Chronic Kidney Disease

CKD: Macronutrients: Executive Summary of Recommendations (2020)

Executive Summary of Recommendations 
Below are the recommendations and ratings for the Academy of Nutrition and Dietetics 2020 Chronic Kidney Disease (CKD) Macronutrient Evidence-Based Nutrition Practice Guideline. Use the links on the left to view the Guideline Introduction. Detailed recommendations, including the evidence supporting these recommendations, is available from the Major Recommendations tab.

  • For  a description of the Academy Recommendation Rating scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.
  • For a description of the GRADE Recommendation Rate scheme (Level 1 (1A, 1B, 1C, 1D), Level 2 (2A, 2B, 2C, 2D), click here

  • Nutrition Intervention
    CKD: Dietary Patterns: Mediterranean Diet
    In adults with CKD 1-5 not on dialysis or posttransplantation, with or without dyslipidemia, we suggest that prescribing a Mediterranean Diet may improve lipid profiles (2C).
    Weak
    Conditional
    CKD: Dietary Patterns: Fruits and Vegetables
    In adults with CKD 1-4, we suggest that prescribing increased fruit and vegetable intake may decrease body weight, blood pressure and net acid production (NEAP) (2C).
    Weak
    Conditional
    CKD: LC n-3 PUFA Nutritional Supplements for Lipid Profile, Maintenance Hemodialysis
    In adults with CKD 5D on MHD, we suggest that 1.3-4 g/d LC n-3 PUFA may be prescribed to reduce triglycerides and LDL cholesterol (2C) and raise HDL levels (2D).
    Weak
    Conditional
    CKD: LC n-3 PUFA Nutritional Supplements for Lipid Profile, Peritoneal Dialysis
    In adults with CKD 5D on PD, it is reasonable to consider prescribing 1.3-4 g/d LC n-3 PUFA to improve the lipid profile (OPINION).  
    Consensus
    Conditional
    CKD: LC n-3 PUFA Nutritional Supplements for Lipid Profile, Non-dialyzed
    In adults with CKD 3-5, we suggest prescribing ~2g/d LC n-3 PUFA to lower serum triglyceride levels (2C).
    Weak
    Conditional
    CKD: LC n-3 PUFA Nutritional Supplements for Mortality and Cardiovascular Disease, Maintenance Hemodialysis and Post-Transplant
    In adults with CKD 5D on MHD or posttransplantation, we suggest not routinely prescribing LC n-3 PUFA, including those derived from fish or flaxseed and other oils, to lower risk of mortality (2C) or cardiovascular events (2B).
    Fair
    Imperative
    CKD: LC n-3 PUFA Nutritional Supplements for Mortality and Cardiovascular Disease, Peritoneal Dialysis
    In adults with CKD 5D on PD, it is reasonable to not routinely prescribe LC n-3 PUFA, including those derived from fish or flaxseed and other oils, to lower risk of mortality or cardiovascular events (OPINION).
    Consensus
    Conditional
    CKD: Protein Restriction, Non-Dialysis, Non-Diabetic
    In adults with CKD 3-5 who are metabolically stable, we recommend, under close clinical supervision, protein restriction with or without keto acid analogs, to reduce risk for ESKD/death (1A) and improve quality of life (2C). 
    • a low protein diet providing 0.55 to 0.60 g dietary protein/kg body weight/day , OR
    • a very-low protein diet providing 0.28 to 0.43 g dietary protein/kg body weight/day with additional keto acid/amino acid analogs to meet protein requirements (0.55 to 0.60 g /kg body weight/day)
    Strong
    Conditional
    CKD: Dietary Protein Intake, Maintenance Hemodialysis, Non-Diabetic
    In adults with CKD 5D on MHD (1C) who are metabolically stable, we recommend prescribing a dietary protein intake of 1.0 -1.2 g /kg body weight per day to maintain a stable nutritional status.
    Fair
    Conditional
    CKD: Dietary Protein Intake, Peritoneal Dialysis, Non-Diabetic
    In adults with CKD 5D on PD (OPINION) who are metabolically stable, we recommend prescribing a dietary protein intake of 1.0 -1.2 g /kg body weight per day to maintain a stable nutritional status.
    Consensus
    Conditional
    CKD: Macronutrients: Protein Type
