Medical Nutrition Therapy for Chronic Kidney DiseaseManual of Clinical Nutrition Management G- 9 Copyright © 20 13 Compass Group, Inc.
different mechanism for fluid and solute clearance (3). Continuous arteriovenous hemofiltration and
continuous arteriovenous hemodialysis rely on arterial and venous cannulation and the patient’s own blood
pressure to provide the gradient for blood flow and dialysis (3). Although continuous RRT has a lower
clearance rate than standard hemodialysis, it provides superior clearance of fluids, nitrogenous waste, and
other metabolic by-products and improved hemodynamic stability because the process is continuous (3). This
procedure is often used in the critical care setting when patients are hemodynamically unstable. In addition,
continuous RRT has become the preferred method of dialysis for acute kidney injury in some centers (3). As
compared to hemodialysis, continuous RRT is more expensive, immobilizes the patient, and requires
continuous anticoagulation (3). The amount of nitrogen loss is dependent on the type of continuous RRT;
however, the differences in losses between methods are not significant (3). Daily protein requirements for
adults on continuous RRT therapy are between 1 and 2.5 g/kg (3,4). The daily protein requirement for
patients who receive continuous arteriovenous hemofiltration is from 1.5 to 1.8 g/kg, because the losses of
small peptides and amino acids can be high (3,5). Fluid losses can be as great as 20 L/day, therefore fluid
replacement is necessary to prevent hypovolemia, and electrolytes should be frequently monitored (3).
Energy needs for acute kidney injury patients receiving continuous RRT are approximately 1.3 times greater
than their resting energy expenditure requirements, or an average of 25 to 35 kcal/kg per day (3). The
dialysate and replacement fluids used in some types of continuous RRT provide dextrose, therefore dextrose
energy should be included in calculations determining total energy (3).
Transplantation
A transplant offers a relatively favorable long-term outlook and improves the quality of life for many
individuals with CKD, especially young children. A functioning transplanted kidney performs the excretory
and regulatory functions of a normal kidney. Successful transplantation frees the patient from the time-
consuming demands of dialysis and a strict dietary regimen. Refer to the Academy of Nutrition and Dietetics’
Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline and the National Kidney Foundation’s
Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease for specific nutrition
guidelines before and after transplantation for adults (1,2).
Nutritional Adequacy
Because individual diets for renal disease vary widely as to the nutrients controlled, a general statement on
nutritional adequacy is not given. Refer to statements for each constituent in the respective sections:
Section IF: Nutrition Management of Potassium Intake
Sodium-Controlled Diet
Nutrition Management of Phosphorus Intake
Section III: Clinical Nutrition Management, Management of Acute Kidney Injury and Chronic Kidney Disease
How to Order the Diet
Refer to the “How to Order the Diet” instructions for each of the components required in the respective
chapters. See Nutritional Adequacy in this section. Also, refer to Nutrition Management of Fluid Intake in
Section IA.
Nutrition Assessment and Nutrition Intervention
Planning the Diet
Refer to Table G-3: Daily Nutritional Requirements for Adults with Renal Disease Based on Type of Therapy.
Body weight estimates are used to calculate the nutritional needs of patients with CKD (1). There are no
standard reference norms in the CKD population (including kidney transplant recipients). Therefore, the
registered dietitian should use clinical judgment to determine which data to include in estimations of body
weight, including actual measured weight; history of weight changes; serial weight measurements, and
adjustments for the suspected impact of edema, ascites, and polycystic organs (Grade IV)* (1). Body weight can be
difficult to determine because as kidney function decreases, the ability to regulate fluid balance may be
compromised, and multiple factors must be considered (1). A variety of published weight norms can be used
in the anthropometric assessment of individuals with CKD (including kidney transplant recipients); however,
each norm has significant drawbacks and should be used with caution (Grade IV) (1). The assessment of standard
body weight can be derived from National Health and Nutrition Examination Survey (NHANES II) weight
table, which is based on sex, age, and frame size. (Refer to Section II: Standard Body Weight (SBW)
Determination Based on NHANES II.) Energy, protein, and trace mineral recommendations use standard body
weight as the basis for determining the nutrient requirements for CKD patients (1,2,5,6). Although standard