[Phosphorus Magnesium Vitamin D Vitamin Iron]
Proteins
Significant functions of protein include maintenance, building and repair of body tissues; synthesis of enzymes, hormones, body secretions, and antibodies; maintenance of osmotic pressure; and transport of vitamins, minerals and most drugs throughout the body.
As the kidney functions deteriorate, urea, one of the end products of protein catabolism, increases in the blood causing uremia. Even so, the body still needs adequate amounts of protein to maintain positive nitrogen balance. The RDA for healthy adults is .8 gm/kg body weight. The protein needs of persons with ESRD are based on "ideal body weight" (or adjusted body weight for overweight persons) and vary with stage of disease, and type of treatment. Persons undergoing peritoneal dialysis or hemodialysis lose protein in their treatment and thus require additional amounts to prevent protein depletion.
It is recommended that 50-65% of the dietary protein be of high biologic
value such as those from animal sources (except gelatin). See Table I.For
those who are vegetarians,dietary modifications are difficult but can be accomplished.
Legumes can approximate the quality of animal proteins provided when they
areeaten in combination with proteins from cereals, soy products,vegetables
and fruits. Foods from vegetable source and soy products canbe high in phosphorus
and appropriate diet modifications need to bemade. An increase in phosphnourus
medication may be required which can cause constipation. Clients do not like
to take large amounts of this medication.
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AVOID |
LIMIT |
GOOD |
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Meat |
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Bologna |
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Beef |
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Chicken |
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Lamb |
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Ham |
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Pork |
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Hot dogs |
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Turkey |
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Sausage |
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Veal |
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Cheese |
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Fish, fresh and frozen |
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Eggs and egg substitutes |
To increase the protein in your diet, try to have a good source
at each meal.
Add cooked egg white, and cheese to lettuce salads. Add extra meat
to soups and stews.
When necessary, there are protein drinks that are appropriate and
can be purchased. These can be taken between meals or when it is
not possible to eat a meal.
Calories
The goal of a nutritionally adequate diet is maintenance of an ideal body weight (IBW). Determine IBW according to Hamwi's formula (Whitney, et al p 547). As BUN rises, dietary protein is decreased. Calories from carbohydrates and fat must then be increased to meet the body's needs and prevent malnutrition.
For those who are overweight, an adjusted body weight (ABW) is used to determine caloric needs, since 25% of body fat tissue is metabolically active: ABW = [(actual body weight - IBW) x 0.25] + IBW.
Potassium
As kidney functions deteriorate, the organ loses its ability to excrete potassium. All persons with ESRD require, at some time, potassium restriction. High serum levels of potassium can cause heart arrthymia and/or cardiac arrest. See Table II for food sources.
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Apricots |
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Blueberries |
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Avocado |
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Cranberry fruit or juice |
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Banana |
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Peaches |
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Cantaloupe |
Watermelon |
Pear |
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Kiwi |
Strawberries |
Fruit cocktail |
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Nectarines |
Grapes |
Applesauce |
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Oranges |
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Alfalfa sprouts |
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Prunes |
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Cabbage: green & red |
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Bamboo shoots |
Broccoli, 2 times per week |
Beans: green, wax |
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Greens |
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Cauliflower |
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Beets |
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Corn |
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Collard |
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Carrots |
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Dried beans & peas |
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Lettuce |
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Lima beans |
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Spinach |
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Peas |
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Soy beans |
White potatoes |
Rice, noodles |
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Sweet potatoes/yams |
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Refried beans |
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Tomatoes |
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Winter squash |
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Zucchini |
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Rice crackers |
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Potato chips |
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Cookies - vanilla type |
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Salt substitutes |
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Herbs & spices w/o salt |
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Soybean nuts |
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Milk 1/2 - 1 c/d |
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Coffee 1-2 c/d |
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Tea 1-2 c/d |
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Sodium And Water
As kidney functions in ESRD deteriorate and the GFR falls, sodium and water are retained in the body. The result can be fluid overload, edema, and hypertension, all leading to congestive heart failure. In addition to drug therapy, sodium restriction is usually one of the first dietary restrictions placed on a person with ESRD. See Table III.
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Bratwurst |
Bacon (2 sl/serv) |
Beef |
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Bologna |
Bologna, low sodium |
Chicken |
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Lamb |
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Cheese, 1 oz 3x/wk |
Pork (fresh) |
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Corned beef |
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Turkey |
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Ham, salt pork |
Veal |
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Sausage |
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Salami |
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Hot dogs |
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Spam |
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Tuna fish, regular |
Tuna, water packed |
Tuna, low sodium |
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Soups, regular |
Soups, reduced sodium |
Soups, low sodium |
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Boxed, prepared dishes |
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Garlic salt |
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Garlic powder or fresh |
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Celery salt |
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Celery, fresh |
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Onion salt |
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Onion, fresh or dried flakes |
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Lowrey's Seasoned Salt |
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McCormick's Seasoned Salt |
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Olives, black & green |
Catsup |
Mustard |
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Pickles, Pickle relish |
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Sauerkraut |
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Vinegar & oil |
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Salad dressing, regular |
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Low fat, low salt dressings |
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Potato chips |
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Nuts, salted |
peanut butter |
Nuts, unsalted |
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Pretzels, regular |
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Pretzels, unsalted |
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Saltines, regular |
Saltines, unsalted |
Crackers, unsalted |
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Pizza (fast food) |
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Homemade pizza with appropriate toppings |
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All sauces |
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Soy, Bar-B-Q, steak |
Sweet sour sauce |
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Calcium
In order for calcium to be absorbed and utilized by the body, the active form of vitamin D [1,25 (OH)2D3] must be present.
