PATHOPHYSIOLOGY &

DIETARY MANAGEMENT
FOR CHRONIC RENAL
DISEASE
Ortiz & Paredes
CHRONIC KIDNEY DISEASE
is a syndrome of progressive and irreversible
loss of the excretory, endocrine, and
metabolic functions of the kidney secondary
to kidney damage.

CKD progresses slowly over time, and there

may be intervals during which kidney
functions remain stable.
Stages of
CKD
Pathophysiology
As GFR begins to decline, the
Advanced impairment of kidney excretion rate of potassium
function results in edema, increases; however, as renal
CKD progresses slowly
metabolic acidosis, hyperkalemia, function continues to decline, this
over time, and there may
anemia, uremia, azotemia, compensatory mechanism can
be intervals during which
hyperphosphatemia, oliguria, no longer prevent the
kidney functions remain
hypertension, and bone and accumulation of potassium, which
stable.
mineral disorders. ultimately results in hyperkalemia
(elevated blood potassium).

In a person with CKD, the normal

Due to the kidney’s inability to
Nitrogenous waste excretion PTH feedback loop is
make adequate erythropoietin,
declines, and blood urea and dysfunctional. It no longer have
the hormone that stimulates the
other nitrogen-containing the ability to convert inactive
production of red blood cells
compounds increase, resulting vitamin D into active calcitriol, and
(Microcytic anemia and iron
in azotemia. without it, calcium absorption
deficiency).
from the intestine is reduced.
Pathophysiology

As a result, the parathyroid cells

Additionally, damaged When damaged kidneys
increase in number (parathyroid
kidneys may not be able to fail to excrete phosphorus,
hyperplasia) and this leads to
reabsorb calcium and the parathyroid gland is
secondary hyperparathyroidism
excrete phosphorus, leading constantly stimulated and
and CKD-bone and mineral
to an imbalance in the blood. continuously releases PTH.
disorder (CKD-BMD).
Dietary Management
Nutrition therapy should be aimed towards the following objectives:

to maintain optimal nutritional status, prevent deficiencies, and stimulate

patient well-being
to provide adequate energy intake
to regulate protein intake in order to minimize uremic toxicity, prevent net
protein catabolism, provide for continuous growth in children and retard
the progression of renal failure and postpone the initiation of dialysis
to regulate fluid intake to balance fluid output by the regulation of sodium
and the restriction of potassium to control edema and electrolyte
imbalance
to provide supplements of appropriate vitamins and minerals; and
to enable patients to eat palatable, attractive diets that fit their lifestyle as
much as possible
Dietary Management
Dietary Management
Energy

Energy requirements are estimated to be 30–35

kcal/kg/day based on overall weight status and
weight goals, age and gender, level of physical
activity, and the presence of metabolic stress.

