the bloodstream.3 Evaluate medications and glycemic control if a patient presents with hyperkalemia but has optimal potassium intake. Advise people with diabetes to treat hypoglycemia with cranberry, grape, or apple juices; glucose tablets; or 10 small jelly beans instead of using high-potassium alternatives such as orange juice. RDs should educate patients to avoid salt substitutes, milk, potatoes, coffee, tomatoes, and orange and grapefruit juices to help regulate their potassium levels. If patients find it difficult to give up potatoes, RDs should recommend soaking the potatoes to decrease potassium content and slice them in a way that maximizes the surface exposure to large volumes of water. Advise patients to soak potatoes at room temperature for at least 30 minutes and then boil them in a large volume of water. This might decrease the potassium content down to 100 to 200 mg per 1 /2-cup serving. To maintain potassium levels between 3.5 and 5.5 mEq/L, patients should consume at least 4 g of potassium daily for stages 1 and 2 CKD or fewer than 2.4 g daily for stages 3 to 5 and transplant recipients. If a patient develops skeletal muscle cramps associated with potassium alterations and dialysis treatments, RDs may want to recommend carnitine supplements since the kidneys are the main site for carnitine synthesis.5 Carnitine facilitates the transfer of long-chain fatty acids into cellular structures, including mitochondria,3 and these acids are the major fuel source for skeletal and myocardial muscles. When patients develop CKD, carnitine synthesis decreases, and muscles can cramp because of inadequate fuel. Carnitine supplementation may increase free and acyl carnitine levels, improve a patient’s capacity for physical activity, and decrease dialysis-related symptoms, including muscle cramps. However, RDs should use carnitine only in patients with disabling muscle weakness, cardiomyopathy, or hypotension when current treatments fail to work. Oral supplementation is 0.8 g/day and can be less expensive than some medical treatments; however, the intestinal absorption of the carnitine is unpredictable. If supplementation is indicated in stage 4 or 5 CKD, RDs can infuse 10 to 20 mg/kg of carnitine at the end of dialysis treatments three times per week. If there is no improvement at the end of three to six months, RDs should discontinue the carnitine supplement.17 Fluid intake: Fluids are important to consider in nutrition assessment, as they can alter the outcome of medical nutrition therapy in CKD. Since the kidneys are responsible for water homeostasis, as stated above, patients with CKD either can become edematous from too much fluid intake or dehydrated from too little intake while on diuretics for blood pressure control. Weight changes can affect how RDs assess calorie and protein intake. As previously mentioned, it’s important to know from the outset the actual dry weight of a CKD patient to accurately calculate nutrition requirements. The amount of fluid intake differs greatly depending on the patient’s stage of CKD. Consider the following: · Stages 1 to 4 CKD: Unless specified by a physician, patients with stages 1 to 4 CKD do not have to limit their fluid intake if they do not have other comorbid conditions, such as heart failure or polycystic kidney disease. Fluid restrictions for CKD patients with these conditions can be from 1,500 to 3,000 mL/day based on a patient’s dry weight.3,5,17 Maintaining proper fluid intake in these stages is important because CKD patients are taking diuretics to control blood pressure and need to maintain as much kidney function as possible. · Hemodialysis: Since hemodialysis patients undergo dialysis only three times per week, it’s important that they don’t consume excessive fluid, which could lead to pulmonary edema or congestive heart failure. Two sources recommend that hemodialysis patients consume only 1,000 mL of fluid plus an equal amount for the urine they produce.3,17 Another source suggests they consume only 750 to 1,500 mL daily.5 · Peritoneal dialysis: Because peritoneal dialysis patients typically dialyze every day,3 their fluid intake is not as restricted as it is for hemodialysis patients. Cyclic peritoneal dialysis patients should consume 1,000 mL of fluid plus the equivalent of urine output. Continuous ambulatory peritoneal dialysis patients should consume 2,000 mL of fluid plus the equivalent of urine output.5 · Nephrotic syndrome: There are no fluid restrictions for patients with nephrotic syndrome at this time.5 · Transplant: There are no fluid restrictions for transplant patients at this time.5 Most patients know about sodium restriction and fluid intake associated with the sodium and fluid guidelines above. However, they often are surprised to learn how much water actually is in the food they eat. RDs should educate patients about the water content in foods, especially during the summer months when people tend to eat more fruits and vegetables, which are high in water content. Figure 2, below, provides a quick reference guide for nutrition therapy through the various stages of CKD.