The Principle of Nutritional

Management in Chronic Kidney

Disease (CKD)
Ria Bandiara
Subbagian Ginjal Hipertensi Bag I Peny Dalam
RS Hasan Sadikin Bandung
Definition of Chronic Kidney Disease
Criteria
1. Kidney damage for 3 months, as defined by
structural or functional abnormalities of the kidney,
with or without decreased GFR, manifest by either:
Pathological abnormalities; or
Markers of kidney damage, including abnormalities
in the composition the blood or urine, or
abnormalities in imaging tests
2. GFR < 60 mL/min/1.73 m2 for 3 months, with or
without kidney damage
Classification stages of Chronic Kidney disease

Stage Description GFR

(mL/min/1.73 m2)

1 Kidney damage with normal or GFR 90

2 Kidney damage with mild GFR 60 89

3 Moderate GFR 30 59

4 Severe GFR 15 29

5 Kidney failure < 15 or dialysis

 Table Stages of Chronic Kidney Disease: A Clinical Action Plan

Stage Description GFR Action

(mL/min/1.73 m2)

1 Kidney damage 80 Diagnosis and treatment,

with normal or Treatment of comorbid
GFR conditions, Slowing progression,
CVD risk reduction
2 Kidney damage 60 89 Estimating progression
with mild GFR

3 Moderate GFR 30 59 Evaluating and treating

complications

4 Severe GFR 15 29 Preparation for kidney

replacement therapy

5 Kidney failure < 15 or dialysis Replacement (if uremia present)

Treatment of chronic kidney disease should include :

1. Specific therapy, based on diagnosis;

2. Evaluation and management of co-morbid conditions;

3. Slowing the loss of kidney function;

4. Prevention and treatment of cardiovascular disease;

5. Prevention and treatment of complications of decreased

kidney function

6. Preparation for kidney failure and kidney replacement therapy;

7. Replacement of kidney function

 Nutritional management start on
GFR 60 ml/mnt (CKD stg 3)
The problem is : in GFR 30 ml/mnt
patients appetite decrease

Malnutrition
 Electrolyte
Uremic toxin
imbalance
accumulation

Chronic Kidney Disease Abnormality protein & amino-

acid metabolism

Abnormality hormonal & Increase of

vitamin metabolism protein malnutrition
catabolism

Nutritional aspect in CKD

THE PROBLEMS OF CKD PATIENTS

Malnutrition
Trauma
CKD +
Manipulation of Surgery
Infection

Progressivity
Mortality
Morbidity
Nutritional management in different state of CKD

Predialytic

Nutritional
Management
HD

Dialytic

CAPD
TABLE. MINIMAL REQUIREMENTS FOR ASSESSMENT OF NUTRITIONAL
STATUS OF PATIENTS WITH STAGE 3,4, OR 5 CHRONIC
KIDNEY DISEASE NOT RECEIVING DIALYSIS TREATMENT

Every 13 months
Patient reviews diet with dietitian
Blood hemoglobin or hematocrit taken
Serum measured:
Urea,Creatinine,Sodium,Potassium, Bicarbonate
Albumin and/or transthyretin (prealbumin)
Edema-free body weight, percent standard body weight assessed
Recent change in body weight determined
SGA (Subjective Global Assessment)
Every 36 months
Dietary interview by dietitian and 3-day diary of daily nutrient intaked
or normalized protein equivalent of total nitrogen ap pearance (see
text) assessed

Every 12 months
Serum or plasma measured
Total cholesterol
Low-density-lipoprotein cholesterol
Highdensity-Lipoprotein cholesterol
Triglycerides
Homocysteine
C-reactive protein
Anthropometry performed
NUTRITIONAL MANAGEMENT IN PRE-
DIALYTIC STAGE OF CKD

Objective :

1. Maintain the nitrogen balance

2. Slowing the progression of CKD

3. Keep the optimal nutritional state

PROTEINS

Exclusive or mainly build out of Amino Acids

20 Amino Acids Are commonly in biological materials

General formula of Amino Acid :

