Creating a Renal Nutrition Care Plan

After you’ve gathered the information needed for your assessment, you must interpret the data before you can integrate it into your plan. There are 7 key areas to investigate to determine what significant nutrition problems are occurring before creating your plan, including:

• Energy
• Protein
• Potassium
• Phosphorus
• Sodium
• Fluid
• Vitamins

Common PES Statement Terminology

As you interpret the data from the assessment, you can form Problem, Etiology, Symptoms (PES) statements or nutrition diagnoses that help identify nutrition concerns that need to be addressed in your plan. If you are not familiar with how to write a PES statement please review this resource from the Academy of Nutrition and Dietetics.

Here are some common nutrition problems that patients with Chronic Kidney Disease (CKD) experience.

• Inadequate energy / protein intake
• Excessive phosphorus / potassium intake
• Excessive fluid / sodium intake
• Increased nutrient needs
• Inadequate vitamin intake (B&C)
• Altered nutrition-related laboratory values
• Involuntary weight loss
• Food and nutrition related knowledge deficit

You can create a PES statement for Raymond as we go through each of the 7 key areas. Use his anthropometric and biochemical data for reference when forming these statements.

Energy

When calculating energy:

• Use weight loss or weight gain to determine if patient is meeting energy requirements on their current diet
• Try to use edema-free weight to calculate energy requirements

If a patient is experiencing unintended weight loss or is consuming inadequate calories, consider:

• Increasing caloric intake via energy-dense foods
• An Oral Nutrition Supplement (ONS)

Choosing an ONS for Renal Nutrition

When deciding what type of ONS to use for a patient who is not meeting their energy needs, consider if they are on dialysis.

• If the patient is on dialysis, choose a formula higher in protein. For example:
  • Nepro (Abbott): high protein, low K, low PO4
  • Novasource Renal (Nestle): high protein, low K, low PO4
• If the patient is not on dialysis, choose a formula lower in protein. For example:
  • Suplena (Abbott): low protein, low K, low PO4

If serum K and PO4 are low secondary to poor intake, you can choose any supplement that meets protein and fluid requirements.

Protein

When determining a patient’s protein needs, consider if they are on dialysis.

• If the patient is on dialysis, aim for 1.2-1.3 g/kg/day
  • May need more depending on additional comorbidities
  • Can use Beneprotein® powder
• If the patient is not on dialysis, aim for 0.8 g/kg/day
  • Avoid high protein diet of >1.3 g/kg/day

Potassium

Consider if the patient’s serum potassium above or below the normal range (3.5 – 5.0 mmol/L). Use the table below to review actions to take based on the patient’s potassium levels.

Reducing Potassium in the Diet

If your patient has high potassium, your plan needs to include how K will be reduced in the diet. To do this the patient can:

• Aim for less than 6 servings per day (less than 200 mg per ½ cup serving) of foods with a high amount of potassium (incl. some specific vegetables, fruit, fruit juice, beans, legumes, and nuts)
• Double boil root vegetables (incl. potatoes, sweet potatoes, and squash)
• Limit consumption of dairy products (incl. milk and yogurt)
• Avoid potassium salt substitutes (incl. “no salt” or “half salt”)

The Ontario Renal Network Fact Sheet on Potassium lists foods that are high and low in potassium with comprehensive guidelines on limiting specific foods.

Phosphorus

Consider if the patient’s serum phosphorus above or below the normal range (0.8-1.45 mmol/L for pre-dialysis and 0.8-1.8 mmol/L for dialysis). Use the table below to review actions to take based on the patient’s serum phosphorus levels.

Reducing Phosphorus in the Diet

To reduce the amount of phosphorus in the diet, you can encourage patients to limit their consumption of:

• Processed foods with phosphate additives, like ‘phosphoric acid’ or ‘sodium phosphate’ in the ingredients list (incl. commercial baked goods, processed deli meats, processed cheese, cola, frozen meats)
• Dairy products to ½ -1 cup per day
• Large quantities of nuts and chocolate

Although meat, poultry and fish contain phosphorus, they are not restricted as they are an important source of protein in the diet. To allow for the recommended intake of meat, poultry and fish, phosphate binders can be added to control phosphorus amounts in the body.

