RENAL PRACTICUM

Renal Nutrition Worksheets

Please try to answer as many of these as you can prior to your rotation. Some may not
be able to be completed until you get to the renal rotation and should be used as
discussion points with the RD.

Part I: Normal Kidney Function

1. What are the normal values for the following:

GFR: 60 or higher Serum PO4: 2.3 - 4.7 mg/dL

BUN: Less than 20 mg/dL Serum Ca: 8.4 - 10.2 mg/dL

Cr: 0.6 - 1.1 mg/dL Serum K: 3.5 - 5 mmol/L

Serum Na: 136 - 145 mmol/L Urine Protein: 6.4 - 8.3 g/dL

2. List the 4 main functions of the kidney?

- Regulatory: the kidney controls composition and volume of the blood and maintains
acid-base balance.
- Excretory: the kidney produces urine and removes metabolic wastes.
- Hormone: the kidney produces renin to control blood pressure and erythropoietin to
stimulate red blood cell marrow production. It also plays a role in converting vitamin D to
its active form.
- Metabolic: metabolizes drugs and endogenous substances and plays a role in
gluconeogenesis.

3. What is the functional unit of the kidney?

The nephron.

4. What is the function of the glomerulus?

To produce ultrafiltrate.

5. Explain the purpose of the renal tubules?

The tubules reabsorb a majority of the components of the ultrafiltrate. This allows the
tubules to produce the final urine, which can vary widely in its composition.
Part II: Acute Kidney Injury ( AKI)
1. Define acute kidney injury (acute renal failure)
A sudden episode of kidney failure or kidney damage that happens within a few hours
or a few days (https://www.kidney.org/atoz/content/AcuteKidneyInjury). AKI is characterized by
a sudden reduction in GFR and altered ability of the kidney to excrete metabolic waste.

2. AKI can be classified into the following 3 categories. Define each one and list 1 or 2
examples of possible etiologies.
Pre Renal: inadequate renal perfusion - severe dehydration / circulatory collapse.

Post Renal: urinary tract obstruction - carcinoma of the bladder or prostate / bilateral ureteral
stones and obstruction.

Intrinsic: diseases within the renal parenchyma - acute tubular necrosis / nephrotoxicity (drugs
or contrast agents).

3. List the general medical nutrition therapy guidelines followed in acute kidney injury. Note
possible reasons for deviation from these guidelines.

Protein: 0.8-1.2g/kg with no dialysis or 1.2-1.5 with dialysis or if catabolic.

Sodium: 2-3g/day for anuric/oliguric phase based on blood pressure and edema. During the
diuretic phase, replace based on urine output, edema, need for dialysis, and serum Na levels.

Potassium: 2-3g/day for anuric/oliguric phase. Replace losses depending on urine volume,
serum potassium levels, and need for dialysis or medication during the diuretic phase.

Phosphorus: 8-15 mg/kg based on serum values.

Fluid: 500 mL + total output for the anuric/oliguric phase. Large volume of fluids may be needed
during the diuretic phase (assess frequently).

Calories: 25-35 kcal/kg or use indirect calorimetry. Consider stress level and include energy
from RRT if applicable.
 Part III: Chronic Kidney Disease (CKD)
A. The progression of chronic kidney disease can be divided into 5 stages based on GFR and
results in complications prior to the initiation of renal replacement therapy. These stages, as
defined by the National Kidney Foundations K/DOQI (Kidney Disease Outcomes Quality
Initiative), were released in January 2002. It is important to be familiar with these guidelines to
know when nutritional intervention should begin. Please refer to the chart in the appendix to
these worksheets.

1. What are some physical symptoms of uremia?

Nausea, vomiting, loss of appetite, malaise, weakness, muscle cramps, itching, metallic taste in
the mouth, and neurologic impairment.

