MNT Final

MEDICAL NUTRITION THERAPY FOR RENAL DISORDERS

Kidneys are the most important organs in the body. You know that nutrition is a process
that involves steps from ingestion to excretion so the last step of nutrition as a biological and
biochemical process

Functions of the Kidney

 Excretory- it’s the one responsible for the excretion of excess water and of course
nitrogenous waste substances. There’s no other way to release nitrogenous waste
products other than through diuresis or urination. We can release urea to sweat, or even
are gut microbiota has the capacity to process urea for other things but it’s actually the
kidneys that are involved in the majority of excreting this nitrogenous waste substance
because these are toxic.
Nitrogen is toxic although we need them in the form of amino acids we
continually degrade amino acids and by degrading means we remove the amino group
we remove the nitrogen part so nitrogen on its own is actually toxic, especially in the
form of Ammonia. So again, it must be detoxified it must be converted into a less toxic
form which is the Urea and through that process, it’s actually the liver. As we know that
the urea cycle happens in the liver.

How do we release Urea?

- We release the urea through the function of the kidney so its excretory aside from
excess fluid, aside from urea creatinine also is excreted. Creatine is also another
nitrogenous substance that is usually the result of muscle breakdown that’s why if the
urinary excretion of creatinine is very high that would indicate the person is experiencing
a protein muscle mass loss which is not good news if we talk about the nutritional status.
It is very important to recognize that creatinine is a nitrogenous substance to understand
the term Azotemia.

