Filed Under (Dietary Management) by mgh on 05-08-2008

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Use this space for any questions or comments on the dietary management of renal patients.



Dorothea Mc Donald on 3 November, 2008 at 11:22 #

I need some assistance on acute renal failure patients in ICU on CVVHD.

I did a bit of a web search on Pubmed and found 3 articles (Crit Care Med. 2000 Apr;28(4):1161-5 ; Nutrition 2003 Sep;19(9):733-40 ; Nutrition 2003 Nov-Dec;19(11-12):909-16.

Basically they say that you need to achieve 2.5g prot / kg/day – HOW? If I have a 100kg man, I need 250g Prot (40g nitrogen). ITN 8001 gives me 22.4g Nitrogen. I cannot double up on the bag, as I then give 5000ml fluid and 600g CHO and 20g fat. Somehow I need to double up on the protein portion only!

The articles state that you loose up to 17% of the amino acids given via the dialysate and 4% of the CHO.

Any comments welcome.

mgh on 4 November, 2008 at 11:22 #

Interesting question! I am aware of the recommendation of 2.5 g/kg but the protein requirements in ARF is still somewhat controversial and we need more research in this area. Most of the sources that I have seen lately suggest that intakes more than 1.5 – 1.8 g/kg may be ineffective to achieve nitrogen balance due to metabolic problems and may only serve to enhance urea formation and nitrogen waste products.

Nazeema Esau on 5 November, 2008 at 20:29 #

If your patient is overweight you should use the ideal weight to calculate protein requirements, which can make your goals more realistic (not sure of your patients nutritional status). More or less for how long will your patient be treated on CVVHD and TPN?

Marion Beeforth on 15 November, 2008 at 16:00 #

During a previous CNE ICU session it seemed that glutamen should not be used in a patient with acute renal failure, I am not sure if I understood correctly that unless dialysis is in place it is best to avoid glutamen supplementation.Would it thus also apply to dipeptivan? Could someone please clarify?

mgh on 17 November, 2008 at 15:10 #

I had an interesting question about the use of pompelmoose(pampelmoes in Afrikaans) by renal patients. I could not find its nutritional content but most see it as similar to grapefruit which has a moderate K content. Also note that grapefruit should not be used together with Cyclosporine as it interferes with the metabolism of CsA. Does anybody have information on the nutritional content of pampelmoes?

Nazeema Esau on 17 November, 2008 at 20:25 #

The pampelmoose is also known as grapefruit and even though it is a moderate potassium fruit, only a half a fruit portion (100g) equals 1 fruit portion / exchange.

Marion Beeforth on 18 November, 2008 at 6:41 #

When a patient is diagnosed with malabsorption and gastroparesis, would you use milk e g 6 portions (750 ml), yogurt etc which is tolerated by patient rather than the meat alternatives. Patient weight is small eg 70 kg and with protein 90g the phosphate will then be 1500mg which is higher than the 15mg/kg. Any articles addressing gastroparesis e g diarrhea and vomiting both and renal patients?

Nazeema Esau on 18 November, 2008 at 19:46 #

Dipeptiven consist of a depeptide N(2)-l-alanyl-l-glutamine 200 mg/mL and is endogenously split into the amino acids glutamine and alanine. According to the product specifications DIPEPTIVEN should not be administered to patients with severe renal insufficiency (creatinine clearance < 25 mL/min), severe hepatic insufficiency, severe metabolic acidosis. However, if the patient is receiving dialysis and parenteral nutrition, for acute renal failure would require proteins as high as 1.2 – 1.5 g/kg. In order to meet these requirements it would be appropriate to add protein sources, in the presence of dialysis.

Nazeema Esau on 18 November, 2008 at 20:45 #

I assume the patient with gatroparesis is on dialysis, hence the protein requirements of 1.3 g/kg. The focus of the dietary management of this patient would be symptomatic relief for diarrhea and vomiting. Due to delayed gastric emptying it is important to limit fats and even consider foods with semi/fluid consistency (consider the indivuals fluid requirements), and the food choices should be consistent with the renal diet. It can also be appropriate to consider an enteral supplement if patient is tolerating very little food. It is also important to consider other causes for symptoms, like ureamia, dialysis or medication.

