MEDICAL NUTRITION THERAPY FOR ACUTE RENAL FAILURE

What is the goal of dietary management for acute renal failure patient??? The recommendation for both micro and macronutrient below which is established for acute renal patient intended to limit further renal injury and also to prevent malnutrition.
Come and have a look about the recommended amount of both micro and macronutrient!

Nutrient	Suggested prescription	Rationale
Energy	30- 35 kcal/kg body weight	Based on nutritional status and stress level of the patient
Protein	Nondialysis patients    :  0.8-1.2 g/kg Hemodialysis patients : 1.2-1.5 g/kg CAPD patients             : 1.2-1.3 g/kg CCPD patients             : 1.2-1.3 g/kg CRRT patients              : 1.5-2.0g/kg	Increase as GFR is back to normal. High biological value protein should be provided for at least 60%
Sodium	1.1-1.3 g/day	Depending on urinary output, blood pressure, edema, dialysis and serum sodium level; replace loss in diuretic phase. Excess sodium can increase fluid retention.
Potassium	2-3 g/day	Depending on urinary output, dialysis and serum potassium level; replace loss in diuretic phase. Excess potassium can result in severe cardiac and neuromuscular complications.
Fluid	24- hours urine output + 500 ml	Based on urinary sodium and total urine output
Phosphorus	Limit as needed	Excess phosphorus may result of decreased renal phosphorus excretion and increased endogenous release of phosphates.  It can also interact with calcium to weaken bones. It has negative effects on the heart tissue, blood vessels, and lungs. May need supplementation with tube feeding and/or with TPN.
Magnesium	Limit as needed	Excess magnesium can affect neuromuscular, cardiovascular and neurologic systems
Calcium	1.0- 1.5 g/day	May require supplementation as needed
Vitamin/ Minerals	Supplement as needed	May need to supplement water soluble and fat soluble vitamin, especially vitamin B & C

This is the recommendation of intake for acute renal failure patient and can be used as a guidance for daily dietary intake. If you can't understand on how this recommendation works, don't worry! Go and meet your dietitian and she/ he will determine how much to take, which food is appropriate for your diet and which to avoid based on your individual needs.
Meet your dietitian now and he/she will help you out on your diet =)

PHOSPHORUS AND KIDNEY DISEASE

What is phosphorus?
- phosphorus is a minerals which help to keep bones strong and healthy.

What is the relationship between phosphorus and kidney disease?
- decline in kidney function lead to a rise in phosphate blood level which causing itchy skin, painful joints and loss of calcium from bone. Thus, those who have kidney disease have to limit amount of high and moderate phosphate- containing food.

Below are some guidelines for kidney patient in choosing phosphate food in their diet.

PHOSPHORUS GUIDELINE FOR CHOOSING FOOD
Instead of these higher phosphorus food	… you can eat these lower phosphorus food
Dairy and dairy-substitutes
8 ounces milk	8 ounces non-dairy creamer or 4 ounces milk
½ cup ice cream	½ cup sherbet (sorbet) or 1 popsicle
½ cup custard or pudding made with milk	½ cup pudding or custard made with non-dairy creamer
Malted milk	Tea, hot apple cider
Brown rice	White rice, barley
Biscuits: store-bought, mixes and refrigerated	Biscuits: homemade (use baking powder substitute below**)
Muffins: all store-bought, mixes, and homemade bran and oat bran flavours	Muffins: homemade, made with white flour (use baking powder substitute below**)
Meat and other proteins
Carp, crayfish, beef liver, chicken liver, fish roe, organ meats, oysters, sardines	Unseasoned beef, chicken, pork, turkey, veal, fish, eggs
Fruit and vegetables
Lima or pinto beans	Mixed vegetables or green beans
Dried fruits, prunes, prune juice	Fresh or canned fruits such as apples, pears, berries, grapes, watermelon, pineapple
Beverages
Cola soft drinks	Non-cola soft drinks (ginger ale, lemon/lime flavoured soda, root beer)
Iced tea with phosphate additives	Homemade iced tea
Cocoa, hot chocolate	Tea, hot apple cider
Snacks and miscellaneous items
Peanuts	Unsalted popcorns
Nuts, peanut butter, sesame or sunflower seeds; avoid pumpkin seeds	Unsalted popcorn, unsalted pretzels, unsalted corn chips
Chocolate bars	Hard candy, fruit flavoured candy or jelly beans

**Since baking powder is high in phosphorus, try this low phosphorus alternative: use ¼ tsp baking soda + ½ tsp cream of tartar instead of 1 tsp baking powder

do consume variety of vegetables!

list of high phosphorus food

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LOW PROTEIN CEREAL FOR CRF PATIENTS

Good day, we meet again with the list of cereal foods that suitable for the consumption of chronic kidney failure patients.  All of the food listed below are low in protein, have a look!