2. List the changes in blood chemistries that occur with uremia. What is the end product of
protein breakdown?
There is an unacceptable level of nitrogenous wastes in the body, fluid and electrolyte
disturbances, and glucose intolerance. The end product of protein breakdown is amino acids,
which have nitrogen in their makeup. The nitrogen is normally excreted by the kidney in the form
of urea, but remains in the body with CKD.

3. What is the etiology of the metabolic acidosis associated with uremia and why is it important to
correct?
The etiology is the impaired kidney function not excreting the nitrogen/urea as it should and
impaired catabolism of protein substances which the kidney normally breaks down.

4. Doesuremia affect carbohydrate metabolism? If so, how?

Yes, glucose intolerance is associated with uremia from peripheral resistance to the
action of insulin.

6. What is the impact of uremia on hematologic parameters?

Elevated urea levels and a build-up of waste products from impaired breakdown of
protein substances.
B. Medical nutrition therapy for chronic kidney disease is pivotal in controlling clinical symptoms
and delaying progression of chronic kidney disease (CKD). . This usually begins in Stage 3 & 4
of CKD.

1. The RDA for protein is __0.8g/kg__. For what population

is the RDA designed to be used for? It is designed for the healthy adult population.

2. Describe the parameters used to identify when a patient with CKD should be instructed to
restrict protein. What is the KDOQI recommendations for protein?
Protein restriction should begin at a GFR < 50. Protein restriction depends on stage of
CKD, diabetes, dialysis, HBV, and whether the person is catabolic. The KDOQI
reccomendations say 0.8g/kg body weight per day
(https://www2.kidney.org/professionals/KDOQI/guideline_diabetes/guide5.htm).

3. Which body weight is used to determine the amount of protein intake

recommended in CKD?
Standard body weight from the NHANES II weight table based on sex, age, and frame size.

4. Describe high biological value; list food source of HBV; and explain how it
is used with patients with chronic kidney disease. What percentage of the protein
prescription is recommended as high biological value?
Protein that has all of the essential amino acids and a high protein digestibility corrected amino
acid score. 50-60% of protein should be from sources of HBV to allow for optimal protein use.

5. List the vitamins that may be inadequate in a diet with < 60 gm protein/day.
Vitamin E and B vitamins, including niacin, thiamin, riboflavin, and vitamin B6
(https://www.choosemyplate.gov/protein-foods-nutrients-health).

6. What are the indications for restricting sodium and potassium for CKD Stage 3-4? What
sodium restriction is recommended for CKD Stage 3-4?
Sodium restriction of 2.4 g/day according to the EAL. Potassium should be restricted to
less than 2.4 g/day.

7. What are the KDOQI recommendations for phosphorus allowed in the diet for CKD Stage
3-4?.
EAL: 800mg to 1,000mg per day or 10mg to 12mg phosphorus per gram of protein.
(Could not find KDOQI guidelines)
8. How and when the decision to restrict phosphorus is made?
Controlling phosphate is important in the early stage of the CKD. Those with a GFR less
than 60 are evaluated for bone disease and benefit from phosphorus restriction.

Part IV: Peritoneal Dialysis

When a patient reaches Stage 5 that is considered kidney failure and renal replacement therapy
(RRT), in the form or peritoneal, hemodialysis, short daily dialysis or nocturnal home
hemodialysis, is needed. Short daily and nocturnal home hemodialysis are not available at all
units. Therefore only HD and PD will be discussed here. Please ask your renal RD for more
information on the other types of HD if you are interested.

1. In Peritoneal dialysis (PD) waste products are removed from the blood by the process of
diffusion across a semi-permeable membrane down a chemical concentration gradient. The
lining of the peritoneal cavity is used as the semi-permeable membrane and dextrose solutions
are used as the dialysate. What 3 things determine the amount of fluid and solute removed
during PD?
Concentration of dextrose, the rate of equilibration between the dialysate and the blood, and
dwell time.

2. Is there a difference in dialytic efficiency between peritoneal dialysis and

Hemodialysis?
HD has a higher dialytic efficiency.

