![\"Step](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/02\/label_2-plan-1024x132.png\")
\r\n- \r\n \t
- Energy<\/li>\r\n \t
- Protein<\/li>\r\n \t
- Potassium<\/li>\r\n \t
- Phosphorus<\/li>\r\n \t
- Sodium<\/li>\r\n \t
- Fluid<\/li>\r\n \t
- Vitamins<\/li>\r\n<\/ul>\r\n
Common PES Statement Terminology<\/h2>\r\nAs 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<\/a>.\r\n\r\nHere are some common nutrition problems that patients with Chronic Kidney Disease (CKD) experience.\r\n
- \r\n \t
- Inadequate energy \/ protein intake<\/li>\r\n \t
- Excessive phosphorus \/ potassium intake<\/li>\r\n \t
- Excessive fluid \/ sodium intake<\/li>\r\n \t
- Increased nutrient needs<\/li>\r\n \t
- Inadequate vitamin intake (B&C)<\/li>\r\n \t
- Altered nutrition-related laboratory values<\/li>\r\n \t
- Involuntary weight loss<\/li>\r\n \t
- Food and nutrition related knowledge deficit<\/li>\r\n<\/ul>\r\nYou 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.\r\n
\r\n Raymond's Anthropometric Data<\/h2>\r\n<\/header>\r\n
\r\n- \r\n \t
- Weight = 65 kg<\/li>\r\n \t
- Weight Hx = 62 kg (usual body weight)<\/li>\r\n \t
- Height = 162 cm<\/li>\r\n \t
- BMI = 24.7 kg\/m2<\/sup><\/li>\r\n \t
- SGA = A (well-nourished)<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
\r\n Raymond's Biochemical Data<\/h2>\r\n<\/header>\r\n
\r\n - SGA = A (well-nourished)<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\n
![\"A](\"http:\/\/pressbooks.library.ryerson.ca\/dietmods\/wp-content\/uploads\/sites\/262\/2022\/01\/Edema_Hands_01-300x191.jpeg\")
Edema is a common sign of fluid overload, which can occur as renal function declines. Photo by Wang Kai-feng, Pan Hong-ming, Lou Hai-zhou, Shen Li-rong, Zhu Xi-yan, ![via Wikimedia Commons<\/a>[\/caption]\r\nEnergy<\/h1>\r\nWhen calculating energy:\r\n\r\n \tUse weight loss or weight gain to determine if patient is meeting energy requirements on their current diet<\/li>\r\n \tTry to use edema-free weight to calculate energy requirements<\/li>\r\n<\/ul>\r\nIf a patient is experiencing unintended weight loss or is consuming inadequate calories, consider:\r\n\r\n \tIncreasing caloric intake via energy-dense foods<\/li>\r\n \tAn Oral Nutrition Supplement (ONS)<\/li>\r\n<\/ul>\r\nChoosing an ONS for Renal Nutrition<\/h2>\r\nWhen deciding what type of ONS to use for a patient who is not meeting their energy needs, consider if they are on dialysis.\r\n\r\n \tIf the patient is on dialysis<\/strong>, choose a formula higher in protein. For example:\r\n\r\n \tNepro (Abbott): high protein, low K, low PO4<\/li>\r\n \tNovasource Renal (Nestle): high protein, low K, low PO4<\/li>\r\n<\/ul>\r\n<\/li>\r\n \tIf the patient is not on dialysis<\/strong>, choose a formula lower in protein. For example:\r\n\r\n \tSuplena (Abbott): low protein, low K, low PO4<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\nIf serum K and PO4 are low secondary to poor intake, you can choose any supplement that meets protein and fluid requirements.\r\n\r\n \r\n\r\n[h5p id=\"2\"]\r\n\r\nRaymond's Energy<\/h2>\r\n<\/header>\r\n\r\n\r\nPES<\/strong> : Adequate caloric intake as evidenced by stable weight and good appetite\/intake as per diet history.<\/div>\r\n<\/div>\r\n\r\n \tCalories 35 kcal\/kg (using 65 kg) = 2275 kcal<\/span><\/li>\r\n \tRegular diet order is sufficient to meet energy needs, therefore no ONS are necessary<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\nProtein<\/h1>\r\nWhen determining a patient's protein needs, consider if they are on dialysis.