This document discusses the nutritional management of various kidney diseases. It begins by describing the structure and function of normal kidneys. It then covers the dietary management of specific kidney disorders like glomerulonephritis, nephrotic syndrome, nephrolithiasis, acute and chronic renal failure, and considerations for renal dialysis and transplant patients. Guidelines are provided for protein, sodium, potassium, fluid and other nutrient intakes based on kidney function and disease stage. The role of nutrition therapy in maintaining nutritional status and minimizing uremic toxicity is also summarized.

1. Nutritional Management in Kidney
Diseases

2. Kidney Disorders
Renal diseases - Review of physiology and function of a normal kidney
Diseases of kidney - Classification, etiology, characteristic symptoms
and dietary management in:
Glomerulonephritis- acute and chronic, Nephrotic syndrome
Nephrolithiasis
Renal failure and uremia, acute and chronic renal failure.
Dietary management in renal dialysis
Dietary management in renal transplant
Use of sodium and potassium, exchange lists

5. Introduction
• Each of your kidneys is made up of about a million filtering units called
nephrons. (each kidney – 1.2 million nephrons)
• Each nephron includes a filter, called the glomerulus, and a tubule. (tuft
between two arterioles)
• Kidney – 3 sections – Cortex / Inner medulla and outer medulla
• Tubules - different based on type of cells they contain :-
• Proximal convoluted tubule – active transport
• Loop of Henle – Passive diffusion (recovery of H2O and Nacl)
• Distal convoluted tubule (regulating extracellular fluid volume & electrolyte
homeostasis)
• Collecting duct
• The nephrons work through a two-step process:
- the glomerulus filters your blood, and
- the tubule returns needed substances to your blood and removes wastes.

6. How does the glomerulus filter the blood
As blood flows into each nephron,
it enters a cluster of tiny blood
vessels—the glomerulus
allow smaller molecules, wastes,
and fluid—mostly water—to pass
into the tubule.
Larger molecules, such as proteins
and blood cells, stay in the blood
vessel.
▪ A blood vessel runs alongside the tubule.
▪ As the filtered fluid moves along the tubule, the blood
vessel reabsorbs almost all of the water, along with
minerals and nutrients your body needs.
▪ The tubule remove excess acid from the blood.
▪ The remaining fluid and wastes come in the form of urine.
The blood circulates through kidneys
many times a day. In a single day, the
kidneys filter about150 quartsof blood

9. Functions
• Main functions – maintenance of
1. homeostasis through control of fluid, pH, and electrolyte balance
2. blood pressure;
3. excretion of metabolic end-products and foreign substances;
4. and the production of enzymes and hormones
Homeostasis = Blood filtration – Production of ultrafiltrate - reabsorption
of amino acids, glucose, selective minerals, and water or by secretion
of solutes and water
Aldosterone – Sodium reabsorption (maintains homeostasis)
Vasopressin – Fluid balance and prevents dehydration (promotes
reabsorption)
Volume - 500 mL -12 liters of urine

10. Lab evaluation of function
• Urine analysis – to see normal and abnormal constituents
• Creatinine -
• Urea
• Blood urea nitrogen
• Sodium and potassium
• Microalbumin
• Albumin
• RBC etc
• Glomerular filtration rate – 130-200 L/day – 99% is rebasorbed
• Calculated using equations

12. Inadequate kidney function
• Advanced impairment –
• edema, metabolic acidosis, hyperkalemia,anemia,
• uremia, azotemia (elevated blood urea nitrogen), hyperphosphatemia,
• oliguria, hypertension, and bone and mineral disorders.
• Very low GFR – sodium retention – HTN
• Lack of H+ excretion – acidosis
• Potassium accumulation – 80-90% is usually excreted
• Microcytic anemia – lack of erythropoietin
• Nitrogen containing wastes – Azotemia

13. NEPHROTIC SYNDROME
❖Who are at risk?
• Have a disease that affects the kidneys such as FSGS, lupus, or IgA nephropathy ,
diabetes , infection , toxins, diabetic nephropathy, hyperlipidemia
• certain medicines like nonsteroidal anti-inflammatory drugs (NSAIDS) or antibiotics
• Have an infection such as HIV, hepatitis B and C, or malaria
• It affects both adults and children
❖Signs of nephrotic syndrome:
• Swelling in your legs, feet, ankles, and sometimes face and hands
• Weight gain
• Feeling very tired
• Foamy or bubbly urine
• Not feeling hungry
A kidney disorder that causes the body to excrete too much protein in the urine.
Abnormal condition - deficiency of albumin - its excretion in the urine
due to altered permeability of the glomerulai.

