Doctor's Reference Guide To Dietetics - Diseases of the kidney

DISEASES OF THE KIDNEY

Chronic Kidney Disease (CKD)
Chronic Kidney Disease - Hemodialysis (HD)
Chronic Kidney Disease - Peritoneal Dialysis (PD)
Chronic Kidney Disease – Kidney Transplants
Chronic Kidney Disease - Nephrotic Syndrome
Urinary Calculus (Urolith)

Chronic Kidney Disease (CKD)

Best time to refer to the dietician:

When chronic kidney disease (=chronic renal failure) is diagnosed, combined with at least one of the following:

stage 3 chronic kidney disease: glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2
hypertension: systolic pressure > 130 mm Hg (repeated measurements); in children this is age dependent
proteinuria > 0.5 g/24 hours
fluid retention
serum potassium: > 5 mmol/L
serum phosphate: > 2.0 mmol/L (children under 1 year of age), > 1.8 mmol/L (children over 1 year of age), > 1.5 mmol/L (adults)
failure to thrive

Relevant information for the dietician:

Diagnosis: chronic kidney disease and etiology, any comorbid conditions
Symptoms: uremic complications, hypertension, fluid overload, failure to thrive
Laboratory tests:

serum: urea, creatinine, eGFR (MDRD formula), sodium, potassium, calcium, phosphate, bicarbonate (HCO3/total CO2), Hb, lipid spectrum, albumin
24-hour urine: sodium, total protein, urea creatinine, creatinine clearance

Medication: (type, dose regimen, time taken) antihypertensivs, diuretics, active vitamin D, phosphate binders, ion exchangers, sodium bicarbonate, erythropoietin, growth hormone, iron supplements, cholesterol-lowering medication, vitamin and mineral supplements

Other: height, (changes in) weight, blood pressure, SGA, growth curve

Aims of the diet:

Treat the factors affecting the rate of progression:

slow the rate of renal deterioration
support blood pressure regulation: aim for a blood pressure of < 130 Hg, age-dependent for children
reduce the fluid retention
reduce the proteinuria to < 1 g/14 hours.

Treat the complications:

contribute to good calcium and phosphate metabolism: aim for a serum phosphate of < 2.0 mmol/L (children < 1 year old), < 1.8 mmol/L (children > 1 year old) and serum calcium 2.1-2.6 mmol/L, < 1.5 mmol/L (adults)
contribute to the treatment of metabolic acidosis: aim for a serum total HCO₃ CO₂ of 20-22 mmol/L; treat with medication in children
regulate the electrolyte balance: aim for serum potassium of < 5.0 mmol/L (children), < 5.5 mmol/L (adults)
prevent nutrition-related complications: aim for serum urea of < 20 mmol/L (children), < 30 mmol/L (adults)

reduce the risk of cardiovascular complications
reduce weight, if overweight
promote healthy habits (exercise, smoking cessation)

Characteristics of the diet:

Children:

Energy: resting metabolism (Schofield) + extra allowances. Maintain ratio of weight to height (growth curve)
Protein: 0.8-1.8 g/kg of body weight, depending on age and serum urea levels
Low sodium: not to exceed 2000 mg
Potassium restrictions based on the lab results: at > 5 mmol/L; restrict based on age, dietary assessment and whether potassium-lowering medications are being taken.
Phosphate restriction based on the lab results: < 400 mg/day (infants), 400-600 mg/day (children < 20 kg), < 800 mg/day (children > 20 kg), in combination with phosphate binding medication, where relevant
Restricted fluids: 300 ml/m² of body surface area + urine production
Restricted calcium: in food, restrict to 100% of the recommended allowance

Adults

Energy: basal metabolism (Harris & Benedict) + extra allowances (unless it is obvious that there is significant fluid retention)
Low protein diet 0.8 g/actual weight (if BMI is > 27 kg/m2, the protein calculation is based on the weight for a BMI of 27 kg/m2)
Low sodium: not to exceed 2400 mg
Potassium restriction based on lab results:
When serum potassium is > 5 mmol/L: 2000-3000 mg per day, depending on dietary assessment and/or use of potassium-lowering medications
Phosphate restriction based on lab results: when serum phosphate is > 1.5 mmol/L: phosphate should be 800-1000 mg, which must not get in the way of adequate protein intake. If phosphate binding medication is indicated, the phosphate binding medication will need to be balanced with phosphate intake in the diet.
Calcium: < 2000 mg elemental calcium, which includes the calcium obtained from calcium-based phosphate binders
Fluids:

at least 1.5-2 L per day
For patients with heart failure, a fluid restriction of 1.5-2 L per day is recommended; if a high dose of diuretics is needed in order to prevent fluid retention, restrict fluid to 1.5 L per day.
Fluids from solid food are not included in the fluid restriction calculation.
for kidney stones and gout: at least 2.5-3 L per day

