UROSEPSIS WITH AKI ON CKD

By-
ROLI JALAN
 UROSEPSIS
Urosepsis is a systemic reaction of the body
(SIRS) to a bacterial infection of the urogenital
organs with the risk of life-threatening
symptoms including shock.
 Pathogenic invasion
(E.coli)

Immune response

Hyperinflammation

Exhaustion of proinflammatory Apoptosis of Formation of an anergy

cytokines lymphocytes
(TNF-alpha, IL-1&2, Interferon-
gamma)

anti-inflammatory cytokines
(IL-4&10)
Immunosuppression

Septic shock
 CASE STUDY

Urosepsis with AKI on CKD

A 70 year old male is diagnosed with Urosepsis, having
AKI on CKD. He is a diabetic since past 15 years. He is
hypertensive with a Blood Pressure of 130/90mmHg. He
was diagnosed with a creatinine of 9.5mg/dl and high
blood urea nitrogen of 38mg/ dl, a low urine output and
fever with accompanied shivering . Also has electrolyte
levels of 129.7| 7.1| 91.3. He consumes a vegetarian diet.
GENERAL
INFORMATION
Name XYZ

Age: 70yrs
Sex: Male
Occupation: Retired
Food Habit: Vegetarian
Family Type: Joint
Family Size: 6
GI Functioning: Normal
Food intolerance: None
Physical Activity: Sedentary
Sleeping Hours: 6-7 hours per day

Meal pattern: 7 meals

ANTHROPOMETRIC
MEASUREMENTS
Height: 167.6 cms

Weight: 70 kgs

IBW:( Broca’s index) 67.6 kgs

BMI 24.8 kg/m2

Evaluation of Weight Status: He is 2.4 kgs overweight.

MEDICAL HISTORY
• Family History: None

• Medical history :
1. Hypertension
2. Diabetes mellitus
3. Coronary Angiography
4. Ischemic Heart Disease
5. Percutaneous Transluminal Coronary Angioplasty (2014)
6. Obstructive Uropathy (2016)
7. Urinary Tract Infection

• Present Complains : Fever with shivering and low urine output

• Diagnosis: Urosepsis with AKI on CKD

• Duration of illness: 4 months

TESTS AND BIOCHEMICAL
PARAMETERS
TEST OBSERVED NORMAL RANGE
VALUE

High Glucose Tolerance test 150mg/ dl 90- 120mg/ dl

Blood Pressure 130/90 mm Hg 120/80 mm Hg

Creatinine 9.5mg/ dl 0.50- 1.06mg/ dl

Blood Urea Nitrogen 38mg/ dl 5- 25mg/ dl

Serum sodium 129.7mg/dl 135-145mg/dl

Serum potassium 7.1Meq/L 3.5-5.5Meq/L

Serum chloride 91.3mg/dl 90-110mg/dl

 BMI CUTOFFS
Asian BMI (kg/m²) WHO BMI (kg/m²)

Underweight < 20 < 18.5

Normal 20-23 18.5–24.9
Overweight 23-25
25.0–29.9

Class I obesity 25-30 30.0–34.9

Class II obesity 30-35 35.0–39.9
Class III obesity 35-40 ≥ 40.0
Ref -www.who.int/bmi
 STAGES OF CKD
CKD STAGE DESCRIPTION eGlomerular Filtration Rate
(ml/min/1.73m2)

Stage 1 Kidney damage with 120-90

normal kidney
function
Stage 2 Mild loss of kidney 89-60
function

Stage 3a Mild to moderate loss 59-45

of kidney function

Stage 3b Moderate to severe 44-30

loss of kidney
function
Stage 4 Severe loss of kidney 29-16
function.

Stage 5 Kidney failure and 15 or less

(End stage renal need for dialysis or
disease) transplant
Ref- National kidney foundation
MEDICATIONS
CATEGORY GENERIC BRAND DOSAGE USAGE SIDE EFFECTS
OF DRUG NAME NAME

Shelcal-500 Calcium/wi Elder Calcium – Helps in calcium Overdose leads

(Calcium th Vitamins 500mg absorption and to elevated
carbonate Vitamin thus, increases blood calcium
and Vitamin D3- 250IU bone loss, nausea,
D3) mineralization vomiting, bone
and bone heath. health loss, poor
apetite
Antacid
Sobisis forte La 500mg Urine alkalization, Tiredness, rapid
renon acidity in the breathing, loss
health blood, heartburn of appetite,
and gastric lavage frequent
in methanol urination
poisioning
CATEGORY GENERIC BRAND DOSAGE USAGE SIDE
OF DRUG NAME NAME EFFECTS

