Medical Nutrition Therapy for Chronic Kidney Disease
Manual of Clinical Nutrition Management G- 14 Copyright © 20 13 Compass Group, Inc.
predisposition for mineral and bone disorders, as well as other conditions that may be affected by insufficient
vitamin D (1). Registered dietitians should recommend nutritional vitamin D supplementation to adults with
CKD, including kidney transplant recipients, whose serum levels of 25-hydroxyvitamin D are less than 30
ng/mL (75 nmol/L) (Grade IV) (1). Supplements of 1,25-dihydroxyvitamin D (calcitriol), the active metabolite of
vitamin D, can be provided to maintain normal calcium homeostasis and prevent osteomalacia (3).
Supplementation with vitamin D analogs, paricalcitol (Zemplar) and doxercalciferol (Hectorol), can be used to
treat secondary hyperparathyroidism. The advantage of using the analogs as opposed to calcitriol is the
decreased absorption of phosphorus and calcium in the gut (13). Supplementation with 1,25-
dihydroxycholecalciferol, the active form of vitamin D, in the presence of CaCO 3 , must be individualized, and
its effects on calcium levels must be frequently monitored (9). Deficiencies of water-soluble vitamins,
especially vitamin C, folate, and vitamin B 6 , may occur secondary to poor appetite, altered metabolism,
uremia, removal by dialysis, and a restricted diet (3,5,6). Each patient should be evaluated and treated with
vitamins according to individual need and after the appropriate assessment of biochemical levels (1,2,4-6,9). In
adults with CKD (including kidney transplant recipients), the clinician should recommend vitamin B 12 and
folic acid supplementation if the mean corpuscular volume is greater than 100 ng/mL and the serum levels of
these nutrients are less than normal values (Grade IV) (1). Vitamin C supplementation at a level greater than the
DRI is not recommended to manage anemia in patients with CKD (stages 1 to 4) due to the risk of
hyperoxalosis (Grade IV) (1). If vitamin C supplementation is proposed to improve iron absorption in stage 1 to 4
CKD patients (including kidney transplant recipients) who are anemic, the registered dietitian should
recommend the DRI for vitamin C (Grade IV) (1). Vitamin C supplementation (60 to 100 mg/day) is
recommended for adults who receive RRT (hemodialysis and peritoneal dialysis) (5,6); however, doses greater
than 200 mg/day increase blood oxalate levels, which can result in the deposition of oxalate in the heart,
kidney, and blood vessels (3). Thiamin supplementation of 1.5 to 2 mg/day is suggested for patients on CAPD
because of dialysis loss (5,6). Supplementation with folic acid (1 mg/day), vitamin B 6 (2 mg/day), and vitamin
B 12 (3 mcg/day) is suggested for patients who receive hemodialysis or peritoneal dialysis (3,5,6).
Trace minerals: Patients with CKD experience alterations in the metabolism of trace minerals, especially
zinc and iron. Serum or tissue levels of these trace minerals can be high or low. Trace minerals should be
supplemented or restricted only after performing the appropriate biochemical assessments (5). Zinc
supplementation (15 mg/day) is suggested for patients who receive hemodialysis or peritoneal dialysis (5).
Iron status should be routinely evaluated and supplemented based on individual need (5,6). In adults with
CKD (stages 1 to 4, including kidney transplant recipients), the dietitian should recommend oral or
intravenous iron administration if the serum ferritin level is less than 100 ng/mL and the transferrin
saturation, referred to as TSAT, is less than 20% (Grade IV)(1). Sufficient iron should be recommended to
maintain adequate levels of serum iron to support erythropoiesis (Grade IV)(1).
See Section III: Clinical Nutrition Management, Management of Acute Kidney Injury and Chronic Kidney
Disease.
Diabetes Management in Patients with CKD
Medical nutrition therapy for people with diabetes mellitus and kidney disease is complex and requires an
individualized approach (1,2,5,6,8). For adults with diabetes and CKD (including kidney transplant recipients),
the clinician should implement medical nutrition therapy to manage hyperglycemia with a target hemoglobin
A1C level of approximately 7% (Grade I) (1). Intensive treatment of hyperglycemia, while avoiding
hypoglycemia, prevents the development of diabetic kidney disease and may slow the progression of
established kidney disease (Grade I)(1). In addition to the nutrient modifications required for managing renal
disease, consistent carbohydrate intake is a primary goal for persons with diabetes mellitus complicated by
CKD. The treatment approach should follow the guidelines outlined in Section IC: Medical Nutrition Therapy
for Diabetes Mellitus. The 2002 versions (second editions) of A Healthy Food Guide for People With Chronic
Kidney Disease and A Healthy Food Guide for People on Dialysis focus on complementing the patient’s existing
diabetes meal planning approaches (eg, constant carbohydrate meal plan, carbohydrate counting meal plan,
or exchange meal plan) (2,6). These publications also recommend strategies that best meet the nutritional
needs of the patient and that promote or maintain glucose tolerance.