FOOD	SERVING SIZE	WT (g)	CALORIE (kcal)	PROTEIN (g)	CHO (g)
Soh-hun	1 cup	31	103	0	25.7
Sago	1 tbsp	11	37	0	9.3
Marie biscuit	1 pcs	7	32	0.5	5.7
Cream cracker	1 pcs	9	40	0.8	6.8
Lo-see-fun	1 cup	141	177	0.8	42.5
Putu mayam	1 pcs	50	95	1.4	19
White bread	1 slice	19	48	1.8	9.8
Rice	1 cup	128	167	2.9	38.5
Kuih teow	1 cup	108	150	3.2	34.3
Mee	1 cup	109	225	4.9	49.4
Mee-hoon	1 cup	53	184	5.9	40.2

NUTRITION PRESCRIPTION FOR CHRONIC KIDNEY DISEASE

NUTRIENT	STAGE CKD	RECOMMENDATION	RATIONALE
CALORIES	Early CKD including Diabetic Nephropathy ( stage 1 & 2) Predialysis ( stage 3 & 4)	-  35 kcal/kg body weight for < 60 years             -30-35 kcal/kg for > 60 years	- Maintaining normal weight is essential.            - Weight loss recommended to obese people to control hypertension, diabetes, hyperlipidemia and either co morbidities.          - Energy requirement in CKD patients are similar to general population.          - Adequate energy intake important to maintain protein utilization and neutral nitrogen balance.
	Heamodialysis (HD)	- 35 kcal/kg body weight for < 60 years             - 30-35 kcal/kg for > 60 years	- Energy expenditure similar to healthy individual.          - 35 kcal/body weights can maintain nitrogen balance.          - Acutely ill maintenance dialysis patients are generally inactive physically and energy needs will diminished. Thus, energy intake recommended is 30-35 kcal/body weight.
	Continuous Ambulatory Peritoneal Dialysis (CAPD) and Peritonitis	- 35 kcal/kg body weight for < 60 years           -    30-35 kcal/kg for > 60 years (include calories from dialysate due to glucose absorption)	- Energy recommended total daily include both diet and energy intake derived from glucose absorbed from peritoneal dialysate should be 35 kcal/BW.         -  Approximately 60 -70% of dialysis fluid glucose may absorb during 6 hours dwell.          - Small and frequent meals are recommended due to early satiety in patients.          CAUTION: monitor weight gain in CAPD patients
PROTEIN	Early CKD including Diabetic Nephropathy ( stage 1 & 2)	- 0.8 g/kg body weight	- The requirement for protein is unchanged in well control diabetics but in hyperglycemic individuals, protein synthesis is decreased and protein breakdown increased, leading to negative nitrogen balance.          - Suggests that during periods of hyperglycemia or weight loss, somewhat higher protein intakes are required to achieve nitrogen balance, but whether this alone will correct the abnormality is unknown.          - 0.8 g/kg of protein is benefit in early diabetic nephropathy.
	Predialysis ( stage 3 & 4)	- 0.6 g/kg BW -          If severe malnourish, use 0.75 g/kg BW          - At least 50% High Biological Value (HBV)	- Low protein will maintain nutritional status.          - Low protein diets reduce the generation of nitrogenous waste and inorganic ions which causes many clinical and metabolic disturbances characteristics of uremic individuals.          - Low protein diets retard the progession of renal failure or delays renal replacement therapy.          - Malnourish patient will increase protein intake which 0.75 g/kg BW.          - HBV has amino acid composition that similar to human protein and tends to be utilized more efficiently by human to conserve body protein individuals.          CAUTION: if patients planning to undergo dialysis, a higher protein intake may be warranted and ensure energy intake is adequate.
	Heamodialysis	-  1.2 g/kg BW           - 1.3 g/kg BW if severe malnourish          -    1.3 g/kg BW if acute illness ( if increase intensity in dialysis)           -    At least 50% HBV protein	- Studies show that protein intake < 1.2 g/kg BW are associated with lower serum albumin levels and higher morbidity in HD patients.          - Increase intake of protein than recommended may also benefit the catabolic, acutely ill HD patients.
	CAPD	-1.2 – 1.3 g/kg BW           -1.3 g/kg BW If acute illness             -At least 50% HBV protein	- Hypoalbuminemia is more likely to occur when the protein intake less than 1.3 g/kg/day and increase incidence of peritonitis and more prolonged hospital stay.
CARBOHYDRATE	Early CKD including Diabetic Nephropathy ( stage 1 & 2)	50-60% of energy intake	- Carbohydrates (CHO) should be utilized to make up the balance of required daily energy intake.           - Complex CHO is recommended & dietary fiber for good glycemic control in diabetic patients.
