CHRONIC KIDNEY DISEASE

CKD is typically a progressive disease. It is defined as:

·         Reduction of kidney function-when estimated glomerular filtration rate (eGFR) < 60Ml/min/1.73m² and/or

·         Evidence of kidney damage, including persistent albuminuria- defined as >30 mg of urine albumin per gram of urine creatinine.

Kidney failure is typically defined as an eGFR < 15 mL/min/1.73m²

USE OF eGFR TO ASSESS KIDNEY FUNCTION

The eGFR provides an estimate of how much blood is filtered by the kidneys each minute.

The formula used to estimate GFR uses serum creatinine, age, gender, and race.

eGFR ( ml/ min/ 1.73 m² ) = 175 x (S_cr )^-1.154 x (Age)^-0.203 x (0.742 if female) x (1.212 if African American).

Kidney failure is an eGFR is less than 15, kidney cannot maintain homeostasis.

 

KIDNEY FUNCTION AND eGFR DECLINES WITH AGE

AGE (years)	mean eGFR
20- 29	116
30-39	107
40-49	99
50-59	93
60-69	85
70+	75

 

STAGES OF CKD

STAGE	eGFR	COMMENT
1	> 90	Normal GFR w/ proteinuria
2	60-89	Age – related decline in GFR w/ proteinuria
3A 3B	45 – 59 30 – 44	Low risk of progression to kidney failure
4	15 – 29	High risk of progression to kidney failure
5 5D (dialysis) 5T( kidney transplant)	< 15	Kidney failure

 

CHRONIC KIDNEY DISEASE (CKD) TESTS

CKD TESTS	RESULTS	REASONS TO TEST
SERUM CREATININ AND ESTIMATED GLOMERULAR FILTRATION RATE (e GFR )	CKD if e GFR is less than 60	As kidney disease gets worse, the creatinine goes up and the e GFR goes down.
URINE ALBUMIN TO CREATINIE RATIO (UACR)	Normal: 0-30(mg/g)   CKD if more than 30	Elevated albuminuria may reflect higher risk for progression. Lower levels are associated with improved renal and cardiovascular outcomes. Limit excessive dietary protein as follows: Non diabetics: 0.8g protein /kg/day. Diabetic: 0.8 to 1.0g protein/kg/day.
BLOOD PRESSURE	Less than 140/90mmHg	High blood pressure makes the heart work harder and can damage blood vessels in the kidneys. Limit sodium intake to 2300mg a day or less.
SERUM ALBUMIN	Normal: 3.4 to 5.0	Albumin is a protein that helps measure how well you are eating.
BICARBONATE	Normal: more than 22	Bicarbonates measures the acid level in the blood. Dietary protein is a source of metabolic acid. Serum bicarbonate levels may increase with dietary protein restriction.
BLOOD UREA NITROGEN (BUN)	Normal: less than 20	To check waste product in the blood.
POTASSIUM	Normal: 3.5 to 5.0	Potassium affects how your nerves and muscles are working. High or low can be dangerous.
CALCIUM	Normal: 8.5 to 10.2	CKD can lower the lower the amount of calcium in your bones. Also important for heart rhythms steady.
PHOSPHORUS	Normal: 2.7 to 4.6	High levels may cause soft bones, hard blood vessels and itchy skin.
VITAMIN D	Normal: 20 and more	Vitamin D is important for bones and heart health.
TOTAL CHOLESTEROL	Normal: less than 200	Too much cholesterol can clog blood vessels or arteries in the heart and kidneys.
	Normal: more than 40	HDL is good cholesterol and clears bad fats out of your arteries.
LDL CHOLESTEROL	Normal: less than 100	LDL is bad cholesterol and can clog your arteries.
TRIGLYCERIDES	Normal: less than 150	It is a type of fat in blood.
HEMOGLOBIN (Hgb)	Normal: 12 to17	Low hemoglobin is a sign of anemia. You may feel tired if you have anemia.
HbA1C	Individualize A1C	As eGFR declines, renal metabolism of insulin and certain oral diabetes medications is reduced, potentially causing hypoglycemia in diabetes. Patients should be advised to treat hypoglycemia with grape juice, apple juice, cranberry juice or glucose to prevent hyperkalemia.

 

NUTRITION IN CHRONIC KIDNEY DISEASE

Malnutrition evolves during the progression of CKD with electrolyte abnormalities, muscle mass reduction and depressed immunological function. High biological value protein intake should be maintained, while sodium, potassium and phosphorus intake are restricted.

