Anemia associated with CKD is due to inadequate production and release of the hormone ________. 

This hormone promotes the production of ____________. 

1. Erythropoetin (EPO)

2. Red blood cells 

1. Hemolysis

2. blood loss

3. lack of erythropoietin production

4. inadequate iron intake

KDOQI Recommendations for Calcium 

• Serum calcium levels should be kept within normal laboratory ranges
• Use corrected calcium when albumin is <4
• Intake of elemental calcium should not exceed 1500 mg/d from phosphorus binders and no more than a total of 2,000 mg/d including dietary intake 
• Serum calcium levels must be monitored, especially when active Vitamin D is being given to prevent hypercalcemia 
• Serum calcium levels are NOT accurate indicators of soft tissue calcification 

• meet current education and nutrition needs
• assist pt in meeting body weight criteria for transplantation 

(Up to 8 weeks after transplant)

• Support the increased metabolic demands of surgery and high dose immunosuppressives 
• develop plan for nutritional rehabilitation

• Nutrition management of complications related to long-term immunosuppressive therapy (i.e. diabetes, CVD)

Research indicates that __________ measured as ________ is a stronger predictor of all-cause and cardiovascular death than _____ in the general population and in renal transplantation 

1. central obesity
2. waist-to-hip ratio
3. BMI

Inflammation leads to:

1. Increased weight loss
2. decreased serum albumin
3. decreased appetite

• cytokines
• hypoalbuminemia 

KDIGO Guideline: 

Standard amino acid parenteral nutrition formulations should be used in AKI 

*True or False?

A: True

**There is insufficient evidence to support using essential amino acid (EAA) PN formulations at this time with AKI. 

KDIGO Guideline: 

Intradialytic parenteral nutrition should not be used as a nutritional supplement in malnourished CKD 5 hemodialysis patients. 

True or Flase?

AKI and sepsis can increase energy needs by ______%

30%

KDIGO Guidelines: AKI

____________ should be used to evaluate energy needs when possible. 

Indirect calorimetry 

KDIGO Guideline: AKI

Patients w. renal failure who require nutrition support therapy should receive ______________ if intestinal function permits. 

enteral nutrition

*EN can be administered in the majority of pts. with AKI

*In malnourished patients with AKI, pts who received PN had a greater mortality and infection rates than those with EN

KDIGO Guideline: AKI

Pts with AKI treated with HD may demonstrate positive nitrogen balance while receiving _____ g/kg/d of protein, but protein intake up to _______ g/kg/d may be needed to achieve positive nitrogen balance or normal amino acid profiles in pts. receiving continuous renal replacement therapy (CRRT). 

1. 1.5 g/kg/d
2. 2.5 g/kg/d

Trauma patients with AKI that were treated with PN and CRRT had profound losses of ____________ and ___________ in the dialysate effluent. Nutritional intervention: Add ________ and ________ during dialysis. 

Calcium and Magnesium

Calcium and Magnesium

KDIGO Guidelines: CKD Stages 1-5

In both diabetic and non-diabetic patients, begin using blood pressure lowering meds when urine albumin excretion is __________ and consistent BP readings of ___________. 

1. <30 mg/24 hr

2. 140/90

1. > 30 mg/24hr

2. 130/80

KDIGO Guideline: CKD 1-5

Use ACE and ARBs when albuminuria is >_______

>300 mg/24hr

KDIGO Guideline: CKD Stage 1-5

Clinician should monitor GFR and albuminuria at least ______________. 

KDIGO Guidelines: CKD 1-5

Use BP lowering agents in children when BP is consistently above the ______ for age, sex, and height. Goal of BP treatment in kids is to consistently get BP readings at or below the _______ for age, sex, and height. 

1. 90%

2. 50%

KDIGO Guideline: CKD stages 1-5

In stages 4 and 5, reduce protein intake to ______, regardless of presence of diabetes. 

<0.8 g/kg/day

KDIGO Guidelines: CKD 1-5

A1C goal: _________

Recommend > ______ for individuals with ______, ________, __________. 