\r\n\r\n \tIf the patient is on dialysis<\/strong>, aim for 1.2-1.3 g\/kg\/day\r\n\r\n \tMay need more depending on additional comorbidities<\/li>\r\n \tCan use Beneprotein\u00ae powder<\/li>\r\n<\/ul>\r\n<\/li>\r\n \tIf the patient is not on dialysis<\/strong>, aim for 0.8 g\/kg\/day\r\n\r\n \tAvoid high protein diet of >1.3 g\/kg\/day<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n \r\n\r\n[h5p id=\"3\"]\r\n\r\nRaymond's Protein<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Excessive protein intake related to kidney dysfunction and\/or nutrition knowledge deficit, as evidenced by high urea (39 mmol\/L) and diet history (~15 ounces\/105 g animal protein per day).<\/div>\r\n\r\n \tNot currently on dialysis<\/li>\r\n \tAvoid high protein diet of >1.3 g\/kg\/day<\/li>\r\n \tAim for 0.8 g\/kg\/day = 52 g\/day (using 65 kg)<\/li>\r\n \t1 oz animal protein = ~7 grams protein<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\nPotassium<\/h1>\r\nConsider if the patient\u2019s serum potassium above or below the normal range (3.5 \u2013 5.0 mmol\/L). Use the table below to review actions to take based on the patient's potassium levels.\r\n\r\n\r\n\r\nPatient's potassium levels<\/strong><\/th>\r\nActions to take<\/th>\r\n<\/tr>\r\n\r\nAbove normal range<\/th>\r\n\r\n\r\n \tPatient may require a low potassium diet and\/or education surrounding a low potassium diet<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nWithin normal range<\/th>\r\n\r\n\r\n \tNo potassium restriction required at this time<\/li>\r\n \tContinue to monitor serum potassium<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nBelow normal range<\/th>\r\n\r\n\r\n \tLikely due to poor intake or good kidney function<\/li>\r\n \tCan liberalize\/omit potassium restrictions and monitor serum potassium levels<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nReducing Potassium in the Diet<\/h2>\r\nIf your patient has high potassium, your plan needs to include how K will be reduced in the diet. To do this the patient can:\r\n\r\n \tAim for less than 6 servings per day (less than 200 mg per \u00bd cup serving) of foods with a high amount of potassium (incl. some specific vegetables, fruit, fruit juice, beans, legumes, and nuts)<\/li>\r\n \tDouble boil root vegetables (incl. potatoes, sweet potatoes, and squash)<\/li>\r\n \tLimit consumption of dairy products (incl. milk and yogurt)<\/li>\r\n \tAvoid potassium salt substitutes (incl. \"no salt\" or \"half salt\")<\/li>\r\n<\/ul>\r\nThe Ontario Renal Network Fact Sheet<\/a> on Potassium lists foods that are high and low in potassium with comprehensive guidelines on limiting specific foods.\r\n\r\n \r\n\r\n[h5p id=\"4\"]\r\n\r\nRaymond's Potassium<\/h2>\r\n<\/header>\r\n\r\n\r\n\r\nPES<\/strong>: Adequate potassium intake as evidenced by serum K within normal range (4.7 mmol\/L).\r\n\r\n<\/div>\r\n<\/div>\r\nNo potassium restriction required at this time.\r\n\r\nEven though Raymond is on a regular diet and admitted to eating french fries (high K food) at home, his serum K is within normal range and we can continue to monitor.\r\n\r\n<\/div>\r\n<\/div>\r\nPhosphorus<\/h1>\r\nConsider if the patient\u2019s 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.