Rantac Antacid Jb 150mg Cures Fatigue,

chemicals acidity, drowsiness,
heartburn constipation
and stomach and muscle
ulcers pain

Imodium Anti- J and J 2mg * 4 Used to Constipation

diarrheal treat , dizziness,
diarrhea and drowziness,
slow gut abdominal
movements pain,
vomiting
and nausea

Chest pain, Nausea,

Prolomet Beta- Sun 25mg heart failure, headache,
XL blocker pharmaceuti high blood fatigue,
cals pressure constipation
, dizziness
 DATE DIET TYPE WATER INTAKE

8th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

9th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

10th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

11th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

12th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

13th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

14th MAY RENAL SALT RESTRICTED DIABETIC DIET 1.2 L/day

15th MAY RENAL SALT RESTRICTED DIABETIC DIET + 800 ml/day

DIABETIC LIQUID

16th MAY DIABETIC LIQUID 800ml L/day

INTERPRETATION OF CASE
Hypertension Diabetes Mellitus

Ischemic Heart Disease

* Indicated by slowly
Chronic Kidney Disease rising creatinine
levels

* Indicated by low urine

Acute Kidney Injury (AKI) output (oliguria)

Urosepsis
PATHOPHYSIOLOGY
Gram –ve bacteria induced sepsis is associated with AKI on CKD

In plasma concentration of endotoxin LPS

In sepsis induced degradation

ed release of LPS, cytokines and consequently NO

E.Coli results in release of LPS in the bloodstream

LPS binds to LPS- binding protein (LBP) through Lipid A

LBP- LPS complex binds to co-receptor leading to an

interaction with the complex on monocytes, macrophages
and neutrophils
 The complex also binds to other cells such as renal
tubular epithelial cells

Proinflammatory cytokines (TNF, IL-1) are induced upon LPS

exposure which bind to specific receptors

TNF receptor 1 on glomerular TNF receptor 2 on renal tubular

endothelial cells epithelial cells

Transcription of inducible NO synthase gene, causing NO formation

Causes systemic vasodilation induced septic shock

arterial volume, sensed by the baroreceptors

sympathetic activity and angiotensin production

Intrarenal constriction with Na and water retention

Reduced GFR
 Clinical
CKD

AKI CKD
Meal Time Menu Ingredient No. Amount CHO Proteins Fats Energy
Of Ex. (g) (g) (g) (g) (Kcal)

Early- Tea Milk ½ 75ml 3 2.5 3 50

morning
(7:00am)

Breakfast Chapati Wheat 1 30 21 2.5 0.5 100

(9:00am) flour

Tur dal ½ 15 8.5 3.5 0.2 50

Dal
Oil - 3 - - 3 27

Lunch Khichadi Rice ½ 15 10.5 1.8 0.3 50

(1:00pm) Moong dal ½ 15 8.5 3.5 0.2 50
Oil - 3 - - 3 27

Tomato Tomato 1 100 6 1 - 25

bhaji Onion ½ 50 5 0.5 - 25
Oil - 3 - - 3 27
Sugar - 5 5 - - 20
Meal Menu Ingredients No. Of Amount CHO Protein Fat Energy
Time Ex. (g) (g) (g) (g) (Kcal)

Snack 1 Tea Milk ½ 75ml 3 2.5 3 50

(4:00pm)
Koki Wheat 1 30 21 2.5 0.5 100
flour ½ 50 5 0.5 - 25
Onion - 8 - - 8 72
Oil
Snack 2 Vada Gram flour 1 30 17 7 0.5 116
(6:30pm) Potatoes 1 100 24 1 - 100
Oil - 8 - - 8 72

Pav Maida 1 40 21 2.5 0.5 100

Dinner Chapati Wheat ½ 15 10.5 1.3 0.2 50
(8:3opm) flour
Palak 1 100 6 1 - 25
aloo sabji Spinach ½ 50 12 0.5 - 50
Potato ¼ 25 1.5 - - 6
Tomato ¼ 25 2.5 0.2 - 13
Onion - 3 - - 3 27
Oil
Bedtime Plain Milk 1 150ml 6 5 6 100
milk
Meal Menu Ingredient No Amount Sodium Potassium Calcium Phosphorus
Time Of (g) (mg) (mg) (mg) (Mg)
Ex.