Treatment time:

CKD stage 3: Care level 2, see “Dietician’s working methods.”
CKD stage 4, predialysis phase: Care level 3, see “Dietician’s working methods.”

Specific remarks:

The dietician discusses with the patient when the prescribed phosphate binders should be taken, based on the dietary recommendations.
Medications such as sodium polystyrene sulfonate and sodium carbonate contribute heavily to the total sodium intake
It may be necessary to supplement vitamins and minerals, in addition to using diet products and tube feeding
Correct the serum calcium results for hypoalbuminemia.
Consumption of star fruit and star fruit products is to be discouraged, due to their neurotoxicity.

References:

CBO. Multidisciplinaire richtlijn Cardiovasculair Risicomanagement. Utrecht: 2006

Franssen CFM. Voeding bij hemodialyse. Richtlijnen Voeding bij hemodialyse, Voeding bij peritoneale dialyse en Voeding bij predialyse, inclusief Vitaminesuppletie en Carnitinesuppletie. Nederlandse Federatie voor Nefrologie, 2008: 14-16

Hans Mak Instituut. Multidisciplinaire richtlijn predialyse en Multidisciplinaire richtlijn chronische nierinsufficiëntie in de predialysefase-aandeel diëtetiek. Naarden: 2009

Richtlijn voor de behandeling van patiënten met Chronische Nierschade (CNS), Nederlandse Federatie voor Nefrologie, 2009

Weijs PJM, Kruizenga HM et al. Validation of predictive equations for resting energy expenditure in adult outpatient and inpatients. Clin Nutr. 2008 Feb;27(1):150-7

Werkgroep nierziekten KODAZ. Landelijke richtlijnen kindernefrologie KODAZ/DNN: 2006

Chronic Kidney Disease was updated by Hans Brandts, dietician at Alysis Zorggroep and Inez Jans, dietician at Ziekenhuis Gelderse Vallei, writing also on behalf of the Diëtisten Nierziekten Nederland (DNN), Anneke van den Berg, dietician at Universitair Medisch Centrum Nijmegen (UMCN), writing on behalf of Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ).

Chronic Kidney Disease - Hemodialysis (HD)

Best time to refer to the dietician:

just before/upon starting hemodialysis

Relevant information for the dietician:

Diagnosis: chronic kidney disease and its etiology, any comorbid conditions
Symptoms: uremic complications, hypertension, fluid overload, constipation, failure to thrive
Laboratory tests:

serum (before dialysis): urea, creatinine, sodium, potassium, calcium, phosphate, PTH, bicarbonate (HCO3/total CO2), Hb, lipid spectrum, albumin
24-hour urine: volume of urine production, sodium, creatinine, urea, protein

Medication: (type, dose, time taken) antihypertensives, diuretics, active vitamin D, phosphate binders, ion exchangers, sodium bicarbonate, erythropoietin, iron supplements, cholesterol lowering medication, vitamin and mineral supplements, growth hormone
Other: height, (changes in) weight, growth curve, blood pressure, SGA, inter-dialytic target weight, duration and frequency of dialysis, access to the bloodstream, Kt/V, nPNA (nPCR)

Aims of the diet:

Treat the complications:

contribute to good calcium and phosphate metabolism: aim for a serum phosphate of < 2.0 mmol/L (children < 1 year old), < 1.8 mmol/L (children > 1 year old), < 1.5 mmol/L (adults) and serum calcium of 2.1-2.6 mmol/L
contribute to the treatment of metabolic acidosis: aim for a serum total CO2 of 20-22 mmol/L; treat with medication in children
regulate the electrolyte balance: aim for serum potassium of < 5.0 mmol/L (children), < 5.5 mmol/L (adults)
aim for serum urea of < 20 mmol/L (children), 20-30 mmol/L (adults)
reduce the fluid retention

maintain/achieve a good growth curve/nutritional status
reduce the risk of cardiovascular complications
support blood pressure regulation: aim for a blood pressure of < 130 Hg (adults), age-dependent for children
reduce weight if overweight
promote healthy habits (exercise, smoking cessation).

