: 250-550 mg
Portion size is essential
Avoid Salt Substitutes
Dairy
 1 cup 380-400 mg
 High phosphorus foods
Potassium

53. Nutritional Supplements
 Oral supplements: Nepro (dialysis), Suplena (non-
dialysis) Ensure, Boost
Powders: Beneprotein, ProSource, Eggpro.
 Modular Protein: Pro-Stat, Promod
 Cookies: NutraBalance
 Protein Bars
 Meal replacements vs. snacks
 Over the counter
 Evaluate potassium, phosphorus

54. Assessment:
 Diet history & any changes in dietary
intake
 Weight history
 SGA
 Underlying medical condition
 Biochemistry
 GI symptoms
 Social and psychological
factors
Nutrition in CKD& HD
Management
Oral Diet
Oral diet + extra snacks
Oral diet, extra snacks + supplements
Oral diet + supplementary NG/ PEG feeding
Exclusive NG/ PEG feeding
TPN
Must also optimize medical management (dialysis adequacy, acidosis, infection)

55. Conclusion
 Poor nutrition is common in CKD & DH patients and has
adverse risk factor
 Nutritional counseling –part of approach to CKD and
dialysis patients.
 Routine nutritional screening & assessment should be done
for CKD and dialysis patients.
 Qualified renal dietitian must be included in the staff of
every dialysis unit.
 Personalized nutritional plan – worked out for every
patient.
Individualization