1. <7.0
2. >7.0 comorbidities, limited life expectancy or risk of hypoglycemia 

KDIGO Guideline: CKD 1-5

Salt Intake; lower to ______ unless contraindicated

<2 grams/day

KDIGO Guidelines: Anemia

Hemoglobin Goals: 

Males:

Females:

Children 0.5-5 years: 

Children 5-12 years: 

Children 12-15 years: 

Males: <13.0 g/dl

Females:<12.0 g/dl

Children 0.5-5 years: <11.0 g/dl

Children 5-12 years: <11.5 g/dl

Children 12-15 years: <12.0 g/dl

KDIGO Guidelines: CKD Stages 1-5

Frequency of measuring hemoglobin to assess anemia

GFR >60: 

GFR 30-59: 

GFR <30:

CKD 5: 

GFR >60: when clinically indicated

GFR 30-59: annually 

GFR <30: twice per year

CKD 5: measure at least every 3 months when on HD or PD

KDIGO Guidelines: CKD Metabolic Bone Disease

Optimal PTH is unknown. If PTH is intact and above the upper limit evaluate for _____________, ____________, and _______________.

1. Hyperphosphatemia
2. Hypocalcemia
3. vitamin D deficiency 

KDIGO Guidelines: CKD Bone Mineral Disorder 

When GFR reaches <45, measure serum levels of _____, ______, _____, ______ at least once for baseline. 

1. calcium
2. PTH
3. Alkaline phosphatase
4. phosphate

KDIGO Guideline: CKD Bone Mineral Disorder

True or False? 

Do not perform bone mineral density testing

KDIGO Guideline: CKD Bone Mineral Disorder

Do not prescribe bisphosphonates in people with GFR < __.

KDIGO Guidelines: CKD Metabolic Bone Disease

Do not routinely prescribe _______ or ________ without documented vitamin D deficiency in CKD pts not on dialysis. 

KDIGO Guidelines: 

Supplement with oral ___________ when serum bicarbonate is < _______. 

bicarbonate

22 mmol/L

KDIGO Guidelines: anemia

Avoid IV iron when there are active _______________. 

KDIGO Guidelines: anemia

Treat anemia with IV iron when an increase in ____ is desired AND Tsat is < _______ and ferritin is < ______.  

1. hemoglobin
2. 30%
3. 500

KDIGO Guidelines: Anemia

Treating anemia with pts that are taking an ESA (but no oral iron). 

Use a trial of IV iron if an increase in _______ is desired OR a decrease of ________ is desired and TSat is < _____ and ferritin is <______.

1. Hemoglobin
2. ESA
3. 30%
4. 500

KDIGO Guidelines: Anemia

Evaluate TSAT and Ferritin every _______ months during ESA therapy. 

KDIGO Guidelines: Anemia 

Address all correctable causes of anemia before starting ESA therapy. What are correctable causes of anemia?

1. 

2. 

1. Iron deficiency 

2. inflammation 

KDIGO Guidelines: Anemia

Avoid using ESAs in CKD patients when Hgb is > ____.

KDIGO Guidelines: Anemia

Do not use ESA therapy to maintain Hgb > ______

KDIGO Guidelines: Anemia

In all adult pts, ESA's should not be used to raise the Hgb above ______ g/dL

KDIGO Guidelines: Anemia

In all pediatric patients the Hgb goal with ESAs is ______. 

KDIGO Guideline: Anemia

ESA Administration: 

CKD 5D:

CKD 5ND and 5 PD: 

CKD 5D: IV or subcutaneous; measure Hgb monthly

CKD 5ND and 5 PD: subcutaneous; measure Hgb every 3 months

KDIGO Guideline: Anemia

Do NOT use androgens, vit c, vit D, vit E, folic acid, L-carnitine, and pentoxifylline as adjuvants to ESA therapy. 