Although whole grains and legumes used to be restricted as part of a low phosphorus diet, studies have shown that they are not entirely absorbed in the gut. As a result they are now generally allowed as part of the renal diet.

The Ontario Renal Network Fact Sheet on Phosphorus lists foods that are high and low in phosphorus with comprehensive guidelines on limiting specific foods.

Consider Phosphorus Binders

You can use this table to help you determine which phosphate binder is the best choice for your patients based on the advantages and disadvantages of each type.

In order to phosphate binders to work effectively, they must be taken WITH food (ideally in the middle of a meal or snack). They should not be taken at the same time as iron supplements.

Sodium

Sodium restriction (<2000 mg per day) is beneficial across all stages of CKD as it can help to:

• Lower blood pressure
• Maintain fluid balance
• Control thirst

To reduce sodium in the diet at home, patients can:

• Choose homemade foods more often
• Limit consumption of processed foods, which contribute > 75% of sodium in the diet

The Ontario Renal Network Fact Sheet on Sodium has comprehensive guidelines on reducing sodium in patients with chronic kidney disease.

Fluid

A fluid restriction is usually only necessary for patients on hemodialysis and can be determined by checking the interdialytic weight gains (IDWG). Some patients in the late stages of pre-dialysis may require a fluid restriction depending on:

• The amount of urine output vs. fluid intake
• The amount of IDWG
• Blood Pressure (BP)
• Shortness of Breath (SOB)
• Edema (swelling in extremities)
• History of congestive heart failure

Fluid restriction always goes in conjunction with a sodium restriction. Otherwise, the patient will be very thirsty.

You can also liaise with the in-patient team members (i.e. doctors, nurse practitioners) to help determine fluid requirements.

Vitamins

When eGFR decreases to less than 30 mL per min, vitamin supplementation can be considered if dietary intake suggests a need.  The supplement should not include vitamin A or Magnesium.

While on dialysis, water soluble vitamins (B and C) are lost so it is important to:

• Replace vitamins lost by taking Replavite® after dialysis once daily
• Avoid regular multi-vitamins in dialysis patients, as toxicity of vitamin A is possible

Replavite® is a multivitamin developed specifically for patients with kidney disease and is similar to a B complex + vitamin C. The ingredients include:

• Vitamin B1 (Thiamine Mononitrate)
• Vitamin B12 (Cyanocobalamin)
• Vitamin B2 (Riboflavin)
• Vitamin B6 (Pyridoxine Hydrochloride)
• Vitamin C (Ascorbic Acid)
• Biotin
• D-Pantothenic Acid (Calcium D-Pantothenate)
• Folic Acid
• Nicotinamide 

Visit Health Canada to learn more information on the product monograph of Replavite®.

Summary of Nutrition Care Plan Recommendations

Now that we have gone through all 7 of the key areas to investigate when creating a nutrition care plan, here is a summary of the recommendations. You can refer to this summary when working with patients with CKD in your practicum if needed.

Creating a Nutrition Care Plan for Diabetes

Diabetes is the leading cause of CKD, therefore, it is common to create nutrition care plans for patients on renal and diabetic diets. To reduce confusion caused by conflicting diet recommendations, tell your patient to try to:

• Eat at regular times throughout the day, no more than six hours apart
• Eat the same amount of carbohydrate-containing foods at each meal
• Limit simple sugars and sweets such as regular pop/soda/soft drinks, fruit juices, sweet desserts, candies, jam, honey, and sugar
• Control blood sugar to help control thirst and fluid gains
• Avoid salt substitutes and processed foods high in sodium
• Choose lean protein foods prepared with little added fat
• Choose low phosphorus and low potassium foods, if necessary (limit whole wheat foods last)
• Do some physical activity each day
  • 150 minutes of moderate aerobic activity a week (as little as 20 min per day or 50 min 3 times a week)

The Ontario Renal Network Fact Sheet on diabetes and diet has comprehensive guidelines on diet recommendations for those with diabetes and CKD.