Early- Tea Milk ½ 75ml 19.2 86.3 88.5 72.5

morni
ng
(7:00a
m)
Breakf Chapat Wheat 1 30 0.6 93.3 9.3 94.5
ast i flour
(9:00a
m)
Tur dal ½ 15 4.5 143.5 6.9 48.8
Dal
Oil - 3 - - - -

Lunch Khicha Rice ½ 15 0.4 16.2 1.2 14.4

(1:00p di Moong dal ½ 15 4.5 143.5 6.9 48.8
m) Oil - 3 - - - -

Tomato Tomato 1 100 9.7 18.8 10.2 204

bhaji Onion ½ 50 7.8 14.3 15.6 156
Oil - 3 - - - -
Sugar - 5 - - - -
Meal Menu Ingredients No Amount Sodium Potassium Calcium Phosphorus
Time Of (g) (mg) (mg) (mg) (mg)
Ex
.
Snack 1 Tea Milk ½ 75ml 19.2 86.3 88.5 72.5
(4:00p
m) Koki Wheat 1 30 0.6 93.3 9.3 94.5
flour ½ 50 7.8 156 15.6 14.3
Onion - 8 - - - -
Oil
Snack 2 Vada Gram flour 1 30 3.1 380.4 12.9 124.8
(6:30p Potatoes 1 100 3.9 474 3.9 37.9
m) Oil - 8 - - - -

Pav Maida 1 40 0.5 44.4 6.1 33

Dinner Chapati Wheat ½ 15 0.3 46.7 4.7 47.3
(8:3op flour
m) Palak 1 100 42.6 625 82.3 32.6
aloo Spinach ½ 50 1.9 237 1.9 18.9
sabji Potato ¼ 25 2.4 51 2.6 4.7
Tomato ¼ 25 3.9 78 7.8 7.2
Onion - 3 - - - -
Oil
 AVERAGE OF HOME
DIERTARY RECALL
ENERGY CARBOHYDRATE PROTEINS FAT
(Kcal) (g) (g) (g)
1357Kcal 197g (2.8g/ 39.3g 42.9g (0.6g/
kgBW) (0.6g/kgBW) kgBW)
= 788kcal = 157kcal = 386kcal
= 59.2% = 12.2% = 28.6%
Sodium Potassium Calcium Phosphorus
(mg) (mg) (mg) (mg)
171.2 mg 2444.6 mg 551.2 mg 1241.6 mg

*The fluid consumption through the diet= 400ml

 HBV PROTEIN
• HBV protein % = Total HBV protein *100
Total protein
= 10 g* 100
39.3
= 25.4%
INTERPRETATION OF HOME RECALL
Consumption of vegetables such as spinach, tomatoe
was seen, which is generally avoided in a CKD patient.

There was uneven distribution of macronutrients.

Phosphorus and potassium rich foods were consumed.

Consumption of high biological value proteins was

less.

There was high consumption of Visible Fat.

3 DAYS DIETARY
RECALL
Days:
Monday- 14th May
Tuesday- 15 May
th
th
Wednesday- 16 May
Meal time Menu Ingredients No. of Amounts CHO Protein Fats Energy
exchanges (g) (g) (g) (g) (kcal)

Breakfast D. Tea Milk (C) ½ 50ml 2 1.7 2 33

(8:30am) Water - 50ml - - - -
Tea powder - - - - - -

Mix veg Semolina 1 30 21 2.5 0.5 100

upma Onion ½ 50 5 0.5 - 25
Carrot ½ 50 5 0.5 - 25
Peas ¼ 25 2.5 0.2 - 13
Oil - 3 - - 3 27

Thick oats Oats ½ 15 10 1.5 1.7 50

porridge Milk - 50ml 2 1.7 2 33

Plain milk Milk ½ 75ml 3 2.5 3 50

Meal time Menu Ingredients No. Of Amount CHO Protein Fats Energy
Ex. (g) (g) (g) (g) (Kcal)

Lunch Jeera rice Rice 1 30 21 2.5 0.5 100

(12:00pm) Oil - 3 - - 3 27

Chapati Wheat flour 1 30 21 2.5 0.5 100

Dahi kadhi Gram flour ½ 15 8.5 3.5 0.2 50

Curd ½ 75 3.5 2.5 3 50
Oil - 3 - - 3 27

Dudhi rassa Dudhi 1 100 6 1 - 25

Oil - 2 - - 2 18

Curd Curd 1 150 7 5 6 100

Salad slices Cucumber 1 100 6 1 - 25

Evening D. Tea Milk (C) ½ 50ml 2 1.7 2 33

snacks Water - 50ml - - - -
( 3:30pm) Tea powder - - - - - -

Seviya upma Vermicelli 1 30 21 2.5 0.5 100

Tomato ½ 50 3 0.5 - 13
Meal Menu Ingredients No. Amount CHO Protein Fat Energy
Time Of Ex. (g) (g) (g) (g) (kcal)