True or False: 

KDIGO Guidelines: Blood pressure management in CKD

Goals for non-dialysis dependent CKD 

• Individualize BP targets and agents according to age, co morbidities, CVD risks, risk of CKD progression, presence of retinopathy and tolerance of treatment. 
• Achieve and maintain a healthy weight (BMI 20-25)
• Reduce salt intake to <2 grams/day (90 mmol)
• Exercise 30 minutes/day at least 5 days per week
• Limit alcohol intake

KDIGO Guidelines: Blood Pressure Management

Guidelines for CKD ND with or without diabetes:

1. When to treat: 

2. Which medications?

1. When urine albumin excretion is <30 and BP readings are consistently >140/90, begin BP lowering meds
2. When urine albumin excretion is 30-300 and BP readings are consistently >130/>80, begin BP meds
3. ACE and ARBs 

KDIGO Guidelines: Blood Pressure management

Transplant Patients

Kidney transplant patients whose BP is consistently >____/>_____ should be treated with BP lowering drugs, regardless of __________. 

>130/>80

urine albumin excretion

KDIGO Guidelines: Blood Pressure Management

When choosing a BP lowering drug for transplant patients, consider timing of transplantation, use of calcineurin inhibitors, presence of absence of persistent albuminuria and other co-morbid conditions. 

Which antihypertensive medications should be first line therapies in transplant patients?

Calcium Channel Blockers

ARBs

Blood pressure management in children with CKD

Use blood pressure lowering agents when BP readings are consistently >______% for age, sex and height

Strive to achieve consistent systolic and diastolic readings < _________ for age, sex and height. 

___ and ____ should be first line therapy for BP in children

90%

50%

ACE and ARBs

KDIGO Guidelines: CKD and Diabetes

Within 2 to 4 weeks of medication initiation (or dose changes) in ACE or ARBS check ________, ___________, __________. 

Continue ACE or ARB therapy unless ________ rises by more than _________ within 4 weeks following initiation of therapy. 

1. Blood pressure
2. serum creatinine 
3. serum potassium

• serum creatinine 
• 30%

KDIGO Guidelines: CKD and Diabetes

Measure A1C at least _____ per year or as often as _____times/year if A1C goal is not achieved or if changes in medication doses. 

True or False?

Accuracy of A1C measurements decreases as GFR declines. 

KDIGO Guidelines: CKD and Diabetes

A _________________________can be used to index glycemia when A1C is not reliable. 

KDIGO Guidelines: CKD and Diabetes

A1C target for CKD ND DM patients: 

Use _____ and ____ to achieve this goal. 

A1C of 6.5-8.0%

SMBG and CGM

KDIGO Guidelines: CKD and Diabetes

1. Protein intake recommendation for CKD ND w/ diabetes:

2. Protein intake recommendation for CKD HD and PD w/ diabetes: 

1. 0.8 g/kg/day
2. 1.0-1.2 g/kg/day

KDIGO Guidelines: CKD and Diabetes

Base Drug Therapy: 

Metformin and SGLT-2 Inhibitors (gliflozins)

Examples of gliflozins: Invokana, Jardiance, Steglatro, Farxigo

________ is the first line of therapy for DM in CKD w/ GFR > 30 and in kidney transplant 

What is the preferred SGLT-2 med in CKD pts. with diabetes?

KDIGO Guidelines: CKD-MBD Recommendations

In CKD G3a-G3b check _______ and _______ every __________ and ________ based on baseline level. 

1. serum calcium
2. phosphate
3. 6-12 months
4. PTH

KDIGO Guidelines: CKD MBD Recommendations

In CKD 4 check ___________ and __________ every __________ and PTH every _________. 

1. serum calcium
2. phosphate
3. 3-6 months
4. 6-12 months

KDIGO Guidelines: CKD MBD Recommendations

In CKD 5, including CKD 5D, check __________ and ___________ every _________ and PTH every __________. 

1. serum calcium
2. phosphate
3. 1-3 months
4. 3-6 months

KDIGO Guidelines: CKD MBD Recommendations

In CKD 4-5D check ______________ every _______ months or more frequently with elevated PTH. 

