Medical Nutrition Therapy (MNT)

for Chronic Kidney Disease

(CKD)
By: Mr. Rosli Mohd Sali,
Dietitian, Ipoh Hospital

09/09/15

MNT for CKD

INTRODUCTION

Pt diagnosed with CKD in Malaysia are an important

group of clients for Dietitians because the no. of pts
with CKD requiring RRT increased from 1,985 in 1994
(1st National Renal Registry Report) to 9,995 in 2003 (11th
Malaysian Dialysis & Transplant Registry). In tandem with
this, the dialysis prevalence rate per million population
also increased from 107 in 1995 to 391 in 2003.
Protein-calorie malnutrition is a common complication of
CKD (Kopple et al, 2000)

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MNT for CKD

INTRODUCTION

In 2003, 66% of HD pt and almost 88% of CAPD pt had

serum Alb < 40 g/dl. Nutritional markers such as serum
Alb, BMI and serum chol level have been identified as
independent factors for death in Malaysian dialysis pt.
(11th Malaysian Dialysis & Transplant Registry)

Appropriate medical nutrition therapy (MNT) provided by

a dietitian can help reduce the burden of nutrition related problems as MNT has an important role slowing
in the progression of CKD while maintaining optimal
nutrition (Levey et al. 1996) In addition, MNT reduces the
risk for CKD in individuals with diabetes and hypertension
(Delahanty et al. 1998)
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MNT for CKD

Stage of CKD
Stage

Description

(Source : K/DOQI 2003)

GFR* (ml/min/1.73m)

Medical action plan

Diagnosis and treatment,

treatment of co-morbid
conditions, slowing
progression, CVD risk
reduction

Kidney damage
with normal or
high GFR

90

Kidney with mild,

reduced GFR

60-89

Estimating progression

Moderate reduced
GFR

30-59

Evaluating and treating

complications

Severe reduced
GFR

15-29

Preparation for kidney

replacement therapy

Kidney failure

<15 (dialysis)

Replacement therapy

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MNT for CKD

Modifiable risk factors for

progression of CKD:

Control of BP (Jafar et al. 2003)

Control of proteinuria or albuminuria (JNC-7,
2003)

Control of HbA1c (DCCT, 1993)

Cessation of smoking, reduction in
dyslipidemia and increase in physical activity
promote organ blood flow and potentially
reduce CKD damage (Beto & Bansal 2004)
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MNT for CKD

Prevailing Causes of primary

CKD:

Diabetes (51%)
Unknown causes (30%)
Glomerulonephritis (5%)
Obstructive nephropathy (3%)
Polycystic kidney disease (1%)
Miscellaneous (8%)

*(11th Malaysian Dialysis & Transplant Registry)

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MNT for CKD

Objectives of Nutrition
Management

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A. Early Chronic Kidney Disease

(Stage 1&2)
Treatment of co-morbid conditions such as
DM, HTN, and other chronic diseases to
slow the progression of renal failure
Reduce the risk for CVD such as
hyperlipidaemia
Providing regular nutritional counseling
based on an individualized plan of care in
order to promote good quality of life
MNT for CKD

Objectives of Nutrition
Management

B. Pre-Dialysis (Stage 3&4)

To delay the progression of kidney failure
Maintain good nutritional status in preventing malnutrition by:
i) giving adequate protein and energy
ii) ensuring sufficient nutrients such as Ca, Fe, and other
vitamins and mineral
Minimize electrolyte and mineral disturbances such as PO4,
K+, Ca, Na+ and fluids to manage co-morbidities (anemia,
bone disease, HTN)
Encourage physical activity according to patients condition
and ability.
Providing regular nutritional counseling based on
individualized
plan of care in order
to promote good QOL
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MNT for CKD

Objectives of Nutrition
Management
C.

Haemodialysis (HD) and Continuous Ambulatory

Peritoneal Dialysis (CAPD) (Stage 5)
Maintain or improve nutritional status in order to prevent
malnutrition by:
i) giving adequate protein and energy
ii) ensuring sufficient nutrients such as Ca, Fe, and other
vitamins and mineral
Minimize electrolyte and mineral disturbances such as PO4, K+,
Ca, Na+ and fluids.
Control fluids intake
Prevent and manage co-morbidities such as CVD, anemia, bone
disease and DM
Encourage physical activity according to patients condition and
ability.
Providing regular nutritional counseling based on individualized
plan of care
in order to promote good
QOL
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MNT for
CKD

The Need for Nutrition

Assessment

GFR of less than 60ml/min is associated in laboratory

parameters of serum albumin, hemoglobin, serum
bicarbonate, decreases in body weight and dietary
intake of protein and energy (Kopple et al. 1989; Ikizler et
al. 1995)

It has been shown that dialysis patients with BMI above

25 had a 28% less risk of death compared to patients
with BMI less than 18.5 (11th Malaysian Dialysis &
Transplant Registry)

However, body composition is also important. BMI of

CAPD patients are higher than HD patients but CAPD
patients are more prone to protein malnutrition (K/DOQI
2003)

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MNT for CKD

Therefore, all CKD patients should

undergo nutrition assessment to
evaluate protein calorie malnutrition
followed with appropriate intervention.