	Predialysis ( stage 3 & 4) Heamodialysis CAPD (stage 5)	50-60% of energy intake -          For diabetic patients, follow diabetic diet guidelines	- Low protein carbohydrate food sources and simple sugars can assist in meeting energy requirements patients on low protein diet.          - For diabetic, simple sugar need to minimized complex CHO and dietary fiber are recommended to minimized elevation of serum triglycerides.          CAUTION: monitor serum potassium & phosphate levels if whole grain products are used.
FAT	Early CKD including Diabetic Nephropathy ( stage 1 & 2) Predialysis ( stage 3 & 4) Heamodialysis CAPD (stage 5)	Total fat: 25-35% total calories            Emphasize reduces saturated fat: < 7% total calories             Polyunsaturated fats (PUFA) up to 10% of total calories             Monounsaturated fats (MUFA) up to 20% of total calories           Cholesterol: <200 mg/day ( monitor blood potassium & phosphate level)             Encourage daily regular physical activity whenever possible             If dietary intervention is inadequate, drug therapy should be started after 3 months	Recommended of diet are considered at highest risk for cardiovascular disease.          In non diabetic predialysis patients, hypertryglyceridaemia can reduce but increase both dietary polyunsaturated: saturated fat ratio and reducing CHO content in diet.          Patient’s high risk of hypertension, obesity need modified lipid diet.           Management of lipid abnormalities by dietary carbohydrate and fat restriction alone has been reported to be effective in dialysis patient.          Promotion of exercise may benefit patients.
SODIUM	Early CKD ( stage 1 & 2)	Low sodium intake ( < 2.4 g/day)	Strict control blood pressure can delay renal and cardiovascular disease.          Lifestyle modification recommended: weight control, reduce intake of saturated fat and cholesterol, limit alcohol and stop smoking.
	Predialysis ( stage 3 & 4)	Low sodium intake ( < 2.4 g/day)            Gradual reduction is recommended to maximize tolerance and acceptance	Sodium excretion is inadequate in advanced renal failure.          High sodium intake will cause increase in extracellular volume and sodium imbalance.          Limit sodium intake can efficacy anti-hypertension medication.
	Heamodialysis	2 -3 g per day	High sodium can cause complicates fluid control.          Sodium should be individualized based on blood pressure and weight.          No added salt diet is recommended.
	CAPD	2 -4 g per day
FLUIDS	Early CKD ( stage 1 & 2) Predialysis ( stage 3 & 4)	Generally no restriction.                  Keep fluid balance to maintain hydration status	Damage kidney’s capacity to handle water limited .          Total fluid must monitor to avoid overload fluid or dehydration.          Fluid recommended must consider temperature of environment and activity level of patient.          Sign of fluid overload and dehydration should be noted.
	Heamodialysis	750 to 1000 ml/day	Fluid balance affected by: 1.       Control of dietary fluid intake 2.       Fluid removal on dialysis 3.       Sodium intake            High interdialytic weight gain among patients on HD increase mortality risk. Maintain fluid gain between HD to < 3-5% dry weight.
	CAPD	Up to 1500 ml/day	Fluid balance affected by: 1.       Control of dietary fluid intake 2.       Ultrafiltration capacity of peritoneal membrane 3.       Sodium intake                Ultrafiltration normally can remove 2.0-2.5 kg fluid per day.                Increasing ultrafiltration through use hypertonic exchanges can treat fluid overload.          Hypertonic solution to control symptoms of fluid overload result in 1.       High risk of obesity 2.       Hypertriglyceridemia 3.       Damage to peritoneal membrane
POTASSIUM	Early CKD ( stage 1 & 2) Predialysis ( stage 3 & 4) Heamodialysis CAPD	No restriction unless blood potassium level is elevated	Hyperkalemia can cause cardiac arrhythmias or cardiac arrest.          Consider non-dietary causes of hyperkalemia 1.       Loss of residual renal function 2.       Acidosis 3.       Catabolism 4.       Inadequate dialysis 5.       Dialysate K concentration too high 6.       Drug induce          CAUTION: use potassium salt substitutes in sodium restricted diet.          In CAPD, patient may hypokalemia due to removal K in dialysate and supplement K is given.
		No restriction unless blood potassium level is elevated
		2-3 g adjust to serum levels