Marion Beeforth on 28 November, 2008 at 3:03 #

Association of Helicobacter Pylori Infection with Nutritional Status in Hemodialysis, Transplantation Proceedings, 36,47-49 (2004). Treatment of the HP lead to better nutritional status of patients in regard to albumin, intradialytic weight gain and BMI it is suggested that patients with poor nutritional status although asymptomatic be tested for HP. Does any one have experience with this.

Does anyone know the I-flex advertisement send to us by DSM which seem to benefit 82% of patients with osteoarthritis. It is also 100% naturalrosehip suppplement. I am wanting to enquire re cost, safety in patients CRF and on hemodialysis as I have two patients suffering from severe pain. I have so far suggested use of an omega supplement. Any other suggestions.

Nazeema Esau on 9 December, 2008 at 11:04 #

In renal and in general surgery patients with weight loss it is not common practice to test for H Pylori in otherwise asymptomatic patients for various reasons like invasive endoscopy, cost and there being multiple other causes that also contributes to weight loss in these patients. The study you referred to showed H Pylori present in only 10% of 163 HD patients and also indicated that only studies with small numbers in this population group were done. A study done on non-renal patients, Ioannou G.N. Aliment Pharmacol Ther 2005;21, a study population of 7464 suggests that H Pylori subjects do not have a lower BMI and has little effect on BMI. The study does indicate the possibility of weight gain experienced after eradication therapy of H Pylori. Information given were in consultation with Caren de Klerk RD, specialising in surgcical cases.

Marion Beeforth on 16 December, 2008 at 6:28 #

Went off line not sure if my question reached you and will re-write please ignore if you already received it. A follow up on Dorothea’s question about ARF and CVVHD. Patient with acute renal failure MVA and ARDS on CVVHD, 10 kg overweight would the 1,5 -1,8 g/kg recommendation with energy a value between Harris Benedict and 35kcal per kg be the guide to follow. Oedemateus severe with albumin 12 (from 11)how would you interpret, stress effect. Blood values Na 133-136, K 3.3-4,1 with urea 17-19,4 creatinine 271-297 with an increase to urea 30 and creatine 483 when problems catheter on sunday to be corrected on Monday. Would you recommend turning the volume of feed down ( e g protein 0,8-1 g/kg)during stop of dialysis or correct urea /creatinine once dialysis is working again. If protein and energy requirements are met the Calsium is high 2780mg and Phosphorous 1950 mg (no binders) or should we try and lower to stay within recommendation Ca less than 2000 mg.

mgh on 17 December, 2008 at 16:01 #

A bit more detail would help with the interpretation of this interesting case. I’d say the most likely reason for the low albumin would be the acute phase response, if it is present (his normal Na levels seems to indicate a normal IV fluid status). What is the cause of the ARF and is the patient catabolic? Is liver and other organ function normal? What feed is he receiving at the moment (EN/ TPN). What are the corrected Ca levels and P levels in the blood? Is he on P-binders?

Marion Beeforth on 23 March, 2009 at 13:00 #

Dear All

Do you know of a way to interpret GFR and creatinine for a sport person trying to have a very high protein diet Mon-Friday with intensive weight training and cardio vascular excercise. Creatinine to be high is expected but GFR for stage 3 is that also to be expected young person 27 and no history himself or family for kidney disease and no hypertension. 100 kg weight and 1,8 m tall.

Nazeema Esau on 24 April, 2009 at 20:06 #

Some research shows that a high protein diet can cause an increase in creatinine values, but on the other side, there’s also research that showed that even in the presence of a high protein diet creatinine values remains normal in the presence of a normal renal function. Initially with a high protein diet the GFR is expected to increase and not decrease. I would recommend this individual to go off a high protein diet and than have his renal function thoroughly checked by a doctor or nephrologist to confirm whether his renal function is normal or impaired.

