{"id":140,"date":"2018-04-23T11:35:11","date_gmt":"2018-04-23T11:35:11","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=140"},"modified":"2021-08-04T11:19:02","modified_gmt":"2021-08-04T11:19:02","slug":"diet-in-renal-disease","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/unithdbk\/fluids-and-electrolytes\/diet-in-renal-disease\/","title":{"rendered":"Diet in renal disease"},"content":{"rendered":"
Documentation on the Renal Database<\/span><\/strong><\/h5>\n

Two Proton (Edinburgh renal EPR)\u00a0screens are maintained and updated by Dietetic staff:-<\/p>\n

    \n
  • Nutritional status<\/li>\n
  • Dietary therapy<\/li>\n<\/ul>\n

    Malnutrition or undernutrition is prevalent in patients with renal disease, the prevalence increasing as GFR falls. The cause is multifactorial. Intake often improves on starting dialysis, but malnutrition on dialysis is common and a strong predictor of mortality.<\/p>\n

    Constituents of food important in renal disease<\/span><\/strong><\/h5>\n

    Protein
    \n<\/span><\/strong>In CKD our policy is to estimate protein intake, and make dietary recommendations to achieve intake in the range 0.8-1g\/kg of ideal body weight.\u00a0 This is not a low protein diet, but may in some patients involve a reduction in intake.\u00a0 In others it will require increased intake.<\/p>\n

    On HD intake is increased to 1-1.2g\/kg ideal body weight (ibw) to compensate for small increased losses and a tendency to under-nutrition.<\/p>\n

    On PD intake is increased to >1.2g\/kg to compensate for peritoneal protein losses, which are variable but at times high.<\/p>\n

    A typical daily intake in the UK is 60-80g; normal requirement is only 45-55g (assuming adequate energy intake).<\/p>\n

    The main sources of animal protein are meat, fish, cheese, eggs, and milk; and of non-animal protein are nuts, beans, pulses, soya products.<\/p>\n

    A typical daily intake in the UK is 60-80g; normal requirement is only 45-55g.<\/p>\n

    The main sources of animal protein are meat, fish, cheese, eggs, and milk; and of vegetable protein are nuts, beans, pulses, soya milk.<\/p>\n\n\n\n\n\n\n\n\n\n
    Food<\/span><\/strong><\/td>\nProtein content (g)<\/span><\/strong><\/td>\n<\/tr>\n
    500ml cows milk<\/td>\n17<\/td>\n<\/tr>\n
    100g meat, poultry, cheese, nuts<\/td>\n25-30<\/td>\n<\/tr>\n
    100g fish<\/td>\n20<\/td>\n<\/tr>\n
    1 egg<\/td>\n8<\/td>\n<\/tr>\n
    1 yoghurt<\/td>\n7<\/td>\n<\/tr>\n
    135g baked beans (small tin, in tomato sauce)<\/td>\n7<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    Sodium
    \n<\/span><\/strong>Typical daily intake in the UK is 150 – 200mmol.\u00a0 Daily requirement is less than half of this.\u00a0 Only around 10% of this is naturally-occurring in fresh\/food – the remainder is added in cooking and food processing or as table salt after cooking.<\/p>\n

    Salt substitutes mainly consist of potassium chloride and are therefore not usually suitable for patients with renal failure.<\/p>\n

    For almost all renal patients without extra losses we recommend an intake of 80-100mmol\/day.\u00a0 We refer to this as \u2018no added salt\u2019 but it also requires avoiding pre-added salt.\u00a0 Lower intake than this is probably desirable but may compromise energy intake.<\/p>\n

    Fluid
    \n<\/span><\/strong>It is impossible for patients to comply with fluid restrictions if their salt intake is high.
    \nHD \u2013 urine output plus 500mls\/d
    \nPD \u2013 normally urine output plus 750mls\/d, but depends on ultrafiltration.<\/p>\n

    Potassium<\/span><\/strong>
    \nTypical daily intake in the UK can vary from 50 to 150mmol. Intake should only be limited if blood tests show it\u2019s necessary, as the fruit and vegetable contribution to potassium intake is important for general health.<\/p>\n

    Potassium is found in many foods but particularly high in fruit, fruit juice, and potatoes and vegetables which have not been boiled.<\/p>\n

    CKD \u2013 restriction not usually required until GFR<20, unless on ACE inhibitions, and their continuation thought important.
    \nHD \u2013 most patients require some restriction.
    \nPD \u2013 some patients require restriction.<\/p>\n

    Phosphate and Calcium
    \n<\/span><\/strong>Typical daily intake of phosphorus in the UK is 35-40mmol.<\/p>\n