Dinner Herb Rice Rice 1 30g 21 2.5 0.5 100

(8:30
pm) Chapati Wheat flour 1½ 45g 30 5.2 2 150

Dal Masur dal 1 30 17 7 0.5 100

Onion ¼ 25 2.5 - - 12
Tomato ¼ 25 0.9 0.5 - 6
Oil - 2 - - 2 18

French F. Beans ¾ 100 6 1 - 25

Beans Onion ¼ 25 2.5 - - 12
Sabji Tomato ¼ 25 0.9 0.5 - 6
Oil - 2 - - 2 18

Cucumber 1 100 - 1 - 6
Salad
Curd - 150 5 7 6 100
Curd (C)
Milk ½ 75ml 3.5 2.5 3 50
D. Custard Custard pdr - 5 - - - -
Carbohydrates Protein Fat Energy
(g) (g) (g) (kcal)

253.8g 61.5g 51.9g 1811kcal

*THE FLUID CONSUMPTION THROUGH DIET= 375ml

DAY 2- MONDAY
th
15 May
 Meal Menu Ingredients No Of Amount CHO Protein Fat Energy
Time Ex. (g) (g) (g) (g) (kcal)

Breakfa D. Tea Milk (C) ½ 50ml 2 1.7 2 33

st Water - 50ml - - - -
(8:30a Tea powder - - - - - -

m)
Rice flour
Idli Urad dal 1 30 21 2.5 0.5 100
½ 15 8.5 3.5 0.2 50
Tur dal
Dudhi 1 30 17 7 0.5 100
Tomato ½ 50 3 0.5 - 13
Sambhar Oil ½ 50 3 0.5 - 12
- 3 - - 3 27

Oats
Thick oats Milk ½ 15 10 1.5 1.7 50
porridge - 50ml 2 1.7 2 33
Milk
Plain milk ½ 75ml 3 2.5 3 50
 Meal Menu Ingredients No Amount CHO Protein Fat Energy
Time Of (g) (g) (g) (g) (kcal)
Ex.
Lunch Masala bhaat Rice 1 30 21 2.5 0.5 100
(12:00pm Oil - 3 - - 3 27
)
Chapati Wheat flour 1 30 21 2.5 0.5 100

Dal fry Tur dal ½ 15 8.5 3.5 0.2 50

Tomato ½ 50 3 0.5 - 13
Oil - 3 - - 3 27

R. Pumpkin R. Pumpkin 1 100 6 1 - 25

bharta Oil - 3 - - 3 27

Curd Curd 1 150 7 5 6 100

Salad slices Cucumber 1 100 6 1 - 25

Evening D. Tea Milk (C) ½ 50ml 2 1.7 2 33

snacks Water - 50ml - - - -
( 3:30pm) Tea powder - - - - - -

Veg. upma Semolina 1 30 21 2.5 0.5 100

Onion ½ 50 3 0.5 - 13
Meal Menu Ingredients No. Amount CHO Protein Fat Energy
Time Of (g) (g) (g) (g) (kcal)
Ex.
Dinner Tricolour Rice Rice 1 30g 21 2.5 0.5 100
(8:30
pm) Chapati Wheat flour 1½ 45g 30 5.2 2 150

Dal Moong dal 1 30 17 7 0.5 100

Onion ¼ 25 2.5 - - 12
Tomato ¼ 25 0.9 0.5 - 6
Oil - 2 - - 2 18

Snackgourd 1 100 6 1 - 25
Sabji Onion ¼ 25 2.5 - - 12
Tomato ¼ 25 0.9 0.5 - 6
Oil - 2 - - 2 18

Salad Cucumber 1 100 - 1 - 6

Curd (C) Curd - 150 5 7 6 100

D. Custard Milk ½ 75ml 3.5 2.5 3 50

(10pm Custard pdr - 5 - - - -
)
Fruit Apple 1 90 10 - - 50
Carbohydrates Protein Fat Energy
(g) (g) (g) (kcal)