1. Alkaline phosphatase
2. 12 months 

KDIGO Guidelines: CKD MBD Recommendations

In CKD 3a-G5D check __________ levels and repeat testing as necessary based on baseline levels. Correct vitamin D deficiency and insufficiency as you would with the general population. 

25(OH)D 

Calcidiol

KDIGO Guidelines: CKD and MBD Recommendations

Treatment goals:

1. Treatment should be based on serial assessments of phosphate, calcium, and PTH
2. Goal is lower serum phosphate towards normal level; avoid hypercalcemia 
3. In pts receiving phosphate lowering agents, suggest restricting calcium-based phosphate binders

KDIGO Guidelines: CKD and MBD Recommendations 

For patients on dialysis, suggest using a dialysate calcium concentration of __________ to __________. 

1.25 to 1.50 mmol/L

2.5-5 mEq/L

KDIGO Guidelines: CKD and MBD Recommendations

Avoid long term use of ___________ and in CKD 5D patients, avoid using dialysate _______contamination to prevent _________ toxicity. 

In patients with CKD 3a-G5 (not on dialysis)

Optimal PTH is unknown. For patients whose iPTH is progressively rising or persistently above the upper limit evaluate for modifiable risk factors: 

1. hyperphosphatemia
2. hypocalcemia
3. high phosphate intake
4. vitamin D deficiency 

KDIGO Guidelines: CKD and MBD Recommendations

Suggest not routinely using ______ and ________ in individuals w. CKD 3a-5 (not on dialysis). 

KDIGO Guidelines: CKD and MBD Recommendations

In patients with CKD 5D requiring iPTH lowering therapy, suggest ___________, ______, ________ or a combination of _________ with _______ or ________. 

1. calcimimetics
2. calcitriol
3. vitamin D analogs
4. calcimimetics w/ calcitriol or vitamin D analogs 

EAL: Assessment of Food/Nutrition Related History 

What should be assessed in the food/nutrition related history?

1. Food and nutrient intake
2. Medication (prescription, OTC, dietary supplements, herbal/botanical use)
3. Knowledge, beliefs, attitudes (readiness to change nutrition lifestyle behaviors)
4. Behavior
5. Factors affecting access to food and food/nutrition related supplies 

Subjective Global Assessment

4 items used to assess nutritional status: 

1. Weight change over past 6 months
2. dietary intake and GI symptoms
3. visual assessment of subcutaneous tissue 
4. Muscle mass 

Individuals who are ____ to ____ of SBW are considered mildly obese. 

Those between _____ and _____ of SBW are considered moderately obese

Those above ______ of SBW are considered severely obese. 

• 115-130%
• 130-150%
• >150%

90-110%

800-1000 mg/day

Or

10-12 mg phos/gram protein

HypO________ is common post transplant. RD should prescribe a high ______ intake (diet or supplements).

Hypophosphatemia

Phosphorus

Hyperparathyroid and Mixed Bone Disease treatment

In CKD pts 3-4 who have plasma levels of iPTH over 70 pg/ml or over 110 pg/ml on more than two consecutive measurements, dietary phosphate intake should be restricted. If this is ineffective in lowering plasma PTH levels, _______ or one of its analogs ________ should be given to prevent or ameliorate bone disease. 

30 ng/ml

Vitamin D2 (ergocalciferol)

Post transplant 

3 years

Interpretation of Biochemical Data

Albumin

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range: 3.5-5.0

CKD range? WNL for laboratory 

Interpretation of abnormal values: 

*High: may indicate severe dehydration

*Low: may indicate fluid overload, infection, chronic liver disease, steatorrhea, nephrotic syndrome, protein-energy malnutrition, inflammatory GI disease

Interpretation of Biochemical Data

Alkaline Phosphatase

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range? 30-85 IU/L

CKD range? WNL

Interpretation of abnormal values: 

*High: May indicate renal osteodystrophy, malignancy, healing fractures, or liver disease

*Low: may indicate congenital hypophosphatemia or nephrotic syndrome

Biochemical Data

Aluminum

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range? <7 mcg/L

CKD range? <20 mcg/L

Interpretation of abnormal values: 