Sufficient kcalories from carbohydrates and fat may

help to prevent muscle and visceral protein from
being utilized for energy.
FAT
Patients with CKD are at increased risk for coronary
artery disease (CAD) and stroke.
Hemodialysis patients typically display normal LDL
cholesterol, HDL cholesterol, and elevated triglyceride
levels.
PD patients exhibit higher total serum cholesterol levels
as well as LDL levels.
It is recommended that both PD and HD patients adhere
to the nutrient composition guidelines of the American
Heart Association (AHA) diet.
FAT
Patients with CKD are at increased risk for
coronary artery disease (CAD) and stroke.
Hemodialysis patients typically display normal
LDL cholesterol, HDL cholesterol, and elevated
triglyceride levels.
PD patients exhibit higher total serum
cholesterol levels as well as LDL levels.
It is recommended that both PD and HD
patients adhere to the nutrient composition
guidelines of the American Heart Association
(AHA) diet.
Protein
Protein intake of 0.6 to 0.75 g/kg body weight (for pre-
dialysis) to slow the progression of the disease
1.2g/kg standard body weight for hemodialysis
patients (HD)
1.2-1.3g/kg body weight for peritoneal dialysis patients.
High biological value (HBV) is recommended to
maintain a neutral or positive nitrogen balance and
lead to an improvement or maintenance of visceral
protein stores.
Fluid
Fluid intake of 2-3 cups (500-700 ml) more
than their urine output is satisfactory; fruit
juices, beverages, ices, soups, and foods with
about 80-90% water must be controlled if
necessary.
Sodium
For advanced renal failure, patients may be
unable to conserve sodium.
A daily intake of 1.0 to 3.0g (40-130 mEq) of
sodium and 1500 ml to 3000 ml of fluids
should maintain sodium and water balance
in most patients;
40 mEq (920mg/day) to decrease edema in
lower blood pressure;
patients who loss excessive amounts of
sodium in their urine may require 6 to 8g/day
of sodium to prevent hypotension and
dehydration.
Potassium
Potassium intake of not more than 70 mEq
(2730 mg) per day.
Careful food selection is important to control
potassium levels in renal patients.
Potassium
Potassium intake of not more than 70 mEq
(2730 mg) per day.
Careful food selection is important to control
potassium levels in renal patients.
Phosphorus
Hyperphosphatemia is prevented by an adaptive
increase in renal excretion and decreased phosphate
reabsorption.

Hyperphosphatemia becomes evident when the GFR

falls between 20 and 30 mL/min/1.73 m2.

Serum phosphorous is controlled by a combination of

actions including dietary restriction, the use of
phosphate binders, and removal through dialysis.
Phosphorus
A dietary phosphorus restriction of 800–1000
mg/day or <17 mg /kg of ideal body weight or
standard body weight per day has been
recommended for both HD and PD patients.

Emphasis on high-protein foods that are lower in

phosphorous is encouraged.
Calcium
Decline in kidney function leads to abnormalities in the
regulation of calcium.

The goal is to maintain serum calcium between 8.4 and 10.2

mg/dL.

Low serum calcium levels often accompany CKD due to

alterations in vitamin D metabolism, decreased absorption
of calcium from the gut, and elevated phosphorus levels.
Foods high in calcium are often restricted because they
tend to be high in phosphorus as well.
Calcium
The amount of calcium from the diet plus the
amount found in supplements and phosphate
binders should not exceed 2000 mg/day. No
more than 1500 mg should come from binders.

The use of active vitamin D supplementation will

increase calcium absorption in the intestine and
therefore assist with low serum calcium levels.
Calcium
Strong relationships exist among elevated serum
phosphorus, Ca × P product, PTH, and cardiac
causes of death in HD patients.

Keep Ca × P product less than 55 mg/dL, calcium

within the normal range of 9–11 mg/dL
(preferably within the low end of normal), and
serum phosphorus within the normal range of
3.5–5.5 mg/dL.
Vitamins & Mineral
Supplementation
The restrictive renal diet interferes with vitamin and
mineral intakes, increasing the risk of deficiencies.

Patients treated with dialysis lose water-soluble

vitamins and some trace minerals in the dialysate.

Thus, multivitamin/mineral supplements are typically

recommended for all patients.
Vitamins & Mineral
Supplementation
Supplements prescribed for dialysis patients typically supply
generous amounts of folic acid and vitamin B6—about 1 milligram
and 10 milligrams per day, respectively— along with recommended
amounts of the other water-soluble vitamins.

Supplemental vitamin C should be limited to 100 milligrams per day.

Intravenous administration of iron is more effective than oral iron

supplementation for improving iron status in these patients
REFERENCES:
Jamorabo-Ruiz et al. (2011). Medical Nutrition Therapy for Filipinos. 6th
Edition. Merriam & Webster Bookstore, Inc.,

Krause & Mahan (2019). Food & The Nutrition Care Process. 15th Edition.
El Sevier.

Rolfes et al. (2021). Understanding Normal & Clinical Nutrition. 12th

Edition. Cengage