Alkaline Fat
cheese, peanut butter, peanuts
Bacon, butternuts, walnuts, pumpkin seeds,
foods sesame seeds, sunflower seeds, creamy salad
dressings
Acidic Carbohydrate All types of bread, oat, rice, macaroni, wheat, rice
foods bran, macaroni, wheat gluten
Sweets Gelatin desserts (dry mix with & without
aspartame), pudding (instant, dry mix)
Dairy Milk Spices/ All types, especially fresh dill weed, dried spices/herbs such as
herbs basil, coriander, curry powder, oregano, parsley
Vegetables Corn
Sweets Sorghum syrup, brown sugar, molasses, cocoa
Sweets White sugar, honey
Beverages Water, tea Beverages coffee
Kidney Stones: Symptoms and Treatment
• Clinical symptoms: severe pain, other urinary symptoms, general
weakness, and fever
• Several considerations for treatment
• Fluid intake to prevent accumulation of materials
• Dietary control of stone constituents
• Achievement of desired pH of urine via medication
• Use of binding agents to prevent absorption of stone elements
• Drug therapy in combination with diet therapy
Nutrition Management
• Normalize urine excretion of stone forming solutes
• Achieve daily urine volume > 2L
• High urine flow rate wash out any formed crystals
• Dietary Ca based on age
• Avoid high oxalate foods add Ca to each meal to bind oxalate (about 150 mg of
Ca to bind 100 mg of oxalate)
• Lower salt intake Reduce oxalate excretion more than a traditional low
oxalate diet
• Moderate animal protein
• Vitamin C not > 500mg/day
• Citrate inhibits urinary stone by forming a complex with Ca in urine (daily intake
> 640 mg/day)
• Mineral water (with Mg & bicarbonate content) raise urine pH & stone inhibition
• Fructose increase urinary excretion of Ca & oxalate increase risk of kidney
stones
Recommendations for Diet & 24 Hrs Urine Monitoring in Nephrolitiasis
Diet Component Intake Recommendation 24-Hrs Urine
Protein Normal intake : avoid excess Monitor urinary urea
Calcium • Normal intake: < 150 mg/L
• 1000 mg (< 50 yrs old)
• 1200 mg (> 50 yrs old)
• Divide intake between 3 or more eating
sessions
Oxalate Avoid moderate to high oxalate foods further < 20 mg/L
restrict if necessary
Fluid > 2,5 L, assess type of fluids consumed >2L
Vitamin C < 500 mg/day Monitor urine oxalate
Vitamin D, cod liver Supplements not recommended
oil
Vitamin B6 > 40 mg/day reduces risk. No recommendation
made
Sodium < 100 mmol/day Monitor urinary sodium
Low-Calcium Diet
ACUTE RENAL FAILURE
Patient with ARF:
• Uremia
• Metabolic acidosis Increase protein
• Fluid & electrolyte imbalance needs
• Physiologic stress
Goal is to improve or maintain nutritional status
Protein remaining 2g
Protein remaining 10 g 3 fruit (0–1 g) −2 g
4 vegetables (1 g) −4 g 0g
6g
Energy
• Energy intake should be approximately about 35 kcal/kg/day for
adults to spare protein for tissue repair & maintenance
Lipid
• Lowering protein intake in adult patients may also lower fat &
cholesterol intake from animal sources.
Sodium
• Total body sodium overload edema
• Control of oedema in this group of diseases should be with dietary
intake of 1500 g/day
INTERMAP: Salt is the leading source of
sodium in middle-aged Americans
Reference: http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx Reference: Adapted from Anderson et al. J Am Diet Assoc 2010; 110(5):736–745.
Potassium
• Variability in disease states, individual intakes, & use of medications
that may decrease potassium.
• Early stage CKD take potassium-wasting diuretics require
supplementation
• When urine output drops below 1 L/day may require a potassium
restriction as the kidney is no longer able to excrete all potassium
ingested (CKD stage 4) based on serum level examination
• The reference range is 3,5 – 5 mEq/L
Numerous sources contribute to potassium levels
in CKD
Potassium-rich foods Medications:
Salt substitutes – K supplements
KCl, K citrate
– Low-sodium products may
have added KCl. – Impair excretion
ACEi
Herbs and dietary ARBs
supplement (examples) K+-sparing diuretics
Nonsteroidal anti-
– Noni juice (56 mmol/L)
inflammatory drugs
– Alfalfa
– Dandelion Potassium food additives
– Horsetail
– Nettle • References: Palmer, N Eng J Med 2004;351(6):585–92;
• Hollander-Rodriguez & Calvert, Am Fam Physician.
