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.