National Renal Nutrition

Practice Guidelines
for Adults

June 2018

National Department of Health Directorate: Nutrition

 National Renal Nutrition
Practice Guidelines for Adults

National Department of Health

Directorate: Nutrition

June 2018

i
TABLE OF CONTENT
ACKNOWLEDGEMENTS iv
ACRONYMS v
SCOPE AND PURPOSE vi
BACKGROUND AND MOTIVATIONS vii
SECTION A: ACUTE KIDNEY INJURY 1
1. DEFINITIONS 1
1.1 Classification of acute kidney injury (AKI) 1
1.1.1 Risk, injury, failure, loss, end stage renal disease (RIFLE) and acute
kidney injury network (AKIN) Classifications 2
2. NUTRITIONAL ASSESSMENT 2
2.1 Anthropometry 2
2.2 Biochemistry 2
2.3 Clinical 2
2.4 Diet history 2
2.5 Urinary analysis 2
2.6 Blood gases 2
3. NUTRITIONAL RECOMMENDATIONS 3
3.1 Summary 3
4. NUTRITIONAL INTERVENTION 4
5. MONITORING 6
5.1 Nutritional assessment monitoring and follow-up 6
5.2 Complications related to AKI 6
5.3 Medication commonly used in acute kidney injury and potential side effects 7
5.4 Patient education 8
SECTION B: CHRONIC KIDNEY DISEASE (INCLUDING RENAL TRANSPLANT) 9
1. DEFINITIONS 9
2. NUTRITIONAL ASSESSMENT 10
2.1 Anthropometry 10
2.1.1 Screening for overnutrition 10
2.1.2 Screening for undernutrition 10
2.2 Biochemistry 10
2.3 Clinical 11
2.4 Diet history 11
2.5 Urinary analysis 11
3. NUTRITIONAL RECOMMENDATIONS FOR CHRONIC KIDNEY DISEASE (CKD) 12
3.1 Nutritional Management of HIV/AIDS in CKD 12
4. NUTRITIONAL INTERVENTION 14
5. MONITORING 16
5.1 Nutritional assessment monitoring and follow-up 16
5.2 Complications related to dialysis treatment [hemodialysis (HD) and peritoneal (PD)] 17
5.3 Medication commonly used in chronic kidney disease and possible side effects 17
5.4 Patient education (chronic kidney disease) 18
5.4.1 Energy requirements 18
5.4.2 Protein requirements 19

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 5.4.3 Sodium restriction 19
5.4.4 Fluid restriction 19
5.4.5 Potassium restriction 19
5.4.6 Phosphate restriction 20
5.4.7 Fibre and the gut microbiome 20
5.5 Transplant patient education 21
5.5.1 Early post transplant phase 21
5.5.2 Intermediate to late post transplant phase 21
5.5.3 Advice on discharge 21
6. REFERENCES 25
7. ANNEXURES 28
Annexure 1: Enteral Product Formulations 28
Annexure 2: Subjective Global Assessment (SGA.) 28
Annexure 3: South African Renal Exchange Lists Updated 2012 29

LIST OF TABLES
Table 1: RIFLE classification 1
Table 2: AKIN staging system 1
Table 3: Nutritional recommendations for acute kidney injury 3
Table 4: Monitoring checklist for the patient with AKI 6
Table 5: Complications related to hemodialysis and possible causes
thereof in the patient with AKI 6
Table 6: Medication commonly used in AKI and potential side effects 7
Table 7: Patient education (AKI) - general guideline 8
Table 8: Classification of overweight and obesity by body mass index (BMI),
waist circumference and associated disease risk 10
Table 9: Nutritional laboratory parameter outcome goals 11
Table 10: Nutritional recommendations for chronic kidney disease 12
Table 11: Nutritional recommendations for adults with diabetic nephropathy 14
Table 12: Monitoring checklist for the hospitalised patient with chronic kidney disease
(CKD) - conservative RRT (HD and CAPD) 16
Table 13: Monitoring checklist for the out-patient with chronic kidney disease (CKD)
- conservative renal replacement therapy (RRT) (HD and continuous
arterial peritoneal dialysis (CAPD) 16
Table14: Examples of the effects of HD and PD on nutrition 17
Table 15: Medication commonly used in renal disease and possible side effects 17
Table 16: Patient education (CKD) - general guide 23
Table 17: Patient education (transplant) - general guide 23

LIST OF FIGURES
Figure 1: AKI flow chart 1
Figure 2: Prognosis/classification of CKD 9
Figure 3: CKD flow chart 15
Figure 4: Patient education flow diagram 22

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ACKNOWLEDGEMENTS
The National Renal Nutrition Practice Guidelines for Adults will
assist in providing standardised and quality nutrition services to
patients attending public health institutions. Providing adequate
and appropriate nutrition in hospitals is imperative in building and
maintaining individuals’ nutritional status and thus decreasing
hospital length of stay.

