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