 Acid-base balance- The other Function of the kidney that is as important as being an
excretory organ is being a regulator of an Acid-base balance. Imbalances in the can
result in fatal consequences and if not treated right away or immediately even death
might follow that’s why if naa galling mo pH imbalances patients ipa ICU nana siya noh
kay very critical na and very common cause of acid-base imbalance is damage on the
kidneys so if the kidney involves the most likely reagent balance are either acidic or
acidosis or alkalosis and it’s metabolic.
Ang Respiratory acidosis and Alkalosis are more related to the pathology of the
lungs and that’s what we have discussed earlier that our patients with CKD experience
acidosis due to the patient’s incapacity to excrete carbon dioxide, therefore, it’s on
respiratory rather than metabolic and again if the kidney is involved in it is metabolic
either it is metabolic alkalosis or a metabolic acidosis so if the kidneys do not have the
capacity to release a lot of acids in the body then it would most likely results
metabolic acidosis but if the kidney is unable to release extra bases then that
would most likely result to metabolic alkalosis. Nutrition and dietetics kay naa jud
role as most exogenous material-like foods can also affect the pH balance in the body
 Endocrine- it has an endocrine function as it secretes renin for regulation of blood
pressure. They are involved in the production of renin. The kidney produces
erythropoiesis. Erythropoietin is responsible for erythropoiesis. Erythropoiesis is a
red blood cell production we can simply call that blood cell production. So the kidneys
are very important in blood production therefore if there is something wrong in your
kidneys you will be unable to produce enough red blood cells and that would result in
some kind of anemia those with CKD are expected to have a low production of red blood
cell so most of them are anemic in a sense that they cannot produce enough RBC
because their kidneys are not capable anymore in producing enough erythropoietin.
Erythropoietin and renin are all hormones and when you say endocrine it is the
capacity of the organs to produce hormones. But there’s another hormone that the
kidneys activate that’s calcitriol or you activate Vitamin D remember that the function of
the Vitamin D is Hormonal or it access hormone that would then stimulate primarily on
the small intestine to absorb more calcium we can say that it is a hormone as siya man
ga send og message in the intestine nga mag absorb kag daghan nga calcium so that
hormonal function would not be possible without the kidneys as it’s the only organs can
activate your Vitamin D so it’s important in the skin not just it is important in the liver but
also to the kidneys as it is the one that activates.
 Fluid and electrolyte Balance- it reabsorbs water to maintain water balance as well as
other minerals. Fluid and water are actually conserved because water is important
because it is one of the important nutrients nga di dapat mawala and if nay mawala then
that’s urine.
For example
if you’re not drinking a required amount of water then the kidneys will adjust and
the body will adjust good thing is that our organs is very smart if wala ka gaamping sa
imoa lawas ang imoang organs mangita jud siyag way nga maaping imong health bisag
dli ka healthy and mao ng if you mess up then your body will find ways to still keep you
healthy despite if the unhealthy lifestyle like drinking water.
there is a mechanism and one of it is activation of the RAAS (renin, amgiotensin,
aldosterone system and aldosterone ang gina release by adrenal glands so the RAAS is
a system of hormones that would cooperate to each other and their main goal is to
conserve water so the RAAS will be activated if your fluid intake is low so that dili ra
kaayo ka ma dehydrated what that system will do as an overall effect is that to make
sure that you have enough water in the body aside from conserving water ma conserve
sab ang sodium remember the principle that the sodium always follow water if ma
conserve ang water then the sodium will be conserve also and vice versa. That’s why
the main goal of RAAS is to conserve both water and sodium that’s why kidneys are very
important and fluid-electrolyte balance another thing is that the kidney can be influenced
by the action of vasopressin. And the reabsorption of water means that dli niya ipagawas
sa urine and only the toxic compounds will release in the urine.
EXCRETORY FUNCTIONS
 Removal of excess fluid and waste products
 180 L of filtrate pass through the kidneys each day producing 1-2 L of urine
Why water is present in the urine? Para ma dissolve ang mga toxic compounds
 Waste excreted from the body in urine includes urea (a by-product of protein
metabolism); excess vitamins and minerals; metabolites of some drugs and poisons.
Cinobiotics are compounds that is not produce in nature but nevertheless pwede
mapasulod sa lawas like microplastic that’s an emerging science right now for the first
time in history microplastics found in the blood. How do we metabolize microplastics?
How we are able to distinguish microplastics and deposit them to urine so that they can
be excreted to the body? There mechanism in the body that could detoxify it’s a current
field of study that related to nutrition
ACID-BASE FUNCTION
 The body tries to keep the body pH in a very narrow range its actually from 7.35-7.45
How does the body maintain that very narrow pH range? It has many mechanism like
the use of buffers in the blood and the use of the kidneys if padulungay nas acidosis iyaa
iexcrete ang mga products that is acidic usually makuha nato sa protein intake that
usually acidify in the blood if sobra sab atoang makuha mga alkali actually bicarbonates
iexcrete ni kidneys ang extra
Hydrogenions are acidic and Bicarbonates are basic that’s why if nay metabolic alkalosis
then si bicarbonates excrete out of the kidney’s kay mao man makapa alkaline sa blood
so gamiton dayon ang kidneys no kung nay acid bases as the kidneys only has the
capability to release through urine the other organ for the acid base is the carbon dioxide
kay mag induce dayon ug hyperventilation para mapagawas ang extra na carbon
dioxide. The kidney of the lungs is actually the one who is responsible.
 Bicarbonate carries hydrogen ions to the kidneys where they are removed from the
extracellular fluid in the tubules and returned to the bloodstream as needed
 Phosphate buffers intracellular fluid
 When fluid volume is low, anti-diuretic hormone (ADH) or vasopressin is released from
the anterior pituitary; increasing the absorption of water in the collecting duct. It is the
hormone also sensitive to temperature as the vasopressin secretion during this cold
climate is low therefore urination is frequent if the ADH is low basically this hormone is
Anti urination if this hormone increases so maconserve kag water so dli kaayo ka mag
ihi ihi but it increases if your body wants you to urinate more water this hormone is one
of the hormones that controls fluid in the body
 When extracellular volume (ECV) decreases, the renin-angiotensin-aldosterone system
is activated that secretes less sodium chloride. The chloride also follows the sodium if
the sodium conserve then the chloride ions will also be conserved
ENDOCRINE FUNCTIONS
 Activation of Vitamin D and excretion of excess phosphate maintain healthy bones
 Erythropoietin acts on the bone marrow to increase the production of red blood cell

