and soybeans can use the majority of nitrogen in a patient’s body, thereby decreasing urea production. Low biological value proteins found in grains, nuts, dried beans, and peas produce more urea than do high biological value proteins because of incomplete amino acid profiles and should be limited. The goal for clinicians is to prescribe as many high biological value proteins as possible to maintain serum albumin levels around 4 g/dL. Also, as when conducting energy calculations, RDs need to consider a patient’s fluid status before making the calculations.17 If the patient has physician approval, exercise might minimize the catabolic effects of restricting protein and can improve the patient’s quality of life. Be aware that as protein intake is adjusted up or down, serum phosphorus levels might be affected since the majority of foods high in protein also contain a significant amount of phosphorus. Although some international agencies recommend using keto-acid supplements in very low protein diets, the Academy and the KDOQI have not approved the use of such supplements for CKD patients.17 As a result, RDs should follow the Academy and the KDOQI recommendations for protein intake without using keto-acid supplements and low-protein diets. While there are some differences between guidelines, the protein intake recommendations of both organizations can be found in Table 3, below.3,5,17 Table 3: Protein Intake Recommendations3,5,17 Stage 1 CKD There are no protein restrictions unless the patient has diabetes. Stage 2 CKD The Academy recommends no protein restriction while filtration is less than 50; the KDOQI recommends beginning protein restriction when the rate is less than 70. Stage 3 to 4 CKD The Academy recommends protein intake of 0.6 to 0.8 g/kg; the KDOQI recommends 0.6 to 0.75 g/kg. There is strong evidence to support maintaining recommendations for protein intake of roughly 0.7 g/kg to prevent malnutrition and kidney disease progression. Patients with diabetes should not be given a protein intake below 0.8 to 0.9 g/kg, as 0.7 g/kg can result in hypoalbuminemia.7 Stage 5 CKD (dialysis) Hemodialysis patients should have a protein intake of 1.1 to 1.2 g/kg; peritoneal dialysis patients should have a protein intake of 1.2 to 1.3 g/kg, which can go as high as 1.5 g/kg because of losses caused by dialysis changes.3 All protein should be 50% to 75% high biological value, or the proportion of absorbed protein in food.7 Nephrotic syndrome Recommendations are for patients to have a protein intake of 0.8 to 1.5 g/kg based on the current inflammatory process involved and the degree of renal failure.5 If a patient is losing more than 5 g of protein through urine, then the protein intake should be decreased to 0.7 g/kg plus 1 g/day for every gram of urinary protein lost above 5 g/day.7 Because inflammation can lower albumin levels, it’s important to note a patient’s appetite and protein intake to determine how much protein will be needed. Acute renal failure For stable patients, protein intake should be 0.8 to 1 g/kg; for unstable patients who are not undergoing dialysis, protein intake should be 0.5 to 0.8 g/kg; and for unstable patients undergoing dialysis, protein intake should be 1 to 2 g/kg.5 Transplant Once the graft is fully functioning, the patient can resume the traditional intake of 0.8 to 1 g/kg of protein for maintenance. 4. Prevent Renal Osteodystrophy and Osteomalacia To prevent renal osteodystrophy, also known as metabolic bone disease, it’s important to maintain the levels of serum phosphorus, calcium, vitamin D, and parathyroid hormone (PTH). RDs should help patients maintain phosphorus levels between 2.7 and 4.6 mg/dL for CKD stages 3 and 4 and between 3.5 and 5.5 mg/dL for stage 5.3 Phosphorus is found in almost all foods at some level, but the most common sources include protein foods, milk products, nuts, legumes, cereals, grains, dark cola, chocolate, cocoa, peanut butter, and beer. Patients who consume cereal will have reduced phosphorus absorption if they consume corn- and oat-based cereals because of their decreased phytase content. Phosphorus therapy is used to treat secondary hyperparathyroidism, which causes renal osteodystrophy and potential soft-tissue calcification.17 Dietary restriction always is the first choice for therapy, and phosphate binders often are used to help lower levels when dietary restriction is not enough. Typically, the use of binders would begin in stages 3 or 4 if serum phosphorus levels or intact PTH is elevated. RDs can adjust these binders with meals and snacks to reach the desired levels. Patients need to be aware that these binders only bind up to 300 to 400 mg/day with maximum dosages. If both dietary restriction and binders fail in the dialysis patient, the last choice of therapy is to increase the dialysis time or flow rate to improve serum levels. Phosphorus guidelines from the Academy can be found in Table 4, below.17 Table 4: Academy Phosphorus Guidelines17 Stages 1 to 2 CKD Phosphorus intake should be 1.7 g/day. Stages 3 to 5 CKD Phosphorus intake should be 0.8 to 1 g/day if serum levels increase in the following situations: above 4.6 mg/dL in stage 3 and 4 CKD patients and above 5.5 mg/dL in stage 5 patients. If serum phosphorus levels are normal but the PTH is above 70 pg/dL in stage 3 CKD patients or above 110 pg/dL in stage 4