267.3g 69.3g 50.6g 1788kcal

*THE FLUID CONSUMPTION THROUGH DIET= 275ml

DAY 3- TUESDAY
th
16 May
(

)
Meal time Menu Ingredients No. of Amounts CHO Protein Fats Energy
exchanges (g) (g) (g) (g) (kcal)

Breakfast D. Tea Milk (C) ½ 50ml 2 1.7 2 33

(8:30am) Water - 50ml - - - -
Tea powder - - - - - -

Corn poha Rice flakes 1 30 21 2.5 0.5 100

Corn ½ 15 10.5 1.7 0.2 50
Carrot ½ 50 5 0.5 - 25
Onion ½ 50 5 0.5 - 25
Oil - 3 - - 3 27

Thick oats Oats ½ 15 10 1.5 1.7 50

porridge Milk - 50ml 2 1.7 2 33

Plain milk Milk ½ 75ml 3 2.5 3 50

Meal time Menu Ingredients No. Of Amount CHO Protein Fats Energy
Ex. (g) (g) (g) (g) (Kcal)

Lunch Basil rice Rice 1 30 21 2.5 0.5 100

(12:00pm) Oil - 3 - - 3 27

Chapati Wheat flour 1 30 21 2.5 0.5 100

Dal Chana dal 1 30 17 7 0.5 100

Tomato ½ 50 3 0.5 - 13
Oil - 3 - - 3 27

Kobi sabji Cauliflower 1 100 6 1 - 25

Oil - 2 - - 2 18

Curd Curd 1 150 7 5 6 100

Salad slices Cucumber 1 100 6 1 - 25

Meal Menu Ingredients No. Of Amount CHO Protein Fat Energy
Time Ex. (g) (g) (g) (g) (kcal)

Evenin D. Tea Milk (C) ½ 50ml 2 1.7 2 33

g Water - 50ml - - - -
snacks Tea powder - - - - - -

(
Mix veg Broken 1 30 21 2.5 0.5 100
3:30pm daliya upma wheat ½ 50 5 0.5 - 25
) Onion ½ 50 5 0.5 - 25
Carrot ¼ 25 2.5 0.2 - 13
Peas - 3 - - 3 27
Oil
Dinner Buttermilk Curd ½ 75 3.5 2.5 3 50
(8:30 Water - 100ml - - - -
pm) Jeera pdr - 5 - - - -

Clear Moong 1 15 8.9 3.7 0.2 52

moong pani (200ml)
pani

D. Jelly Jelly 1 50ml - - - -

crystals
Carbohydrates Protein Fat Energy
(g) (g) (g) (kcal)

187.4g 43.7g 36.6g 1253kcal

*THE FLUID CONSUMPTION THROUGH DIET= 650ml

 EVALUATION OF HOSPITAL
DIETARY RECALL
TOTAL ENERGY PROTEIN CHO FATS
(kcal) (g) (g) (g)

DAY-1 1811kcal 61.5g 253.8g 51.9g

DAY-2 1788kcal 69.3g 267.3g 50.6g

DAY-3 1253kcal 43.7g 187.4g 36.6g

TOTAL 4852kcal 174.5g 708.5g 139.1g

AVERAGE 1617kcal 58.2g 236.2g 46.4g

(23kcal/ (0.8g/ kgBW) (3.4g/ kgBW) (0.7g/ kgBW)
kgBW) 14.4% 58.4% 25.9%
INTERPRETATION OF HOSPITAL RECALL

Adequate Energy was given

with even distribution of
macronutrients.
The patients apetite was fair
during the stay.

Low Potassium foods were

introduced and the patient was
kept on a salt restricted renal diet.

There was fluid restriction of

1.2L/day.

A wide variety of fruits and

vegetables were included in the
diet.
SAMPLE DIET PLAN
 DIET PLANING SHEET
Problem case- A 70 year old male is diagnosed with Urosepsis, having
AKI on CKD. He is a diabetic since past 15 years. He is hypertensive
with a Blood Pressure of 130/90mmHg. He was diagnosed with a
creatinine of 9.5mg/dl and high blood urea nitrogen of 38mg/ dl, a low
urine output and fever with accompanied shivering . Also has electrolyte
levels of 129.7| 7.1| 91.3. He consumes a vegetarian diet.