The kidneys are made up of hundreds and thousands of Nephrons this is where the blood is
filtered this is where the toxic substances are incorporated to the urine this are your blood
vessels. Ipromote ra ang excretion if nay antineurotic peptide which is a hormone that promotes
sodium excretion those dialyzer machines gina imitate nilaa ang nephrons since those nga ga
under dialysis especially nonfunctional na ang kidney ang ilaa dialyzer kay artificial kidneys.
Efferent arteriol one of the magconnect the blood rest to the venous system mao naming
pabalik sa heart dri na part na sala na ang blood (clean blood) ang muagi dani are those that
are yet to be filtered and pass through the different tubules the blood and the toxic substances
are being remove from the blood and mag concentrate dayon ang urine dana
What happened if the blood is concentrated with glucose? Like diabetic patients with
hyperglycemia? What would happened?
If masobraan na gani dli na makaya. The renal threshold for glucose maximum
concentration of glucose that the nephrons can carry beyond that glucose will leak to the urine
glucose will not be reabsorb anymore Ma reabsorb man dapat ang glucose dli pwede nga may
glucose sa urine that’s why if mag pa urinary mo if nay glucose sa urine kay kulba na basig naa
nay diabetes that means that daot na ang nephrons so if you have a long standing of
hyperglycemia mga daot na ang mga arteries so mo leak ang glucose dli siya ma reabsorb dli
siya mabalik sa bloodstream so therefore ang tendency niyaa kay maleak siya sa urine and
mao ang hinungdan sa classic type of diabetes dira na dayon ang polydipsia, polyphagia
because maleak man ang glucose sa urine that would supposedly ma reabsorb back to the
blood stream.

Renal Threshold Value- 180

THE MOST COMMON KIDNEY DISEASE

 DIABETIC NEPHROPATHY- damage to the nephrons in the kidneys from unused sugar
in the blood, usually due to the diabetes this disease dli na makaya because of the
hyperglycemia na reach na ang renal threshold so the result is the leakage in the urine
(that’s why amigason na ang urine sa diabetic patiens. Glycosuria
 HIGH BLOOD PRESSURE- can damage the small blood vessels in the kidneys. The
damaged vessels cannot filter poison from the blood as they are supposed to. Can also
destroy the arteries in the body
 POLYCYSTIC KIDNEY DISEASE (PKD)- is a hereditary kidney disease in which many
cysts grow in kidneys. These cysts may lead to kidney failure that might be benign or
cancerous
 ACUTE RENAL FAILURE- sudden kidney failure caused by blood loss, drugs or
poisons if the kidneys are not seriously damaged acute renal failure may be reversed
ARF and AKD are the same.
 CHRONIC RENAL FAILURE- Gradual loss of kidney function is called Chronic renal
failure or chronic renal disease same as CKD
  END-STAGE RENAL DISEASE- the condition of total or nearly total and permanent
kidney failure patients undergoing hemodialysis (artificial Kidney)
 KIDNEY DISEASE
 Glomerular disease
- Nephrotic syndrome
- Nephritic syndrome- tubular or interstitial

NEPHROTIC SYNDROME

 Alterations of the glomerular basement membrane allows persistent loss of large

amounts of protein in the urine
 Associated with diabetes, glomerulonephritis, amyloidosis, lupus
 High risk for cardiovascular disease
 Hypercoagulability- clotting events
 Abnormal bone metabolism

NOTE: This is when a patient develops excessive proteinuria or excessive

proteins in the urine supposedly wla dapat protein sa ihi as protein is important
and must conserve in the blood but in this disease, there is something wrong in
the nephrons.

 Albuminuria more than 3g/day urinary albumin losses, with proportionally lesser amounts
for children x 0.16 (480)
 Hypoalbuminemia
Why hypoalbuminemia and hypoalbuminuria coexist together?
The material or the fluid the point of view na fluid is the urine therefore it is
in the urine (from the word urea). Emia- is in the blood therefore albumin content
in the blood that is low. Natural magamay ang albumin in the blood because
ipagawas man in the urine. If sobra2 ang ginagawas na blood sa urine then
makagamay jud siyaa
 Hypertension
 Hyperlipidemia (high lipid Value)
 Edema- vitamin B1 (thiamine) has something to do with preventing edema because
someone, when thiamine is deficient edema, is one of the manifestations (NOT THE
CASE OF THE NEPHROTIC SYNDROME).
Because of the albumin as its carriers of nutrients as it maintains the osmotic
gradient between what inside our cells and their environment or extracellular space so if
the albumin is low then that would be altered and that would promote fluid retention and
dli mamaintain sa lawas na nag dugo would remain in the blood vessels. Interstitial
spaces are spaces between the cells so instead nga naa sa sulod sa cells nga muipon
silaa diha that would later cause edema. Albumin is an anchor. That’s why congestive
heart failure the heart inability to pump blood sufficiently the other reson why the patient
develop edema due to inflammation. The effect of inflammation it reduces albumin
makaedema pod ang patient that’s why person nga nay kwashiorkor kay mga
edematous because of low albumin
MEDICAL MANAGEMENT OF NEPHROTIC SYNDROME