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MNT for CKD

Nutrition Assessment and

Monitoring

Anthropometric Assessment : Height,

Weight; post-dialysis (HD)/post drainage
(CAPD), body composition (bioimpedance,
BIA), triceps skinfold or mid-arm
circumference (MAC), SGA
Biochemical Assessment : Serum albumin, Na+, Ca,
PO4, creatinine / urea, microalbumin, serum lipids, FBS /
HbA1c, Hb, Kt/V, BP.
Dietary Assessment : Nutrient intake & meal plan,
food/supplement intake, eating out, smoking/alcohol,
recipe modification & food preparation, food label,
physical activity/functional status Activity of Daily Living
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MNT for CKD

Nutrition Prescription
A. Calories
Stage 1-4, Hemodialysis, CAPD and Peritonitis :
35 Kcal/kg body weight if < 60 years of age
30 35 Kcal/kg if > 60 years of age
(Includes calories from dialysate due to glucose absorption)

Adequate energy intake is important to maintain neutral

nitrogen balance, to promote higher serum albumin
concentrations and more normal anthropometric
parameters and to improve protein utilization (Kopple et
al 1986)

Approximately 60 70% of dialysis fluids glucose may

be absorbed during a 6 hr dwell (Bannister DK et al 1987)
Caution: Monitor weight gain in CAPD patients.
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MNT for CKD

Nutrition Prescription
A. Calories
Energy expenditure of patients undergoing maintenance HD
is similar to that normal, healthy individuals ( K/DOQI 2000)
Acutely ill maintenance dialysis patients are generally
inactive physically and their energy needs will be diminished
by the extent to which their physical activity has been
decreased. Thus energy intakes of 30 35 kcal/kg BW are
recommended (K/DOQI 2000)
The recommended total daily energy intake, including both
diet and energy intake derived from the glucose absorbed
from peritoneal dialysate should be 35kcal/kd/d ( K/DOQI 2000)
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MNT for CKD

Nutrition Prescription
B. Protein (Stage 1&2)
0.8 g/kg BW
The requirement for protein is
unchanged in well control DM, but in hyperglycemic
individuals, protein synthesis is decreased and protein
breakdown increased, leading to a negative nitrogen
balance. This suggests that during periods of
hyperglycemia or weight loss, somewhat higher protein
intakes are required to achieve nitrogen balance, but
whether this alone will correct the abnormality is
unknown (Dikow et al 2002)
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MNT for CKD

Nutrition Prescription
B. Protein (Stage 3&4; Pre-dialysis)
0.6 g/kg BW, if severe malnourish, use 0.75 g/kg
BW (K/DOQI 2000) at least 50% HBV protein
Low protein will maintain nutritional status ( Kopple et al
1973, Walser 1993, Tom et al 1995, Kopple et al 1997,
Fleischmann et al 1998) particularly if they receive

higher

energy intake (ie. 35 kcal/kg/d)

Low protein diet reduces the generation of nitrogenous
waste and inorganic ions which causes many of the
clinical and metabolic disturbances characteristic of
uremic individuals (K/DOQI 2000)
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MNT for CKD

Nutrition Prescription
B. Protein (Stage 3&4; Pre-dialysis)
HBV has an amino acid composition that is similar to
human protein, is likely to be animal protein and tends
to be utilized more efficiently by human to conserve
body proteins individuals (K/DOQI 2000)
Caution: if patient is planning to undergo dialysis, a
higher protein intake may be warranted and ensure
energy intake is adequate.

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MNT for CKD

Nutrition Prescription
B. Protein (HD patients)
1.2 g/kg BW, if severe malnourish and acute illness
(if increase intensity in dialysis, use 1.3 g/kg BW
with at least 50% HBV protein (Acchiardo et al 1990)
Studies show that protein intake less than 1.2 g/kg/d
are associated with lower serum albumin levels and
higher morbidity in HD patients.
Protein intakes greater than 1.2 or 1.3 g/kg/d may also
benefit the catabolic, acutely ill HD patients.

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MNT for CKD

Nutrition Prescription
B. Protein (CAPD Patients)
1.2 1.3 g/kg BW, if acute illness use 1.3 g/kg BW
with at least 50% HBV protein (Shilling et al 1985)
Hypoalbuminemia is more to occur when the protein
intake is less than 1.3 g/kg/d and significantly
associated with an increased incidence of peritonitis
and more prolonged hospital stay.