Patient’s profile:
Age-70years Sex: Male Occupation: Retired
Food habits : Vegetarian Activity: Sedentary
Height: 167.6cm’s Weight: 70 kg’s

•Nutritional requirements
IBW= As per Broca’s index ,for women
=Height(cm)-100
=167.6-100 = 67.6kg’s
BMI- Weight (kgs) = 70 = 24.8 Kg/m²
Height (m²) ( 1.68)²

%Desirable weight-
Current weight (kgs)-IBW (kgs) X 100
IBW (kgs)
=70-67.6 X 100 = 3.55%
67.6

Evaluation of weight status-

Current weight (kgs) -IBW (kgs)
=70-67.6
= +2.4kg’s

The patient is 2.4kg’s overweight.

•Energy requirement=25.5kcal×BW
=25.5×70 = 1800 Kcal

•Protein requirement: 0.8g/kg BW = 0.8 x 70

= 56gms = 224kcal
= 12.8%

•Carbohydrate requirement: 67.2% of 1750= 67.2×1750/100

= 1176kcal/ 4
=294gms

•Fats requirement: of 1650 = 20% of 1750

= 350kcal
= 38.9gms

•Visible fat= 20g WATER INTAKE = URINE OUTPUT + INSESSIBLE LOSSES

•Visible sugar= 0g = 700ml + 500ml
•Sodium= 1.5mg = 1200ml (1.2L)
MEDICAL NUTRITION THERAPHY
The energy of CKD patients on HD
ENERGY should be 20-25kcal/kgBW to support
anabolism.

55-60% of total calories from the diet

CHO should come from Carbohydrates for their
protein sparing action and energy.

CKD patients develop hyperlipidemia

therefore Visible Fat should be less. Total
FATS fat intake should be <30% of the total
calories.
PROTEINS - Proteins need to be restricted in CKD,
0.8g/kgBW is recommended of which 50% should be of
high biological value because the body is able to digest
and use the amino acids and also to prevent
hypoalbuminemia.
 Serum Phosphorous levels increase as the
GFR declines which causes bone problems
CALCIUM and therefore phosphate binders become
AND necessary. Calcium and Vitamin D rich foods
PHOSPH- and supplements become necessary to
OROUS prevent hypocalcemia and
hyperphosphatemia associated Renal
Osteodystrophy. Phosphorous <1000mg/day.

Hyperkalemia (>5.1) occurs due to

POTASSIUM catabolism, acidosis and medications.
Potassium intake should be <2000mg/day.

Sodium and fluid intake depends on the persons GFR. A

SODIUM moderate sodium restriction of 1-3g/day is
AND recommended coupled with edema and serum sodium
FLUID levels. Fluid Intake – 1.2 – 1.5L/day is recommended
depending on the urine output.

Iron – Iron rich foods and supplements should be given to

prevent anemia since the kidneys ability to produce the
hormone erythropoietin which stimulates the bone marrow to
produce RBC’s is greatly affected.
 FOOD
EXCHANGE
LIST
Food exchanges No. of Amount (g) CHO Protein Fat Energy
exchange (g) (g) (g) (Kcal)

CEREALS 8½ 167.5g 20.5g 3.9g 800kcal

Rice 2½ 75 52.5 6.7 1.2 250

Wheat flour 2 60 42 5 1.5 200

Rice flakes 2 60 42 5 1 200

Oats 1 30 20 2.5 0.5 100

Semolina 1 30 21 2.5 0.5 100

PULSES 2½ 42.5g 17.5g 1.2g 250kcal

Moong dal 1½ 45 25.5 10.5 0.7 150

Tur dal 1 30 17 7 0.5 100

MILK &PRODUCTS 3¾ 24.4g 17.6g 21g 350kcal

Milk(C) - 325ml 19.8 14.2 17 283

Curds(C) - 100 4.6 3.4 4 67

Food exchanges No. of Amount CHO Protein Fat Energy
exchange (g) (g) (g) (g) (Kcal)
VEGETABLE A 2½ 15g 2.5g - 63kcal
Cucumber 1½ 150 9 1.5 - 38

Cabbage 1 100 6 1 - 25
VEGETABLE B 1 10g 1g - 50kcal
Onion ½ 50 5 0.5 - 25
Carrot ¼ 25 3 0.3 - 13
Peas ¼ 25 2 0.2 - 12

