patients on two consecutive measurements, phosphorus intake should be restricted, with vitamin D sterol treatments initiated if the restriction fails. Hypophosphatemia after transplant Monitor serum phosphorus levels daily for the first week after transplant. Supplement for phosphorus levels that fall below 2.5 mg/dL.7 RDs also should consider calcium intake in metabolic bone disease. CKD patients should maintain calcium at normal levels between 8.4 to 9.5 mg/dL or the normal range for the laboratory used in all stages of CKD.3 The calcium/phosphate product (the product of the serum calcium level multiplied by the serum phosphate level) is a good way to determine whether a CKD patient has metabolic bone disease. The goal is to stay below a product of 55. If the product is greater than 70, this indicates the presence of osteodystrophy and an increased risk of soft-tissue calcification, especially if the serum PTH is elevated. If calcium is administered when the serum phosphorus level exceeds 5.5 mg/dL, the risk of soft-tissue calcification increases. Calcium absorption can be altered by age, vitamin D status, gastrointestinal transit times (eg, gastroparesis, celiac disease, irritable bowel disease), decreased phosphorus intake, and decreased stomach acids as seen with peptic ulcers. Good sources of calcium include darkgreen leafy vegetables, sardines, clams, oysters, canned salmon, soybeans, rhubarb, spinach, chard, fortified orange juice, milk products, and antacids.24 Vitamin D guidelines from the Academy can be found in Table 5, below. 17 Table 5: Academy Vitamin D Recommendations17 Stages 1 and 2 CKD Use a daily multivitamin to help correct deficiencies. Stages 3 to 5 CKD without metabolic bone disease Maintain vitamin D at a level greater than 30 ng/mL and PTH between 150 and 300 pg/mL. Begin vitamin D2 therapy once serum levels fall below target levels for prevention. Never initiate vitamin D therapy if the serum calcium level is greater than 9.5 mg/dL and the serum phosphorus level is greater than 4.6 mg/dL. Monitor serum calcium and phosphorus levels every three months. If the serum calcium level increases above 10.2 mg/dL at any time, discontinue vitamin D therapy. If the serum phosphorus level increases above 4.6 mg/dL, add or increase phosphote binders and continue vitamin D therapy. Once vitamin D levels are replenished, discontinue vitamin D therapy in favor of a daily multivitamin with vitamin D and continue to monitor calcium and phosphorus every three months. Although osteomalacia (softening of the bones because of a lack of vitamin D or the body’s inability to break down and use this vitamin) is uncommon in CKD patients, it can occur. RDs need to be aware of current practice recommendations, although the majority of the recommendations from the Academy’s Evidence Analysis Library are opinion based and should be used with caution. Because of the lack of vitamin D resulting in elevated PTH levels, RDs should increase serum phosphate levels, within reason, by liberalizing the diet and adding vitamin D2 or D3 to improve bone markers.3,17 Osteomalacia guidelines from the Academy are as follows17: · For stages 1 to 4, treat with phosphorus and vitamin D2 or D3 supplements. · For stages 1 to 4, increase phosphorus supplements until serum levels normalize. · If this treatment fails in stage 5 CKD patients, consider treating with vitamin D sterol. 5. Suggest Recommendations for Fat, Sodium, Potassium, and Fluid Intake Fat intake: There are no studies looking at fat modification’s effect on CKD progression. However, there is limited evidence to recommend a low-fat (30%), low-cholesterol (fewer than 300 mg) diet in transplant patients with elevated fasting lipids. There also is preliminary evidence that fish oil and omega-3 fatty acid supplements decrease oxidative stress and improve fasting lipids in CKD patients.17 While current recommendations suggest that all CKD patients follow a low-fat, low-cholesterol diet to improve elevated fasting lipid levels, diet alone may not always work. In that case, as an adjunct therapy, omega-3 supplements can be added. Sodium intake: The following guidelines are recommended for sodium intake in CKD patients3,17: · Stages 1 to 4 CKD: 1 g to 3 g/daily · Stages 1 to 4 CKD with hypertension: Fewer than 2.4 g/daily · Stage 5 CKD on dialysis: 750 mg to 1,000 mg/daily · Transplant: Fewer than 2.4 g/daily Adjust and monitor sodium levels based on blood pressure, medications the patient is taking, kidney function, hydration status, acidosis, glycemic control, catabolism, and gastrointestinal complications (nausea, vomiting, and diarrhea). Sources of high levels of sodium include salt, processed foods, and sodium bicarbonate therapy. A discussion of sodium with your patient is not complete without referencing fluid intake (see below). Potassium intake: RDs should monitor potassium levels because a low level can cause muscle cramps and cardiac arrhythmias, the latter of which can lead to death. Serum potassium levels can rise not only after the patients have consumed certain foods, such as bananas, but also with the use of antihypertensive medications (eg, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers) and from poor glycemic control, which leads to potassium being pulled out of cells from the high osmolarity of sugar in