Characteristics of the diet:

Children:

Energy: resting metabolism (Schofield) + extra allowances. Maintain ratio of weight-to-height (growth curve).
Protein: 1.2- 2.6 g/kg of body weight, depending on age and serum urea levels
Low sodium: not to exceed 2000 mg (to prevent fluid overload, hypertension and to support the fluid restrictions)
Potassium restriction based on the lab results: if > 5 mmol/L, restrict potassium depending on age, dietary assessment and whether potassium-lowering medications are being taken
Phosphate restriction based on the lab results: if serum phosphate is more than the indicated limit, restrict as follows: < 400 mg/day (infants), 400-600 mg/day (children < 20 kg), < 800 mg/day (children > 20 kg), possibly in combination with phosphate binding medication
Restricted fluids: 300 ml/m² of body surface + urine output, depending on maximum weight gain of about 1-2 kg between 2 dialysis periods
Calcium restriction: in food, restrict to 100% of the recommended allowance

Adults

Energy: basal metabolism (Harris & Benedict) + extra allowances (unless it is obvious that there is a significant fluid retention)
Protein: 1.0-1.2 g/kg of body weight, based on the actual body weight, unless the patient is overweight and/or has fluid overload, in which case: When BMI is > 27 kg/m2, base the protein allowance on the weight for a BMI of 27 kg/m2. When there is fluid overload, base the protein allowance on the weight before there was fluid overload. In the case of severe malnourishment, the protein requirement will be higher.
Low sodium: not to exceed 2400 mg
Potassium restriction based on lab results: when serum potassium is > 5.5 mmol/L: 2000-3000 mg per day, depending on dietary assessment and/or use of potassium-lowering medications.
Phosphate restriction based on lab results: when serum phosphate is > 1.5 mmol/L: 800-1000 mg, which must not get in the way of adequate protein intake. If phosphate binding medication is indicated, the phosphate binding medication will need to be balanced with the phosphate intake in the diet.
Calcium: < 2000 mg elemental calcium, which includes the calcium obtained from calcium-based phosphate binders
drinking fluids: 0.8 L + urine output per day (depending on BMI, urine output and cardiac function). The interdialytic weight gain must not exceed 4.0-4.5% of the dialysis target weight for stable patients without heart failure.
if there is constipation: see “Chronic Constipation”

Treatment time:

Care level 4, see “Dietician’s working methods.”

Specific remarks:

The dietician discusses with the patient when to take the prescribed phosphate binders and how to take potassium-lowering medication, based on the dietary recommendations.
Medications such as sodium polystyrene sulfonate and sodium bicarboniate contribute significantly to the total sodium intake.
It is standard practice to recommend vitamin supplements.
Diminished appetite may be present. Children often have a poor appetite in combination with spitting up.
It may be necessary to begin using dietetic preparations and/or tube feeding, as well as intradialytic parenteral nutrition.
Correct the serum calcium results for hypoalbuminemia.
Consumption of star fruit and star fruit products is discouraged, due to their neurotoxicity.
In nighttime dialysis, the duration of dialysis is longer and dialysis frequency may also be greater. In that case, depending on the dialysis there are often fewer metabolic complications, as a result of which there may be less emphasis on the number of dietary restrictions.
With home dialysis, the duration and frequency of dialysis may be greater than dialysis at a hemodialysis center. In that case, depending on the dialysis regimen, there are often fewer metabolic complications, as a result of which there may be less emphasis on the number of dietary restrictions.

