Diet Planning Guide: Nutritional Considerations in CKD and ESRD
James J. Matera DO, FACOI
Practicing Nephrologist, Senior Vice President for Medical Affairs, Chief Medical Officer, CentraState Medical Center, Freehold, New Jersey
Jamie Miller, MS, RD
Transplant Dietitian, Clinical Dietitian, Saint Barnabas Medical Center, Livingston, New Jersey
Adjunct Instructor, Department of Nutrition and Food Studies, Montclair State University, Montclair, New Jersey
Citation: Matera JJ, Miller J. Diet planning guide: nutritional considerations in CKD and ESRD [Published online June 7, 2019]. Nutrition411.
Chronic kidney disease (CKD) has significant health and lifestyle implications for those affected, including increased risks of cardiovascular disease and malnutrition. CKD is a public health burden, particularly in cases that progress to end-stage renal failure (or end-stage renal disease [ESRD]) and require renal replacement therapy (dialysis) or transplantation.1 There are several stages of CKD, which include:
Malnutrition is associated with higher mortality in CKD and ESRD patients, increasing by as much as 500% based on the severity of malnutrition, age greater than 5 years, dialysis treatment duration of less than 2 years, and the presence of diabetes.3 Ensuring appropriate nutritional intake in these populations can have a crucial impact on patient outcomes.
The main objectives of nutritional management in the renal patient include achieving and maintaining optimal nutritional status, assessing individualized calorie and protein needs in order to preserve adequate fat stores and muscle mass, managing comorbid conditions such as diabetes and hyperlipidemia, and preventing possible complications including, but not limited to, hyperkalemia, renal bone disease, calcification, and hypertension.
The Academy of Nutrition and Dietetics (Academy) and the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) have put forth guidelines for patients with CKD and ESRD. The guidelines recommend the following:4
- A nutrition assessment should be conducted for each individual patient in order to determine the appropriate medical nutrition therapy that should be initiated.
- Obtain a diet history from the patient in order to determine usual energy and protein intake (dietary interviews and/or diaries or 24-hour food recalls may be utilized).
- Assess anthropometric values (height, weight, body mass index [BMI], weight history, fat/muscle stores).
- Review pertinent laboratory parameters.
- Review past medical history, medications, psychosocial factors, and other subjective information.
- An appropriate daily calorie prescription should be determined for each individual based on age and BMI.
- 35 kcal/kg of actual weight for those younger than age 60 years.
- 30 to 35 kcal/kg of actual weight for those older than 60 years.
- 23 kcal/kg of actual weight to promote weight loss in patients who are overweight without fear of initiating malnutrition.
- 50 kcal/kg of actual weight to promote weight gain in patients who are underweight or to prevent weight loss during times of stress.
- An appropriate goal for total daily protein intake should be determined based on CKD or ESRD stage and/or transplant status.
- Clinicians should ensure a patient’s diet is geared towards the prevention of osteodystrophy, or bone and mineral metabolism.
- Phosphorous intake should be 1.7 g/day for CKD stages 1 to 2.
- Phosphorus intake should be 0.8 to 1 g/day (10 to 12 mg per gram of protein prescribed) if serum levels increase in the following situations:
- Above 4.6 mg/dL in stage 3 and 4 CKD patients.
- Above 5.5 mg/dL in stage 5 patients.
- Phosphate binders may be prescribed with meals to reduce absorption of dietary phosphorous in patients in the later stages of CKD.
- Calcium should be maintained at normal levels between 8.4 to 9.5 mg/dL or the normal range for the laboratory used in all stages of CKD.
- Patients are in ++Calcium Balance.
- For hyperphosphatemia in patients with CKD: Apart from inducing secondary hyperparathyroidism and renal osteodystrophy, CV calcification is also an important prognostic factor for morbidity and mortality in patients with ESRD undergoing dialysis.5
- Appropriate fat, fluid, potassium, and sodium intakes should be determined.
- There are currently no studies looking at the effect of fat modification on CKD progression. However, there is limited evidence to recommend a low-fat (less than or equal to 30% of total daily calories), low-cholesterol (fewer than 300 mg) diet in transplant patients with elevated fasting lipids.
- Stages 1 to 4 CKD should consume 1 to 3 g daily.
- Stages 1 to 4 CKD with hypertension should consume fewer than 2 g daily.
- Stage 5 CKD on hemodialysis should consume 2 to 3 g daily (if 1 L or less of fluid output, limit to 2 g).
- Stage 5 CKD on peritoneal dialysis should consume 2 to 3 g daily; adjust to maintain fluid balance.
- Transplant patients with hypertension and/or edema should consume 2 to 4 g daily.
- The goal is to maintain serum potassium levels between 3.5 and 5.5 mEq/L.
- CKD stages 1 to 4: Potassium is not restricted unless serum level rises above normal.
- For HD patients, potassium intake is prescribed at 2 to 3 g per day and adjusted based on serum levels.