    Phosphate is commonly found in association with protein \u2013 milk, yogurt and cheese being particularly rich.\u00a0 However, there are some other foods that contribute phosphate, e.g., oatcakes; also offal, shellfish, nuts, milk chocolate, eggs, scones, Horlicks). Other sources are convenience foods that have phosphates added by food manufacturers.<\/p>\n

    Dietary prescriptions in renal failure<\/span><\/strong><\/h5>\n\n\n\n\n\n\n\n\n\n
    Status<\/span><\/strong><\/td>\nProtein<\/span><\/strong><\/td>\nEnergy<\/span><\/strong><\/td>\nFluid<\/span><\/strong><\/td>\nSodium<\/span><\/strong><\/td>\nPotassium<\/span><\/strong><\/td>\nPhosphate<\/span><\/strong><\/td>\n<\/tr>\n
    CM<\/span><\/strong><\/td>\n0.8g – 1g\/kg IBW*<\/td>\n35kcals\/kg IBW min (unless overweight)<\/td>\nNormal (some exceptions require restrictions)<\/td>\n\u2018No added salt\u2019<\/p>\n

    80-100mmols<\/td>\n

    		Restricted only if blood levels high<\/td>\nRestriction may be required if levels high or dietary intake excessive<\/td>\n<\/tr>\n
    Nephrotic Syndrome<\/span><\/strong><\/td>\n1g\/kg IBW<\/td>\n35 kcals\/kg IBW<\/td>\nMay require restriction<\/td>\n\u2018No added salt\u2019<\/p>\n

    80-100mmols<\/td>\n

    		Unrestricted unless levels high<\/td>\nUnrestricted unless levels high<\/td>\n<\/tr>\n
    Haemo-dialysis<\/span><\/strong><\/td>\n1g – 1.2g\/kg IBW<\/td>\n35 kcals\/kg IBW<\/td>\n500mls + UO<\/td>\n\u2018No added salt\u2019<\/p>\n

    80-100mmols<\/td>\n

    		most require some restriction <1mmol\/kg<\/td>\ndietary restriction and phosphate binders<\/td>\n<\/tr>\n
    Peritoneal dialysis<\/span><\/strong><\/td>\n>1.2g\/kg IBW – higher in peritonitis<\/td>\n25-30kcal\/kg IBW (300-600kcals from PD fluid)<\/td>\nbased on ultrafiltration – or 750mls + UO<\/td>\n\u2018No added salt”<\/p>\n

    80-100mmols<\/td>\n

    		unrestricted for most patients<\/td>\nDietary restriction and binders often required<\/td>\n<\/tr>\n
    Transplant<\/span><\/strong><\/td>\n1g\/kg IBW Higher 1-2 wks post-op<\/td>\nDepends on BMI and need for weight gain\/loss<\/td>\nhigh fluid requirements normally<\/td>\n\u2018No added salt\u2019<\/p>\n

    80-100mmols<\/td>\n

    		unlikely to need restriction<\/td>\nhigh intake advised post-op<\/td>\n<\/tr>\n
    Acutes<\/span><\/strong><\/td>\n0.17-2g Nitrogen per kg<\/td>\nBMR + stress and activity factors<\/td>\nDepends on UO and RRT<\/td>\n\u2018No added salt\u2019<\/p>\n

    80-100mmols<\/td>\n

    		based on blood levels but intake often low anyway<\/td>\nbe aware of hypophosphataemia – re-feeding syndrome<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    * IBW = Ideal Body Weight * CM = Conservative Management * UO = Urine Output<\/p>\n

    Dietetic Referral Criteria<\/span><\/strong><\/h5>\n

    Chronic Renal Failure<\/span><\/strong><\/p>\n

    Patients with any of the following should be referred to the renal dietitian for individual dietary assessment and advice.<\/p>\n

      \n
    1. CKD stages 4 and 5 (GFR <30ml\/min\/1.73m2)<\/li>\n
    2. Hyperkalaemia, Serum K+ \u2265 5.5mmol\/l on an upward trend, not acidotic.<\/li>\n
    3. Starting an ACE Inhibitor with serum K+ \u2265 5.0mmol\/l<\/li>\n
    4. Malnutrition related to uraemia\n
        \n
      1. BMI < 20kg\/m2<\/li>\n
      2. Unintentional weight loss >5% in 3 months<\/li>\n<\/ol>\n<\/li>\n
      3. Serum PO4 \u2265 1.8mmol\/l<\/li>\n
      4. Patients with moderate to severe nephrotic syndrome requiring no added salt diet \u00b1 nutritional support.<\/li>\n
      5. Renal stones \u2013 patients with calcium oxalate or uric acid stones who will benefit from dietary information, at the dietitian\u2019s discretion.<\/li>\n<\/ol>\n

        General Nephrology and Transplant Clinics<\/span><\/strong><\/p>\n