References:

Diëtisten Nierziekten Nederland. Richtlijnen voor het dieet bij hemodialyse (inclusief achtergrondinformatie). 2004

Diëtisten Nierziekten Nederland. Richtlijn intradialytische parenteral nutrition. 2008

Fouque D, Vennegoor M et al. EBPG Guideline on Nutrition. Nephrology Dialysis Transplantation 2007, 22 [Suppl 2]: ii45 – ii87

CBO. Multidisciplinaire richtlijn cardiovasculair risicomanagement.Utrecht: 2006

Franssen CFM. Voeding bij hemodialyse. Richtlijnen Voeding bij hemodialyse, Voeding bij peritoneale dialyse en Voeding bij predialyse, inclusief Vitaminsuppletie en Carnitinesuppletie. Nederlandse Federatie voor Nefrologie, 2008: 3-11

Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention and treatment of chronic kidney disease – mineral and bone disorder (CKD-MBD). Kidney International (2009) 76 (Suppl 113), S1–S130; doi:10.1038/ki.2009.189

Werkgroep nierziekten KODAZ. Landelijke richtlijn kindernefrologie KODAZ/DNN, 2006

Chronic Kidney Disease – Hemodialysis was written by Sophie Luderer, dietician at Canisius Wilhelmina Ziekenhuis Nijmegen, Angelique van Empel-Van den Braak, dietician at Ziekenhuis Bernhoven Oss-Veghel, Hans Brandts, dietician at Alysis Zorggroep and Inez Jans, dietician at Ziekenhuis Gelderse Vallei, also on behalf of Diëtisten Nierziekten Nederland (DNN), Anneke van den berg, dietician at Universitair Medisch Centrum Nijmegen (UMCN), also on behalf of the Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ)

Chronic Kidney Disease - Peritoneal Dialysis (PD)

Best time to refer to the dietician:

just before/upon starting hemodialysis

Relevant information for the dietician:

Diagnosis: chronic kidney disease and its etiology, any comorbidity
Symptoms: uremic complications, hypertension, fluid overload, constipation, peritonitis, failure to thrive
Laboratory testing:
serum: urea, creatinine, sodium, potassium, calcium, phosphate, PTH, bicarbonate (HCO3/total CO2), Hb, lipid spectrum, albumin
24-hour urine: amount of diuresis, sodium, creatinine, urea, protein

Medication: (type, dose, time taken) antihypertensives, diuretics, active vitamin D, phosphate binders, ion exchangers, sodium bicarbonate, erythropoietin, iron supplements, cholesterol lowering medication, vitamin and mineral supplements, growth hormone
Other: height, (changes in) weight, blood pressure, SGA, growth curve, dialysis target weight, number of exchanges per day, volume, type of PD, type and concentration of the PD dialysate, Kt/V, nPNA (nPCR).

Aims of the diet:

Treat the complications:

contribute to good calcium and phosphate balance: aim for a serum phosphate of < 2 mmol/L (children < 1 year old), < 1.8 mmol/L (children > 1 year old), < 1.5 mmol/L (adults) and serum calcium of 2.1-2.6 mmol/L
contribute to the treatment of metabolic acidosis: aim for a serum total CO2 of 20-22 mmol/L; treat with medication in children
regulate the electrolyte balance: aim for serum potassium of < 5.0 mmol/L (children), < 5.5 mmol/L (adults)
aim for serum urea: < 20 mmol/L (children), 20-25 mmol/L (adults)
reduce fluid retention
prevent unwanted weight gain.

maintain/achieve a good growth curve/nutritional status
reduce the risk of cardiovascular complications
support blood pressure regulation; work towards a blood pressure of < 130 Hg; this is age-dependent in children
reduce weight if overweight
promote healthy habits (exercise, smoking cessation)

Characteristics of the diet:

Children

Energy: resting metabolism (Schofield) + extra allowances. Maintain the ratio of weight-to-height (growth curve).
Protein: 1.4-3.0 g/kg body weight, depending on age and serum urea levels.
Sodium: not to exceed 2000 mg (to prevent fluid overload and hypertension, and to support fluid restrictions)
Restricted potassium based on the lab results; if over 5 mmol/L: restrict according to age, dietary assessment and whether potassium-lowering medications are being taken
Phosphate restriction based on lab results; restrict when serum phosphate is above the designated limit: < 400 mg/day (infants), 400-600 mg/day (children < 20 kg) and < 800 mg/day (children > 20 kg), if applicable in combination with phosphate-binding medication
restricted fluids, only restricted in the event of reduced ultrafiltration: 300 ml/m² body surface area + urine production
restricted calcium: in food, restrict to 100% of the recommended allowance

