Medical Nutrition Therapy for Chronic Kidney Disease
Manual of Clinical Nutrition Management G- 10 Copyright © 20 13 Compass Group, Inc.
body weight data is validated and standardized and uses a large database of ethnically diverse groups, data
provides only actual weights, not ideal weights for the reduction of morbidity and mortality (Grade IV) (5).
Energy
CKD (stages 1 to 5): The energy requirements of CKD patients who do not receive dialysis are similar to the
requirements of healthy individuals and are influenced by age, sex, and physical activity level (1,5). Resting
metabolic rates determined by direct and indirect calorimetry are similar for patients with CKD and healthy
control subjects. Studies of individuals who consumed less than 0.8 g protein per kg of ideal body weight
reported a neutral or positive nitrogen balance when energy intakes were between 35 and 45 kcal/kg of ideal
body weight and a negative nitrogen balance when energy intakes were 15 to 25 kcal/kg of ideal body weight
(1,7). Therefore, energy intakes should be greater for patients who consume less than the Recommended Daily
Allowance for protein (Grade I) (1). Five randomized controlled trials published between 2001 and 2007
examined patients with a normal body weight and found that a total energy intake of 23 to 35 kcal/kg of body
weight (when consuming a protein-restricted diet with a daily protein intake of 0.3 to 0.7 g/kg of body
weight) is adequate to maintain a stable body mass index in adult nondiabetic patients with CKD (Grade II) (1).
Overweight patients with CKD and type 1 or type 2 diabetes who receive a total energy intake of 1,780 to
1,823 kcal (when consuming protein-restricted diets with a daily protein intake of 0.68 g to 0.86 g/kg body
weight) can decrease body weight without signs of malnutrition (Grade II) (5). When prescribing energy
requirements for persons with CKD, the primary goals should be to provide an adequate amount of total
energy to maintain or achieve a reasonable body weight and positive nitrogen balance (1). Based on this
emerging evidence, the 2010 Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline recommends
a daily energy intake of 23 to 35 kcal/kg body weight for all adults with CKD, including patients who have
recovered from kidney transplantation surgery (Grade II)(1). The registered dietitian should consider weight
status, nutrition goals, age, sex, physical activity level, and metabolic stressors when determining energy
requirements (Grade II)(1).
Hemodialysis: For patients 60 years and older with stage 5 disease who receive dialysis, an energy intake of
30 to 35 kcal/kg of ideal body weight or standard body weight is suggested (2,5,6). For patients younger than
60 years of age, energy needs should be calculated at a minimum of 35 kcal/kg of ideal body weight or
standard body weight (2). The Academy has explored evidence regarding the accuracy and application of
methods to measure energy expenditure. For additional information, refer to Section II: Estimating Energy
Expenditure.
Peritoneal dialysis: In peritoneal dialysis, glucose is absorbed from the dialysate. Therefore, the dietary
energy intake may need to be decreased to prevent excess weight gain and obesity. Glucose absorption varies
among patients due to differences in peritoneal permeability. Some patients who receive CAPD or CCPD
absorb more than 800 kcal/day from the dialysate, depending on the exchange concentrations (5). (See
Determination of Glucose Absorption in Peritoneal Dialysis later in this section.) Energy absorbed from the
dialysate should be subtracted from the daily energy intake from the diet (2,5,6).
Protein
CKD (stages 1 to 5): The Modification of Diet in Renal Disease (MDRD) trial found that a low protein intake
reduces intraglomerular pressure, solute load, and overall nephron activity and may preserve renal function
or delay its progressive decline. (3,6,7). However, more recent trials with larger samples of subjects and a
longer duration (up to 2 years) have demonstrated that a low-protein diet (0.6 to 0.897 g/kg of body weight
per day without ketoacid supplementation) did not significantly alter the decline in GFR when compared to a
typical level of protein intake (1.0 to 1.4 g/kg per day), regardless of the stage of CKD or the type of diabetes
among patients with diabetic nephropathy (Grade II)(1). A few studies have demonstrated that protein-
restricted diets (0.7 g dietary protein per kg of body weight per day) with adequate total energy intake can
slow the GFR decline and maintain a stable nutrition status in adult nondiabetic patients with CKD (Grade II)(1,7).
Nutrition practice guidelines recommend that the protein intake be based on the patient’s creatinine
clearance, estimated GFR, and urinary protein losses (1,2,4,6). A protein-controlled diet with a daily protein
intake of 0.6 to 0.8 g/kg of body weight is recommended for nondiabetic adults with CKD who are not on
dialysis and have an estimated GFR that is less than 50 mL/minute/1.73 m^2 (Grade II)(1). Clinical judgment
should be used when recommending lower protein intakes; the patient’s level of motivation, willingness to
participate in frequent follow-up testing, and risk for protein-energy malnutrition should be considered (Grade
II) (1).
Diabetic nephropathy: For adults with diabetic nephropathy, a protein-controlled diet providing a daily
protein intake of 0.8 to 0.9 g/kg of body weight is recommended by the 2010 Chronic Kidney Disease Evidence-