The national Department of Health would like to express its

sincere gratitude to all national and provincial departments for their
contribution to the development of these guidelines. Thanks are
extended to Hiliary Goeiman for her assistance in providing a core
clinical working group within the Western Cape for the development
of this document. Special thanks to the core technical team for their
technical input, commitment and dedication, which contributed to
the development of this document. The following members were
instrumental in this process:

Lynette Cilliers: Western Cape Department of Health

Zarina Ebrahim: Western Cape Department of Health
Nazeema Esau: Western Cape Department of Health
Nolene Naicker: National Department of Health

The Directorate: Affordable Medicines and the National Essential Medicines List Committee, The South
African Society for Parenteral and Enteral Nutrition in South Africa, Association for Dietetics in South Africa
and provincial nutrition units also contributed to the development of these guidelines and we thank them for
their time and technical inputs.

MP MATSOSO
DIRECTOR GENERAL: HEALTH
DATE:

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ACRONYMS
ACE Angiotensin converting enzyme
AIDS Acquired Immunodeficiency Syndrome
AKI Acute kidney injury
AKIN Acute kidney injury network
ARF Acute renal failure
BEE Basal energy expenditure
BMI Body mass index
BP Blood pressure
BUN Blood urea nitrogen
CAPD Continuous ambulatory peritoneal dialysis
CKD Chronic kidney disease
CRP C-reactive protein
CRRT Continuous renal replacement therapy
DRI Dietary reference intake
DPI Dietary protein intake
EPO Erythropoietin
ESRD End-stage renal disease
GFR Glomerular filtration rate
HB Harris Benedict Equation for determining basal energy expenditure
HD Hemodialysis
ICU Intensive care unit
IHD Intermittent hemodialysis
IBW Ideal body weight
KDOQI Kidney disease outcome quality initiative
LDL Low density lipoproteins
NKF KDOQI National Kidney Foundation Kidney Disease Outcome Quality Initiative
PCR Protein catabolic rate
PD Peritoneal dialysis
pmp Per million population
PTH Parathyroid hormone
RIFLE Risk, injury, failure, loss, end stage renal disease
RRT Renal replacement therapy
SGA Subjective global assessment
TE Total energy
TG Triglycerides
TPN Total parenteral nutrition
UUN Urinary urea nitrogen (g/day)
VLDL Very low density lipoproteins

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SCOPE AND PURPOSE
These guidelines aim to provide nutritional recommendations based on current evidence for best practice in
the management of acute and chronic renal disease. The guidelines are targeted at nutrition professionals
that play a role in the prevention and treatment of renal disease in adult patients attending public health
facilities for care.

vi
BACKGROUND AND MOTIVATION
Acute kidney injury (AKI) is increasingly prevalent in both developed and developing countries and associated
with severe morbidity and mortality. Worldwide, one in five adults experience AKI during a hospital episode of
care, which should raise concern and awareness amongst healthcare workers1, 2.

Efforts should focus on minimising the causes of AKI, providing guidance on preventive strategies and early
recognition and management. It is said that prevention is the key to avoid the heavy burden of mortality and
morbidity associated with AKI3, 4.

Chronic kidney disease (CKD) affects mainly adults aged between 20 and 50 years in Sub-Saharan Africa
and is primarily due to hypertension and glomerular diseases. Hypertension (especially in black patients) and
diabetes (especially in whites and Asians) are the main causes of chronic kidney disease in South Africa.

Human immunodeficiency virus (HIV) infection is an epidemic, however there is very little data available on
HIV-related glomerular disease. This is due to patients presenting late for treatment and usually already in
need of dialysis. The availability of renal replacement therapy (RRT) is limited due to high costs and shortage
of skilled employees. Dialysis rates are 4.5 per million population (pmp) for hemodialysis and 23 pmp for
continuous ambulatory peritoneal dialysis (CAPD) in South Africa. The transplant rate averages 4.7 pmp in
South Africa5. Thus, screening of high risk populations for CKD is a strategy that should be implemented,
directed at patients with hypertension, diabetes mellitus, proteinuria, HIV infection and a family history of
CKD6.

In addition, medical nutrition therapy plays a vital role in both the prevention and management of both
non-communicable and renal disease. Thus, a team approach is suggested with a registered dietitian taking
the key role in providing appropriate nutrition care.

