Practice Consideration
The Evidence-Based Nutrition Guidelines for Chronic Kidney Disease have two different protein recommendations for CKD Stage 3 to 5. One recommendation for those individuals WITH diabetes and one for those individuals without diabetes. As you can see in the table below these recommendations are quite similar to those recommended for normal nutrition for healthy adults.
NOTE: The following information sets the context for he nephrologist discussion of the change in philosophy regarding levels of protein restriction.in CKD.
- Historically most patients with CKD used to be prescribed Very Low Protein (sometimes as low as 0.28 gm/kg body weight) and often were prescribed Low Protein (0.5 gm/kg body weight).
- However as shown below these levels are now only recommended for specific subpopulations that are NOT diabetic AND have significantly reduced eGFR. (Check Mei's medical history and laboratory results)
- The current focus is on preventing malnutrition, particularly in patients who are likely to start on dialysis. Having a positive nutrition status is a prime concern and if protein is significantly limited in the time before starting dialysis, the overall nutritional status is more likely to be compromised leading to poorer overall outcomes.
- When dialysis is considered imminent achieving positive nutritional status is more important that attempting to preserve kidney function (Check the physicians consultation request).
- The level of protein is being compared to DRI standards for healthy adults (see first line in table below), NOT usual intake.
- Usual intake of protein in westernized nations usually exceeds the actual "normal" requirements, so even though the level of protein is close to "normal", this may be a protein restriction from USUAL intake.
| Guideline | Recommended Protein Intake |
|
Institute of Medicine Dietary Reference Intakes for Healthy Adults |
Reference Female 51-70 years old — 46 g protein |
| Evidence Based Guideline for Chronic Kidney Disease (EAL) |
0.8 to 0.9 g/kg
eGFR <50 ml per minute per 1.73m2 = 0.6 to 0.8 g/kg body weight
eGFR <20 ml per minute per 1.73m2 = 0.3 to 0.5 g/kg |
| Australian Guidelines for Chronic Kidney Disease | Stage 4 eGFR 15-29 = 0.75 to 1 g/kg IBW/day — 50% from High Biological Value (HBV) protein |
| Nutrition in CKD (UK Renal Association) | Minimum daily protein intake of 0.75 g/kg IBW for Stage 4 to 5 not on dialysis |
|
McCarthy et al, Chronic Kidney Disease and the Nutrition Care Process |
23 to 35 Kcal/Kg 0.8 to 0.9 g/Kg |
| PEN Practical Evidence for Nutrition | 0.60 to 1.0 g.kg body weight Avoid protein intake >1.3 g/kg body weight |
References
1. CKD: Executive Summary of Recommendations (2010). 2010; http://www.andeal.org. Accessed July 30, 2016.
2. Australian Institute of Health and Welfare. Chronic Kidney Disease. http://www.aihw.gov.au/chronic-kidney-disease/. Accessed May 1, 2016.
3. Wright M, Colin J. CLINICAL PRACTICE GUIDELINES: Nutrition in CDK. 2010; 5th 2009-2010:http://www.renal.org/docs/default-source/guidelines-resources/Nutrition_in_CKD_-_Final_Version_-_17_March_2010.pdf?sfvrsn=0. Accessed July 30, 2016.
4. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). The National Academies Press. Washington, DC. Available at http://www.nap.edu . Accessed August 20, 2016.
5. McCarthy MP, Pavlinac JM, Aoun A. Chronic Kidney Disease and the Nutrition Care Process. Chicago, IL: Academy of Nutrition and Dietetics; 2014
5. Key Practtice Points, Nephrology-Chronic Kidney Disease: Non-Dilayzed (Adult). Available at: www.pennutrition.com. Accessed Dec 17, 2016 (By subscription)