FRUITS 1 10g - - 50kcal

Apple 1 90 10 - - 50
Papaya 1 100 10 - - 50
FATS & OILS - 20 - - 20g 180kcal
TOTAL 290.9g 56.8g 42.9g 1812kcal
RDI 294g 56g 38.9g 1800kcal
DIFFERENCE -3.1g +0.8 +4 +10
IDEAL DISTRIBUTION
MICRONUTRIENT OF
CONTENT
NUTRIENTS PER MEAL
Food exchanges No. of Amount (g) Sodium Potassium Calcium phosphorus
exchange (mg) (mg) (mg) (mg)

CEREALS 8½
Rice 2½ 75 - - 10 150

Wheat flour 2 60 1.26 186.6 18.6 189

Rice flakes 2 60 1.6 88.8 5.5 117

Oats 1 30
18 60 38 86
Semolina 1 30
5.4 24 5 30
PULSES 2½
Moong dal 1½ 45 8.4 168.7 24.7 60.3

Tur dal 1 30 2.4 73.5 5.5 22.5

MILK &PRODUCTS 3¾
Milk(C) - 325ml 158.2 303.3 303.3 180.6
Curds(C) - 100 21.3 86.7 149.3 62
Food exchanges No. of Amount Sodium Potassium Calcium Phosphorus
exchange (g) (mg) (mg) (mg) (mg)
VEGETABLE A 2½
Cucumber 1½ 150
51 250 90 130
Cabbage 1 100 14.9 233 51.7 30.2

VEGETABLE B 1
Onion ½ 50
2 63.5 23.5 25
Carrot ¼ 25 4.2 60.6 9.8 19.2

Peas ¼ 25 0.9 62.3 7.1 13.9

FRUITS 1
Apple 1 90 25 70 10 14

Papaya 1 100 6.7 173 15 17.7

FATS & OILS - 20 - - - -

TOTAL 321.3 mg 1904 mg 767 mg 1147.4 mg

IDEAL DISTRIBUTION OF
NUTRIENTS PER MEAL
 MEAL % OF TOTAL CALORIES PROTEINS CARBOHYDRATE FAT
TOTAL KCAL (kcal) (g) (g) (g)

IDEAL PLAN % 1812Kcal 56.8g 290.9g 42.9g

EARLY MORNING 5% 5% 90kcal 2.9g 14.5g 2.2g

BREAKFAST 25% 24.5% 453kcal 14.5g 72.4g 10.7g

MID - MORNING 5% 5.4% 90kcal 2.9g 14.5g 2.2g

LUNCH 25% 25.1% 453kcal 14.5g 72.4g 10.7g

SNACKS 10% 10.1% 181kcal 5.8g 30g 4.3g

DINNER 25% 24.5% 453kcal 14.5g 72.4g 10.7g

BED - TIME 5% 5.4% 90kcal 2.9g 14.5g 2.2g

100%
DISTRIBUTION
OF EXCHANGES
PER MEAL
FOOD TOTAL EARLY BREAKFAST MID LUNCH SNACKS DINNER BED
EXCHANGE MORNING MORNING TIME

CEREALS 8½ - 3 - 2 1 2 -

PULSES 2 - - - 1 - 1 -

MILK & MILK 3¾ ½ 1¼ - 50g 50ml 50g 1

PR.
VEGETABLE A 2½ - - - 2 - ½ -

VEGETABLE B 1½ - ¼ - ¾ ½ - -

FRUITS 2 - - 1 - - - -

FATS 20g 3 3 - 5 4 5 -

Energy(kcal) 1812kcal 90 449 98 453 182 441 100

Proteins(g) 56.8g 4.1 7.5 1.4 15.5 6.5 19 5

CHO(g) 290.9g 9 44 18.8 81 28 81 6

Fats(g) 42.9g 4.2 5 0.2 7.5 8 7.5 6

MENU PLANNING
Meal timing Menu Ingredients No.of Amount Justification
exchanges (g)
Early Morning Tea / Plain Milk (C) ½ 75ml HBVprotein, rich in calcium
(7:30 am) milk Tea powder - 5 and Vitamin B12 therefore
- important for bone health
and anemia.

Breakfast Poha/ Upma/ Rice flakes 2 60 Rice flakes are low in

(9am) Uttapam / Onion ¼ 25 sodium and potassium,
Daliya/ Oil - 3 high in iron and is easily
Sago Khichdi digestible.

D. Thick oats Oats 1 30 Oats – complex

porridge/ Milk ½ 75ml carbohydrate, low in
Rava porridge sodium, potassium and
phosphorous. Milk- HBV
protein.