 Corticosteroids
 Immunosuppressants
 ACE inibitors/angiotensim receptor blockers to reduce protein losses, control blood
pressure and fluid balance
 Coenzyme A reductase

DIFFERENCES WITH AKD AND CKD

The only difference between akd and ckd is that acute renal failure has very sudden onset so it
would develop by a very short period of time usually due to chemical insults like the patient got
overdose with some chemical it can cause arf.
MNT ARF
THE PRINCIPLE ON THE PROTEIN INTAKE OF ARF PATIENT IS ACTUALLY THE SAME
WITH THOSE CKD PATIENT. THE GENERAL RULE IS THAT WE RESTRICT THE PROTEIN
REQUIREMENT ESP THE PATIENT IS UREMIC OR AZOTEMIC OR IF THE BUN OR CREA
LEVEL IS HIGH. The level of restriction is dependent on the severity of the azotemia the more
severe the azotemia is the more restricted the proteins.
PROTEIN REQUIREMENT
The protein req will also depend on the nutritional status. The more catabolic the patient the
more protein is needed. If the patient is catabolic but their bun and crea is not that high we can
still used 1.5 .
ENERGY REQUIREMENT
It is very important that the energy requirement is sufficient because there is already protein
restriction so that means in order for the protein to not be used or utilize we need enough
energy that will act as a protein sparing effect. So the protein will not be used for energy but it
can be used for other function or roles such as muscle protein synthesis.
FATS REQUIREMENT
Thats why do not limit the used of fats on meal planning for kidney patient because it can help
you meet the energy requirement for the patient.
Hyperphosphatemia-an electrolyte imbalance that is very common in kidney patient . It is very
dangerous because if sustained na taas ang phosphorus level it can lead to bone loss or
calcium loss, renal osteodystrophy.
Phosphorus binder- taken with meals and the goal is to bind phosphate levels so that it cannot
be absorb by the small intestine so this binders render dietary phosphorus to be insoluble
thereby preventing from being absorb so it is really for lowering the phosphate level.
NITROGEN BALANCE IN ARF
THE HIGHER THE GRF THE BETTER THE FUNCTIONING OF THR KIDNEY, BUT THE
LOWER THR GFR THE HIGHER THE LVEL OF DAMAGE IN KIDNEY.
UNA IS THE GOLD STANDARD IN DETERMINING NITROGEN BALANCE FOR PATIENT
WITH ACUTE KIDNEY DISEASE. Better used in patient undergoing dialysis or renal
replacement therapy (hemodialysis or peritoneal diaylysis)

Example:
Postdialysis BUN1 -24
Predialysis BUN2- 50
BWI - 52
BW2- 55
UUN- 6
UNA = 6 + [ 50-24] x .6 x 52] + [(55- 52) x 50]
= 6 + [26] x 31.2] + [(3 x 50)]
=6 + 811.2 + 150
= 967.2 / post dialysis bodyweight
to convert UNA to protein just multiply to 6.25

CHRONIC KIDNEY DISEASE

-develops overtime
-if stage 5 already that patient needs to undergo dialysis
-GFR unit is ml/min/1.73m2 (There is direct relationship between GFR and urine outputs as
the GFR decreases the urine output also decreases)
NOTE: as the ckd stage progresses thus the risk also for edema since the water is not
excreted in the urine it will be deposited in the extracellular spaces leading to edema.

ESRD: medical management

-Immunosuppressant drugs because the body will think that the dialyzer is a foreign body so
this act as a suppressant for the undesirable action of the immune system against the dialyzer.
- kidney transplant is viable is it is match with the patient
Uremia- refers to high BUN and CREA this is synonymous with azotemia.
Itching can either indicate either uremia or hyperphosphatemia

AS THE STAGES OF CKD PROGRESSES THE

REQUIREMENT FOR PROTEIN DECREASES.

WHAT IS THE RATIONALE? That protein should be lowered aside from managing the BUN
AND CREA? To not overwork the kidney so that it will not progress to higher stage. To delay the
need for dialysis.
Bases for ketoacid used is to see if the azotemia is severe.
Keto acids- produce amino acids which maintain your protein balance, non essential amino
acids. So the 0.2-0.43 should be essential amino acids.