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SECTION A: ACUTE KIDNEY INJURY

1. DEFINITIONS

Acute kidney injury (AKI)

Recently acute kidney disease has been referred to as acute kidney injury.7AKI is an abrupt and sustained reduction
in kidney function due to isolated kidney dysfunction or it may be a complication of severe illness8and it is defined as:
• an increase in serum creatinine by ≥26.5 µmmol/l (≥0.3mg/dl) within 48 hours or
• an increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the
prior seven days, or
• urine volume < 0.5ml/kg/h for six hours
1.1 Classification of AKI
1.1.1 Risk, injury, failure, loss, end stage renal disease (RIFLE) and acute kidney injury network (AKIN) classifications
The widest used classification for AKI is the RIFLE model (acronym for risk, injury, failure, loss, end stage renal
disease).9,10 Also commonly used is the Acute kidney injury network (AKIN) staging system, which is a modification of
the RIFLE classification. Both models are based on serum creatinine and urine output, and both have been validated. In
clinical practice, oliguria appears to be the main factor considered by clinicians when deciding to initiate RRT.

The RIFLE classification is defined in Table 1.8

Table 1: RIFLE classification

Class S* creatinine or glomerular filtration rate (GFR) criteria Urine output criteria
Risk (stage 1) Serum creatinine x 1.5 or GFR decreased by >25% <0.5ml/kg/hr x 6hr
Injury (stage 2) Serum creatinine x 2 or GFR decreased by >50% <0.5ml/kg/hr x 12hr
Failure (stage 3) Serum creatinine x 3 or s creatinine 354mmol/L ( ³4mg/dL) with an acute rise 44mmol/L <0.3ml/kg/hr x 24hr
(>0.5mg/dL) Or anuria x 12hr
Loss Persistent AKI = complete loss of kidney function > 4wks
End stage kidney disease End stage kidney disease > 3 months

• AKIN criteria
The AKIN criteria have similar urine output criteria to the RIFLE classification, but differ in the serum creatinine
levels as illustrated in Table 2.

Table 2: AKIN staging system11

Stage Serum creatinine Urine output
1 *
Increase in serum creatinine of more than or equal to 26.4 μmol/l (0.3 mg/dl) or Less than 0.5 ml/kg per hour for more than 6 hours
increase to more than or equal to 150% to 200% (1.5- to 2-fold) from baseline
2 Increase in serum creatinine to more than 200% to 300% (> 2- to 3-fold) from Less than 0.5 ml/kg per hour for more than 12
baseline hours
3# Increase in serum creatinine to more than 300% (> 3-fold) from baseline (or serum Less than 0.3 ml/kg per hour for 24 hours or anuria
creatinine of more than or equal to 354 μmol/l (4.0 mg/dl) with an acute increase for 12 hour
of at least 44 μmol/l (0.5 mg/dl)

* =Modified from RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. The staging system
proposed is a highly sensitive interim staging system and is based on recent data indicating that a small change
in serum creatinine influences outcome. Only one criterion (creatinine or urine output) has to be fulfilled to qualify
for a stage.
# = Given wide variation in indications and timing of initiation of RRT, individuals who receive RRT are considered to
have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT.

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2. NUTRITIONAL ASSESSMENT

Nutritional assessment of the AKI patient is comparable to the routine nutrition assessment of normal individuals.
2.1 Anthropometry

Use actual body weight if normal body mass index (BMI).

Use ideal body weight if overweight and critically ill.

2.2 Biochemistry (if available and/or indicated as part of routine monitoring)

• full blood count
• Na, K, Cl, urea, creatinine
• calcium, magnesium, phosphate
• serum triglycerides
• serum glucose
• c-reactive protein
• albumin

2.3 Clinical
• signs and symptoms of fluid overload
• abdominal distension and discomfort
• stools (frequency and consistency)
• temperature
• blood pressure (BP)

2.4 Diet history

Dietary intake assessment can be completed as indicated using traditional choices of 24-hour recall, food diary, food
frequency questionnaires.12
• food/medication allergies or intolerances
• dietary intake prior to hospital admission
• period nil per mouth within hospital/when was last meal taken
• special dietary needs/interventions
• medicine-nutrient interactions
• herbal/supplement use

2.5 Urinary analysis (dipsticks and microscopy)

• glucose
• protein
• urea and creatinine

2.6 Blood gasses

• PH
• PO2/PCO2
• TCO2/HCO3

Nutritional support of AKI patients particularly demands an integrated and overall view on energy, protein, fluid, electrolyte
metabolism, and a careful and accurate assessment of nitrogen and electrolyte balances. 13 Nutritional support in AKI
should be started very early after injury. 13Nutritional support varies considerably between individual patients, depending
on the degree of renal failure, co-morbid illness and medical management. Therefore, there is no standard dietary
regimen that can be used for all patients. 14