Adults

Energy: basal metabolism (Harris & Benedict) + extra allowances (unless it is obvious that there is significant fluid retention)
Protein: 1-1.2 g/kg body weight, based on the actual body weight, unless the patient is overweight and/or there is overfilling, in which case: When BMI is > 27 kg/m2, base the protein guidelines on the weight for a BMI of 27 kg/m2. When there is overfilling, base the protein allowance on the weight prior to overfilling. The protein requirements are higher in the presence of peritonitis or malnutrition.
Low sodium: not to exceed 2400 mg
Restricted potassium based on lab results; if serum potassium is over 5.5 mmol/L: 2000-3000 mg per day or depending on dietary assessment and/or use of medications that lower potassium
Phosphate restriction based on lab results; restrict when serum phosphate is above 1.5 mmol/L: 800-1000 mg; this must not get in the way of adequate protein intake. If phosphate binding medication is indicated, the phosphate-binding medication will need to be balanced with phosphate intake in the diet.
Calcium: < 2000 mg elemental calcium, which includes the calcium obtained from calcium-based phosphate binders
fluids: normal fluid intake: 1.5 L/day, unless there is poor ultrafiltration
for constipation: see “Chronic constipation”

Treatment time:

Care level 4, see “Dietician’s working methods.”

Specific remarks:

The dietician discusses with the patient when to take the prescribed phosphate binders and how to take potassium-lowering medication, based on the dietary recommendations.
It is standard practice to recommend vitamin supplements.
There may be poor appetite, nausea and vomiting.
Liquid meals or tube feeding and dietetic preparations may be needed
The calories (from glucose) absorbed from the dialysate should be counted as part of the energy requirement.
There are various types and concentations of dialysate available:
The common dialysates contain glucose; the glucose concentrations are between 1.25% and 4.25%. The absorption of glucose from the dialysate is approximately 50-90%. The glucose concentration determines the degree of ultrafiltration.
Amino acid-containing dialysates contain 11 g of amino acids per liter. This fluid can be used when there is undernourishment.
The icodextrin dialysate contains 7.5% polyglucose. This is not absorbed as well as glucose, and therefore provides less energy. Its ultrafiltration is high in long dwell times.
Use of icodextrin dialysate in diabetic patients may interfere with the blood sugar measurement results.
Correct the serum calcium results for hypoalbuminemia.

References:

CKD-MBD Work Group. Kidney Disease: Improving Global Outcomes (KDIGO). KDIGO clinical practice guideline for the diagnosis, evaluation, prevention and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl. 2009 Aug;(113):S1-130

Diëtisten Nierziekten Nederland. Richtlijnen voor het dieet bij peritoneal dialyse (inclusief achtergrondinformatie). 2004

Dombros N, Dratwa M et al. EBPG Expert Group on Peritoneal Dialysis. European best practice guidelines for peritoneal dialysis. 8 Nutrition in peritoneal dialysis. Nephrol Dial Transplant. 2005 Dec;20 Suppl 9:ix28-ix33.

Werkgroep Nierziekten KODAZ. Landelijke richtlijn kindernefrologie KODAZ/DNN: 2006

Chronic Kidney Disease – Peritoneal Dialysis was co-written with Sophie Luderer, dietician at Canisius Wilhelmina Ziekenhuis Nijmegen and Angelique van Empel-Van

den Braak, dietician at Ziekenhuis Bernhoven Oss-Veghel, writing also on behalf of Diëtisten Nierziekten Nederland (DNN), Anneke van den berg, dietician at Universitair Medisch Centrum Nijmegen(UMCN), writing also on behalf of Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ).

Chronic Kidney Disease – Kidney Transplants

Best time to refer to the dietician:

from the time of the kidney transplantation on

Relevant information for the dietician:

Diagnosis: chronic kidney disease and etiology, any comorbid conditions
Symptoms: hypertension, fluid overload, unwanted weight gain, abnormal lipid spectrum
Laboratory tests:

in serum: urea, creatinine, eGFR (MDRD formula), sodium, potassium, calcium, phosphate, bicarbonate (HCO3/total CO2), Hb, lipid spectrum, albumin, CRP
in 24-hour urine: urine output, sodium, total protein, urea, creatinine, creatinine clearance.

Medication: (type, dose, time taken) including immunosuppressants (corticosteroids), antihypertensives, diuretics, cholesterol-lowering medication, growth hormone
Other: height, (changes in) weight, growth curve, blood pressure.