		2-4 g adjust to serum levels
PHOSPHATE	Early CKD ( stage 1 & 2) Predialysis ( stage 3 & 4) Heamodialysis CAPD	No restriction unless indicated by lab values             800-1000 mg/day	Hyperphophatemia and associated condition begin to appear as GFR declines < 60 ml/min.          Hyperphosphatemia can elevated parathyroid hormone (PTH) and high of PTH in blood will depressed serum calcium and Vitamin D deficiency are metabolic disturbance.          Require detection and treatment to prevent bone disease and CVD.          In predialysis, low protein intake shown to be effective to prevent hyperphosphatemia.          Limited removal phosphate occurs with dialysis.          Appropriate dose of phosphate binder should be ideally based on meals and snacks.
CALCIUM	Early CKD ( stage 1 & 2)	Intake should meet recommended daily intake requirements
	Predialysis ( stage 3 & 4) Heamodialysis CAPD	Total elemental calcium provided by calcium-based phosphate binder should not exceed 1500 mg/day             Calcium from diet plus phosphate binder should not exceed 2000 mg/day	Serum calcium level is influenced by dietary intake and calcium based phosphate binder.          Excessive calcium containing phosphate cause hypercalcemia and metastatic calcification of soft tissues.          Aluminium  based phosphate binder are also used in some patient as a short term therapy.          When determining the calcium needs of a patients, consider: 1.       Calcium concentration in dialysate. 2.       Amount of calcium in phosphate binder. 3.       Dietary and supplemental intake.          Food rich in calcium also high in phosphate and protein such as dairy product should recommended under caution.
IRON	Early CKD ( stage 1 & 2) Predialysis ( stage 3 & 4) Heamodialysis CAPD	Intake should meet recommended daily requirement             Achieve with supplement of 200 mg elemental iron	Iron supplement is necessary for effective erythropoiesis of red blood cell (RBC).          Folate and vitamin B12 needed for adequate response to erythropoiesis.          In HD, increase iron loss through dialyser and poor absorption in gastrointestinal tract.          Iron tablets should taken 1-2 hours after meals to enhance absorption and not taken with phosphate binder.          Iron tablets can cause constipation and laxative may prescribed.
WATER SOLUBLE VITAMINS			Anorexia and co morbid condition can cause inadequate vitamin and minerals.          Water soluble vitamin losses from body especially for HD and CAPD.          Patients need supplemented with most water soluble vitamins during predialysis and dialysis stage and usually is vit B complex.
THIAMINE	Predialysis ( stage 3 & 4) Heamodialysis CAPD	Supplement to meet recommended daily intake requirement	Thiamine deficiency is associated with potassium and protein restricted in diet.          Increase loss during dialysis.
RIBOFLAVIN		Supplement to meet recommended daily intake requirement	Riboflavin is found mostly in meat, thus low level found in patient’s protein restricted.
FOLATE/VIT B12		Supplement to meet recommended daily intake requirement	Low folate can increase risk of cardiovascular disease in predialysis and dialysis patients.          Regular supplement of folate and B12 up to 1 mg are safe and recommended.
VIATMIN C		Supplement uo to 60-100mg/day	Vit C supplement helps in oral iron absorption.          Increase loss and absorption during dialysis.          High vit C intake result in hyperoxalosis and increased vascular disease.
FAT SOLUBLE VITAMIN VITAMIN A VITAMIN E VITAMIN D	Predialysis ( stage 3 & 4) Heamodialysis CAPD	Intake should meet recommended daily intake requirement	Serum vit A is high in predialysis and dialysis patients .          Oral supplements are not recommended.          CAUTION: against use of fish/ cord liver oil and other vitamin A rich supplement.
		Intake should meet recommended daily intake requirement	Oral supplements are not recommended for vitamin E.
		May be given active vitamin D therapy by physician	CKD is characterized by diminished synthesis and resistance to active vitamin D metabolite (calcitriol).          Treatment with calcitriol may help raise serum calcium (improves bone turnover) and suppress secondary hyperparathyroidism. However, treatment with vitamin D may need to be stopped to prevent adynamic bone disease.          Serum calcium, phosphate and PTH level needs tobe monitored with Vit D supplementation.