Page 589 - Nutrition Essentials for Nursing Practice

C H A P T E R 2 1 Nutrition for Patients with Kidney Disorders 577

Table 21.5 Nutrient Recommendations for CKD Renal Replacement Therapy

Nutrient Hemodialysis Peritoneal Dialysis Transplant

Protein (g/kg/day) Ն1.2; Ն50% HBV Ն1.2–1.3; Ն50% HBV Initial: 1.3–1.5
Calories (cal/kg/day) Maintenance: 1.0
35 if Ͻ60 years 35 if Ͻ60 years
Fat 30–35 if Ն60 years 30–35 if Ն60 years Initial: 30–35
Sodium (g/day) Maintenance:
Heart-healthy Heart-healthy
Fluid (mL/day) guidelines guidelines 25–30
Potassium (g/day)
1–3 2–4 Heart-healthy
Phosphorus (mg/day) guidelines
Calcium (g/day) 1000 ϩ urine 1500–2000 (monitor)
output Unrestricted;
3–4 monitor effects
2–3 of medication
800–1000
800–1000 Generally
Յ2 from diet and unrestricted
Յ2 from diet and medications
medications Unrestricted;
monitor effects
of medication

Generally
unrestricted

1.2

Source: National Kidney Foundation. Kidney Disease Outcomes Quality Initiative, 2000, 2002, 2003; and
Beto, J., & Bansal, V. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice
guidelines. Journal of American Diet Association, 104, 404–409.

When dialysis begins and protein allowance increases, phosphorus intake correspond-
ingly increases, yet the recommendation is to limit intake to 800 to 1000 mg. People who
adhere to a low-phosphorus diet are at risk of consuming an inadequate protein diet, which
can lead to malnutrition and protein–energy wasting. A study by Shinaberger et al. (2008)
concluded that the risk of controlling serum phosphorus by restricting dietary protein may
outweigh the benefit of controlling phosphorus and may lead to greater mortality, especially
in patients on maintenance hemodialysis. Phosphate binders, which decrease GI absorption
of phosphorus and promote fecal excretion, allow for a higher protein (and phosphorus)
intake. Phosphate binders, which must be taken with all meals and snacks, are necessary to
control serum phosphorus levels for the majority of patients.

For people on hemodialysis, fluid allowance equals the volume of any urine produced
plus 1000 mL. Fluid intake is monitored by weight gain: anuric hemodialysis patients
should not gain more than approximately 2 pounds/day between treatments. For many
patients on hemodialysis, limiting fluid intake is the biggest challenge. Teaching clients why
the fluid restriction is important is only half the battle; teaching them how to control their
intake and thirst is vital. Strategies to relieve thirst are listed in Box 21.2. Peritoneal dialysis
patients usually have fewer problems with fluid retention.

Translating Recommendations into Meals

The diet for CKD is challenging; modifications can be numerous, extensive, and lifelong,
and changes are frequent. It is a difficult task to design a meal plan that balances what the
individual needs with what the individual can tolerate—and will accept. Getting the client