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3. NUTRITIONAL RECOMMENDATIONS

3.1 Summary
Note: Recommendations vary according to reference used. Clinical judgement remains important.

Table 3: Nutritional recommendations for acute kidney injury 7,9,15,16,17,18,19,20,21,22,23,24,25

Conservative Hemodialysis
(non-dialysed)
Protein (g/kg/d) 0.6 – 1.0 IHD 1.2-1.5
CRRT 1.7
Hypercatabolic 1.7 (maximum 2g/kg)

Glutamine Glutamine is contraindicated in patients with multi-organ failure and where GFR is less than 30 ml/min.

Note: In CRRT, approximately 0,2g amino acid is lost per litre of filtrate, resulting in a total loss of 10 to 15g amino acid (protein) per day.

Energy (kcal/kg/d) 20-30 (TE) 1-30 (TE)

Note: Internationally, the recommended energy requirement for AKI is 25 to 35kcal/ kg/ day (total energy). In practice, 20 to 30kcal/kg/day is more
achievable.
Fat (%TE) 30-35 30-35
IV 0.8-1.2 g/kg IV 0.8-1.2 g/kg

Note: It is important to monitor serum TG and to reduce or stop fat /simple sugar intake, if TG exceeds 4.52 mmol/L (400mg/dL).

CHO (mg/kg) 50-60 % (TE) 50-60% (TE)

4-7 (critically ill) 4-7 (critically ill)
Note: In AKI critically ill patients with elevated blood sugars, infusion insulin therapy targeting plasma glucose at 6.1 to 8.3mmol/L, is recommend-
ed.
Sodium (mg/d) 2000-3000 2000-3000
Increased need to replace losses with diuresis
Fluid (ml/d) Output PLUS Output PLUS
500-750 (maintain balance) 500-750
Increase fluid during diuresis PLUS 1000ml (maintain balance), Increase fluid during diuresis and
CRRT
Potassium (mg/d) 2000-3000 2000-3000
Needs may increase with dialysis, diuresis, anabolism
Calcium (mg/d) Maintain normal levels Maintain normal levels
Phosphate (mg/kg/d) 10-15 10-15
May need P-binders May need P-binders
Needs may increase with CRRT, return of kidney function, anabolism
Zinc (mg/d) Unknown Unknown
Copper (μg/d) - 300-500 CRRT
Note: Copper should be withheld from nutritional support when the total bilirubin is greater than 51.3 umol/L (3mg/dL).
Thiamine (mg/d) 1.1-1.5 25-100 CRRT
Selenium(μg/d) - 100 CRRT
Folate (mg/d) 1.0 1.0
Vit C (mg/d) <100 IHD 100
CRRT 100-200
Vit A (μg/d) 700 -900 700 - 900
Note: Vitamin A toxicity (hypervitaminosis A) due to increased plasma retinol levels as a result of the loss of renal degradation of retinal binding
protein in renal failure, occurs in patients on prolonged RRT.
Vit D (μg/d) Unknown Unknown

Note: Risks of vitamin D supplementation (>10 000 to 40000 IU per day) taken for extended periods, include hypercalcaemia, hypercalciuria and
acute kidney injury. Optimal vitamin D supplementation for critically ill patients with AKI has not yet been established.

Vit E(mg/d) 0-15 (Individualise) 0-15 (Individualise)

Vit K(μg.d) DRI DRI

*Using ideal body weight (ESPEN enteral guidelines, 2006)26

Note: Refer to anthropometry section for the appropriate weight to use in calculations

3
4. NUTRITIONAL INTERVENTION

Prescribe an appropriate renal diet based on modality of treatment, patient’s tolerance and fluid restrictions. Patients
with poor oral intake should be supplemented accordingly or be considered for enteral feeding. Critically ill patients with
AKI would often require enteral feeding. Enteral feeding of AKI critically ill patients may be challenging due to impaired
gastrointestinal motility and decreased absorption of nutrients secondary to bowel oedema. AKI is a major risk factor
for gastrointestinal haemorrhage. Enteral feeding may potentially exert a protective effect in reducing the risk of stress
ulcers or bleeding.15

When sufficient enteral feeding cannot be achieved, the combination of enteral and parenteral feeding may be required
to achieve successful nutritional support. The two routes of feeding should be considered complementary, and not
mutually exclusive.18 Enteral nutrition is the preferential route in the first 24 to 48 hours upon intensive care unit (ICU)
admission, and if adequate enteral nutrition cannot be achieved between three and five days, parenteral nutrition should
be introduced.15

At the onset of AKI, when few patients can tolerate oral feedings because of vomiting and diarrhoea, intravenous
(IV) preparations can be used to reduce protein catabolism. Some patients can be managed with enteral feedings,
depending on the degree of severity of symptoms, but in most AKI patients, IV feedings e.g. total parenteral nutrition
(TPN) must be used. The preferred treatment is illustrated in Figure 1.