3. Define CAPD and CCPD.

CAPD: continuous ambulatory peritoneal dialysis - manual PD, a series of fill and drain
sessions are performed throughout the day.
CCPD: continuous cyclic peritoneal dialysis - dialysate is surgically placed and fluid is allowed to
remain in the peritoneal cavity and is then drained.

4. List the nutrition prescription for patients on peritoneal dialysis.

Protein: 1.2-1.5 g/kg BW

Phosphorus: 0.8-1.2 g/day

Sodium: 2-4 g/day

Potassium: 3-4 g/day

Fluid: Ad lib with minimum of 2000 mL per day urine output.

5. Describe methods by which insulin can be delivered to patients with diabetes

mellitus on peritoneal dialysis. Discuss the advantages/disadvantages. Briefly explain
diet modifications required for patients with diabetes mellitus.
Both subcutaneous and intraperitoneal administration of insulin can be used.

Part V: Hemodialysis

A. The process of hemodialysis (HD)

The dialyzer is the synthetic semi-permeable membrane that selectively removes compounds
from the blood. The blood flows across the membrane and a rinsing fluid (dialysate) flows on
the other side of the membrane ( dialysate and blood do not physically contact each other). The
dialysate creates an osmotic gradient based upon its composition compared to the patients
blood concentration. This difference permits diffusion of waste material from the blood into the
machine for disposal. Water and small molecular weight molecules and ions pass through the
membrane and are removed from the blood. Ultrafiltration of salt and water is induced by
hydrostatic pressure.

1. List the waste products removed by hemodialysis.

Urea, potassium, and phosphate.

B. Medical nutrition therapy for hemodialysis

1. What are the KDOQI protein recommendations for a patient on hemodialysis? What is the
rationale for this protein allowance? What percentage of protein that should be HBV?
KDOQI guidelines recommend 1.2 g/kg standard body weight per day with at least 50%
being HBV. The rationale: protein is lost through HD, so the recommendations are designed to
compensate these losses.

2. What is the preferred weight gain between hemodialysis treatments? How are fluid
recommendations determined? .
1 kg/day or less. It should not exceed 5% of the patients body weight between dialysis
treatments. The recommendations should be individually assessed based on the patients
comorbid conditions, age, activity level, and body size.
3. State the amount of sodium recommended and explain the reason for sodium
restriction in hemodialysis patients.
2-3 g/day. Hypertension in CKD is usually salt sensitive and lowering sodium intake to 2
g/day lowers thirst, extracellular fluid volume, weight, proteinuria, and blood pressure while
enhancing the effects of antihypertensive medications (Byham-Gray, Stover, & Wiesen, 2013,
p. 57).

4. What range of dietary potassium is recommended? What other factors and/or

co-morbidities need to be considered when determining potassium restriction?
2-4 g/day or 40-50 mg/kg IBW, depending on urine output. Consider the amount of potassium
in the dialysate, metabolic acidosis, use of NSAIDs, potassium-sparing diuretics,
angiotensin-converting enzyme inhibitors, angiotensin blockers, aldosterone receptor
antagonists, or B-receptor blockers.

5. What is the recommended amount of dietary phosphorus for an HD patient?. What

nutrient must be considered in determining the amount of phosphorus allowed for
patients on HD?
0.8-1.2 g/day or < 17 mg/kg IBW. Protein should be considered. High protein is recommended
to achieve albumin level of 4 mg/dL. Counselling should incorporate high protein foods that are
lower in phosphorus.

6. List the vitamin therapy recommended for patients on

hemodialysis. Explain the rationale for supplementation. What vitamins are excluded
from standard therapy for HD patients and why?
Vitamin C, folic acid, thiamin, riboflavin, niacin, vitamin B6 and B12, pantothenic acid, and
biotin. Water soluble vitamins are lost during dialysis, so there is an increased need for them.