Aims of the diet:

In the short term

Treat the complications:

regulate the electrolyte balance, aim for a serum potassium of <5.5 mmol/L
support blood pressure regulation
reduce fluid retention
contribute to good calcium and phosphate balance. Aim for a serum phosphate of < 1.5 mmol/L (adults).

maintain/achieve good growth curve/nutritional status
prevent food infection

In the long term (after about 2 months)

prevent or treat complications, which arise partly as a result of taking immunosuppressants and corticosteroids (there is an elevated risk of diabetes)
prevent overweight

Adults

BMI < 25 kg/m2 or waist circumference of < 80 cm for women and < 94 cm for men. If BMI and/or waist circumference is higher, weight should be reduced by at least 5-10%.

Children:

maintain/achieve good growth curve/nutritional status
prevent osteoporosis
reduce the risk of cardiovascular complications: aim for a serum LDL cholesterol of < 2.5 mmol/L
promote healthy habits (exercise, smoking cessation).

Characteristics of the diet:

Children:

Energy: resting metabolism (Schofield) + extra allowances (if there is a tendency to be overweight, then low-calorie diet)
Protein: 0.9-2.5 g/kg body weight/day depening on age and serum urea levels
Phosfate: hypophosphatemia is often seen in the short term, and is treated with medication
Fluids: when there is good renal function, ensure ample fluid intake: depending on age, this can be 1000-2000 ml/day
Base nutrient composition as far as possible on the recommended allowances
If the kidney has begun functioning well, no restrictions are necessary. Depending on the clinical course of the transplant, temporary dietary restrictions may be necessary. See “Chronic Kidney Disease”

Adults

Energy:

in the short term: basal metabolism (Harris & Benedict) + extra allowances
in the long term: adequate amounts, balancing consumption with the elevated risk of excess weight gain.

Protein:

in the short term: 1.2-1.5 g/kg of actual body weight (when BMI is > 27 kg/m2; the protein allowance calculation is based on on the weight for a BMI of 27 kg/m2)
in the long term: 0.8 g/kg of actual body weight (when BMI is > 27 kg/m2; the protein allowance calculation is based on the weight for a BMI of 27 kg/m2)
when corticosteroids are taken at doses of > 0.2 mg/kg/day: 1.0 g/kg of actual body weight (when BMI is > 27 kg/m2; the protein calculation is based on the weight for a BMI of 27 kg/m2)

Sodium: not to exceed 2400 mg
Potassium: restrict based on lab results: when serum potassium is > 5 mmol/L: 2000-3000 mg per day depending on dietary assessment and/or use of potassium-lowering medications
Calcium and vitamin D: When corticosteroids are being taken at high doses, supplement calcium carbonate and vitamin D
Phosphate: restrict based on lab results: when serum phosphate is > 1.5 mmol/L: 800-1000 mg, which must not get in the way of adequate protein intake. If phosphate binding medication is indicated, the phosphate binding medication will need to be balanced with phosphate intake in the diet.
Fluids:

If urine output is insufficient, restrict fluids: 1000 ml (500 ml drinking fluids + 500 ml from solid food) + diuresis
If urine output is sufficient, drink at least 2 L per day.

Treatment time:

uncomplicated course: Care level 1, see “Dietician’s working methods.”
complicated course: Care level 2, see “Dietician’s working methods.”

Specific remarks:

Pay extra attention to food safety, to prevent food infections.
Supplementing vitamins and minerals may be necessary, as well as use of liquid meals or tube feeding
Children often get hypophosphatemia, which is treated with medication
Correct the serum calcium results for hypoalbuminemia.

References:

Bellinghieri G, Bernardi A et al. Metabolic Syndrome after kidney transplantation: Journal of Renal Nutrition: Vol 19, No 1, 2009: 105-110

Kent PS. Issues of Obestiy in kidney Transplantation: Journal of Rernal Nutrition: Vol 17, No 2, 2007: 107-113

Strejc J. Nutrition Guidelines after Kidney Transplantation: Journal of Renal Nutrition: Vol 10, No 3, 2000: 161-167

Teplan V, Valkovsky I et al. Nutritonal Consequences of Renal Transplantation: Journal of Renal Nutrition, Vol 19, No 1, 2009: 95-100