\r\n\r\n\r\n\r\nPatient's serum phosphorus levels<\/strong><\/th>\r\nActions to take<\/th>\r\n<\/tr>\r\n\r\nAbove normal range<\/th>\r\n\r\n\r\n \tPatient may require a low phosphorus diet and\/or education surrounding a low phosphorus diet<\/li>\r\n \tPatient may require phosphate binders or an increase in dose<\/li>\r\n \tMake sure patient is taking phosphate binders as prescribed and\/or with meals<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nWithin normal range<\/th>\r\n\r\n\r\n \tNo phosphorus restriction required at this time<\/li>\r\n \tContinue to monitor serum phosphorus<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nBelow normal range<\/th>\r\n\r\n\r\n \t\r\nLikely due to poor intake or good kidney function<\/div><\/li>\r\n \t\r\nCan liberalize\/omit phosphorus restrictions and monitor serum phosphorus levels<\/div><\/li>\r\n \t\r\nCan decrease phosphate binder dose<\/div><\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nReducing Phosphorus in the Diet<\/h2>\r\nTo reduce the amount of phosphorus in the diet, you can encourage patients to limit their consumption of:\r\n\r\n \tProcessed foods with phosphate additives, like \u2018phosphoric acid\u2019 or \u2018sodium phosphate\u2019 in the ingredients list (incl. commercial baked goods, processed deli meats, processed cheese, cola, frozen meats)<\/li>\r\n \tDairy products to \u00bd -1 cup per day<\/li>\r\n \tLarge quantities of nuts and chocolate<\/li>\r\n<\/ul>\r\nAlthough 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.\r\n\r\nAlthough 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.\r\n\r\nThe Ontario Renal Network Fact Sheet<\/a> on Phosphorus lists foods that are high and low in phosphorus with comprehensive guidelines on limiting specific foods.\r\nConsider Phosphorus Binders<\/h2>\r\nYou 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.\r\n\r\nIn 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<\/strong> be taken at the same time as iron supplements.\r\n\r\n\r\n\r\nPhosphate Binder (Brand Name)<\/th>\r\nAdvantages<\/th>\r\nDisadvantages<\/th>\r\nDosing Info<\/th>\r\n<\/tr>\r\n\r\nCalcium Carbonate\r\n(Tums)<\/th>\r\n\r\n\r\n \tExcellent binder<\/li>\r\n \tInexpensive<\/li>\r\n \t1st line of therapy unless patient is hypercalcemic<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tRisk for calcification<\/li>\r\n \tContraindicated if pt is hypercalcemic<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tGeneric Brand Ca Carbonate 1250 mg = 500 mg Ca<\/li>\r\n \tTums Ultra strength 1000 mg = 400 mg elemental Ca<\/li>\r\n \tTums Extra strength 750 mg = 300 mg elemental Ca<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nSevelamer\r\n(Renagel)<\/th>\r\n\r\n\r\n \tNon-calcium based<\/li>\r\n \tLess risk of hypercalcemia<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tExpensive (often used if pt has coverage)<\/li>\r\n \tGI side effects<\/li>\r\n \tRisk of acidosis<\/li>\r\n \tIncreases pill burden<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tComes in 800 mg tabs<\/li>\r\n<\/ul>\r\n <\/td>\r\n<\/tr>\r\n\r\nLanthanum\r\n(Fosrenal)<\/th>\r\n\r\n\r\n \tNon-calcium based<\/li>\r\n \tLess risk of hypercalcemia<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tExpensive (often used if pt has coverage)<\/li>\r\n \tGI side effects<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tComes in 250 mg, 500 mg and 1000 mg tabs (single tab for dosage = less pill burden)<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n\r\nSucroferric Oxyhydroxide\r\n(Velphoro)<\/th>\r\n\r\n\r\n \tNon-calcium based<\/li>\r\n \tLess risk of hypercalcemia<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \tExpensive (often used if pt has coverage)<\/li>\r\n \tGI side effects<\/li>\r\n \tReduced pill burden<\/li>\r\n<\/ul>\r\n<\/td>\r\n\r\n\r\n \t500 mg tabs, usually 3-4 tablets required daily<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n\r\n[h5p id=\"5\"]\r\n\r\nRaymond's Phosphorus<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Excessive PO4 intake related to reliance on processed foods and kidney dysfunction, as evidenced by diet history (high P foods such as, deli meats & bacon) and hyperphosphatemia (serum PO4 1.55).<\/div>\r\n\r\n \tConsider low phosphorus (800-1000 mg) diet and\/or PO4<\/sub> binders<\/li>\r\n \tCalcium-based PO4<\/sub> binders are reasonable to start, since serum Ca is within normal range<\/li>\r\n \tLiaise with team to start with 1 tab daily with dinner (largest meal)<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\nSodium<\/h1>\r\nSodium restriction (<2000 mg per day) is beneficial across all stages of CKD as it can help to:\r\n\r\n \tLower blood pressure<\/li>\r\n \tMaintain fluid balance<\/li>\r\n \tControl thirst<\/li>\r\n<\/ul>\r\nTo reduce sodium in the diet at home, patients can:\r\n\r\n \tChoose homemade foods more often<\/li>\r\n \tLimit consumption of processed foods, which contribute > 75% of sodium in the diet<\/li>\r\n<\/ul>\r\nThe Ontario Renal Network Fact Sheet<\/a> on Sodium has comprehensive guidelines on reducing sodium in patients with chronic kidney disease.\r\n\r\n \r\n\r\n[h5p id=\"6\"]\r\n\r\nRaymond's Sodium<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Excessive sodium intake related to knowledge deficit \/ reliance on convenience foods, as evidenced by diet history, edema, and CHF.<\/div>\r\nAim for sodium intake less than 2000 mg\/day\r\n\r\n<\/div>\r\n<\/div>\r\nFluid<\/h1>\r\nA 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:\r\n\r\n \tThe amount of urine output vs. fluid intake<\/li>\r\n \tThe amount of IDWG<\/li>\r\n \tBlood Pressure (BP)<\/li>\r\n \tShortness of Breath (SOB)<\/li>\r\n \tEdema (swelling in extremities)<\/li>\r\n \tHistory of congestive heart failure<\/li>\r\n<\/ul>\r\nFluid restriction always goes in conjunction with a sodium restriction. Otherwise, the patient will be very thirsty.\r\n\r\nYou can also liaise with the in-patient team members (i.e. doctors, nurse practitioners) to help determine fluid requirements.\r\n\r\n \r\n\r\n[h5p id=\"7\"]\r\n\r\nRaymond's Fluid<\/h2>\r\n<\/header>\r\n\r\nPES<\/strong>: Excessive fluid intake related to cardiac and kidney dysfunction, as evidenced by diet history (2L fluid intake\/day), edema, hyponatremia (Na 129) and admission for congestive heart failure.<\/div>\r\n\r\n \tFluid restriction always goes in conjunction with a sodium restriction<\/li>\r\n \tFluid intake should be restricted to 1.5 L per day, after liaising with team to determine optimal fluid restriction given his history of CHF and CKD<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\nVitamins<\/h1>\r\nWhen [pb_glossary id=\"1620\"]eGFR[\/pb_glossary] decreases to less than 30 mL per min, vitamin supplementation can be considered if dietary intake suggests a need.\u00a0 The supplement should not<\/strong> include vitamin A or Magnesium.