    In adults with CKD 1-5D, there is insufficient evidence to recommend a particular protein type (plant vs animal) in terms of the effects on nutritional status, calcium or phosphorus levels, or the blood lipid profile (1B).
    Strong
    Imperative
    CKD: Macronutrients: Protein Type, Post-Transplant
    In adults with CKD posttransplantation, there is insufficient evidence to recommend a particular protein type (plant vs animal) in terms of the effects on nutritional status, calcium or phosphorus levels, or the blood lipid profile (OPINION).
    Consensus
    Conditional
    CKD: LC n-3 PUFA Nutritional Supplements for AV Graft and Fistula Patency for Maintenance Hemodialysis
    In adults with CKD 5D on maintance himodialysis (MHD), we suggest not routinely prescribing fish oil to improve primary patency rates in patients with AV grafts (2B) or fistulas (2A).
    Fair
    Imperative
    CKD: LC n-3 PUFA Nutritional Supplements for Kidney Allograft Survival
    In posttransplantation adults, we suggest not routinely prescribing LC n-3 PUFA to reduce the number of rejection episodes or improve graft survival (2D).
    Weak
    Conditional
    CKD: Oral Protein-Energy Supplementation for CKD 3-5D
    In adults with CKD 3-5D at risk of or with protein-energy wasting, we suggest a minimum of a 3-month trial of oral nutritional supplements to improve nutritional status if dietary counselling alone does not achieve sufficient energy and protein intake to meet nutritional requirements (2D).
    Weak
    Conditional
    CKD: Oral Protein-Energy Supplementation for Post-Transplant
    In adults with CKD posttransplantation at risk of or with protein-energy wasting, it is reasonable to consider a minimum of a 3-month trial of oral nutritional supplements to improve nutritional status if dietary counselling alone does not achieve sufficient energy and protein intake to meet nutritional requirements (OPINION).
    Consensus
    Conditional
    CKD: Enteral Nutrition Supplementation
    In adults with CKD 1-5D, with chronically inadequate intake and whose protein and energy requirements cannot be attained by dietary counselling and oral nutritional supplements, it is reasonable to consider a trial of enteral tube feeding (OPINION).
    Consensus
    Conditional
    CKD: Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN) Protein-Energy Supplementation
    In adults with CKD with protein-energy wasting, we suggest a trial of total parenteral nutrition (TPN) for CKD 1-5 patients and IDPN for CKD 5D on MHD patients, to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake (2C).
    Weak
    Conditional
    CKD: Dialysate Protein-Energy Supplementation
    In adults with CKD 5D on PD with protein-energy wasting, we suggest not substituting conventional dextrose dialysate with amino acid dialysate as a general strategy to improve nutritional status, although it is reasonable to consider a trial of amino acid dialysate to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake (OPINION). 
    Consensus
    Conditional
    CKD: Protein Restriction, Non-Dialysis, Diabetic
    In adults with CKD 3-5 and who have diabetes, it is reasonable to prescribe, under close supervision, a dietary protein intake of 0.6–0.8 g /kg body weight per day to maintain a stable nutritional status and optimize glycemic control (OPINION).
    Consensus
    Conditional
    CKD: Dietary Protein Intake, Maintenance Hemodialysis and Peritoneal Dialysis, Diabetic
    In adults with CKD 5D and who have diabetes, it is reasonable to prescribe a dietary protein intake of 1.0 -1.2 g /kg body weight per day to maintain a stable nutritional status. For patients at risk of hyper and/or hypoglycemia, higher levels of dietary protein intake may need to be considered to maintain glycemic control (OPINION).
    Consensus
    Conditional
    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.
    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.
    Consensus
    Conditional
 

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