Mariam Allaik Kamareddine

Clinical Dietitian

 The

dietitian

Only advise patients to loose weight.

Consulted if the patients blood studies are not
normal.
Does not need to be consulted if the patient has
already seen a doctor.

You

can answer patients questions related to

diet.

To be able to
1. Recognize the role of the
dietitian as member in the
multidisciplinary medical
team.
2. Realize the importance of
optimized nutrition.
3. Understand the type of diet
given during all stages of the
kidney disease.
4. Identify foods to be avoided.
5. Be able to answer simple
patients questions about the
diet.

CKD Stages 1-4

Hemodialysis

CKD
Stage
5
Peritoneal
Dialysis

Transplantation

Nurse

Doctor

Multidisciplinary
Team

Others

Social worker

Psychologist

 Support

and help patients cope with

their disease and diet related stresses.

Motivate

Monitor

patients to follow diet.

,detect any signs and

symptoms of malnutrition.

Malnutrition Prevention in Kidney disease

Medical Nutrition Therapy

The Renal Diet

Protein
Sodium
Potassium
Phosphorus
Meal plan

Myths & Facts

Vascular
Diseases
Catabolism
Malnutrition

&
Inflammation

Mineral
&Bone
Disorders

Protein
Energy
Wasting
Anemia

 Albumin

is an inflammatory marker and is not a

good indicator of malnutrition.

It

can be used partly in the assessment of

malnutrition.

Poor
appetite

Mortality
Hospitalization

Hypophagia

Molfino .A.et al.Nutrition.28(2012);1012-1015

Whats the
nurses role?

Prevention of
Malnutrition
Identifying

anorexia
and poor appetite.

Nurses Role
Assess

patients
P.O. intake .

Identify

significant
weight loss.

Early

intervention
will delay or prevent
PEW

Consult

the

dietitian.

Weight loss of
5% during last
month.

Decreased appetite or sign of

malnutrition

Complete nutritional assessment

Nutrition Care Plan

Eliminate the cause that might
interfere with condition
feeding

No improvement

Start ONS within 2days to 2 weeks

Fortify diet with energy and protein

supplement
No improvement

Tube feeding

Better
appetite &
nutritional
status

No improvement

IDPN can be offered if IDPN+ Food

Intake= Needs
No improvement

Daily total or partial Parenteral

Nutrition can be given

A.S.P.E.N Nutrition Support Practice Manual 2nd Ed.

 MNT

is recommended for all stages of

Kidney disease.
Prevents and treats protein-energy
malnutrition and mineral and
electrolyte disorders.
Improves patient outcome
Minimizes the impact of other
comorbidities on the progression of
kidney disease

Medical
history

Diet history

Anthropometric
measurements

Biochemical
Parameters

Nutrition
requirements

Anthropometric measurements
Height

Dry weight
Body

Mass Index=weight/height(m)2

Adjusted

body weight (if patient is

overweight or obese)

Biochemical Parameters

Glycemic control
Protein-energy malnutrition
Inflammation
Kidney function
Mineral and bone disorders
Anemia
Dyslipidemia
Electrolyte disorders
Others as appropriate.

Nutritional laboratory
Outcome prevention focus
parameters
Serum bicarbonate

Metabolic acidosis

n-PCR gr/KG body weight

Decreased protein intake

Serum albumin

Protein-energy malnutrition

Pre-dialysis serum
creatinine

Protein-energy malnutrition
Muscle loss

Serum cholesterol

Protein-energy malnutrition
Fat loss
Hyperlipidemia

Kt/V , urea reduction ratio

Dialysis adequacy

PTH

Hyperparathyroidism

Serum phosphorus

Bone disease

Corrected serum calcium

Bone disease

Serum calcium-phosphorus
product

Bone disease

Hemoglobin

Anemia

Transferrin saturation

Anemia

Ferritin

Anemia

HbA1C

Diabetes control

Lipid profile

LDL
HDL

Triglycerides

Cardiovascular disease

 Sufficient

in protein

Adequate

in calories

Restricted

in sodium, potassium,
phosphorus, and fluids(Dialysis).

Protein

Salt

Fluids

Phosphorus

Potassium

Protein needs: 0.6-0.8 grams/Kg.

Caloric needs: 25-35Cal/Kg
Sodium: 2.4 grams/day.
Potassium: Not restricted unless serum K is high. (2-4 grams
daily).
Phosphorous: 10-12mg/gram of protein or 800-1000mg/day
Calcium: 2000mg/day
Fluids: unrestricted
Suggested table of BMI
ranges

Predialysis

Underweight
Healthy

<18.5
20-25

Overweight

25-30

Obese

>30

Protein needs: 1.2-1.5 grams/Kg.

