• Albuminuria 
• Hypoalbuminemia
• Hypertension
• Hyperlipidemia 
• Edema

Symptoms

• Excretory
• Endocrine
• Acid-base balance
• Fluid/electrolyte balance

Nutrition Assessment

Obtaining History

• Comorbid conditions
• medications
• hospitalizations
• adequacy of current intake
• changes in oral intake
• GI conditions
• changes in height and weight
• economic status
• socialization
• functional status
• information from the physical exam

3 day food record 

% Weight Loss =

[(UBW- Actual Body Weight/ UBW] x 100

% UBW

(Actual Body Weight/ UBW) x 100

% SBW

(Actual BW/SBW) x 100

% SBW

Terms of Nutritional Status 

<90% - malnutrition

115-130%- mildly obese

130-150%- moderately obese

>150% severely obese

KDOQI Recommendation

If the patient's body weight is less than _______ and more than _________ of the standard body weight as determined by NHANES data, then adjusted edema free body weight should be used. 

95% and 115%

Adjusted Edema Free Body Weight:

BWef + [(SBW-BWef) x0.25]

Amputation Adjustments

•  Entire Arm: 5%
• Upper arm (to elbow): 2.7%
• Forearm: 1.6%
• Hand: 0.7%
• Entire leg: 16%
• Thigh: 10.1%
• Calf: 4.4%
• Foot: 1.5%

Excessive IDWG defined as: 

>5% of body weight

Low IDWG defined as:

Can cause lab values to be falsely _____ due to _______. 

<2% of body weight

high; dehydration

Creatinine is the nitrogenous waste product of _______ metabolism. 

Muscle

Creatinine is unrelated to dietary _______ intake. 

protein

The higher the serum creatinine, the greater the loss of ______ function. 

Kidney

True or False?

A sudden increase in creatinine, along with a change in blood pressure, BUN, and/or potassium levels  may indicate a need to assess dialytic access and change the dialysis treatment plan. 

True

Creatinine: 

CKD Range: 

2-15 mg/dL

High Creatinine may indicate: 

Reference range for creatinine:

• muscle damage
• catabolism
• myocardial infarction
• AKI
• CKD
• inadequate dialysis
• transplant rejection

CKD: 2-15 mg/dL

Low creatinine < _____ in chronic dialysis patients may indicate: 

less than 10 mg/dL

protein/energy malnutrition

muscle wasting

residual renal function

Low levels of albumin may be seen in the following situations:

1. Decreased protein production
2. Increased protein loss
3. Redistribution- during sepsis or ascites
4. Increased peritoneal permeability

_____ can cause high serum albumin levels. 

Dehydration

Albumin reference ranges

_________ is a more accurate measure of protein reserves and response to treatment modalities. 

*less affected by liver disease and dehydration

Transthyretin (Prealbumin)

In dialysis patients, a prealbumin < _______ may indicate malnutrition and an increased risk of mortality. 

Prealbumin reference range: 

15-36 mg/dL

CKD range: >30 mg/dL

High prealbumin may indicate: 

use of corticosteroids

Low prealbumin may indicate: 

liver disease, malnutrition or inflammation

________ is a statistically powerful determinant of albumin level in CKD and may assist clinician in determining between hypoalbuminemia and inflammation

C-Reactive Protein

C-Reactive Protein Reference Range:

Increases during _______

<0.8

**increases during infection

The criteria for the diagnosis of diabetes includes:

1. FPG of 126 mg/dL or greater

2. A1c = 6.5% or greater

3. 2-hr plasma glucose of greater than or equal to 200 mg/dL

4. Random plasma glucose > or equal to 200 mg/dL in a pt with hyperglycemic symptoms

Reasons for high iPTH: 

Reference range for iPTH:

1. hyperparathyroidism
2. non-PTH producing tumors
3. lung or kidney cancer
4. hypocalcemia
5. malabsorption
6. vitamin D deficiency
7. rickets

CKD: 150-300 (KDOQI); 2-9 times the normal limit (KDIGO)

Reasons for low iPTH:

iPTH reference range: 

1. Hypoparathyroidism
2. Hypercalcemia
3. metastatic bone tumor
4. sarcoidosis
5. vitamin D intoxication
6. hypomagnesemia

Reference Range: KDOQI 150-300; KIDGO 2-9x normal limit

Corrected Calcium formula

[(4- reported albumin) x 0.8)] + Reported Calcium

Possible non-dietary causes of hyperkalemia

• metabolic acidosis
• high serum glucose
• insulin deficiency or resistance
• inadequate dialysis
• drug content or interactions (ACE inhibitors, potassium sparing diuretics, cyclosporine, tacrolimus, digitalis toxicity
• Tissue destruction
• Catabolism/starvation
• Concomitant disease
• chronic constipation
• infection
• GI bleed
• Blood transfusion

Potassium reference range: 

3.5-5.5 mEq/L

CKD range: 3.5-6 mEq/L

Calcium reference range: 

9-10.5 mg/dL

CKD range: WNL

3-4.5 mg/dL

CKD Range: WNL

Dialysis toward normal

Hemoglobin reference range

CKD: 11-12 g/dL

Hemoglobin is the oxygen-carrying, pigment portion of erythropoietin.

As kidney function declines, _________ production declines. When erythropoietin declines, production of ________ diminishes. This leads to _______. 

erythropoietin 

erythrocytes

anemia

Oral iron should be taken on an __________ stomach.

Space oral intake at least ______ hours between meals and phosphate binders. 

empty

2

*iron binds to phosphate binders

Iron reference ranges: 

Men: 

Women:

Men: 60-175 ug/dL

Women: 50-170 ug/dL

1. Hemolysis
2. Iron overload

1. iron deficiency
2. decreased iron intake
3. blood loss 

Ferritin measures _______ iron

stored that can be extracted for release

• Iron overload
• blood transfusions
• Marker of inflammation *most common

Men: 12-300 ng/mL

Women: 10-150 ng/mL

CKD Range: Hemodialyis >20 ng/mL; peritoneal >100 ng/mL

• high dietary protein intake
• GI bleed
• decreased clearance of dialysis
• dehydration
• increased catabolism

• Low dietary protein intake
• loss of protein due to emesis or diarrhea
• protein anabolism
• overhydration
• hepatic failure
• residual renal function

Hemodialysis: <1.2

Peritoneal: <1.7

SGA

4 points on a 7 point scale: 

1. Medical: weight loss over the past 6 months, dietary intake, GI symptoms

2. Physical: visual assessment of subcutaneous tissue and muscle mass

Advantages: cost effective, reproducible, validated measurement of malnutrition in pts with CKD