Nutrition in Renal Failure - Stanford Medicine



Nutrition in Renal Failure

Nutritional Guidelines for Chronic Renal Failure

| |Infant (108 |102 |4-6yr: 90 |♀11-14yr: 47 |

|(kcal/kg/d) |6-12mo: >98 | |7-10yr: 70 |♀ 15-18yr: 40 |

| | | | |♂11-14yr: 55 |

| | | | |♂ 15-18yr: 45 |

|Protein |0-6mo: 2.2 |1.2 g/kg |4-6: 1.2 g/kg |11-14: 1g/kg |

|(g/kg/d) |6-12mo: 1.6 | |7-10: 1g/kg |15-18:0.9 g/kg |

Nutritional Guidelines for Hemodialysis

| |Infant (108 |102 |4-6yr: 90 |♀11-14yr: 47 |

|(kcal/kg/d) |6-12mo: >98 | |7-10yr: 70 |♀ 15-18yr: 40 |

| | | | |♂11-14yr: 55 |

| | | | |♂ 15-18yr: 45 |

|Protein |0-6mo: 2.6 |1.6 g/kg |4-6: 1.6 g/kg |11-14: 1.4 g/kg |

|(g/kg/d) |6-12mo: 2.0 | |7-10: 1.25 g/kg |15-18: ♂ 1.3 |

| | | | |♀ 1.2 |

Nutritional Guidelines for Peritoneal Dialysis

| |Infant (108 |102 |4-6yr: 90 |♀11-14yr: 47 |

|(kcal/kg/d) |6-12mo: >98 | |7-10yr: 70 |♀ 15-18yr: 40 |

| | | | |♂11-14yr: 55 |

| | | | |♂ 15-18yr: 45 |

|Protein |0-6mo: 2.9-3.0 |1.9-2.0 g/kg | | |

|(g/kg/d) |6-12mo: 2.3-2.4 | |4-6: 1.9-2.0 g/kg |11-14: 1.7-1.8 g/kg |

| | | |7-10: 1.7-1.8 g/kg |15-18: 1.4-1.5 g/kg |

Nutrition on Peritoneal Dialysis

▪ Nutritional benefits:

▪ Liberalization of dietary restrictions

▪ Calories from dialysate dextrose (9-18 kcal/kg/day; 7-15% of total daily caloric intake)

▪ Nutritional cons:

▪ Losses of proteins (Ig, albumin, transferrin), amino acids, vitamins, trace elements

▪ Intra-abdominal pressure ( anorexia, reflux

▪ Hyperglycemia

▪ Protein losses: between 100-300 mg/kg/day (10% of total daily intake)

▪ Increased losses during peritonitis

CRRT

▪ Common modality in acutely ill patients

▪ Allows for unrestricted fluid intake

▪ Hypercatabolism, hypermetabolism

▪ High protein requirements

▪ Amino acid losses

▪ Losses of vitamins and trace elements (Selenium, Copper, Thiamine, Phosphorus)

Caloric requirements during acute illness

▪ Average Hospital Requirements:

▪ 0-10 kg: 100 kcal/kg/day

▪ 10-20 kg: 1000 + 50 kcal/kg

▪ 20-30 kg: 1500 + 20 kcal/kg

▪ Increased energy requirements:

▪ Fever: ↑12% per degree celsius >37

▪ Heart Failure: ↑15-25%

▪ Surgery: ↑20-30%

▪ Severe Sepsis: ↑40-50%

Basal Metabolic Rate

|Males |Females |

|0-3: 60.9 x wt - 54 |0-3: 61.0 x wt - 51 |

|3-10: 22.7 x wt + 495 |3-10: 22.5 x wt + 499 |

|10-18:17.5 x wt + 651 |10-18: 12.2 x wt + 746 |

|Energy Requirement= BMR x activity factor |Activity Factor |

| |Confined to bed: 1.2 |

| |Sedentary: 1.5 |

| |Normal: 1.7 |

| |Athlete: 2.0 |

Calcium Recommendations (provided patient does not have hypercalcemia)

• Infants: 600mg/day

• Toddlers: 800mg/day

• Children: 800mg/day

• Adolescents 1200mg/day

Vitamins/Minerals

▪ Water soluble vitamin supplementation

▪ B vitamins

▪ Avoid high doses of vitamin C and B6: Hyperoxalemia and peripheral neuropathy

▪ Avoid fat soluble vitamins- risk of toxicity

▪ Vitamin A levels often increased due to increased retinol binding protein

▪ Accumulation/deficiency of trace elements

▪ Zinc deficiency

▪ Selenium deficiency

▪ Accumulation of aluminum

Nutritional Supplements

▪ DPI = RDA + losses

▪ Use of amino acid-based dialysis solutions

▪ Risks: increased BUN, metabolic acidosis, anorexia, nausea, expensive

▪ Water soluble vitamins-goal RDA

Dyslipidemia

▪ Affects up to 70% of patients with CKD

▪ Type IV hyperlipoproteinemic pattern (Hi triglycerides, Hi VLDL, Low HDL, Low/low-nl LDL)

▪ Do not be misled by a low Total Cholesterol– a common sign of malnutrition!

Food: Renal Diets

▪ Restrictions may include: Sodium, Potassium, Phosphorus, Fluid

▪ Renal Diet Orders – Do’s & Don’ts

▪ Do specify each restriction quantitatively ie. 2 gm K+ (not ‘Low sodium’)

▪ Don’t write for mMoles phos – write it as mg Phos

Renal Formulas

▪ Similac PM 60/40

▪ Calories: 0.67 cal/mL

▪ Protein:16g/L (whey/casein)

▪ Fat 38 g/L

▪ K: 15 meq/L

▪ Ca/P: 380/190 (mg/L)

▪ Amin-aid

▪ Calories: 2 kcal/mL

▪ Protein: 19 g/L (free AA)

▪ Fat: 46 g/L

▪ K: ................
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