Caloric needs: 30-35Cal/Kg.
Sodium: 2-3 grams/day.
Potassium: 40 mg/Kg.
Phosphorous: 10-12mg/gram of protein or 800-1000mg/day
Calcium: 2000mg/day
Fluids: 500-1000ml/day plus urine output
Suggested table of BMI
ranges

Predialysis

Dialysis (HD,PD)

Underweight

<18.5

<18.5

Healthy

20-25

23-26

Overweight

25-30

26-32

Obese

>30

>32

CKD patient who weighs 75kg and is 178cm tall .

BMI=23.6kg/m2
Energy needs=75*30=2250 calories
Protein needs=75*0.8= 60 grams of protein

Needs=60grams
protein

45 grams (HBV)
protein
=75%

 Help

to build and repair body tissues.

Protein needs: 0.6-0.8 grams for CKD
1.2-1.5 grams/Kg for ESRD
Rich sources : Dairy products, meat, poultry,
fish, eggs, legumes and soya.
Low protein food items: Bread, rice, pasta,
potatoes, cornflakes, oats and other grains.

90
grams

90 grams meat
7*3=21 grams protein

Meat Group
60 grams

60 grams

60 grams

90
grams
60
grams
90
grams

1 slice =2 grams protein

Starch Group

Canned and processed food: mortadella, bastourma,

readymade & frozen meals, canned & dehydrated soups and
chicken stock, canned vegetables and tomato juice.

Seasonings and dressings like salt, soy sauce, teriyaki sauce,

barbeque sauce, ketchup, mustard.

Salted pretzels, potato chips, processed cheese, pickles,

olives, roasted nuts, zaatar, kishek and most fast food items.

Normal Potassium blood level: 3.5-5.5mEq/L

Low potassium food items

Medium potassium food items

High and very high food items

0-100mg K per svg

Allow 1 or 2 Exchanges
daily
Applesauce

cup

Blueberries

cup

Cranberry

cup

Lemon

1 medium

Persimmon

1 medium

Apple, canned

cup

Pears, canned

cup

100-250 mg K per svg

Allow 2 Exchanges daily

Apple with skin

Apple juice
Blackberries

1 medium
cup
1 cup

Peach, canned

cup

Peach, raw

1 medium
1 small

Cherries, sweet raw

10

Pear, raw

Chestnut

Dates
Fruit cocktail, juice

3
cup

Pineapple, canned ,juice drained

1cup
Pineapple, raw
1 cup
Plums, raw
1 medium

Fruit salad canned

cup

Prunes, canned

Grapefruit, juice
Grapefruit
medium
Grapes
Jujube

cup

Quince

Raspberries, raw
10
75gr (15 each)

Strawberries, raw
Tangerine, raw

Kiwifruit, raw

medium

Watermelon, raw

Mango

medium

Yellow melon

3
1 medium
1 cup
cup
1 medium
1 cup
1/6 medium

200-350mg K per svg

Apricots, raw

3 medium

Custard Apple

1/3 piece (75g)

Figs

Guava, raw

1 medium

Loquats, raw

6 medium

Plums, green

Pricklypear
Orange juice, fresh

1 medium
cup

Orange

1 medium

Pomegranate

1 medium

Raisins

2 Tbsp

>350mg K per svg

Apricot, dried
Avocado

5
1 medium

Banana

1 medium

Cantaloupe/Honey dew

1 cup

Figs, dried

Papaya

1 medium

Peach, dried

Tamarind (tamerhindi) paste cup or 100gr

0-100mg K per svg

Allow 2 Exchanges daily

Beans sprouts

cup

Eggplant, raw

Cabbage, red raw

cup

Garlic

cup

Grape leaves, boiled

Cabbage, boiled

cup

Green pepper, raw

cup

Cauliflower, boiled

cup

cup

Cucumber, raw
(slices)
Coriander, raw

cup

Lettuce
(shredded)
Rocket (rocca)
Radishes ,raw

5 medium

Green raw

Endive, raw

1 cup

cup Watercress, raw

cup
4 cloves
cup(100gr)

1 cup

cup

100-250mg K per
svg
Allow 2 Exchanges
daily

Asparagus, boiled cup-6 spears Squash (kussa)

cup

Broccoli, raw

cup

cup Mint

Carrots, boiled
Cauliflower, raw

cup-slices

Mushroom, raw

cup pieces Okra, cooked

1 cup
cup

Celery

cup

Onions, raw

cup

Eggplant, cooked

cup

Parsley, raw

cup

Green broad beans

cup
(Ful Akhdar) cooked
Grape leaves, raw
cup (50gr)

Peas green, raw

or cooked

cup

Green beans, cooked

cup

Turnip, cooked

cup

Green pepper, cooked

cup

Zucchini, raw

cup-slices

200-350mg K per svg

Artichoke, boiled
Broccoli, cooked
Purslane (bakleh)
Beets
Carrots, raw
Celery, raw
cooked
Corn yellow, cooked
French fries
Potato, boiled
Mushrooms, boiled
Palmito
Tomato, raw
Zucchini, boiled
Truffles (kema)

cup
cup
cup
cup
1 medium
2 stalks
cup
cup
10
cup
cup
cup (100gr)
1 small
cup
9 small