Ward HJ. Nutritonal and metabolic issues in solid organ transplantation: targets for future research: Journal of Renal Nutrition, Vol 19, No 1, 2009:

111-122

Werkgroep Nierziekten KODAZ. Landelijke richtlijn kindernefrologie KODAZ/DNN: 2006

Chronic kidney disease – Kidney Transplants was written by Anke Vroomen, dietician at Maastricht Universitair Medisch Centrum (MUMC+), Hans Brandts, dietician at Alysis Zorggroep and Inez Jans, dietician at Ziekenhuis Gelderse Vallei, writing also for the Diëtisten Nierziekten Nederland (DNN) and Anneke van den Berg, dietician at Universitair

Medisch Centrum Nijmegen (UMCN), writing also on behalf of the pediatric nephrology working group within the Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ).

Chronic Kidney Disease - Nephrotic Syndrome

Best time to refer to the dietician:

following diagnosis

Relevant information for the dietician:

Diagnosis: nephrotic syndrome and its etiology, any comorbid conditions
Symptoms: proteinuria, (peripheral) edema, hyperlipidemia, failure to thrive, hypertension, malnourishment
Laboratory tests:

serum: urea, creatinine, eGFR (MDRD formula), sodium, potassium, lipid spectrum, albumin, Hb, glucose
24-hour urine: urine output, sodium, total protein, urea, creatinine

Medication: (type, dose, time taken) antihypertensives, diuretics, cholesterol lowering medication, growth hormone
Other: height, (dry) weight (fluctuations), growth curve, blood pressure.

Aims of the diet:

Treat the complications:

reduce fluid retention
reduce protein loss
support blood pressure regulation

maintain/achieve good growth curve/nutritional status
prevent or treat complications that arise partly from the use of immunosuppressants and corticosteroids: there is an elevated risk of diabetes with long-term use

prevent overweight
prevent osteoporosis

reduce the risk of cardiovascular complications: aim for a serum LDL cholesterol of < 2.5 mmol/L
promote healthy habits (exercise, smoking cessation)
prevent food infections (when taking high doses of immunosuppressants and/or corticosteroids)

Characteristics of the diet:

Children:

Energy: resting metabolism (Schofield) + extra allowances (over the long term may need to be slightly restricted, due to the elevated risk of excess weight gain from prolonged use of corticosteroids)
Protein: follow recommended dietary allowances for age per kg of ideal body weight (no protein restriction)
Sodium restriction: amount of sodium depending on weight/age and use of ACE inhibitors (usually mildly low-sodium food; when there is severe fluid overload, a stricter sodium restriction may be necessary)
Calcium and vitamin D: based on recommended amounts. Supplement as needed, when there is prolonged use of corticosteroids.
Fluids: restrict when there is fluid overload, depending on weight/age.

Adults

Energy: basal metabolism (Harris & Benedict) + extra allowances (adequate caloric intake over the long term based on consumption in association with elevated risk of excessive weight gain due to prolonged use of corticosteroids)
Protein: 0.8 g/kg actual body weight, corrected for fluid retention.(If BMI is > 27 kg/m2, the protein calculation is based on the body weight for a BMI of 27 kg/m2)
Sodium restriction: not to exceed 2400 mg (if there is severe fluid overload, a stricter sodium restriction of up to 1200 mg may be necessary)
Potassium restriction based on lab results: if serum potassium is > 5.5 mmol/L: 2000-3000 mg per day, it is dependent on dietary assessment and/or use of potassium lowering medications
Calcium and vitamin D: based on recommended amounts. Supplement as needed during prolonged use of corticosteroids.
Fluids: 1.5-2 L per day, or if there is severe fluid overload, 1.5 L per day
for hyperlipidemia: see “Hypercholesterolemia”
for chronic renal dysfunction: see “Chronic Kidney Disease”
for diabetes mellitus: see Diabetes mellitus”

Treatment time:

Care level 2*, see “Dietician’s working methods.”

Specific remarks:

Pay extra attention to food safety, to prevent food infections.
Supplementing vitamins and minerals may be necessary, as well as use of liquid meals or tube feeding
Correct the serum calcium results for hypoalbuminemia.
When there is fluid retention, base it on the weight prior to development of the nephrotic syndrome.