In ESRD, the kidneys are unable to produce the active form of vitamin D, resulting in hypocalcemia, hyperphosphatemia, hyperparathyroidism, and eventually, the development of osteodystrophy.
All renal diets are low in calcium since foods high in calcium also contain large amounts of phosphorus and potassium. Therefore, supplemental calcium and the active form of vitamin D is prescribed.
Phosphorus
Urine phosphorus excretion remains relatively constant until the GFR falls to approximately 25 mL/min. When excess phosphorus accumulates in the blood, a chain reaction is set off, i.e., production of the active form of vitamin D is suppressed, less calcium is absorbed and excess PTH is excreted to remove excess phosphorus. (As the kidney deteriorates, it is unable to make the active form of vitamin D and this aggravates the above problem). If this cycle continues as it does in persons with ESRD, the results is hyperparathyroidism and osteodystrophy.
To prevent high levels of phosphorus, phosphorus binding drugs are given along with a diet restricted in high phosphorus-containing foods. See Table IV.
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Coke |
Milk, 1/2 c/d |
7-Up |
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Pepsi |
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Gingerale |
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Dr. Pepper |
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Vernors, Hawaiian Punch |
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Kool-aid |
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Lemonade, frozen or powdered |
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Limeade, frozen or powdered |
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Tea |
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Biscuits |
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French toast |
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Pancakes |
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Waffles |
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Bran Muffins |
Plain muffins |
Plain donuts |
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Bran cereals |
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Alpha bits, cornflakes |
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Cheerios |
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Rice Krispies |
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Oatmeal |
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Puffed Wheat & Rice |
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Whole grain breads |
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White bread |
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Dried peas or beans |
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Baked beans |
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Green or wax beans |
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Lima beans |
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Cabbage |
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Soy beans |
Tofu or soybean curd |
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Cheese 1 oz |
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Peanut butter, 2 T two |
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Magnesium
Most magnesium is bound to protein. When protein (albumin) levels are low, magnesium levels appear to be low. However, with decreased urine excretion, magnesium can become elevated. Vitamin D has no effect on the bioavailability of magnesium; however, decreased amounts of calcium can cause increased absorption of magnesium. Also, antacids and laxatives, secondary to their composition, can cause elevated levels of magnesium. There is no dietary restriction of magnesium at this time.
Vitamin D
One of the major functions of the kidney is the conversion of vitamin D to the active form of vitamin D [1,25 (OH)2D3]. Persons with ESRD are not able to produce the active form of vitamin D. As mentioned previously, the result is hypocalcemia, hyperphosphatemia, hyperparathyroidism and renal osteodystrophy.
The active form of vitamin D is made available to persons with ESRD through pharmaceutical companies. However, it must be monitored very closely to prevent calcification of soft tissue secondary to elevated levels of calcium and phosphorus.
Vitamins
Clients with chronic renal failure are at risk for developing deficiencies of water-soluble vitamins secondary to decreased intake, altered metabolism, and dialysis losses. These vitamins must be supplemented as needed.
The fat soluble vitamins include A, E & K (D is discussed above). Vitamin A is absorbed by the small intestine and transported to the liver where it is stored. Persons with ESRD may have elevated levels of vitamin A and thus must not take supplements containing this vitamin. Deficiencies of vitamin E are uncommon due to the widespread dietary availability of this vitamin. However, because this vitamin is bound to protein, low protein intake may require dietary supplementation. Vitamin K is recommended for clients who are on antibiotic therapy and who are not eating.
Iron
Iron deficiency is common in persons with ESRD due to:
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-occult blood losses in the intestine |
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-blood loss due to hemodialysis |
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-loss from the binding of iron to the dialysis membranes |
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-decreased production of erythropoietin (EPO) |
EPO is a hormone produced by healthy kidneys to stimulate the bone marrow to produce red blood cells. It is not produced by diseased kidneys.
EPO therapy is available for ESRD persons. It is usually given
in conjunction with iron, because EPO therapy does not respond
when iron deficiency exists. Iron deficiency is highly probable
because of increased utilization and rapid depletion of iron
stores following EPO therapy. Clients receiving EPO need 100 mg
iron supplement to maintain serum ferritin and transferrin
saturation close to normal levels.
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Protein |
.6-.8 g/kg/d |
1.2-1.5 g/kg/d |
1.1-1.4 g/kg/d |
1.3-2.0 g/kg/d |
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Calories |
>35 kcal/kg/d |
25-35 kcal/kg/d |
30-35 kcal/kg/d |
30-35 kcal/kg/d |
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Sodium |
1-3 gm/d when Na/fluids are retained |
3-4 gm/d when Na/fluids are retained |
2-3 gm/d when Na/fluids are retained |
2-4 gm/d when Na/fluids are retained |
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Potassium |
2800 mg when serum elevated |
unrestricted unless serum elevated |
1600-3000 mg when serum elevated |
2400-3000 mg when serum elevated |
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Phosphorus |
8-12 mg/kg/d |
15 -17 mg/kg/d |
15 -17 mg/kg/d |
RDA; may need supplementation until serum levels normalize |
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Calcium |
1200-1600 mg/d |
Depends on serum levels |
Depends on serum levels |
800-1500 mg/d |
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*Modified from The American Dietetic Association
National Renal Diet: Professional Guide (1993) |