>350mg K per svg

Legumes:
Lentils
Chick peas, boiled
Kidney beans, boiled
Fava beans
Swiss Chard (siliq), boiled

1 cup
1 cup
1 cup
1 cup
cup

Chicory greens (hindbeh), raw

Mouloukhieh

cup-chopped

cup

Potato, baked with skin

1 potato

Spinach, boiled

cup

Sweet potato

1 small

Tomato juice

cup

Tomato paste, canned

cup

1 Tbsp=1 Tomato
* Tabbouli and Fattouch (as specified by dietitian)

 Avoid

nuts and seeds, salt substitutes,

chocolate, vegetable juices.

Milk

and yogurt can be taken in limited

amount.

Limit

daily.

coffee to 1 cup daily and tea to 2 cups

Dairy products: Allowed in limited amount

Milk, yoghurt (laban), yellow cheese, and ice-cream.
Legumes: Lentils, chickpeas, kidney beans, green peas, fava beans, lupines
(turmus), and any kind of dried beans.

Grains and cereals: Products made from the whole grain such as: bran cereal
and muffins, Granola, whole wheat cereal or crackers, bread with oatmeal, dark
rye, or whole wheat, pancakes, waffles, and corn tortillas.
Beverages: Cola, chocolate drinks, beer, coffee drinks with milk.
Vegetables: Corn, green peas, mushrooms, okra, sweet potato, spinach,
asparagus.
Other: Dried fruits, avocado, halawi, tahini, chestnut, sardines, organ meats,
chocolate, cocoa powder, molasses, nuts & seeds, coconut, peanut butter, coffee
mate (if more than 1Tbsp), sour cream (if more than 2 Tbsp).

Canned products : Avoid foods with long words containing PHOS in

the ingredient list.

What is considered fluid?

-

Alcohol
Coffee
Gelatin
Gravies
Ice cream
Ice cubes
Juices
Lemonade
Milk
Pudding
Sherbet/Sorbet
Sodas/Soft Drinks
Soups
Tea
Water
Yogurt

ESRD
ON HD

Breakfast

CKD

Lunch or Supper
ESRD
ON HD

CKD

I cannot eat red meat if Im on a

protein restricted diet.

Tomatoes can raise my creatinine

levels.

Im allowed 40 grams protein per day, which

means I can eat only 40 grams of chicken or
fish.

A patients complaint: I have diabetes and

I have received white bread on my tray.

Consult the
dietitian for
weight
management
and advise on a
healthy diet.
Inadequately
decreasing
portions might
cause fatigue
and muscle
breakdown.

I want to loose weight. I will decrease

my portions of meat and bread.

30 grams of
chicken is
equivalent to one
meat serving. It
has 7 grams of
protein. Some
food items may
increase your
potassium or
creatinine levels.
Consult the doctor
for iron
supplementation.

I have anemia. I should increase my

consumption of red meat , liver and spinach.

I am not frying or eating oil because

I have dyslipidemia.

I feel tired I will eat more proteins

and drink protein shakes.

I have nausea when I smell cooked food. I will

exclusively eat legumes instead of meat,
chicken and fish.

Tomatoes contain salt and are hence

restricted on a salt restricted diet.

I shouldnt drink fluids as I have

kidney disease.

I can eat non allowed foods on the

same day of dialysis.

Weight Change

Appetite

GI symptoms

Monitor
Patients

Consult the
dietitian
Change in electrolytes

Non-compliance to dietary
recommendations

Patient will start on dialysis

Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic

kidney failure: integrating clinical practice guidelines. Journal of the
american dietetic association, 104(3), 100-108. doi:
10.1016/j.jada.2003.12.028
Friedman, A. N., & Fadem, S. Z. (2010). Reassessment of albumin as a
nutritional marker in kidney disease. Journal of american society of
nephrology , 21, 223-230. doi: 10.1681/ASN.2009020213
Molfino, A., Chiappini, M. G., Laviano, A., Ammann, T., Bollea, M. R.,
Alegiano, F., Fanelli, F. R., & Muscaritoli, M. (2012). Effect of intensive
nutritional counseling and support on clinical outcomes of hemodialysis
patients. Nutrition, 28, 1012-1015. doi: 10.1016/j.nut.2012.01.008
National Kidney Foundation. (2009). Pocket guide to nutrition
assessment of the patient with chronic kidney disease. (4th ed.). New
York: Council on renal nutrition
U.S. Department of Agriculture, Agricultural Research Service. 2011.
USDA National Nutrient Database for Standard Reference, Release 24.
Nutrient Data Laboratory Home Page,
http://www.ars.usda.gov/ba/bhnrc/ndl
http://www.kidney.org
A.S.P.E.N Nutrition Support Practice Manual 2 nd Ed.