A 24 hours urine collection for, urea nitrogen and creatinine is highly informative regarding the levels of compliance with dietary prescription. To preserve lean body mass, patients should be advised to exercise for at least 150 minutes of moderate to vigorous physical activity each week. Start slowly and accumulate activity in 10 minutes blocks throughout the day.

Kidney still work well in stage 1 and 2. Focus must be given to reduce blood pressure and in people with diabetes, control blood sugar. Carbohydrate must be given in moderate amount by including high fiber and low sugar foods.

 

NUTRITIONAL TARGET FOR CKD SATGES 1 - 5

CKD STAGES	CALORIES (Kcal/kg/d)	SODIUM (mg/d)	POTASSIUM (g/d)	PHOSPHORUS (mg/d)	PROTEIN (g/kg/d)	FLUID
1	BMR X activity/stress factor	1000-3000 < 2400 g daily (CKD with hypertension)	-	-	0.8- 1.4 ( no protein restriction unless patient is diabetic)	Per doctor
2	BMR X activity/stress factor	1000-3000 <2400 g daily (CKD with hypertension)	-	-	0.8 – 1.4 ( protein restriction while filtration is less than 50 to 70)	Per doctor
3 and 4	35 (age< 60) 30-35 (age>60) Overweight 23-25 Underweight 35 Nephrotic syndrome 35 Acute renal failure 30-40	1000-3000 < 2400 g daily (CKD  with hypertension)	<2.4	600-1000	0.6 – 0.8 Chronic renal failure 0.6 -0.75 (without diabetes) 0.8- 0.9 (with diabetes) Acute renal failure 0.5 – 0.8 (no dialysis) 1-2 ( with dialysis) 0.8 -2 (stable) Nephrotic syndrome 0.8-1.5	Per doctor Acute renal failure 500+ urine output
5	Normal 35 (age<60) 30-35(age>60) Overweight 23-25 Underweight 35-40 Acute renal failure 30-40	750-1000	<2.4	800-1000	Normal 0.6-0.8 Hemodialysis 1.1-1.2 Peritoneal dialysis 1.2- 1.5	1000ml + urine output
TRANSPLANT	Normal 35(age<60) 30-35 (age>60) Overweight 23-25 Underweight 35-40	<2400	<2.4	No limit- increase as needed.	0.8 -1	Per doctor

 

Potassium is usually not restricted in stage 3 CKD unless lab tests show potassium is too high.

Fluid is not restricted till stage 3 CKD unless you experience fluid retention. Sudden weight gain, shortness of breath, swelling in feet, hands and face and high blood pressure are signs of fluid retention

 

HOW TO REDUCE SODIUM INTAKE

Sodium intake must be within 1500 to 2300mg/day.

FOOD GROUP	SUITABLE	MINIMISE
FISH	Fresh fish Canned fish with no added salt	Smoked fish, canned fish in salted water or sauces.
MEAT & POULTRY	Fresh beef, mince, lamb, pork, chicken, offal meats (organ meats)… 70 to 80gm or palm size.	Tinned, processed or smoked meats. Readymade meat dishes.
MILK	Milk, all types, cream, butter, margarines (salted reduced type), yoghurt, cheese (not more than 20 gm/day).	Cheese based dishes, e.g., macaroni cheese, pizza, cheese sauce.
EGGS	Egg white	Whole egg
VEGETABLES	Potato based, boiled, mashed and roasted. All vegetables (fresh and frozen)	Salted, fried and chips. Canned vegetables unless labelled “ no added salt” or “reduced salt” Baked beans in tomato sauce. Dehydrated vegetables.
SOUPS	Homemade soups	Tinned packet or instant soups Homemade soups with stock cubes or powder.
SAUCES & PICKLES	Homemade sauces, tomato puree, mayonnaise.	Stock cubes. Soya sauce, regular tomato sauces, pickles, and canned instant sauces.
CEREALS & BISCUITS	All breakfast cereals, all types of bread, rice, sweet and semi biscuits.	Salted porridge, salted cracker biscuits.
FRUITS	All fruits
DRINKS	Water Hot drinks including tea, coffee, cocoa and drinking chocolates. Fruit juices (diluted apple, pineapple, cranberry etc)	Stock broth Tomato juice Mineral water
SNACKS	Unsalted nuts Unsalted crisps Unsalted popcorn	Salted nuts Dry roasted nuts Instant noodles and rice etc.

 

HOW TO REDUCE PHOSPHATE LEVEL

Dietary phosphate should be restricted to 800 to 1000mg/day (adjusted to dietary protein needs) when serum phosphorus levels are elevated (> 4.6mg/dl) at stage 2 and 3 of CKD, and >5.5mg/dl in those with kidney failure (stage 5).