Carboxyl group
COOH

H C NH2

R Amino group
 Standard Abbreviation
Molecular 3-Letter 1-Letter Weight

Essential amino acids

Isoleucine Ile l 131
Leucine Leu L 131
Lysine Lys K 146
Methionine Met M 149
Phenylalanine Phe F 165
Threonine Thr T 119
Tryptophan Trp W 204
Valine Val V 117
Histidineb His H 155
Nonessential amino acids
Alanine Ala A 89
Arginine Arg R 174
Aspartic acid Asp D 133
Asparagine Asn N 132
Glutamic acid Glu E 147
Glutamine Gln Q 146
Glycine Gly G 75
Proline Pro P 115
Serine Ser S 105
Conditionally essential amino acids
Cysteine Cys C 121
Tyrosine Tyr Y 181
Some Special amino acids
Alloisoleucine alle 131
Citrulline 175
Homocysteine 135
Hydroxylysine Hyl 162
Hydroxyproline Hyp 131
3-Methylhistidine 169
Ornithine Orn 132
 Oral protein
intake 70 g/day

Cell proteins
0.3 g/kg/day 5.8 kg
3.7-4.7 g/kg/day

Plasma Total free

proteins Ribosome
amino-acid pool
0.5 kg
62 g
Amino Proteins
acids

Nitrogen exretion
11.2 g/day Proteasome

Figure 1. Turnover of Cellular and Plasma Proteins in a Normal 70-kg Man.

The value are based on the rates of turnover of whole-body protien1 minus the turnover of albumin plus immunoglobulin as
estimates of plasma proteins under conditions of neutral nitrogen balance.23 The diet is assumed to contain 1 g of protein per
kilogram of body weight per day, with equivalent amounts of nitrogen excreted as urea and total albumin and immunoglobulin
content.23 These values are lower in women than in men and are lower in older men than in younger men. The estimate of
cell protin does not include protein contained in the skeleton (approximately 1.8 kg) or extracellular, stable proteins, such as
collagen and elastin (a total of about 2.8 kg).
 Protein Turnover in the Body PROTEIN
PROTEIN SYNTHESIS
IN : INTAKE MUSCLE 75 g (30%)
90 g
VISCERA, 127 g (50%)
BRAIN, LUNG

PLASMA PROTEINS (20%)

SECRETED ALBUMIN 12 g
OTHER 8g
PROTEIN WBC 20 g
LIVER RBC: Hemoglobin 8g
GUT 70 g
250 g (100%)

ABSORBED KIDNEY
N
150 g

OUT : FECAL URINARY OTHER

N N LOSSES
10 g 75 g 5g
(1.6 gN) (12 gN) (0.8 gN)
Amino Acid type changes

Valine E
Leucine E
Iso-leucine E

Threonine E
Lysine E
Serine NE

Tyrosine spE
Tryptophane E

Glycine NE
Aspartate NE
Methionine E
Methyl-
Histidine spAA
Table : Circulating levels of hormones
in patients with advanced renal insufficiency
Increased Decreased
Insulin, proinsulin, C peptide Erythropoietin
Glucagon 1,25-dihydroxycholecalciferol
Growth hormone Progesterone
Parathyroid hormone Testosterone
Calcitonin Thyroxine
Gastrin Triiodothyronine
Endothelin
Prolactin (particularly in women)
Vasopressin
Luteinizing hormone
Follicle-stimulating hormone
Luteinizing hormone-releasing
hormone
Secretin
Cholecystokinin
Vasoactive intestinal peptide
Gastric inhibitory peptide
MAINTAIN THE NITROGEN BALANCE

Nitrogen balance indicated the protein

metabolism balance

Degradation of protein have to balance

with the synthesis

Urine creatinine excretion have to

balance with creatinine generation
(body creatinine formation)
In CKD Regulation of nitrogen balance
becomes difficult.

Since there is reduced excretory

function of kidney, nitrogenous end
products will accumulative.
On the other hand, if patient is fed too
little protein the catabolism of body
protein results in negative nitrogen
balance
If this condition persists, the nutritional
status of patients will deteriorate and
cause several complications.
SLOWING THE PROGRESSION OF CKD

Nutrition therapy is not only to decrease

uremic toxin level reducing uremic
syndrome.
Decrease hyperfiltration on SNFGR
retarding the progression of renal failure
It is proven that controlled protein diet could
retard the decrease progressivity of renal
function.
KEEP THE OPTIMAL NUTRITIONAL STATE

The cause of malnutrition in renal

failure patients is influenced by several
factors, as follows:
Less or imbalance nutritional intake
Accompanied metabolism disturbance
Other accompanied illnesses i.e
infection, stress etc.
ENERGY
Old concept:

Calorie required by Chronic Kidney Disease patient is

between 40-50 kcal/kg bw/day

New concept:

High Calorie will have no good effect and will cause

metabolic stress.
Amount suggested is 30-35 kcal/kg bw/day
PROTEIN

Old concept:

- Low protein diet : <0.5 g / kg / day

Ando 1989

New concept:

controlled protein diet :

a protein intake between 0.6 and 0.8 g / kg bw / day with
a calorie intake no less than 30 kcal / kg bw / day
 A decrease in protein intake from 0.9 to 0.6 g
/ kg b w / day resulted in a 33% slowing of
the progression.