Hemodialysis vs. Peritoneal Dialysis

- PD has more protein losses than HD thats why usually mas higher ang protein requirement for
PD to make it up for protein loss.
- Mas dako ang protein req for dialysis because there are protein losses happened during
dialysis because the membrane in the dialysis is not that perfect so very possible that protein
will leak from bloodstream to the dialyzing fluid thats why higher protein is needed.
- For energy in PD we need to adjust the requirements coming from the foods bc the dialyzing
fluid of PD have glucose and this glucose can be absorb by the peritoneum. So to make sure
that the patient under PD will not gain weight we should minus the calories coming from glucose
in the dialyzing fluid to her TER.
- If high fluid output the mas liberal mas dako ang sodium intake but if the fluid output is less
than 1 liter you might need to restrict the sodium to 2000 mg only.
- In HD, the water soluble vitamins is remove so it needs to be increased.

BODY WEIGHT ASSESSMENT IN CKD

-use edema free body weight in obtaining the protein and energy
BUN
High BUN- dehydration
Low BUN- overhydration, this is also an indicator that the patient might recovering because
patient is anabolizing.
High BUN will indicate azotemia thats why we have to lower out protein intake to lower this.

CREATININE
-this is not related with dietary protein intake so thats why if we increase the protein intake it
would not actually affect the crea levels it will affect BUN but not the crea.
-proxy indicator for renal losses function if GFR is not present. Higher crea means higher
damage of kidney,
-come from the breakdown of muscle mass

POTASSIUM AND PHOSPHORUS

-the effects of hyperphosphatemia causes the release of too much PTH and PTH stimulates
calcium absorption
CALCIUM
-thats why there is a need to used the ionized calcium instead of the total calcium because half
of the calcium is bound in the albumin so if serum calcium is low evaluate albumin level.
-calcium phosphorus product is another indicator . The product of serum calcium and serum
phosphorus.
SODIUM
-if high sodium dont target lowering the sodium intake but the fluid intake
-if high sodium that might mean that patient is dehydrated so increase the fluid intake.

HEMATOLOGICAL INDICATOR
-doesnt mean need i taas ang iron, nigamay ra ang hemoglobin because of low production of
EPO so the treatment the patient should receive synthetic EPO. THE PATIENT NEED EPO
NOT IRON.
-anemia of chronic disease is another type of anemia that doesnt need additional iron because
this would not respond to iron Supplmentation
-higher ferritin higher EPO resistance
GFR
-best index of kidney function
- in order to compute for the GFr need ang serum crea
- need to know the GFR because we will be familiar unsa na siya na stage and para makabalo
tas sa nutrient recommendation.

INTERDIALYTIC WEIGHT GAIN

-this is the amount of weight gain after hemodialysis treatment
-normal interdialytic weight gain is between 2-5%
Example:
Pre weight - 75
Post weight - 77.5
INTERDIALYTIC weight gain = 2.5 kg to determine the percentage (divide it from the
preweight x 100) 2.5 / 75 x 100 = 3.33% normal

THE NATURAL HISTORY OF DIABETIC NEPROPATHY (a form of CKD)

Onset proteinuria will be observe usually stage 1 to 3
Rising crea means rising kidney damage
Thats why it is very important to manage the diabetes so that it will not progress to Diabetic
neuropathy which is a form of CKD.

WHAT IS THE PURPOSE OF DECREASING PROTEIN

The other purpose of decreasing the protein is to decrease the animal foods which can create
acidic substances that can disturb the acid based balance of the body which can result to
metabolic acidosis. So another strategy for us to lower the risk to acidosis is to restrict the
protein especially the intake of animal based proteins because when this is metabolize can
create acidic substances.
MNT IN HD: PHOSPHORUS
-Hyperphosphatemia is not longer an issue in dialysis because excess phosphorus is cleared
out by dialyser.
-HARD TO MANAGE BECAUSE DURING DIALYSIS WE NEED TO INCREASE THE
PROTEIN REQUIREMENT AND MOSTLY PROTEIN ARE HIGH WITH PHOSPHORUS.
MNT IN HD: vitamins
B complex are dialyzable meaning they are loss during treatment thats why there is a need to
prescribe b complex vitamins which is taken after session.

