Mariam Allaik Kamareddine

Clinical Dietitian
 The dietitian
 Only advise patients to loose weight.
 Consulted if the patient’s blood studies are not
normal.
 Does not need to be consulted if the patient has
already seen a doctor.
 You can answer patient’s 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
patient’s questions about the
diet.
CKD Stages 1-4
 Hemodialysis

CKD
Stage
5

Peritoneal Transplantation
Dialysis
 Nurse

Doctor

Multidisciplinary
Team

Others Social worker

Psychologist
 Support and help patients cope with
their disease and diet related stresses.

 Motivate patients to follow diet.

 Monitor
,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
Protein &Bone
Energy Disorders
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 ↑Mortality

Hypophagia
appetite ↑Hospitalization

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

What’s the
nurse’s role?
 Prevention of
Nurse’s Role
Malnutrition
 Identifying
anorexia  Assess patient’s
and poor appetite. P.O. intake .

 Identify
significant
weight loss.
 Earlyintervention
will delay or prevent  Consult the
PEW dietitian.

Weight loss of
≥5% during last
month.
 Decreased appetite or sign of
malnutrition
Nutrition Care Plan

Eliminate the cause that might

Complete nutritional assessment interfere with condition
feeding
No improvement

Start ONS within 2days to 2 weeks

Fortify diet with energy and protein Better

supplement
appetite &
No improvement
nutritional
status
Tube feeding

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 Anthropometric Biochemical Nutrition
Diet history measurements Parameters requirements
history
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 Protein-energy malnutrition

creatinine Muscle loss

Protein-energy malnutrition
Serum cholesterol
Fat loss
Hyperlipidemia

Kt/V , urea reduction ratio Dialysis adequacy

PTH Hyperparathyroidism

Serum phosphorus Bone disease

Corrected serum calcium Bone disease

Serum calcium-phosphorus
Bone disease
product

Hemoglobin Anemia

Transferrin saturation Anemia

Ferritin Anemia
HbA1C Diabetes control

Lipid profile

LDL Cardiovascular disease

HDL

Triglycerides
 Sufficient in protein

 Adequate in calories

 Restricted
in sodium, potassium,
phosphorus, and fluids(Dialysis).
 Protein

Fluids Salt

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 Predialysis
ranges

Underweight <18.5
Healthy 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 Predialysis Dialysis (HD,PD)
ranges

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

45 grams (HBV)
Needs=60grams protein
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 meat
7*3=21 grams protein
90
grams 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 ½ cup

Blueberries ½ cup

Cranberry ½ cup

Lemon 1 medium

Persimmon 1 medium

Apple, canned Ø ½ cup

Pears, canned Ø ½ cup

 100-250 mg K per svg
Allow 2 Exchanges daily

Apple with skin 1 medium

Apple juice ½ cup Peach, canned Ø ½ cup

Blackberries 1 cup Peach, raw 1 medium

Cherries, sweet raw 10 Pear, raw 1 small

Chestnut¶ 3 Pineapple, canned ,juice drained Ø

1cup
Dates ¶ 3 Pineapple, raw 1 cup
Fruit cocktail, juice Ø ½ cup Plums, raw 1 medium

Fruit salad canned Ø ½ cup Prunes, canned Ø 3

Grapefruit, juice ½ cup Quince 1 medium

Grapefruit ½ Raspberries, raw 1 cup

medium
Grapes 10 Strawberries, raw ½ cup

Jujube 75gr (15 each) Tangerine, raw 1 medium

Kiwifruit, raw ½ medium Watermelon, raw 1 cup

Mango ½ medium Yellow melon 1/6 medium

 200-350mg K per svg

Apricots, raw 3 medium

Custard Apple 1/3 piece (75g)

Figs 2

Guava, raw 1 medium

Loquats, raw 6 medium

Plums, green 2

Pricklypear 1 medium

Orange juice, fresh ½ cup

Orange 1 medium

Pomegranate 1 medium

Raisins 2 Tbsp
 >350mg K per svg

Apricot, dried¶ 5

Avocado ¶ 1 medium

Banana 1 medium

Cantaloupe/Honey dew 1 cup

Figs, dried¶ 4

Papaya 1 medium

Peach, dried¶ 5

Tamarind (tamerhindi) paste ½ cup or 100gr

 0-100mg K per svg
Allow 2 Exchanges daily

Beans sprouts ½ cup Eggplant, raw ½ cup

Cabbage, red raw ½ cup Garlic 4 cloves

Green raw ½ cup Grape leaves, boiled ½ cup(100gr)

Cabbage, boiled ½ cup Green pepper, raw ½ cup

Cauliflower, boiled ½ cup Lettuce ½ cup
(shredded)
Cucumber, raw ½ cup Rocket (rocca) 1 cup
(slices)
Coriander, raw 1 cup Radishes ,raw 5 medium
Endive, raw ½ cup Watercress, raw ½ cup
 100-250mg K per
svg
Allow 2 Exchanges
daily

Asparagus, boiled¶ ½ cup-6 spears Squash (kussa) ½ cup

Broccoli, raw ½ cup Mint ½ cup

Carrots, boiled ½ cup-slices Mushroom, raw¶ 1 cup

Cauliflower, raw ½ cup pieces Okra, cooked¶ ½ cup

Celery ½ cup Onions, raw ½ cup

Eggplant, cooked ½ cup Parsley, raw ½ cup

Green broad beans ½ cup Peas green, raw¶ ½ cup
(Ful Akhdar) cooked or cooked
Grape leaves, raw ½ cup (50gr)

Green beans, cooked ½ cup Turnip, cooked ½ cup

Green pepper, cooked ½ cup Zucchini, raw ½ cup-slices
 200-350mg K per svg

Artichoke, boiled ½ cup

Broccoli, cooked ½ cup
Purslane (bakleh) ½ cup
Beets ½ cup
Carrots, raw 1 medium
Celery, raw 2 stalks
cooked ½ cup
Corn yellow, cooked ¶ ½ cup
French fries 10
Potato, boiled ½ cup
Mushrooms, boiled¶ ½ cup
Palmito ½ cup (100gr)
Tomato, raw 1 small
Zucchini, boiled ½ cup
Truffles (kema) 9 small
 >350mg K per svg

Legumes:
Lentils¶ 1 cup
Chick peas, boiled¶ 1 cup
Kidney beans, boiled¶ 1 cup
Fava beans¶ 1 cup
Swiss Chard (siliq), boiled ½ cup

Chicory greens (hindbeh), raw ½ cup-chopped

Mouloukhieh ½ cup

Potato, baked with skin 1 potato

Spinach, boiled¶ ½ cup

Sweet potato ¶ 1 small

Tomato juice ½ cup

Tomato paste, canned ½ 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 coffee to 1 cup daily and tea to 2 cups

daily.
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 Breakfast
CKD
ON HD
Lunch or Supper
CKD
ESRD
ON HD
I cannot eat red meat if I’m on a
protein restricted diet.
Tomatoes can raise my creatinine
levels.
I’m allowed 40 grams protein per day, which
means I can eat only 40 grams of chicken or
fish.
A patient’s 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 shouldn’t 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 Consult the

Patients 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.