- For PD patients, potassium intake is prescribed at 2 to 4 g per day and individualized for maintenance of serum levels within normal limits.
- For transplant patients, potassium is typically unrestricted in post-transplant patients unless serum level rises above normal.
- Certain medications inherent to patients with CKD will predispose them to hyperkalemia, precipitating arrhythmia, and possibly death. These include:
- Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers.
- Non-steroidal anti-inflammatory drugs.
- Angiotensin receptor-neprilysin inhibitors, such as sacubitril/valsartan.
- Fluid is typically only restricted in dialysis patients.
- For patients on HD:
- Fluid output of at least 1 liter: 2 L fluid per day.
- Fluid output of 1 liter or less: 1.5 L fluid per day.
- Anuria: 1 L fluid per day.
- For patients on PD:
- 1 to 3 L fluid per day depending on PD ultrafiltration and residual urine output.
- Generally, 1 L + urine output.
- An appropriate carbohydrate intake should be determined.
- A daily goal of 20 to 30 g dietary fiber is typically recommended for most patients in order to decrease incidence of constipation or diverticulosis.6 CKD patients may have difficulty meeting this goal due to limited food choices, potassium and phosphorous restrictions, and gastrointestinal side effects with potential fluid restrictions. Supplemental fiber products may be utilized in certain patients if appropriate.
- For CKD and dialysis patients with diabetes:
- For patients on insulin, emphasis should be placed on knowing how many and when carbohydrates should be consumed with insulin and insulin secretagogues complementing the carbohydrate content of the meal.6
- Form a meal plan that emphasizes consuming meals at the same times each day and includes a consistent amount of carbohydrates at each meal is usually beneficial for patients with diet-controlled diabetes, as well as for those who are on fixed insulin doses or have low literacy.
- Carbohydrate counting is more flexible and allows insulin doses to be adjusted around usual dietary intake. Patients who follow this method count the grams of carbohydrates that they will consume and then match this number with the appropriate amount of insulin.
- For transplant patients:
- Simple carbohydrate intake should be limited in patients with elevated blood glucose levels and/or unwanted weight gain.
- Carbohydrate intake should be distributed evenly throughout the day, with an emphasis on complex carbohydrates.
- Post-transplant diabetes mellitus (PTDM) can occur as a result of immunosuppression, surgical stress, genetic predisposition, obesity, advanced age, and infection.6 Graft loss and infection risk are increased in patients who develop PTDM. Insulin and/or oral hypoglycemic agents should be used in combination with a high fiber, carbohydrate-controlled diet and exercise for improved glycemic control.
Guidelines on the Horizon
KDOQI, in collaboration with the Academy, is currently in the process of updating its Clinical Practice Guideline on Nutrition in CKD. The KDOQI guidelines were most recently updated between 2000 and 2001, and the next update can be expected by next year. The guidelines will provide evidence-based recommendations for assessment, prevention and treatment of protein-energy wasting, mineral and electrolyte disorders, and other metabolic disorders associated with kidney disease, as well as provision of medical nutrition therapy. The evidence review will cover macronutrients (protein, carbohydrate and fats/lipids), micronutrients (such as vitamins B1, B6, C; folic acid; riboflavin; and zinc), and electrolytes (such as sodium, magnesium, calcium, potassium and phosphorous), as well as net acid base intake. Populations of interest include patients in CKD stages 1 to 5, as well as dialysis patients and renal transplant recipients.7
- Muscaritoli M, Molfino A, Bollea MR, Fanelli FR. Malnutrition and wasting in renal disease. Curr Opin Clin Nutr Metab Care. 2009;12:378–383. doi:10.1097/MCO.0b013e32832c7ae1.
- Estimated glomerular filtration rate (eGFR). National Kidney Foundation. https://www.kidney.org/atoz/content/gfr. Accessed June 4, 2019.
- De Mutsert R, Grootendorst DC, Boeschoten EW, et al. Subjective global assessment of nutrition status is strongly associated with mortality in chronic dialysis patients. Am J Clin Nutr. 2009;89(3):787-79 https://doi.org/10.3945/ajcn.2008.26970.
- Chronic kidney disease evidence-based nutrition practice guidelines. Academy of Nutrition and Dietetics Evidence Analysis Library. https://www.andeal.org/category.cfm?cid=14. Accessed June 4, 2019.
- Jiameng L, Wang L, Han M, et al. The role of phosphate-containing medications and low dietary phosphorus-protein ratio in reducing intestinal phosphorus load in patients with chronic kidney disease. Nutr Diabetes. 2019;9(14). https://doi.org/10.1038/s41387-019-0080-2.
- Byham-Gray L, Stover J, Wiesen K. A clinical guide to nutrition care in kidney disease, 2nd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2013.
- Current KDOQI projects. National Kidney Foundation. https://www.kidney.org/professionals/guidelines/current-KDOQI-projects. Accessed June 4, 2019.