For each 0.2 g / kg b w / day reduction in

protein intake, there was an associated 29%
slower rate of loss of GFR and prolongation
until dialysis was required
AMINO-ACID

Old concept:
- Only Essential Amino Acid is given.
- Non Essential Amino Acid could be obtain from Urea
Synthesis.

New concept:
- A combination of Essential Amino Acid and Non
Essential Amino Acid is given.
- The occurence of Non Essential Amino Acid is
synthesis not proven.
- A free Non Essential Amino Acid dietary could result
hyperamonemia due to Urea cycle disfunction.
NKF-K/DOQI GUIDELINE : Dietary protein
intake for nondialyzed CKD patients

For individuals with CKD (GFR<25 mL/min)

low protein diet 0.6 g/kg/d should be
considered
For individuals who will not accept such a diet
or who are unable to maintain adequate
dietary energy intake, an intake of up to 0.75
g/kg/d maybe prescribed
At least 50% of dietary protein should be of
high biologic value
CONSENSUS : International Advisory Board
Meeting 2006

Protein-restricted diets preferentially

supplemented with keto/amino acids
should be considered as the basic
therapy in a treatment program of CKD
patients
Evidence: the beneficial effect of keto/amino
acid supplemented protein-restricted diets in
CKD patients have been demonstrated to
have the following benefits :
Decrease in uremic toxins
Reduced proteinuria
Improvement in calcium-phosphat
metabolism & hyperparathyroidism
May improve the lipid profile
Can slow the progression of CKD
Does not induce malnutrition
Components of Keto/Amino acid
Supplemented Protein-Restricted Diets

Protein : 0.4-0.6 g/kg bw/day depending on

the stage of CKD (3-5)
Keto/Amino acid supplementation : 1 tabl/5
kg bw/day (0.1 g/kg bw/day)
Energy : 30-35 kcal/kg bw/day
Phosphat : 5-7 mg /kg bw/day
(<800 mg/day)
 Carbohydrate given: Total calorie substracted
by calorie originated from fat and protein.
A glucose supply around 6-8 g/kg
bodyweight/day is suggested.
Insulin could be given if blood glucose is over
200 mg/dl.
 Fat given 20-25% of total energy
requirement (TER)
Could be given 10-20% lipid infusion to
restrict fluid
Could prevent the occurence of
essensial fatty acid defisiency
ACID BASIC AND ELECTROLYTE IMBALANCE

Most of CKD patients experienced acidosis,

hyperkalemia, hyperphosphatemia.
Acidosis state will cause:
- increase of protein breakdown
- reducing several amino acid level in muscle
and intracellular.
- increasing bone calcium release.
- hyperkalemia
Metabolic acidosis

Plasma bicarbonate level should be at least 22

mEq/L, using a controlled protein diet,
calcium carbonate and small dose of sodium
bicarbonate
NUTRITION THERAPY RESUME ON PREDIALYSIS CRONIC KIDNEY
DISEASE PATIENTS

Calorie
- Amount : 30-35 kcal/kg bw/day
- Type : 20-25 % in the form of lipid.

Protein
- Amount : 0.6-0.8 g/kg bw/day
- Type : A combination of Essential Amino Acid and Non
Essential Amino Acid.

Carbohydrate
- Amount : To fullfil the calorie required
- average 6-8 g/kg bw/day

Electrolyte : Sodium 70 mEq/L

Potassium : limited
Phosphate : 500-600 mg/day
To ensure successful nutritional therapy,
CKD patients must undergo :

extensive training concerning the principle

of nutritional therapy & the design and
preparation of diets
they need to be encouraged continuously
to adhere to the prescribed diet
 A team approach is required
participation of physician, dietitian, close
family member, nursing staff, social
worker/psychiatrists

NST (Nutrition Support Team)

may improve adherence of

patients