2006;73(2):283–90.
Phosphorus
• Serum phosphorus levels elevate at the same rate as eGFR (estimated
GFR) decreases.
• Early initiation of phosphate reduction therapies is advantageous for delaying
hyperparathyroidism and bone disease often asymptomatic during the
early phase of hyperparathyroidism and hyperphosphatemia not attend to
their modified diets or understand the need to take phosphate binders with
meals.
• No more than 1000 mg/day a limit that allows approximately 1 – 2
dairy foods/day
• Patients who are in later stages of CKD and intolerant of red meats
because of uremic taste alterations often are able to substitute milk
foods for meat and still maintain a limited phosphate intake.
Vitamin
• Restrictions may cause the diet to be inadequate CKD patients are
routinely recommended a water-soluble renal customized vitamin
supplement
END STAGE RENAL DISEASE
End-Stage Renal Disease
• 90 % ESRD patients have chronic:
• Diabetes mellitus
• Hypertension
• Glomerulonephritis
• Dialysis or transplant are only options
Goals of MNT in ESRD
• Prevent deficiency & maintain good nutrition status through adequate
protein, energy, vitamin, & mineral intake.
• Control edema & electrolyte imbalance by controlling sodium, potassium,
& fluid intake.
• Prevent/slow the development of renal osteodystrophy by controlling Ca, P,
Vit D & PTH (Pituitary Hormone).
• Enable the patient to eat a palatable, attractive diet that fits their lifestyle
as much as possible.
• Coordinate patient care with families, dietitians, nurses, & physicians in
acute care, outpatient facilities.
• Provide initial nutrition education, periodic counseling & long term
monitoring of patients with the goal of patients receiving enough
education to direct their own care and diet.
Protein
• Dialysis drain on body protein protein intake must be increased.
• Protein losses of 20 to 30 g can occur during a 24-hour PD, with an average of
1 g/hr.
• Peritoneal Dialysis:
• Daily protein intake of 1.2 to 1.5 g/kg of body weight (At least 50% should be HBV
protein)
• Receive Haemodialysis 3x/week
• Daily protein intake of 1.2 g/kg of body weight
• Serum BUN and serum Cr levels, uremic symptoms, and weight should be
monitored, and the diet should be adjusted accordingly.
Energy
• Adequate to spare protein for tissue protein synthesis and to prevent
its metabolism for energy (Therrien, 2015) depending on the
patient’s nutrition status and degree of stress (between 25 and 40
kcal/kg of body weight)
Lipid
• The patient with ESRD typically has an elevated triglyceride level with
or without an increase in cholesterol.
• Lipid-lowering drugs, including most statins, may have a significant
effect on better management.
• Use of lipid-lowering drugs should be monitored and cut back if
necessary in these patients, particularly if they are underweight or
suffering from malnutrition.
Fluid & Sodium Balance
• The vast majority of dialysis patients need to restrict sodium and fluid
intakes.
• Excessive sodium intake is responsible for :
• increased thirst,
• increased fluid gain,
• resultant hypertension.
• Haemodialysis
• Sodium and fluid intake are regulated to allow for a weight gain of 2 to 3 kg from
increased fluid in the vasculature between dialyses.
• The goal is a fluid gain of less than 4% of body weight.
• A sodium intake of 65 to 87 mEq (1500 to 2000 mg) daily
• A limit on fluid intake (usually about 750 ml/day plus the amount equal to the urine
output) is usually sufficient to meet these guidelines.
Potassium
• Potassium usually requires restriction, depending on:
• the serum potassium level,
• urine output,
• medications, and
• the frequency of HD.
• Reduced to 60 - 80 mEq (2.3 - 3.1 g) per day
• Anuria patient on dialysis reduce to to 51 mEq (2 g) per day.
• Cose monitoring of the patient’s laboratory values, potassium content
of the dialysate, and dietary intake is essential.
• Some low-sodium foods contain potassium chloride as a salt
substitute rather than so- dium chloride.
Phosporus
• Phosphate intake is lowered by restricting dietary sources to 1200
mg/day or less.
• The difficulty in implementing the phosphorus restriction comes from
the necessity for a high-protein diet.
• Thus high-phosphorus foods cannot be eliminated without restricting protein,
creating a challenge to balance intake with dietary intervention alone.
• Require phosphate-binding medications (calcium carbonate, calcium
acetate, sevelamer carbonate, sucroferric oxyhydroxide, ferric citrate,
and lanthanum carbonate)
• used routinely with each meal or snack to bind to phosphorus in the gut.