14. Symptoms –
Proteinuria – 6-8 g/day (75-90% is albumin) – due to membrane damage
Hyperlipidemia – lack of LPL (lipo protein lipase), more fibrinogen by liver,
bad lipid profile
Edema – shift of fluid due to change in oncotic pressure and Na retention
Kwashiorkar - Muscle wasting
Anorexia , absominal pain etc
Oliguria , high or low BP also seen

15. Nutrition Therapy
❖Goal : -
• minimizing the effects of edema, proteinuria, and hyperlipidemia
• Replacing nutrients lost in the urine;
• reducing the risks of further renal progression and atherosclerosis
❖Assessment :-
• A /B /C / D (protein, phosphorous, calcium, potassium, and sodium
intake)
• RFT , acid base balance , fluid and electrolyte balance , protein status ,
lipid profile etc

16. Therapy
• high carbohydrate, To include 50-60%
• 35 kcals/kg/day for adults and 100 to 150 kcal/kg/day for children
• protein recommendations are 0.8 to 1.0 g/kg/day - HBV
• with restricted fluid – 1L
• Sodium restriction – less than 2000mg per day [2g]- salt restricted
• moderate fat (TLC diet can be followed)
• No benefit with protein supplementation
• Soya and flaxseeds may be beneficial

17. Nephritic syndrome or Glomerulonephritis
Nephritis marked by inflammation of the
capillaries of the renal glomeruli and
membrane tissue that serves as a filter
Causes :-
• streptococcal infection such as tonsillitis,
pneumonia and respiratory infections
• headache,anorexia, nausea and vomiting.
• Hypertension and dimness of vision may occur.
• Classic symptoms include haematuria,
proteinuria, oedema and shortness of breath as a
result of sodium and water retention
• The patient is generally anorexic which
contributes to feeding problems.
• If the disease progress, oliguria or anuria occurs
which signals the development of acute renal
failure.

18. Therapy
• Maintaining nutritional status
• Nausea and vomiting - avoiding loss of LBM
• Usually no restriction
➢Symptomatic diet
• Edema , HTN or Oliguria – Sodium restriction
• High BUN and oliguria – protein restriction
• Hyperkalemia – potassium restriction
• Similar to nepgrotic syndrome.

19. Nephrolithiasis
• Formation of stones due to abnormal crystallization of :-
• oxalate, struvite, cysteine, hydroxyapatite, or uric acid
• that needs to be excreted normally in the urine
❖Causes: -
• Risk factors for kidney stones include family history;
• Certain medical conditions, such as hypercalciuria, hyperuricosuria,
and hyperoxaluria; and low urine volume.
• Excess vit D , gout , UTI etc
• Environment , humidity,

21. Therapy
• About 90% of stones are calcium phosphate or calcium oxalate
• Nutrition – minimizing factors Based on analysis of stone
composition is important.
Goals :-
Avoid super saturation of urine
Reduce reoccurrence stones
• most effective preventative treatment is to increase fluid by 3 L/day
• Good calcium intake – low risk of kidney stones
• People prone to oxalate stones – oxalate consumption – 50-60
mg/day
• More uric acid stones - Purine restriction in foods
[red meat, organ meals, alcohol ]

24. Acid ash and alkaline ash diets
•The acid ash diet should maintain the urine pH between 4.5
and 5 and
•with an alkalineash diet, a urinary pH of 7.6 to 8 is maintained
•When stonesare composedof calcium, magnesium
phosphatesand carbonatesthe urine is alkalineand acid –
ash diet is used
•If stonesof uric acid or cystine type occur, an alkaline -
ash diet is given

