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Recommendations Summary

CKD: Macronutrients: Energy Intake (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CKD: Statement on Energy Intake in CKD 1-5D

    In adults with CKD 1-5D (1C) and who are metabolically stable, we recommend prescribing an energy intake of 25-35 kcal/kg body weight per day based on age, gender, level of physical activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation to maintain normal nutritional status.

    Rating: Fair
    Imperative

    CKD: Statement on Energy Intake in Post-Transplant

    In adults with CKD posttransplantation (OPINION) who are metabolically stable, we recommend prescribing an energy intake of 25-35 kcal/kg body weight per day based on age, gender, level of physical activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation to maintain normal nutritional status.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Individualization is the key. There is variation in the actual requirements between individuals. Hence, regular monitoring is important.

    • Conditions of Application

      Special Discussions

      In the context of these recommendations, “metabolically stable” indicates absence of any active inflammatory or infectious diseases; no hospitalization within two weeks; absence of poorly controlled diabetes and consumptive diseases such as cancer; absence of antibiotics or immunosuppressive medications; and absence of significant short-term loss of body weight.

      Implementation Considerations

      • The registered dietitian nutritionist (RDN) should consider a number of factors when determining the energy requirements for adults diagnosed with CKD, and these include the patient’s overall health status, CKD diagnosis and associated therapies, level of physical activity, age, gender, weight status, metabolic stressors, and treatment goals. 
      • Patients should be monitored routinely to assess whether energy requirements are being met satisfactorily. Changes in nutritional status should be treated and the energy prescription modified accordingly.
      • Among patients with CKD 5 on maintenance dialysis (hemodialysis or peritoneal dialysis), there are several factors that may influence energy expenditure, beyond the traditional determinants (age, sex, and fat-free mass), such as hyperparathyroidism, hyperglycemia, and chronic inflammation that should be considered into the overall energy prescription.
      • Energy needs will be variable depending on the health status of the patient, e.g., acutely ill versus chronically managed and overall health goals, weight maintenance, repletion or loss.
      • Energy needs may be different depending on the stage of CKD and its respective treatment (dialysis vs transplantation)
      • Ideal body weight (IBW) is the body weight associated with the lowest mortality for a given height, age, sex and frame size and is based on the Metropolitan Life Insurance Height and Weight Tables and many other methods. [Caution: Not generalizable to the CKD population and data-gathering methods were not standardized.]. The IBW can also be estimated as follows: in males as 50.0 kg + 2.3 kg for each inch over 5 ft (each 2.5 cm over 152.4 cm) and in females as 45.5 kg + 2.3 kg for each inch over 5 ft.

    • Potential Costs Associated with Application

      There are no direct costs related to implementing these recommendation statements.

    • Recommendation Narrative

      Energy metabolism maybe impaired in patients with chronic kidney disease. Hence, maintaining adequate energy intake is necessary to prevent protein-energy wasting. 

      Evidence from ten controlled trials in pre-dialysis population and from 3 studies in maintenance hemodialysis (MHD) patients indicates that energy intake ranging from 30-35 kcal/kg/d helps maintain neutral nitrogen balance and nutritional status (Bellizi et al 2007;  Herselma et al 1996, Mirescu et al 2007; Feiten et al 2005, Prakash et al 2004, Sanchez et al 2010, Williams et al 1991; Kopple et al 1997, Garneata et al 2016, Locatelli et al. 1991, Li et al 2011, Kloppenburg et al 2004, and Kuhlmann et al 1999).  However, it is important to remember that many other factors may influence energy expenditure beyond traditional determinants like age, sex, and fat-free mass.  Some of these factors include hyperparathyroidism, hyperglycemia, and chronic inflammation that should be considered into the overall energy prescription, health status (e.g., acutely ill versus chronically managed), overall health goals, and weight maintenance-repletion or loss.

      There is still paucity of controlled metabolic studies, as well as long-term well-designed outpatient clinical trials studying energy intake in this population.  Results from an old metabolic study examining energy requirements in MHD (sample size = 6) indicated that mean energy intake of 35 kcal/kg/d helped maintain neutral nitrogen balance and body composition (Kopple et al 1969). Another similar study in 6 individuals indicated that average intake of 38 kcal was desirable to maintain neutral nitrogen balance (Slomowitz et al 1989). Recent review articles not included in this evidence review, also suggest that energy intake in the range of 30-35 kcal/kg/d is appropriate to maintain maintains neutral nitrogen balance and nutritional status (Kalantar-Zadeh et al 2017, Fouque et al 2007).

    • Recommendation Strength Rationale

      The evidence supporting these recommendations is based on Grade III evidence and opinion of expert workgroup.

    • Minority Opinions

      Consensus reached.