Marion Beeforth on 18 March, 2010 at 10:45 #

Hi All
a quick question re constipation and PD and HD patients- one patient started on a aloe ferrox product and seem to have a more natural relief-does anyone know of a contra-indication.

Marion Beeforth on 18 March, 2010 at 10:50 #

Hi All
Another quick question re tea coffee and whiskey consumption- could we use the genl recomm whiskey 1-2 tot per day , tea and coffee 3-4 cups depending on fluid allowance or do we need to be more restrictive-there seems to be genl education done stating limiting all dark liquids/food e g whiskey, tea coffee and wholewheat bread, maltabella etc I cannot pick up the need to do this from the exchange lists. Looking at condiments tomato sauce we count as low K vegetable but where does mustard, chutney, vinegar, curry-K containing feature? Sweeto and coolaid as well as baking powder what is the consensus

Nazeema Esau on 18 March, 2010 at 21:36 #

Hi Marion
In the renal patient you might be guided by fluid restrictions to allow certain volumes of tea’s, coffee’s and alcoholic beverages. However, it would also be safe to follow the general recommendation for alcohol, herbal and rooibos tea’s are best (lowest in K+), while coffee should be limited to about 2 cups / day (also depending on how strict you want to be with K+). I’ll get back to you shortly regarding the other products.

Nazeema Esau on 18 March, 2010 at 21:43 #

Hi Marion
I included an analysis of the Aloe Ferox powder. It contains various minerals, it’s potassium content may be of concern 145mg/ 100g powder. However, if not used regularly or patient does not have K+ disturbances it might be safe to use in moderation.

Product Specification and Certificate of Analysis

Product Name: Aloe Ferox
Production Process: Bitter sap collected from freshly harvested leaves, filtered and spray dried to produce a fine powder.
i. Preservatives added: None


Analyte Units Count
Ash g/100g <8%
Calcium (Ca) mg/100g 34.0
Carbohydrate g/100g 94
Copper (Cu) mg/100g <0.1
Fat g/100g <0.3
Iron (Fe) mg/100g 4.5
Kilojoules kJ/100g 1513
Manganese (Mn) mg/100g 0.7
Moistures g/100g <5
Potassium (K) mg/100g 145.4
Protein g/100g 0.6
Total Dietary Fibre g/100g 0.70
Sucrose g/100g Not Detected

Appearance Fine Powder

suparna on 9 June, 2010 at 13:11 #

Hi All
I have few Questions,please help me to get the answer
1.Through leaching how much amount of potassium is comming out(authensity of leaching)?
2.When patient on dialysis,can he/she can have potassium rich fruits.Is that potassium will come out through dialysis?
3.Food Source of Low phosphorus but high protein whole foods……..specially for vegeterian patient.

Thanks in advance

Nazeema on 11 June, 2010 at 17:11 #

Hi Suparna
Here’s my response to your questions:
There are some research done on the effect of leaching on potatoes and vegetables like a report from kdoqi indicates that leaching does occur when vegetables are soaked for 2 hours in luke warm water when the vegetable is peeled and cubed. Leaching alone did not significantly reduce levels of potassium or other minerals in potatoes, however boiling it cubed and or shredded decreases potassium levels by 50% and 75%, respectively. Reductions in mineral amounts following boiling were observed for phosphorus, magnesium, sulfur, zinc, manganese, and iron. (1. Bethke PC, Jansky SH. The effects of boiling and leaching on the content of potassium and other minerals in potatoes. J Food Sci. 2008 Jun;73(5):H80-5, 2. J Nutr Sci Vitaminol (Tokyo). 1990;36 Suppl 1:S25-32; discussion S33. Cooking losses of minerals in foods and its nutritional significance.)

Low phosphate diet for the vegetarian:
It is virtually impossible to effectively stay within the phosphate restrictions for patients with renal failure that are vegetarians, unless you are providing a very low protein diet like in conservatively managed cases, since the quality protein sources are mainly from the legumes, nuts, soya and dairy products. Remember your aim will also be to provide enough protein together with energy to prevent PEM, while possibly exceeding phosphate restrictions.