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MNT for CKD

Nutrition Prescription
C. Carbohydrate (Stage 1 5)
50 60% of energy intake; but for DM patients, follow
diabetic diet guidelines. Fiber 20 30 g per day.
CHO should be utilized to make up the balance of the
required energy intake
Complex CHO is recommended & dietary fiber for good
glycemic control in diabetic patients (Beto 1995)
Incorporating low protein CHO food sources and
simple sugars can assist in meeting energy
requirements of pt on low protein diet.
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MNT for CKD

Nutrition Prescription
D. Fats (Stage 1 5)
25 35% of total kcal; emphasize reduced SFA less
than 7% total kcal, PUFA up to 10% of total kcal, MUFA
up to 20% of total kcal, cholesterol < 200 mg/day.
Encourage daily regular physical activity whenever
possible. If dietary intervention is inadequate, drug
therapy should be started after 3 months ( K/DOQI 2003)
Patients are considered at highest risk for CVD ( K/DOQI
2003)

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MNT for CKD

Nutrition Prescription
D. Fats
In non-diabetic pre-dialysis pt, hypertryglyceridaemia can
be reduced by both increasing the dietary PUFA:SFA
ratio and reducing the CHO content of the diet.
Pt with other coronary risk factors (smoking, HTN,
obesity and lack of exercise) should be encourage to
modify their behavior + modified lipid diet
Management of lipid abnormalities by dietary CHO and
fat restriction alone has been reported to be effective in
dialysis pt. However, additional dietary restriction is
difficult to achieve in the already fluid and protein
restricted pt, and the limited of diet is counterbalanced by
the risk of malnutrition in these pts.
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MNT for CKD

Nutrition Prescription
E. Sodium (Stage 1&2)

Low sodium intake (less than 2.4 g/d) (K/DOQI 2003)

Strict control of BP can delay renal progression and

control CVD
Other lifestyle modifications recommended: wt control,
intake of SFA & Chol., glycemic control, limit alcohol,
exercise and stop smoking.

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MNT for CKD

Nutrition Prescription
E. Sodium (Stage 3&4)

Low sodium intake (less than 2.4 g/d) (K/DOQI 2003)

*Gradual reduction is recommended to max. tolerance
and acceptance
Na+ excretion is inadequate in advanced renal failure
Na+ intake extra cellular volume and Na+
imbalance
Na+ intake limits the efficacy of anti-hypertensive
medication (Mailloux et al, 1998)
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MNT for CKD

Nutrition Prescription
E. Sodium (Stage 5)
HD : 2 3 g Na+ per day (ADA 2002)
CAPD : 2 4 g Na+ per day (ADA 2002)
Na+ intake thirst and complicate
fluid control
Should be individualized based on BP
and wt (ADA 2002)
No added salt diet is recommended.

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MNT for CKD

Nutrition Prescription
F. Fluids (Stage 1 4)
Generally no restriction. Keep fluid balance to maintain
hydration status (ADA 2002)
Capacity to handle water is limited must monitor fluid
intake to avoid overload or dehydration
Fluid retention require individualized advice
Must take into consideration environmental temperature
and activity level of the pt.
Aware all signs of fluid overload and dehydration

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MNT for CKD

Nutrition Prescription
F. Fluids (HD Patients)
750 to 1000 ml/day
Fluid balance affected by:

Fluid intake
Fluid removal from dialysis
Na+ intake

interdialytic wt gain among pts on HD results in

mortality risk (Kimmel et al)
Maintain fluid gain between HD to less than 3% - 5% dry
wt (ADA 2002) or 2 to 3kg
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MNT for CKD

Nutrition Prescription
F. Fluids (CAPD Patients)
up to 1500 ml/day
Fluid balance affected by:

Fluid intake
Ultrafiltration capacity of peritoneal membrance
Na+ intake

Ultrafiltration normally can remove 2.0 2.5 kg fluid per

day
ultrafiltration through the use of hypertonic exchanges
can treat fluid overload. But hypertonic solution may risk
in

risk of obesity
Hypertriglyceridemia
Damage to peritoneal membrane
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MNT for CKD

(EDTNA/ERCA 2002)

Nutrition Prescription
G. Potassium
Stage 1-4 : no restriction unless blood potassium level is
elevated
HD : 2 3g adjust to serum levels (8-17 mg/kg body wt)
CAPD : 3 4g adjust to serum levels (8-17 mg/kg body wt)
K+ levels may be depressed or elevated
Hyperkalemia cardiac arrhythmias / cardiac arrest
Consider non-dietary causes of hyperkalemia (Bansal
1992)