25. Things to remember
• Try to avoid sodas, fructose based , sweetened ice teas and grape fruit
juice.
• Hydrate with water – Specially when exercising – more sweat less
urination- minerals to settle and deposit in the kidneys.
• Not to completely restrict calcium from the diet- work with sodium
(As extra sodium causes to lose more calcium from the urine. As sodium and
calciu share the same transport in the kidney – if they eat more sodium it
increases the calcium leakage in the urine –thereby increase chances of
stones)
3 serves of dietary calcium is recommended
Excess of Vitamin C may produce uric acid stones- RDA
Moderate protein – as high protein leads increased calcium excretion – may
form stones

27. Renal Failure

28. Classification of GFR

29. What does the kidney tests say?
Blood Pressure
GFR
Urine Albumin
> 4mg/dl
HbA1c (Diabetics)

31. Acute renal failure
• disorder characterizedby abrupt cessationor reductionin GFR
and accumulationof nitrogenouswastes
• Causes: -
• 1. Pre-renal azotemia – reduced perfusion to the kidney – Ex:
dehydration,circulatory collapse, GI bleeding
• 2. Intrinsic – damage to anatomical structure – drugs , toxins, dyes,
chemotherapy / also nephritis
• 3. Obstructive– blockage of ureter or neck of bladder – stones ,
tumor, blood clots etc

32. Stages of ARF
initiation
(when GFR declines)
extension
(when ischemia and inflammatory damage continue)
maintenance
(when GFR is at its lowest level)
and finally, recovery
(when epithelial cells regenerate)

33. Clinical manifestations
• When GFR declines – oliguria or anuria
• Potassium , magnesium and phosphorus elevation
• Muscle wasting- weakness/ fatigue – more potassium
• When CHO is given opposite may happen – refeeding syndrome
• Lethargy , anorexia
• Urea , creatinine elevated
• Aim – BUN – 80-100 mg/dl
• Underlying cause is treated , CRRT (continuous renal replacement
therapy) is used - slow rate of dialysis which can remove 1-2 L of
fluid per hour

34. Nutrition therapy
• Malnutrition is seen in a short period
• High nitrogen losses per day – 30g/day
• Loss of LBM,
• toxicity-relatedsymptoms (anorexia, nausea, vomiting,
bleeding)
• (impaired glucose utilization and protein synthesis) from
uremia
- NT depends on :
• type of renal replacement therapy (if any),
• nutritional and metabolic status,
• and the degree of hypercatabolism

35. • Catabolism of proteins , amino acids seen
• Improper utilization of nutrients also seen
• When feasible – Oral diet , if low - EN or PN to supplement
• Vitamin A will be high – release of retinol and RBP by liver and
decreased breakdown by kidneys
• Vit D – low
• Water soluble vitamin losses due to dialysis
• Supplementation should be carefully planned
• Hepatic clearance of fatty acids may be altered – high TGL seen -
= monitor
• Avoid high omega 6 fatty acids
Cont..

36. Cont..
• Protein restriction - 0.6 (no dialysis) to 1.4 (dialyzed) g/kg/d
• Mix of both ESS and NONESS amino acids
• Overall calories – 25-35 kcals/kg/day
• FLUID – urine output + 500 ml (Insensible losses)
• Weight loss of 0.2-0.5 kg is allowed (Fluid loss)
• Supplementation of minerals, electrolytes, and trace elements,
when appropriate, is regulated by monitoring serum and urine
levels in order to prevent excess or deficiency states
FOLLOW STANDARD GUIDELINES – ASPEN / ESPEN / KDOQI etc

