Nutritional Management of

End-Stage Renal Disease

Grace Kim

December 2017

Queens College Dietetic Internship

Chronic Disease Description: Epidemiology & Etiology
● ESRD fifth and last stage of CKD
○ GFR
● 13.1% of the U.S. general population
● Asymptomatic in early stages
● African-American descent, older age, family history, obesity,
glomerulonephritis
● 1 in 3 people with diabetes and 1 in 5 people with hypertension have
CKD
● Excessive alcohol, smoking, pain medication
● Healthy 100-120 mL/min
● Irreversible < 60 mL/min
○ Even when underlying condition is
resolved
● ESRD requires kidney transplant
or dialysis
● Kidneys dependent on normal BP
for proper function
CKD: Pathology
● Diabetes → excess glucose stick to proteins → arterioles more rigid →
hyperfiltration because increased pressure → overworked glomerulus create
matrix → glomerulosclerosis

● HTN → thickened walls of kidneys → narrow lumen → less blood & O2 to

kidney → ischemic injury → immune cells (macrophages, foam cells) release
growth factors → mesangial cells secrete extracellular matrix →
glomerulosclerosis
CKD: Sx, Co-morbidities
● Functions: fluid/electrolyte balance, blood waste filtration, vitamin D
activation, blood pressure regulation
● Decreased urine output, fluid retention, acidosis, and imbalance in fluid
and electrolytes
● Hyperparathyroidism - loss of appetite, excessive thirst
● Uremia - nausea, fatigue, edema, and mental status changes
● Renal osteodystrophy
○ Phosphorous
Case Presentation
● Meal delivery program for chronically ill patients
● Counseling sessions & assessments over the phone
● Reassessment x 6 months
● Self-reported data
● No physical examination or in-person
counseling
● Handouts mailed
Case Presentation
● 6-month reassessment
● 64-year-old woman with ESRD
○ Diabetes
○ Stage-4 Anal Cancer
● Treatments:
○ Hemodialysis
○ Recently ending radiation treatment
● 1 year meal recipient
Assessment: Client History
● Medical: Diabetes with
Assessing Food in the Household: complications, ESRD, anal cancer,
Enough money to purchase food throughout month? panic attacks
○ Nausea/Vomiting
SNAP benefits?
○ Chronic diarrhea
Access to food programs? Help from friends/family?

In past 3 months, how often not enough money for

food? ● Treatments: Hemodialysis,
Get enough of kinds of food you want to eat?
radiation

In the last 30 days, did you go a whole day without

eating because no money for food?

● Social: Food insecurity

Assessment: Food/Nutrition-Related History
● Limited intake
○ Chronic diarrhea
○ Sometimes 1 meal/day (GLWD meals)
● 1 fruit, 2 vegetables/day
● 32 fl oz fluid restriction
● Receptive to counseling & importance of nutrition
● PA: Walks as tolerated
Assessment: Food/Nutrition-Related History
Medications: Supplements:

Benedryl, Claritin, Creon, Gabapentin, ● Calcium

Humalog, Imodium, Lorazepam, ● Iron
Tylenol, Valsartan ● Multivitamin
● Vitamin B12
● Vitamin D
● Vitamin C
Assessment: Anthropometric & Biochemical
● Renal labs
Ht 5’4” (61 inches)
○ High phosphorus
CBW 143 lbs/64.9 kg (dry wt)
○ Normal potassium
PBW 140 lbs

% Change 2.14% x 6 months

Not significant
● SMBG daily
BMI 24.41, Normal
○ Well-managed blood
glucose levels
○ 85-92 mg/dL - preprandial
Assessment: Nutrient Needs
Kcal 23-35 kcal/kg (AND EAL)
30-35 kcal/kg = 1947 - 2272 kcal

Protein ≥ 1.2 g/kg, ≥ 50% HBV protein = ≥ 78 g protein (AJCN)

Fat 25-35% kcal = 54 - 75 g fat

Fluids 32 fl oz as per MD (~1 L or ~4 cups)

Na < 2.4 g (AND EAL)

K 2-3 g (AND EAL)

Phosphorous 0.8 - 1 g (AND EAL)

Diagnoses
Altered nutrition-related laboratory values (NC-2.2) related to food- and
nutrition-related knowledge deficit (NB-1.1) as evidenced by high
phosphorous levels.

Disordered eating pattern (NB-1.5) related to altered GI function (NC-1.4) as

evidenced by diet recall.
Intervention
Nutrition Education: Nutrition Counseling:
Food and/or Nutrient Delivery
Content Strategies

● Decreased sodium diet ● Recommended ● Self monitoring (C-2.3)

(ND-1.2.11.7.2) modifications (E-1.5) ○ SMBG
● Decreased potassium ○ Multivitamin ○ Monitor diarrhea
diet (ND-1.2.11.5.2)
○ Phosphorous triggers
● Decreased phosphorus
sources ● Problem Solving (C-2.4)
diet (ND-1.2.11.6.2)
● Fluid restricted diet ○ Well-tolerated
(ND-1.2.8.2) foods during
diarrhea
Monitoring & Evaluation
Participation in community programs (FH-6.1.4). Monitor renal meal tolerance.
Adequate PO intake. Adequate F/V. Appropriate fluid intake. Medication
compliance. SMBG glucose, fasting (BD-1.5.1) and glucose, casual (BD-1.5.2).
Normal phosphorous (BD-1.2.11). Weight maintenance. PA as tolerated.
Increase access to food and nutrition-related supplies (FH-6.4.1).

Follow up in 6 months for reassessment over the phone.

References
1. De Nicola L, Zoccali C. Chronic kidney disease prevalence in the general population: heterogeneity and concerns. Nephrology Dialysis
Transplantation. 2016; 31(3): 331-335.

2. Hill NR, Fatoba ST, Oke JL, et al. Global Prevalence of Chronic Kidney Disease – A Systematic Review and Meta-Analysis. Remuzzi G, ed.
PLoS ONE. 2016;11(7):e0158765. doi:10.1371/journal.pone.0158765.

3. Kazancioğlu R. Risk factors for chronic kidney disease: an update. Kidney International Supplements. 2013;3(4):368-371.
doi:10.1038/kisup.2013.79.

4. Mahan, LK, Escott-Stump S. Medical Nutrition Therapy for Renal Disorders. Krause’s Food and the Nutrition Care Process. 2012; 13th ed.:
711-727.

5. Snelson M, Clarke RE, Coughlan MT. Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD? Nutrients. 2017; 9(3):265.
doi:10.3390/nu9030265.

6. Monhart, V. Hypertension and chronic kidney diseases. Cor et Vasa. 2013; 55(4): e397-e402.

7. Kluthe R, Lüttgen FM, et al. Protein requirements in maintenance of hemodialysis. American Journal of Clinical Nutrition. 1978; 10: 1812-20.