Medical Nutrition Therapy for Chronic Kidney DiseaseManual of Clinical Nutrition Management G- 11 Copyright © 20 13 Compass Group, Inc.
Based Nutrition Practice Guideline (Grade II)(1). Dietary protein intake of 0.7 g/kg of body weight per day may
cause hypoalbuminemia in some patients (Grade II)(1,7). However, a few studies have found that protein-
restricted diets may improve microalbuminuria (1).
Hemodialysis: The recommended protein intake for patients who receive hemodialysis three times per
week is at least 1.2 g/kg of standard body weight per day (2,5,6). A nonfasting patient loses 10 to 13 g of amino
acids and small peptides during a single hemodialysis treatment (3). Approximately 30% to 40% of the amino
acids lost during hemodialysis are essential. Therefore, high–biological value protein should provide at least
50% of the total protein in the diet (2,5-7). The reuse of artificial dialyzer membranes may increase amino acid
losses, depending on the composition of the dialyzer.
Peritoneal dialysis: The protein recommendations for patients who receive peritoneal dialysis are 1.2 to 1.3
g/kg of standard body weight (2,4-6). Protein requirements may be even higher, depending on the patient’s
stress level or metabolic needs. When used for long-term management of CKD, peritoneal dialysis is
associated with progressive wasting and malnutrition (3). Factors that contribute to wasting include: anorexia
caused by inadequate dialysis, additional and secondary illnesses, discomfort, fullness, or severe dietary
restriction; the loss of protein, amino acids, and vitamins to the dialysate; and peritonitis leading to
catabolism.
Kidney transplant: For adult kidney transplant recipients who have recovered from surgery and have an
adequately functioning allograft, a daily protein intake of 0.8 to 1.0 g/kg of body weight is recommended (Grade
IV)(1). The registered dietitian should consider the medical status of each patient, addressing individual issues
as needed (1). Adequate but not excessive protein intake supports allograft survival and minimizes the impact
on comorbid conditions (Grade IV)(1).
Fat
Elevated levels of lipoproteins and abnormalities in lipid metabolism are common in patients with CKD (2).
The National Kidney Foundation Task Force on Cardiovascular Disease has recommended the use of the
National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines for patients with
chronic renal disease, including kidney transplant recipients (Grade II)(1,2). For patients with renal disease, the
target goals for cholesterol are modified slightly based on data from morbidity and mortality studies (2,5,8).
For therapeutic lifestyle diet modifications, see Section C: Medical Nutrition Therapy for Disorders of Lipid
Metabolism.
Table G-2: Recommended Lipid Levels for Adults with Chronic Kidney Disease (8)
Stage of Renal Failure Recommended Lipid Levelsa^
CKD (stage 1-5) Cholesterol <200 mg/dL
Low-density lipoprotein cholesterol <100 mg/dL
High-density lipoprotein cholesterol >40 mg/dL
Triglycerides (fasting) <150 mg/dL
CKD with maintenance dialysis (stage 5) Cholesterol 180-200 mg/dL
Low-density lipoprotein cholesterol <100 mg/dL
aLevels may be measured as nonfasting levels except where indicated.
Source: National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. Guideline 4: Management of Dyslipidemias in Diabetes
and Chronic Kidney Disease. National Kidney Foundation; 2007. Available at:
http://www.kidney.org/professionals/kdoqi/guideline_diabetes/guide4.htm. Accessed February 20, 2009.
Sodium and Fluid
CKD (stages 1 to 5): For adults with CKD, including kidney transplant recipients, the 2010 Chronic Kidney
Disease Evidence-Based Nutrition Practice Guideline suggests a sodium intake of less than 2.4 g/day with
adjustments for blood pressure, medications, kidney function, hydration status, acidosis, glycemic control,
catabolism, and gastrointestinal issues (eg, vomiting, diarrhea, constipation, or gastrointestinal bleeding)
(Grade II)(1). The prescribed fluid intake should be sufficient to maintain appropriate hydration (1,4-6).
Hemodialysis: The daily sodium allowance for patients who receive hemodialysis is 2 g/day with
adjustments based on urine output (2,4-6). The more urine that the patient produces, the more sodium the
patient may eliminate via the urine. Under steady-state conditions, urinary output usually provides a good
guide for fluid intake. The volume of urine output per day plus 1,000 mL of fluid is recommended to maintain
fluid weight gain of less than 3% to 5% of the interdialytic weight between hemodialysis treatments (2,4-6). If