37. • CHO – minimum 100g
• Sodium -For the non-dialysed patient 500 to 1000 mg per day is given.
• Patients on dialysis are permitted 1500 to 2000 mg per day.
• Potassium and phosphorus - based on serum levels
Calories
Kcals / kg
Protein
g/kg
Sodium
Calcium
Mg/day
Potassium Fluid Phosphorus Lipids
20 – 30
(NPC)
0.6 – 0.8
Not < 40 g
/day
Anuric/oliguric –
500 – 1000mg
Polyuric/
diuretic –
replace losses
Based on
individual
needs
If
high,
40 – 70
mmol
Based on
balance /
edema
If
hyperPO4,
< 800mg
0.8 – 1.2 /kg
Max -1.5 g /kg
1 g salt has 0.387g sodium

38. Persistent low-grade inflammation -- essential componentof CKD -- developmentof
protein-energy wasting.
• Omega-3 fatty acids/fish oil, catechins/decaffeinated green tea extract, soy fibers
and probiotics.
• Recent study found that fish oil altered the gene expression profile of adipose
tissue toward an anti-inflammatory status, particularly in non-dialysis patients with
CKD.
• In a randomized placebo-controlled trialsupplementation of HD patients with
gamma-tocopherol and docosahexaenoicacid decreased IL-6
• Recent meta-analysis concluded that marine-derivedn-3 polyunsaturated fatty
acids lower CRP, IL-6, and TNFα.
Malnutrition and Inflammation

39. Physical activity for reducing inflammation
• Physical activity was shown to decrease inflammatory activity in
both healthy subjects and in CKD
• In patients with pre-dialysis CKD, six months of regular walking
exercise (30 min/day for 5 days/week) exerted anti-
inflammatory effects (reduction in the ratio of plasma IL-6 to IL-
10 levels)
12-Aug-22 39

40. Chronic Renal Failure
• Known as Uremia
• occurs when 90 per cent of the functioning renal tissue is destroyed
• end result of ----
• 1. acute glomerulonephritis and nephrotic syndrome
• 2. Chronic infection of the urinary tract
• 3. Kidney stones
• 4. High blood pressure
• 5. Exposure to toxic substances
• All kidney functions are disrupted

41. Symptoms
• nausea or vomiting, ulcerations in the mouth
• drowsy, irritable and sink to coma
• headache, dizziness, muscular
• The functioning of the heart is seriously disturbed
• Death results when hyperkalemia
• Diarrhoea, Sodium depletion, high serum potassium, acidosis,
• increased susceptibility to infection

42. The objectives of treatment
• 1. To maintain optimal nutritional status
• 2. To minimize uremic toxicity
• 3. To prevent protein catabolism
• 4. To improve the patients well-being
• 5. To delay the progression of renal failure
• 6. To delay the need for dialysis

43. Nutrition Therapy
• calorie needs range from 35 - 45 kcal per kg of ideal body weight
Requirements are decided after the assessment
-(between 25kcal – to 35 kcal depending on comorbidities/sepsis/current nutritional status/activity
level)
• Protein intake can be reduced to 0.6-0.75 g/kg body weight per day
[CKD patients are predisposed to PEW and can easily become malnourished with aggressive protein
restrictions. Hence protein allowances / sources – counselling has to be done with utmost care. ]
• 50% HBV
• High protein only in dialysis patients
• Dietary sodium intake depends on the amount of sodium in serum and urine
• Restriction is necessary if edema, hypertension and threat of congestive heart failure is present.
• Ascorbic acid and B vitamin deficiency / Vit D deficiency
• FLUID – Daily monitoring and planned based on output

44. Low protein diet in non-dialysis patients
• A hypoproteic diet in chronic kidney disease is like real therapy.
It helps in -
➢preventing the worsening and rapid progression of residual renal function (RRF),
➢delaying replacement treatment,
➢reducing the production of much more toxic nitrogenous compound molecules,
such as protein-bounduremic toxins
➢obtaining a phosphorus balance that could lead to a better control of uremic
osteopathy
➢lower incidence of cardiovascular events,
➢thus improving survival rates in end-stage renal disease (ESRD) patients.
• Ref: The Power of Hypoproteic Nutrition in End-stage Renal Failure is Like Real Therapy, Bolasco P Journal of Clinical
Nutrition and Dietetics 17 Aug, 2018.
12-Aug-22 44

