Medical Nutrition Therapy for Chronic Kidney Disease
Manual of Clinical Nutrition Management G- 12 Copyright © 20 13 Compass Group, Inc.
the patient is anuric, 1,000 to 1,500 mL/day of fluid is recommended (3,5,6).
Peritoneal dialysis: Sodium balance and blood pressure can be well controlled with CAPD or CCPD. As much
as 5,700 mg/day of sodium can be removed with CAPD. Patients must understand the symptoms of
hypotension as well as the methods to avoid it. The appropriate sodium requirement for each patient should
be determined from an evaluation of parameters including weight (dry weight vs fluid weight), blood
pressure (hypotension or hypertension), shortness of breath, and edema (5). The sodium intake for most
patients should be 2 g/day (2). The suggested fluid intake for patients who receive CAPD or CCPD it is 2,000
mL/day (2). Patients should monitor their weight and blood pressure and adjust their sodium and fluid intake
as necessary. Adjustments in fluid balance can be made by altering the quantity or concentration of
hypertonic solutions. Patients must measure their own blood pressure and weigh themselves regularly to
determine the glucose concentration of dialysate necessary to maintain fluid balance (2,5,6).
Potassium
CKD (stages 1 to 5): The 2010 Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline suggests
that CKD patients (stages 3 and 4), including kidney transplant recipients) who exhibit hyperkalemia should
be prescribed less than 2.4 g/day of potassium, with adjustments based on serum potassium levels, blood
pressure, medications, kidney function, hydration status, acidosis, glycemic control, catabolism, and
gastrointestinal issues (eg, vomiting, diarrhea, constipation, or gastrointestinal bleeding) (Grade II)(1). Dietary
and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce
cardiovascular disease risk in adults with CKD (1). The degree of hypokalemia or hyperkalemia can have a
direct effect on cardiac function and should be carefully monitored and adjusted based on biochemical values
(1,2).
Hemodialysis: For patients who receive hemodialysis, a potassium intake of 40 mg/kg of standard body
weight is recommended; or, the potassium intake can be determined from laboratory values (2,5,6). An intake
of 2 to 3 g/day has also been suggested (3,6). Hemodialysis removes potassium; therefore, monitoring
potassium levels and ensuring adequate intake is important (3). Inadequate dialysis, gastrointestinal bleeding,
hyperglycemia, infection, and catabolism can cause hyperkalemia, which can lead to life-threatening medical
problems (2). Adjustments in potassium intake (either from the diet or from the dialysate bath) can be made
to achieve target potassium levels (2).
Peritoneal dialysis: Patients who receive CAPD or CCPD may not need potassium restrictions; however, an
assessment should be based on the patient’s laboratory values (2,5,6). Peritoneal dialysis can increase the risk
for hypokalemia, since most commercially available solutions do not contain potassium (3). If needed oral
supplementation and/or dietary intake can be adjusted to compensate for low potassium levels. A target
intake of 3 to 4 g/day of potassium is suggested (3,5,6).
Phosphorus
Alterations in calcium, phosphorus, and vitamin D metabolism result in secondary hyperparathyroidism,
causing renal osteodystrophy and cardiac and extraskeletal calcification (5,6,9). Derangements in mineral and
bone metabolism common to CKD are associated with increased morbidity and mortality (9). This association
prompted the development of the KDOQI (Kidney Disease Outcomes Quality Initiative) Clinical Practice
Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease (9). These guidelines provide
recommendations for the evaluation of phosphorus, calcium, plasma intact parathyroid hormone, and
alkaline phosphorus and for the management and treatment of abnormalities with vitamin D, phosphate
binders, and dialysate baths (9). Phosphorus control is the cornerstone for the treatment and prevention of
secondary hyperparathyroidism, bone disease, and soft-tissue calcification in CKD (1).
CKD (stages 1 to 5): The 2010 Chronic Kidney Disease Evidence-Based Nutrition Practice Guideline
recommends that adults with CKD (stages 3 and 4) receive a low-phosphorus diet providing 800 to 1,000
mg/day or 10 to 12 mg/g of protein (Grade II) (1). Serum phosphorus levels are difficult to control with diet
alone, therefore a phosphate binder may be required (1,5,6). For adults with CKD (stages 3 and 4), the dose
and timing of phosphate binders should be individually adjusted according to the phosphate content of meals
and snacks to achieve the desired serum phosphorus levels (Grade IV ) (1).
Hemodialysis and peritoneal dialysis: Phosphorus requirements should be individualized or limited to10-
12 mg/kg of standard body weight or 800-1000 mg when serum phosphorus levels approach the upper limit of
normal range (1,5,6).
A phosphorus restriction is advised when the intact parathyroid hormone level is greater than 70 pg/mL in