*High: May indicate ingestion of aluminum containing medications. Other possible sources of aluminum include parenteral fluids, injections, antiperspirants, or dialysates

If >60 mcg/L perform deferoxamine (DFO) test

Biochemical Data

B-12

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range? 100-700 pg/mL

CKD range? WNL

Interpretation of abnormal values: 

*High: May indicate leukemia, polycythemia vera, or severe liver dysfunction 

*Low: may indicate pernicious anemia, atrophic gastritis, malabsorption syndrome, inflammatory bowel disease, or vitamin C or folic acid deficiency 

Biochemical Data

Blood Urea Nitrogen (BUN)

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range? 10-20 mg/dL

CKD range? 60-80 mg/dL

Interpretation of abnormal values: 

*High: May indicate GI bleeding, dehydration, hypercatabolism, congestive heart failure, transplant rejection, inadequate dialysis, excessive protein intake 

*Low: may indicate liver failure, over hydration, malabsorption, acute protein intake, elevated secretion of anabolic hormones, residual renal function 

Biochemical Data

Creatinine

Reference Range?

CKD range?

Interpretation of abnormal values: 

*High: 

*Low:

Reference Range? Women 0.5-1.1; men 0.6-1.2

CKD range? 2-15  mg/dL (based on muscle mass, GFR, and/or dialysis clearance)

Interpretation of abnormal values: 

*High: May indicate muscle damage, catabolism, myocardial infarction, acute kidney injury, chronic kidney disease, inadequate dialysis, or transplant rejection

*Low:<10 mg/dL in chronic dialysis may indicate protein-energy malnutrition/muscle wasting or residual renal function

MNT Recommendations: CKD 1-5 ND

Energy, kcal/kg

MNT Recs CKD 1-5 ND

Sodium g/d

Sodium

<2.4 g/d 

MNT Recs CKD 1-5 ND

Phosphorus mg/day

Stages 1-2: 1700 mg/day

Stages 3-5: 800-100 mg/day

MNT Recs CKD 1-5 ND

Calcium g/d

Calcium 

Stages 1-2: N/A

Stages 3-5: <2.0 g/day

No more than 1.5 g/day from binders in CKD 5

MNT Recs CKD 1-5 ND

Potassium

Stages 1-2: >4

Stages 3-5:  <2.4

MNT Recs CKD 1-5 ND

Protein 

Stages 1-2: 1.4 g/kg/day

Stages 3-5 ND: 0.6-0.8

Stages 3-5 ND with diabetes: 0.8-0.9

MNT Recs CKD 1-5 ND

% calories from carbohydrate

MNT Recs CKD 1-5 ND

Fiber g/day

Stages 1-5: 20-30 grams/day

5-10 grams from soluble fiber

MNT Recs CKD 1-5 ND

Cholesterol 

Lipid Treatment Goals: Stages 1-5 ND

Total Cholesterol

150-180 mg/dl

Lipid Treatment Goals: Stages 1-5 ND

HDL

Men >40 mg/dL

Women > 50 mg/dL

Lipid Treatment Goals: Stages 1-5 ND

Triglycerides

<200 mg/dl

Lipid Treatment Goals: Stages 1-5 ND

LDL

<100 mg/dL

<70 mg/dL may be recommended for patients with diabetes

Lipid Treatment Goals: Stages 1-5 ND

non HDL 

(Total cholesterol - HDL)

<130 mg/dL (for patients with TG > 200)

Vitamin D supplementation is recommended if a patients 25-hydroxyvitamin D is less than _______. 

Supplement with ______ IU's of _________

30 ng/ml

800-1,000 cholecalciferol (D-3) per day

CKD Stage 1-5 ND

No B12 supplementation is necessary unless protein intake is < ___________

KDOQI Guidelines for parathyroidectomy

• PTH > 800 pg/mL
• Hypercalcemia and hyperphosphatemia that does not respond to medical treatment

1.3-2.0 

reverse negative nitrogen balance and boost muscle mass

<100 ng/ml

<20%