45. Phosphorus
• Meat diet Vs Vegetarian Diets
• Protein has a linear association with phosphorus.
• 1g protein contains 13 – 15 mg phosphate
• (of which 30 – 70% is absorbed through the intestinal lumen
• Sources of Phosphorus :
• Plant proteins (50 to 75% absorption)
• Dairy products (70 to 80% absorption)
• Animal proteins (65 – 75% absorption)
• Food additives/inorganic phosphates (80 -90% absorption)
45

46. Potassium
• Potassium intake in CKD < 1 mEq/kg/day
High serum K+ can cause severe fatigue, nausea, numbness of
limbs.
Most importantly: Hyperkalemia can cause arrhythmia –
cardiac arrest.
Maintain Sr. K+ in the normal range:
3.5 to 5.0 mEq/L
46

47. ANEMIA OF CKD
• Diseased kidneys make insufficient erythropoietin.
➢Bone marrow makes fewer red blood cells, causing anemia.
• Other common causes of anemia in people with kidney disease include
➢Blood loss from hemodialysis
➢Diet based on low protein/potassium/phosphorus are also poor sources of
• Iron
• Vitamin B12
• Folic acid
However consuming iron rich foods to improve Hb is not recommendedas it
increases the risk of hyperkalemia

48. Dialysis
• Replaces kidney function, although not fully
• a renal replacement procedure that removes excessive and toxic by-
products of metabolism from the blood
• Can maintain life in ESRD patients
• Endocrine and metabolic functions are not replaced fully
• Started in : uncontrollable fluid overload, pulmonary edema,
uncontrollable and repeated hyperkalemia, coma, and lethargy

49. Types
• Hemodialysis and Peritonial Dialysis , CRRT
• Factors deciding types are:-
• underlying kidney disease
• Other comorbid factors such as cardiovascular disease, uncontrolled
diabetes and so on
• age, family support, and proximity to a dialysis center
• Waste and fluid removal :- diffusion, ultrafiltration, and osmosis
• To maintain balance while removal – Dialysate with various ion and
mineral concentrations are used

50. Hemodialysis
• Requires access to circulatory system
• Arteriovenous fistula (AVF) or graft is performed first
• Electrolyte content of dialysate and blood will be same - more
electrolytes flow from blood to dialysate
• Dialysate – contains- chloride
Salts of Na, K+,Ca, Mg, acetate &
Glucose ( -200mg)
• 9-11 g of amino acids are lost
• Usually given 3-4 times a week
• Duration – 4 hours
• Can be done at home too
• Day and night options

52. Peritoneal Dialysis
• Catheter is placed into peritoneum = abdominal cavity
• Solutes from plasma – pass around peritoneum – pass into dialysate
• Dwell time
• No of exchanges are variable
• Contains good amount of glucose – monitor intake
• Types:-
• Continuous ambulatory peritoneal dialysis (CAPD) - No machine
required – 4 to 6 hrs – replacement – 30 to 40 mins
• Continuous cycling peritoneal dialysis (CCPD) – Machine required to
cycle the dialysate frequently 3-4 times through out day or night

55. ❖objectives are to
• 1. Maintain protein and kilocalorie balance.
• 2. Prevent dehydration or fluid overload.
• 3. Maintain normal serum potassium and sodium blood levels
• 4. Maintain acceptable phosphate and calcium levels.
❖Fluid – fluid balance – 500-750 ml / day.
• Interdialytic weight gain should not be more than 5% of weight
• A daily supplement of all water soluble vitamins is given
• Potassium – 1.5 -2 g /day
• Sodium – 1 – 2 g/day when output – 1L , if 2L then 2-4 g /day

57. Non-DialysisVs Dialysisand transplant
NON DIALYSIS DIALYSIS Post Transplant
Protein Restriction High Protein Requirement 0.8g/kg BW.Avoid high protein
diet
As kidney functions reduce-
potassium, Sodium need to be
monitored strictly.
Sodium and Potassium
monitoring.
Phosphorus restritiction.
Electrolyte restrictions are not
routinely required.
Hyperkalemia and
Hypomagnesemia may occur
due to medications.
Food safety and hygiene
precautions- to prevent
infections
Fluid allowances are dictated
by the urine output/edema.
Fluid restriction- as the patient
becomes oliguric /anuric
No fluid restriction when the
graft is functioning well.