You may be prescribed phosphate binder tablets to help keep you blood phosphate lower. These must be taken at the start of your meals and snacks containing protein to work properly. Avoiding excess phosphate in your diet can also help to reduce blood potassium levels.

FOOD HIGH IN PHOSPHATE Try to reduce	SUITABLE ALTERNATIVES
MILK/ MILK PRODUCTS/EGGS Milk, calcium enriched milkshakes, cheese, cheese sauce, cheese spreads Tinned milk Yoghurt, milk pudding and custards Egg yolks	Cottage cheese, sour cream Egg white
MEATS Liver, kidneys, duck, sausages.	Beef, lamb, turkey, chicken, minced meat.
FISH Sardine, salmon, prawns, mackerel, smoked fish	White fleshed fish e.g, cod, tuna, shrimps.
VEGETABLES Hot chips	All fresh and frozen vegetables
LEGUMES (DREID PEAS & BEANS), NUTS Baked beans, red kidney beans, lima beans, pinto beans, chickpeas, lentils( unless taken in place of meat) All nuts Peanut butter	Nuts –small handful (30g or ¼ cup)
FRUITS Dried fruits	All other fruits are suitable
BREAD AND FLOURS Wholemael breads, bran flakes, bran cereals	All white breads, white flours.
BISCUITS AND CAKES Oatcakes, bran muffins	Cream crackers, digestive, plain biscuits.
MISCELLANEOUS Milk chocolates Malted milk drinks e.g Horlicks Milk powder Mineral water Coco cola and pepsi drinks	Plain chocolates (2-3 squares) Popcorn
SAUCES, HERBS AND FLAVOURING	Herbs, spices, salad dressings, mayonnaise, mustard, vinegar, tomato sauce.

 

HOW TO MANAGE POTASSIUM INTAKE

FOOD GROUP	LOW POTASSIUM FOODS	HIGH POTASSIUM FOODS
FRUITS & VEGETABLES Aim to serve of 5 fruits and vegetables a day e.g. 2 serves of fruit &        3 of vegetables Cut, boil & drain your vegetables to reduce potassium	Apple, berries, canned fruits (drain the juice), pear, plum, pineapple, watermelon, guava, jamun, papaya, cherries, dried tinned foods (100g)   Beans-sprouts, green, bottle gourd, ridge gourd, cabbage, capsicum, cauliflower, carrot, celery, corn, cucumber, lettuce, peas, broccoli, onion ladyfinger, watercress, peas, turnip,  pumpkin (3tbsp)	All dried fruit, apricot, banana, coconut fresh, grapefruit, mosambi, musk melon, grapes, grapefruit, peaches kiwifruit, mango, oranges (50 -70gm)    spinach, broad beans, kidney beans, baked beans, fennel, brinjal, coriander leaves, salad (1tbsp)
CARBOHYDRATE (STRACHY) FOODS Keep to one fist sized serve of boiled potato, taro and yam each day. Rice can be taken.	Noodles, pasta, rice, semolina, vermicelli, potato, taro, yam	Green banana, chips, millets (makka, bajra, ragi)
BREAKFAST CEREALS	Porridge, rolled oats made with water	Bread that contain dry fruit.
MEAT, MEAT ALTERNATIVES &DAIRY	“Not too much not too little”- you need to eat the right amount of protein foods each day. Choose palm size portions at each meal.
BEVERAGES ( FLUIDS)	Soft drink ( choose diet drinks if you have diabetes), coffee, tea, water	Fruits and vegetable juices, milky and espresso coffees.
SNAKES	Plain biscuits, cakes, popcorn, unsalted rice cakes that do not contain dry fruits, nuts, chocolate or coconut	Biscuits, cakes that contain fruits, nuts, chocolate or coconut.
MISCELLANEOUS	Garlic, ginger, herbs, mayonnaise, honey, Nutella, spices, vinegar	Baked beans, peanut butter, soup, tomato puree.

 

THINGS TO REMEMBER IN CKD

Include a small amount (2 to 3 tbsp) of unsaturated fat each day. This include oil used for cooking, salad dressing, margarine and mayonnaise.

 Best oil for CKD are mustard oil, olive oil, canola oil, rice bran oil and safflower oil etc.

Exercise at least 150 minutes of moderate to vigorous physical activity each week like walking briskly, cycling, dancing and swimming and playing tennis etc. Start slowly, and accumulate activity in 10 minutes blocks throughout the day. 

 

Dt. Roshan (Nutritionist and Diet Consultant)