Manual of Clinical Nutrition Management G- 7 Copyright © 20 13 Compass Group, Inc.
MEDICAL NUTRITION THERAPY FOR CHRONIC KIDNEY DISEASE
Description
The approach to medical nutrition therapy for chronic kidney disease (CKD) is based on the stage and
progression of kidney disease, comorbid conditions (eg, diabetes mellitus, hypertension, or cardiovascular
disease), and renal replacement therapy (RRT). Medical nutrition therapy and nutrition intervention are
provided based on the individualized needs of the patient. The dietary approach is modified in one or more
of the following constituents: protein, sodium, potassium, total fluid, and phosphorus. The diet may also be
modified to provide adequate amounts of energy, vitamins, and minerals. The Academy of Nutrition and
Dietetics’ Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline and recommendations from the
National Kidney Foundation serve as a framework for providing care to renal patients based on disease stage
and the requirement for RRT (1,2). These guidelines and resources, in addition to the guidelines cited below,
are consistent with the language and terms used for reimbursement in Medicare beneficiaries.
Indications
Management of CKD: This disease causes a progressive reduction in renal function for more than 3 months
that results in a reduced ability to control body water volume, acid-base balance, hormonal regulation, and
electrolyte concentrations (3). The five stages of CKD are described in Table G-1: Definition and Stages of
Chronic Kidney Disease (2). Stage 1, which is the least severe stage, is characterized by kidney damage with a
glomerular filtration rate (GFR) greater than 90 mL/min per 1.73 m^2 ; stage 5, the most severe stage, is
characterized by kidney failure with a GFR less than 15 mL/min per 1.73 m^2 (3). The leading causes of CKD
are diabetes mellitus and hypertension, which account for 65% to 70% of all new cases of end-stage renal
disease requiring RRT (3). Other causes of CKD include vascular disease, urologic disorders, and primary
glomerular or interstitial kidney diseases (3). Symptoms of uremia, such as nausea, anorexia, and altered taste
sensation, can lead to reduced oral intake and an increased risk of malnutrition in patients with CKD (3,4). The
goals for dietary management in CKD are to minimize uremic toxicity, prevent wasting and malnutrition, and
complement the prescribed RRT regimen.
Table G-1: Definition and Stages of Chronic Kidney Disease
GFR
(mL/min/1.73 m^2 )
With Kidney Damage* Without Kidney Damage*
With HBP** Without HBP** With HBP** Without HBP**
≥90 1 1
“High Blood
Pressure”
“Normal”60 - 89 2 3
“High Blood
Pressure with ↓
GFR”“↓GFR”α30 - 59 3 3 3 3
15 - 29 4 4 4 4
<15 (or dialysis) 5 5 5 5
Shaded area represents chronic kidney disease; numbers designate stage of chronic kidney disease.
*Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging
studies. **High blood pressure (HBP) is defined as ≥140/90 mm Hg in adults and >90th percentile for height and gender in children.
αMay be normal in infants and the elderly.
- Resource: Definition and Stages of Chronic Kidney Disease. In: Part 4. Definition and Classification of Stages of Chronic Kidney
Disease. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease Evaluation, Classification and Stratification. Available at
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm. Accessed January 10, 2011.
Typically, CKD progresses until treatment by RRT (dialysis) or transplantation is required. Dietary
modifications and practice guidelines outlining the scope of nutrition therapy are based on the classification
or stage of the disease (1,2). Patients with CKD are generally classified in two groups (2,3):
Patients in stages 1 to 5 who do not yet require RRT; management is primarily by diet modifications and
medication, or
Stage 5 patients who require RRT (hemodialysis, peritoneal dialysis, or other types of RRT).
This section focuses on medical nutrition therapy for CKD. The Academy’s Chronic Kidney Disease Evidence-
Based Nutrition Practice Guideline provides the most current recommendations for CKD patients (stages 1 to
5) who are managed primarily by diet modifications and do not require dialysis (1). For stage 5 patients who
require RRT, the clinician should refer to recommendations outlined in the National Kidney Foundation’s
Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease (2). Both of these resources
provide specific guidelines for the nutrition care of adult kidney transplant recipients (1,2). The American