58. RENAL TRANSPLANTATION
• Malnutrition is common in renal patients and the incidence may be
as high as 70 per cent
• CKD , ARF, CRF etc

59. •Etiology of PEM in renal patients
• Decreased nutritional intake -
• Overzealous dietary restrictions
• Delayed gastric emptying and diarrhea
• Other medical co-morbidities , Intercurrent illnesses and
hospitalizations
• Decrease in food intake on dialysis days
• Medications causing dyspepsia (phosphate binders, iron preps)

60. • Suppression of oral intake by peritoneal dialysate glucose load
• Inadequate dialysis
• Monetary restrictions
• Depression
• Other medical co-morbidities
• Altered sense of taste
• Nausea, vomiting , gut dysfunction by uremia

61. ❖Objectives post transplant MNT
• Promote healing and prevent infections, especially during acute phase.
• Prevent or control Antibody Mediated Rejection.
• Support immunity and prevent new infections.
• Monitor for abnormal electrolyte levels
• Maintain good blood pressure control and near-normal fasting blood
glucose levels and HbA1c levels.
• Manage fluid intake according to intake and output. Most patients can
return to a normal or increased fluid intake

62. Nutrient
Acute Phase (up to 8 weeks following
transplant
and during acute rejection)
Chronic Phase (after 8 weeks)
Proteins
1.3–1.5 g/kg; based on standard or adjusted
body weight
1.0 g/kg; limit with chronic graft
dysfunction
Calories
30–35%kcal/kg; may increase with
postoperative
complications
Maintain desirable weight
CHO
50%–60% of total kcal; limit simple CHO if
intolerance is
apparent
50%–60% of total kcal; emphasis on
complex CHO and
20–30 g dietary fi ber (5–10 g per day
soluble fi ber)
Fats 25%–35% of total kcal
25%–35% of total kcal with saturated
fat <7% of total kcal; up
to 10% of kcal from PUFA, and up to
20% of kcal from MUFA

63. Cholesterol NA
<200 mg per day; consider plant
stanols/sterols,2 g per day
Potassium 2000–4000mg if hyperkalemiaexists
No restrictionunless hyperkalemia
exists
Sodium 2000–4000mg may be necessary 2000–4000mg with hypertension
Calcium 1200–1500mg 1200–1500mg
Phosphorus
1200–1500mg (supplements may be
needed)
1200–1500mg (supplements may
be needed)
Vitamins/mineral
s/trace elements
RDA RDA, May need extra VitaminD
Fluids
No restrictionunless graft not
functioning
No restrictionunless graft not
functioning

64. ❖IMPORTANT FOR ALL TRANSPLANT
• Careful food handling and hand washing are important to
prevent introduction of food-borne pathogens to the
transplantation individual who may be experiencing graft–host
rejection.
• • Prevent infections from foodborne illness;
• patients who have undergone transplantation may be prone to
increased risk more than other individuals.

65. ❖ General Neutropenic diet guidelines:
• All milk products, juice, and honey should be pasteurized (yogurt is allowed).
• All fresh fruit and raw vegetables must be well washed and easily cleaned.
• Steroid increase appetite , risk for NODAT,hyperlipidemia – obesity.
• Modify carbohydrates. Avoid simple sugars.
• Modify/monitor fat intake. Include Omega 3 sources of fat.
• Restrict salt to manage hypertension.
• Follow diet instructions to manage the pre-existing disorders (DM, HTN)
• No pre-cut vegetables or fruits.
• No raw sprouts.
• All meat, poultry, seafood, egg, and tofu products should be cooked until well done.
Cheese are usually avoided
• No raw nuts.
• No restaurant food or beverages/conveniencestore foods
• No herbal supplements / No outdated foods