\r\n\r\nWhile on dialysis, water soluble vitamins (B and C) are lost so it is important to:\r\n\r\n \tReplace vitamins lost by taking Replavite\u00ae after dialysis once daily<\/li>\r\n \tAvoid regular multi-vitamins in dialysis patients, as toxicity of vitamin A is possible<\/li>\r\n<\/ul>\r\nReplavite\u00ae is a multivitamin developed specifically for patients with kidney disease and is similar to a B complex + vitamin C. The ingredients include:\r\n\r\n \tVitamin B1 (Thiamine Mononitrate)<\/li>\r\n \tVitamin B12 (Cyanocobalamin)<\/li>\r\n \tVitamin B2 (Riboflavin)<\/li>\r\n \tVitamin B6 (Pyridoxine Hydrochloride)<\/li>\r\n \tVitamin C (Ascorbic Acid)<\/li>\r\n \t\r\nBiotin<\/div><\/li>\r\n \t\r\nD-Pantothenic Acid (Calcium D-Pantothenate)<\/div><\/li>\r\n \t\r\nFolic Acid<\/div><\/li>\r\n \t\r\nNicotinamide\u00a0<\/span><\/div><\/li>\r\n<\/ul>\r\nVisit Health Canada to learn more information on the product monograph of Replavite\u00ae.<\/a>\r\n\r\n \r\n\r\n[h5p id=\"8\"]\r\n\r\nRaymond's Vitamins<\/h2>\r\n<\/header>\r\n\r\n\r\n \tRaymond is not on dialysis and has adequate intake.\u00a0 He does not require Replavite\u00ae at this time<\/li>\r\n \tHe benefits from taking vitamin D and omega-3, which can continue to be administered<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/div>\r\nSummary of Nutrition Care Plan Recommendations<\/h1>\r\nNow 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.\r\n\r\n\r\n\r\nNutrient<\/strong><\/th>\r\nCKD\/Pre-Dialysis<\/strong><\/th>\r\nHemodialysis<\/strong><\/th>\r\nPeritoneal Dialysis<\/strong><\/th>\r\n<\/tr>\r\n<\/thead>\r\n\r\n\r\nEnergy\r\n(kcal\/kg\/day)<\/th>\r\n25 - 35<\/td>\r\n25 - 35<\/td>\r\n25 -35<\/td>\r\n<\/tr>\r\n\r\nProtein\r\n(g\/kg\/day)<\/th>\r\n0.6 - 0.8<\/td>\r\n1.0 - 1.2<\/td>\r\n1.0 -1.2<\/td>\r\n<\/tr>\r\n\r\nPotassium\r\n(mg\/day)<\/th>\r\nIndividualized\r\n(Restrict if high K+)<\/td>\r\n2000 - 4000\r\n(50 - 100 mmol\/day)<\/td>\r\nIndividualized\r\n(Restrict if high K+)<\/td>\r\n<\/tr>\r\n\r\nPhosphorus\r\n(mg\/day)<\/th>\r\n800 - 1000,\r\nonly if PO4<\/sub> >1.5 mmol\/L<\/td>\r\n800 - 1000<\/td>\r\n800 - 1000<\/td>\r\n<\/tr>\r\n\r\nSodium\r\n(mg\/day)<\/th>\r\n< 2300<\/td>\r\n< 2300<\/td>\r\n< 2300<\/td>\r\n<\/tr>\r\n\r\nFluid\r\n(mL \/day)<\/th>\r\nUsually not restricted<\/td>\r\n1000 mL + urine output<\/td>\r\nIndividualized\r\n(Restrict if needed)<\/td>\r\n<\/tr>\r\n\r\nVitamins<\/th>\r\nUsually not required<\/td>\r\nReplavite\u00ae OD after dialysis<\/td>\r\nReplavite\u00ae OD<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n\r\nSummary of PES Statements for Raymond<\/h2>\r\n<\/header>\r\n\r\n\r\n\r\nHere is a list of all of the nutrition problems that we identified for Raymond using the information we gathered in our assessment and will address in the nutrition care plan.\r\n\r\n<\/div>\r\n\r\n \tAdequate caloric intake as evidenced by stable weight and good appetite.<\/li>\r\n \tExcessive protein intake related to kidney dysfunction, as evidenced by high urea and diet history.<\/li>\r\n \tAdequate potassium intake as evidenced by serum K within normal range.<\/li>\r\n \tExcessive PO4<\/sub> intake related to reliance on processed foods and kidney dysfunction, as evidenced by diet history, hyperphosphatemia.<\/li>\r\n \tExcessive sodium intake related to knowledge deficit \/ reliance on convenience foods, as evidenced by diet history, edema, CHF.<\/li>\r\n \tExcessive fluid intake related to cardiac and kidney dysfunction, as evidenced by diet history, edema, hyponatremia, and CHF.<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>\r\n\r\nRaymond's Nutrition Care Plan<\/h2>\r\n<\/header>\r\n\r\n\r\nOur nutrition care plan for Raymond includes:\r\n](\"https:\/\/commons.wikimedia.org\/wiki\/File:Edema_Hands_01.jpg\"){kind=link}