References:

Charlesworth JA, Gracey DM, Pussell BA. Adult nephrotic syndrome: non-specific strategies for treatment. Nephrology (Carlton). 2008 Feb;13(1):45-50

Gansevoort RT, Zeeuw D de, et al. De behandeling van het nefrotisch syndroom, de plaats van een eiwitbeperkt dieet and ACE-remmers. Ned Tijdschr Diëtisten 1996;51(7/8):126-30

Giordano M, Feo P de, et al. Effects of dietary protein restriction on fibrinogen and albumin metabolism in nephrotic patients. Kidney Int 2001;60(1):235-42

Nederlandse Federatie voor Nefrologie. Richtlijn behandeling en diagnostiek van membraneuze glomerulopathie/IgA-nefropathie/focale segmentale glomerulosclerose. Nieuwegein: 2006

Werkgroep Nierziekten KODAZ. Landelijke richtlijn kindernefrologie KODAZ/DNN: 2006

Nephrotic Syndrome was updated by Nancy Lamarche, dietician at Meander Medisch Centrum and Henny Termeulen, dietician at VU medisch centrum (VUmc), writing also on behalf of the pediatric nephrology working group of dieticians within the Kinderdiëtetiek Overleg Diëtisten Academische Ziekenhuizen (KODAZ), Hans Brandts, dietician at the dialysis unit of Alysis Zorggroep Arnhem, and Inez Jans, dietician at Ziekenhuis Gelderse Vallei Ede, writing also on behalf of the Diëtisten Nierziekten Nederland (DNN).

Urinary Calculus (Urolith)

Best time to refer to the dietician:

when there is (recurrent) stone formation

Relevant information for the dietician:

Diagnosis: urinary calculi (stones), type of urinary calculus and possible cause, any comorbid conditions
Medication: calcium, vitamin C and D supplements, thiazides, allopurinol.

Aims of the diet:

prevent further growth of the stone
contribute to preventing recurrent stones

Characteristics of the diet:

Extra fluids: a quantity of drinking fluids that results in at least 2 L of urine output. In particular, drink copiously at and around mealtimes and before bedtime. For cystine calculi, aim for urine output of at least 3½ L. In selecting beverages, half should consist of water or mineral water, and the rest of (low-calorie) drinks.
Calcium: follow recommended allowances
Low sodium: not to exceed 2400 mg
Protein: normalize to 0.8-1.0 g protein/kg. Avoid consumption of large quantities of animal protein.
Restrict the use of dietary oxalate
Follow national Nutritional Guidelines, with extra attention to:

consumption of adequate amounts of vegetables and fruit
consumption of adequate dietary fiber
moderate use of alcohol.

If there is excessive uric acid being excreted (hyperuricosuria), restrict purine
If overweight, see “Overweight”

Treatment time:

Care level 1, see “Dietician’s working methods.”

Specific remarks:

Megadoses of vitamins C and D can increase the risk of urinary calculi.
Calcium restriction for urinary calculi is no longer practiced.
There are indications that foods high in citric acid and/or phytic acid may have a preventive effect on the development of urinary calculi.

References:

Boevé ER, Lyclama à Nijeholt. Richtlijn 11 Ned Vereniging Voor Urologie, Metabole screening, medicamenteuze behandeling en metafylaxe bij urolithiasis. Utrecht: 2000

Borghi L, Meschi T et al. Dietary therapy in idiopathic nephrolithiasis. Nutrition Reviews® 2006, Vol. 64, No. 7 doi: 10.1301/nr.2006.jul.301-312

Grases F, Costa-Bauza A, Prieto RM. Renal lithiasis and nutrition. Nutrition. Journal 2006, 5:23 doi:10.1186/1475-2891-5-23

Reynolds T.M. Chemical pathology clinial investigation and management of nephrolothiasis. J Clin Pathol 2005;58:134-140. doi: 10.1136/jcp.2004.019588

Siener R, Hesse A. Recent advances in nutritional research on urolithiasis. World J Urol (2005) 23:304-308 doi 10.1007/s00345-005-0027-1

Straub M, Hautmann RE. Developments in stone prevention. Curr Opin Urol 2005, 15:119-126

Urinary Calculi was updated by Hans Brandts, dietician at the dialysis unit at Alysis Zorggroep, and Inez Jans, dietician in the kidney unit at Ziekenhuis Gelderse Vallei, writing also on behalf of Diëtisten Nierziekten Nederland (DNN)