Consuming potassium rich food while on dialysis:
Could not find good literature on when or if consuming high potassium foods are allowed on dialysis. However, based on experience if high K foods are consumed shortly before dialysis is started, than dialysis will be effective with removing it. If it is consumed while they on dialysis it increases the risk of serum K levels remaining high. In principal i would be cautious and extremely selective in giving this advice to any patient on dialysis. Research does indicate that K is effectively cleared on dialysis, ‘potassium removal averages 70-150mmol per session. Musso CG. Potassium metabolism in patients with CKD. Part II: patiens on dialysis (stage5). Int Urol Nephrol. 2004;36(3):469-72.

Marion Beeforth on 26 June, 2010 at 17:31 #

Hallo All
I would like to know in a patient who has a fluid restriction of 500ml due to fluid overload. How much do we have to look at the contribution of water containing food e g porridge , thick soup, pasta and if she has mainly change to bread to avoid the fluid holding starch could the salt intake of bread influence the fluid retention significantly or is the possibility of her not sticking to the fluid restriction more likely cause? Question asked in the light of the previous research that SA bread significant contributor to salt intake in population
Patient on PD dialysis and extraneal was already tried.Thanx

Marion Beeforth on 10 September, 2010 at 12:01 #

Dear All

I would like to know the best approach. Small patient 61 kg with urate 0.42 on admission starts hemodialysis GFR <4.
Would you calculate the diet on 1.2 g protein per kg and 35 kcal for a person under 54 years. Or would you wait for the urea and creatinine to come down a bit and for the fluid to be taken off or do you aim for the 1.2 g/kg from start of dialysis. I waited two or free days just on normal ward diet e g <1.2 g/kg although can be a bit less due to portioning and then also provided a supplement as the patients albumin is low. The patient is complaining from severe joint pain has a history of osteoarthritis which he says can also be gout. I have seen these symptoms a few times before in newly hemodialysed patients with history of gout. Should progress a bit slower with the protein intake or should the symptoms be treated medically and will improve and is now due to the fluid removal and the Urate crystals???? Regards Marion
The patient is not diabetic and had some juice in hospital which I now have stopped due to the gout type symptoms.

Nazeema on 16 September, 2010 at 12:46 #

Hi Marion
If your patient starts on dialysis, regardless of the urea, you must provide the recommended 1.2g/kg, there is no need to wait and the patient should not become uremic as long as effective dialysis is given.
Be sure of whether the patient has gout or not. If it is gout, restricting for the patient on dialysis is NOT recommended. Medical treatment is important and dialysis will help, while some low purine dietary advice can be given to the patient without compromising his total protein requirement.

Marion Beeforth on 13 October, 2010 at 6:23 #

Dear All
Diet therapy during HIVAN.

What diet intervention would you recommend for a patient with pneumonia starting on treatment (e g TB medication and purbac) with raised urea initially urea 13.8 and creatinine 348. Would you try a protein intake of 1-1.2 g with high calories (40-50kcal/kg)due to the catabolic nature of the disease and the increased recommendations for HIV and tuberculosis dietary treatment or would you aim for a lower protein content to minimise raise in urea and creatinine and kidney damage. Is there any literature available more specific to diet treatment, the literature I have seen emphasize more the HIVAN incidence and disease process rather than dietary aims. Hypertension also seem to develop with sharp increase in urea and creatinine e g urea 16.1 and creatinine 611 and potassium 4.7. Is there a lower initial recommendation for protein with the start of HIVAN e g similar to stage 4 chronic kidney disease 0.8g/kg protein and 35 kcal/kg protein and then possible increase of calories to 40-50kcal without increase to protein? Thank you Marion

Nazeema on 15 October, 2010 at 7:01 #

Hi Marion
There are no formal recommendations for the HIVAN patient, it is indicated to provide sufficient energy to prevent malnutrition. Regarding the protein recommendation, first it would depend if the patient is receiving dialysis or not and if it CRF or ARF. Otherwise it is important to individualise management, if the patient is uremic try to be more restrictive with protein, about 1 g/kg max. If the patient is not uremic and renal function not rapidly deteriorating than aim for at least 1 g/kg.