Liquid supplements alternative to milk for renal patient that has a high amount of
phosphorus which is 240.
nPCR= 0.22 + (.036 x interdialytic rise in BUN x24)/ (intradialytic interval) last dialysis session to
the next one
=0.22 + (44.928) / (44)
= 45.148 / 44
= 1.02 so the patient consume 1.24 g/kgBW/day of proteins which when compare with
standards it is okay because the excessive one is 1.4. So that means we can say that the
patient is well nourish and patient is fit with their dialysis session.
nPCR = doesnt only for protein catabolic rate but this is also reflective with how much
protein does the patient consume. Protein intake and protein appear in the urine.

Example: pre dialysis is 70, postdialysis is 18 so 70-18 = 52 (interdialytitc rise)

Comprehensive malnutrition inflammation (MIS) FORM

The lower the albumin the higher the inflammation
The lower the TIBC the higher also the inflammation

Seven SGA

PERITONEAL DIALYSIS
-mas cheap compare to HD
-main advantage is that mas regular ang pag drain sa blood unlike HD that you have to wait like
around two days for the next session but here your blood is constantly filtered as long as you
have dialysates for peritoneal dialysis.
-disadvantage is that prone to infection such as peritionitis (infection of peritoneum)
-we need to know about CAPD AND CCPD because the amount of glucose that we can absorb
from the dialysate should be taken into consideration when we want to determine the amount of
calories that should come from foods because if this is not consider then the patient will be at
risk of overfeeding.
SAMPLE GLUCOSE ABSORPTION
One 2-L exchange of 1.5% solution = 30g
(2000 x 0.015 = 30) this means that the amount of glucose that is contained in one exchange of
this solution is 30 grams but not all this glucose is absorb by the blood only a farction which is
60%
30x 60% = 18 g
18 x 3.7 = 66.6
67 x 4 = 268 if her TER is 1800 subtract this from 268.

ASIDE FROM WEIGHT GAIN WHICH IS THE RESULT OF OVERFEEDING, ACUTE

CHANGES IN METABOLISM WILL BE HYPERGLYCEMIA. THATS WHY USUALLY IF
DIABETIC ANG PATIENT PERITONEAL DIALYSIS IS NOT THE FIRST CHOICE BECAUSE
THERE IS GLUCOSE ABSORPTION IN THIS DIALYSIS.

Calorie Booster
-can act as a free foods which come from fats and sugar to increase or meet the TER of the
patient
-to promote weight gain or anabolism
-increase energy value of your meal plan without affecting the electrolyte levels but if patient is
hyperlipidemic then somes foods is still restricted. Simple sugars can increase the level of LDL.

High dose steroids- promote catabolism

ACID ASH DIET

- usually animal products
ALKALINE ASH DIET
- usually fruits and vegetables

NUTRITION THERAPY FOR CKD

-first monitor the fluid status and electrolyte imblances
- second prevent protein energy wasting
NT for AKD/ARF
-anuria (below 50mL)
Probiotics is encouraged because gut bacteria decrease oxalate absorption because it is
used by them.

MNT for UTI

Cranberry juice has an antibiotic effect on the e coli growing in the kidneys.
-cranberry juice acidify the urine and make the surrounding environment of the infectious agent
a more hostile for them that limit their growth.
Neutropenic diet is encouraged since the patient is using immunosuppressant drugs to
avoid contracting foodborne disease.
3.7 not 3.4 kcal in PD

The Standard Body Weight can be obtain in the Nhanes Data.

The used of food sources remains to be the priority mas nindot that the nourishment of the
patient is dikan sa food sources. The used of ONS will only be consider if there are sign and
symptoms that limit the food intake of the patient.
Maintenance hemodialysis equation vs 25-35 kcal (1C) mas easy to use

Ketoanalogues is used to support the body for the synthesis of non essential amino acid. Most
of non essential amino acid can no longer be produce because of very low protein intake.
Essential AA is to create non essential amino acid in the body. So to support your body with that
then you have to provide more carbon skeleton and this will becoming from your keto acids or
keto analogues. Really needed if patient is under VLPD.

NOTE: Not all fruits and vegetables has high level of potassium and phosphorus
so limit these if patient has hyperkalemia or hyperphosphatemia. So patient can
still eat these.