Tea /Plain milk Milk ½ 75ml HBVprotein, rich in

Tea powder - 5 calcium and Vitamin B12
therefore important for
bone health and anemia.
Meal timing Menu Ingredients No.of Amount Justification
exchanges (g)

Mid – Fruit Apple 1 90g GAP3 fruit, rich in

Morning (Guava,Pear) soluble fibre, very low
( 10:30pm) content of
Sodium and potassium.
Papaya 1 100

Lunch Rice / Rice ½ 15g Easy to digest and does

(2:00pm) Pulav/Daliya not contain sodium and
khichdi potassium.

Tur dal 1 30g Protein rich, Low sodium

Dal Oil - 2g content, contains less
(Any Dal) potassium compared to
other dals.

Wheat flour 1½ 45g Complex carbohydatre,

Roti (2 no.) rich in fibre, contains
/JowarBhakri/ high levels of folic acid.
Rotla /
Paratha
Meal timing Menu Ingredients No.of Amount Justification
(g) exchanges (g)
Mix Sabji Cabbage 1 100g High content of iron, folic
( Carrot ¼ 25g acid and calcium therefore
Methi/Tinda/ Peas ¼ 25g important for anemia and
Parwar/Khol Oil - 3g bone health. Low content
– Khol/Papdi) of sodium and potassium
therefore perfect for a CKD
patient.

Curd/Butter Curd - 50 HBV protein, Vit. A content

milk , rich is calcium and B12,
imp for bone health and
anemia respectively.

Salad Cucumber 1 100 Low in sodium and

potassium. Vit. C content-
Antioxidant and imp. For
iron absorption.

Snacks Tea /Plain Milk - 50ml HBVprotein, rich in calcium

milk Tea powder - 5 and Vitamin B12 therefore
(5:30pm)
important for bone health
and anemia.
Meal timing Menu Ingredients No.of Amount Justification
exchanges (g)

Onion Semolina 1 30 Low on glycemic index,

uttapam/ Onion ¼ 25 moderate carbs, low
Rava chilla Oil - 4 sodium and potassium
Dinner
Khichdi /Dal Rice 2 60 Protein rich, good
(8:00pm) rice Moong dal 1½ 45 combination of cereal and
Oil - 5 pulse, easy to digest.Low
sodium and potassium.

75 HBV protein, Vit. A content

Curd/Buttermi Curd (C) ½ , rich is calcium and B12,
lk imp for bone health and
anemia respectively.

Low in sodium and

50 potassium. Vit. C content-
Salad Cucumber ½ Antioxidant and imp. For
iron absorption.

Milk Milk (C) 1 150ml HBV protein, calcium and

Bed – Time B12 rich imp. For bone
(10pm) health and anemia.
 LIST OF ADJUNCTS
• Lime piece
• Amchur powder
• Kokum
• Coriander Chutney
• Mint Chutney
• Pepper powder
• Chaat masala
• Sodium from diet =321.3mg
• Total sodium recommended = 1500mg (1.5g)
• 1g of salt = 400 mg of sodium
• Sodium remaining from diet = 1500 – 321.3(mg)
= 1178.7mg
• Therefore salt intake = 1178.7 /400
= 2.95g

FLUID INTAKE

1.2L/day is recommended.
Fluid coming from Diet is 350ml
Therefore amount of water which can
be consumed is
1200ml – 350ml = 850ml
 HBV PROTEIN
• HBV protein % = Total HBV protein *100
Total protein
= 17.6g* 100
57.8
= 30.5%
 CAL:N RATIO
• 1gm of nitrogen = 1/6.25g of protein
• 1gm of nitrogen = 57.8g/6.25g of protein
= 9.3 N
• Cal : N = Total calorie/ nitrogen
= 1810/ 9.3
= 195:1
 DIETARY GUIDELINES
Salt restricted diet
has been advised to
Less quantity of Milk and its products prevent
sugar and fat should should be taken in hypertension and
be taken since it adequate amounts as the progression of
increases the they are rich in CKD. 2.9g of salt to
cholesterol levels. be used/day.
calcium, HBV protein
and important for
bone health.
Fruits and vegetables High potassium foods such
should be taken in as dark green leafy
Citric fruits such as
adequate amounts as pineapple and orange vegetables like spinach
they are rich in should be a part of the and starchy cereals like
antioxidants, fiber and diet. Lemon juice should potato and should be
micronutrients. be squeezed in the food avoided.
since it contains Vitamin
Pulses and dals
C which enhances iron
must be
absorption and acts as an
leached before
adjunct.
consumption
to remove the
potassium
content from
it.