Marion Beeforth on 7 February, 2011 at 11:45 #

Dear Nazeema and other dietitians working in the renal field. Do any of you have information re Post PD catheter diet e g cleansing bowel pre-operation and then proceeding with liquid and soft diet as tolerated post operatively is that a general approach?

Regards Marion

Nazeema on 8 February, 2011 at 17:07 #

Pre-operatively the patients receive a laxative to clean the bowel to decrease the risk of bowel-related complications during the surgical placement of the catheter in the peritoneal cavity.
Post-surgery the patients will continue with a normal consistency renal diet as before the procedure. Varying degrees of discomfort is experienced post-surgery which is a factor that can possibly affect the patient’s intake.

Marion Beeforth on 27 May, 2011 at 6:32 #

Hallo Nazeema

I would like to know if anyone have a workable approach. Sometimes a newly diagnosed patient in renal failure e g GFR 24-45 ranges or sometimes GFR a bit lower see you for the first time and due to the high potassium levels e g 5.3 or 4.9 I have a moderate potassium restriction. After the dr visit and change of medication e g sometimes a diuretic the potassium is then low and dr prescribe a K supplement e g slow K. The patients then want to know and I am also wondering if it would not be easier to lift the potasssium restrictions and retest the potassium? Is the slow K just an interim measure?
Intake of 2000mg-3000mg (but rarely 3000mg) given if K high and intake of >3000 mg if normal at time of seeing me.
If a patient ‘s K is low how would you approach the situation if they would rather want to eat a more varied diet in regard to their favourite vegetables e g tomatoes and butternut rather than drink the slow K but restrict diet.
Thanx marion

Nazeema on 30 May, 2011 at 21:32 #

Hi Marion
Firstly it is IMPORTANT to assess the possible reasons for the low K e.g. very poor intake, any form of losses, medication interaction etc. and address this where you can. With this level of renal impairment the patient will become more at risk for raised K, so to just allow liberal intake of K must be done with extreme caution (not always a good idea, it can be confusing for the patient). If patient is receiving K supplementation it will be monitored by the dr’s and stopped as soon as levels normalise, so dietary supplementation at this point is usually not that important.

If a low K is a known chronic problem in your patient than liberal intake or no dietary restriction of K would be appropriate.

Ansie Engelbrecht on 11 September, 2011 at 22:32 #

Dear Nazeema.Can you kindly let me know where does white chocolate fir in, is that also high it phosphate?
Then what about the potassium content of smash? Hope to hear from you soon.

Kind regards.

nazeemaf on 12 September, 2011 at 13:52 #

Good afternoon
All chocolates are high in phosphate, since it includes dairy product,normal chocolate and white chocolate have about the same amount of phosphate of about 230mg / 100g portion. If it includes nuts the phosphates increases to > 300mg / 100g portion.

Similarly all potato sources are high in potassium e.g. 240mg / 100g K in mashed potato, compared to a boiled potato withouit skin contains 279mg / 100g K.(> 100mg K / portion is considered high)


Marion Beeforth on 26 October, 2011 at 15:15 #

A patient who had a transplant 5 months ago and is doing well but feels tired would like to use a multivitamin, while looking for causes would you be satisfied with her drinking a multivitamin at only 100% RDA if bloodworks for anaemia and bloodsugar is stable and u and e also fine.

Keep well Marion

Nazeema on 27 October, 2011 at 10:45 #

Good morning
There are no recommendations for routine supplementation for the transplant patient. Usually their intake are so good that supplementation is not required. I would first assess the patients current intake and advise on how to make the intake adequate with dietary modifications only. I would only consider maybe a B vitamin supplement after all other underlying conditions are excluded and if the patients intake is still insufficient.

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