Part VI: Hemodialysis and Peritoneal Dialysis

1. State the normal range for hematocrit/hemoglobin. Why is hemoglobin x3 a better reflection
of anemia in CKD than hematocrit? Explain the etiologies of anemia in
dialysis patients. Provide possible treatment options to reduce or minimize the
occurrence of anemia.
 Current target hemoglobin levels are 10-12 g/dl. In CKD, anemia is often caused by
depressed EPO, which decreases hemoglobin levels. Hematocrit levels are more susceptible to
hydration changes, so the hemoglobin is a better indicator of anemia. Other etiologies of anemia
in dialysis patients include insufficient iron supply in bone marrow, blood loss through the GI
tract, blood sampling, and blood loss through access sites and dialyzer leaks. Anemia can be
treated with EPO stimulating agents (ESA) and iron supplementation.

2. Describe the factors that contribute to constipation in dialysis patients.

Low fluid intake, inactivity, and calcium or aluminum phosphate binders.

3. List the acceptable laboratory values for the dialysis patients in the center to
which you are assigned.

BUN - 60-80 mg/dL

serum Ca - >10.2 mg/dL
serum Na - 135-145 mEq/L
serum K - 3.5-5.5 mEq/L
serum PO4 - 3-6 mg/dL

4. When are the following medications used in the management of

dialysis patients? Give an example of each medication.

phosphorus binder: When serum phosphorus needs to be controlled. Example, Renvela

calcium supplement: As a phosphate binder or when calcium supplementation is needed.

Example, calcium acetate.

active vitamin D: When PTH increases.

B-complex vitamin: When patient cannot meet vitamin needs.

Part VII: Calcium and Phosphorus metabolism in chronic renal failure

The KDOQI Guidelines for Bone Disease were released in October 2003. The KDIGO
guidelines were released in 2006. Please discuss the guidelines used at the unit you are at
with your preceptor, as they will have an important impact in how the RD manages bone
disease for the CKD patient..
1. List the steps that lead to secondary hyperparathryoidism.

his is the excessive secretion of parathyroid hormone in response to low blood calcium levels.
T
The failing kidneys to not convert enough vitamin D to its active form nor do they excrete
phosphate adequately. Therefore, calcium phosphate forms in the body and removes calcium
from the blood.

2. State the GFR level at which the plasma phosphorus begins to increase.
Explain the importance of dietary intervention to limit phosphorus at this critical
stage.

When GFR is less than 10% of normal.

3. Describe the role of active vitamin D in absorption of calcium.

Active vitamin D promotes the absorption of calcium.

4. Describe the regimen used to prevent secondary hyperparathyroidism.

At FMC Grand, the parathyroid hormones are commonly removed.

5. Explain the adverse effects of aluminum hydroxide use in dialysis patients.

Dementia, encephalopathy, aluminum bone disease/osteomalacia, and impaired bone

mineralization.

6. What are the KDOQI recommended maximum amounts of oral/dietary Calcium that a
dialysis patient should ingest? Why?

No more than 2,000 mg, so your body can get the vitamin D it needs.

VIII: Transplant

Chapter 3
Read: Adult Kidney Transplantation by Linda S. Blue, MS, RD, FADA
In Comprehensive Guide to Transplant Nutrition, Jeanette M. Hasse, PhD, RD, FADA
and Linda S. Blue, MS, RD, FADA, editors
1. Renal transplant patients require immunosuppressive agents for the rest
of their lives. The most common three agents are tacrolimus, prednisone
and Cellcept. List the common side effects of each and how they are
treated.

2. What are the short-term recommendations immediately post op for

calories, protein, carbohydrate, fat and fluid? What are the short-term
recommendations for vitamins and minerals?

3. What are the four most common long-term adverse nutritional side effects
of the immunosuppressive meds? List them and how they are treated.

4. What are the long-term recommendations for calories, protein,

carbohydrate, fat and fluid? What are the long-term recommendations
for vitamins and minerals?

5. W
hat are the three categories of kidney transplant patients?

6. N
ame three common diseases that cause chronic kidney disease?

7. W
hat is ATN and what causes it?