Loss of residual renal function, acidosis, catabolism, inadequate

dialysis, dialysate K concentration too high, drug induced.
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MNT for CKD

Nutrition Prescription
H. Phosphate
Stage 1-2 : no restriction unless indicated
Stage 3-5 : 800 1000 mg/d (adjust for dietary protein needs)
HyperPO4 and the associated conditions begin to appear
as GFR declines <60 ml/min elevated PTH
Require early detection and treatment to prevent bone
disease of chronic hyperparathyroidism, and to minimize
the increased risk for CVD (Slatopolsky E, Block et al, 1998;
Ammann K et al, 1999; Block GA et al 2000)
In pre-dialysis pt, prescriptions of low protein intake has
been shown to be effective to prevent or correct
hyperPO4. (MDRD, 1994)
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MNT for CKD

Nutrition Prescription
H. Phosphate
A limited removal of PO4 occurs with dialysis
The appropriate dose of PO4 binder should be ideally
based on PO4 content meals and snacks. It should be
taken with meals. The type of PO4 binder usually used
are calcium carbonate and calcium acetate.

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MNT for CKD

Nutrition Prescription
I. Calcium
Stage 1&2 : should meet RDI
Stage 3 - 5 : total calcium provided by calcium-based
phosphate binder should not exceed 1500 mg/d
Calcium from diet + PO4 binder should not exceed 2000
mg/d (K/DOQI 2003)
J. Iron
Stage 1 - 5 : should meet RDI. Achieve with
supplementation of 200mg elemental iron (K/DOQI 2003)

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MNT for CKD

Nutrition Prescription
K. Water Soluble Vitamins
Stage 1 5 : supplement to meet recommended daily
intake requirements
For Vitamin C; supplement up to 60 100 mg/d
L. Fat Soluble Vitamins
Stage 1 5 : Intake should meet recommended daily
requirements.
For CAPD pt, may be given active Vitamin D therapy by
physician.

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MNT for CKD

Special Topics
A. Vegetarian Diets
Indian-styled vegetarians various dhals and legumes
incorporated into gravies, stews and snacks, milk and
milk product eg yoghurt
Chinese-styled vegetarians tofu, textured vegetable
proteins (meat analogues) and soy milk.
Caution: may not protein adequacy, may also face
problems of controlling K+, PO4 and Na+

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MNT for CKD

Special Topics
Guidelines for Planning Vegetarian Renal Diets:
Should consume a wide variety of plant foods such as
cereal, legumes, nuts and seeds, fruits and vegetables.
Some vege consume milk and eggs considered.
Consider that cereal foods will contribute a substantial
amount of protein in the vegetarian diet.

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MNT for CKD

Special Topics
B. Nutrition Support in CKD:
Moderate protein and electrolyte levels plus added fiber
products may be given. Too high protein can risk of
dehydration, hypernatremia, and azotemia.
Concentrate formulas to minimize fluid overload. Monitor
fluid status.
PO4 binders may need to be withheld if refeeding
syndrome occurs.
Chose appropriate formulas.

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MNT for CKD

Special Topics
C. Use of herbal supplements:

Herb

Use

Comments/effects

Ginseng

Multiple, stress,
memory,
strength

Can create anxiety, increased BP,

hypoglycemia, decreased anti-coagulant
activity, insomnia, headache, asthma attacks.
Do not use in CKD.

Garlic

Cardiac/reduce
lipid levels

Side effects, bad breath, gastritis, impaired

blood clotting, can effect insulin & OHA.

Gingko biloba Memory,

concentration

Headache, anxiety, restlessness, diarrhea,

anorexia

Ref : McCann (2002)

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MNT for CKD

Special Topics
D. Diabetics with kidney failure:
Ensure protein and energy intake is adequate to prevent
malnutrition
Total CHO intake should be monitored and use of simple
sugars should be limited to improve glycemic control
Ensuring adequate fiber intake may be beneficial to
improve glycemic control and prevent constipation.
However, PO4 and K+ intake should be monitored
especially with the use of whole grain products, beans
and legumes.
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MNT for CKD

Enteral Formula

Calorically dense 2 Kcal/ml

Low in Protein (7.1 g / serving)
Each can provides at least 25% of
recommended levels of vitamins / minerals for
pre-dialysis patients.
Contraindications : Chronic or
acute kidney failure not
receiving dialysis
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MNT for CKD

Enteral Formula

Calorically dense 2 Kcal/ml

Moderate in Protein (16.6 g / serving)
Each can provides at least 25% of
recommended levels of vitamins / minerals for
dialysis patients.
Contraindications : Chronic or
acute kidney failure requiring
dialysis
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MNT for CKD

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MNT for CKD