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5
5. MONITORING

5.1 Nutritional assessment monitoring and follow-up

Table 4 summarises measurements and laboratory tests used to monitor the effectiveness of therapy for the patient with
AKI. The frequency of testing will vary on an individual basis or as indicated.

Table 4: Monitoring checklist for the patient with AKI27, 28*

Parameter Frequency of assessment
Unstable patient* Stable patient
Anthropometry
Weight 1-2x/week 1x/week
Depending on how stable the patient is. Ideally daily to monitor changes in fluid status.
Biochemistry #
Serum potassium, sodium Daily Daily
Serum urea and creatinine Daily Daily
Serum phosphorus, calcium and magnesium Daily 3x/week
Full blood count Daily 1x/week
Blood glucose 4 hourly Daily
Serum albumin 3x/week 1x/week
C-reactive protein (CRP) 2x/week 1x/week
Clinical
Abdominal distension and discomfort Daily Daily
Fluid intake and output Daily Daily
Signs and symptoms of oedema or dehydration Daily Daily
Stool output and consistency Daily Daily
Urine (dipstix and microscopy) As indicated As indicated
#
Practices related to frequency of assessments may vary amongst hospitals but minimum requirements should be according to internal hospital
protocols.
*Note: Haemodynamically unstable patients may require more frequent assessments.

5.2 Complications related to AKI

Table 5 presents complications related to treatment and possible causes thereof in the patient with AKI.

Table 5: Complications related to hemodialysis and possible causes thereof in the patient with AKI29
Complication Cause
Protein and electrolyte loss leads to, e.g.: Inadequate protein and or calorie intake due to anorexia and uraemia,
Malnutrition altered taste, metabolic acidosis, inflammation, and reduced dietary
Poor rehabilitation intake
Fatigue
Anaemia
Infection
Hypotension Taking anti-hypertensive medication before dialysis
Heart disease
Septicaemia
Anaemia
Dehydration
Anaphylaxis
Air embolism
Eating/drinking during dialysis
Dialyzer reaction
Muscle cramps Removal of large amounts of fluids; changes in electrolytes
Nausea and vomiting Hypotension
Uraemia
Disequilibrium syndrome
Headache Hypertension
Too much fluid removal
Disequilibrium syndrome
Chest pain Ischemia
Hypertension Fluid overload prior to dialysis.
Non-compliance with blood pressure medications patients not taking
medication
Anxiety

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5.3 Medication commonly used in acute kidney injury and potential side effects

Listed in this section are the commonly prescribed renal specific medications used in AKI, similar to chronic kidney disease,
displaying their indication, action and side-effects limited to nutrition and gastrointestinal function. It includes various
diuretics, anti-hypertensives, phosphate binders (not routinely used) and certain immuno-suppressive medication, etc.

Table 6: Medication commonly used in AKI and Potential Side Effects30, 31,32,33
Medication Indication Action Nutritional side-effects
Furosemide Oedema, fluid overload Loop diuretic Urinary loss of potassium, zinc, magne-
sium, calcium, sodium
dehydration
Thiazide Diuretics Hypertension Potent diuretic, prevent re-absorption Nausea, anorexia, hyponatraemia,
of sodium, potassium, chloride hypokalaemia, hyperuricaemia, hyper-
glycaemia
Spirinolactone Hypertension, fluid overload Aldosterone antagonist, potassi- Hyperkalaemia, dry mouth, nausea,
um-sparing diuretic, which blocks vomiting, gastritis, diarrhoea
exchange of sodium with potassium
and hydrogen
Calcium Hyperphosphataemia, Calcium supplement and phosphate Constipation, increased Ca-P product,
hypocalcaemia binder. If used as a supplement, do hypercalcaemia, calcium citrate increas-
not use with food es aluminium absorption, nausea and
vomiting
Aluminium hydroxide sus- Hyperphosphataemia Binds the phosphorus from ingested Constipation, aluminium toxicity, in-
pension food in the gut (Ca-P complex), pre- crease thiamine requirements, impaired
venting absorption. iron and folate absorption
Take with meals while restricting
phosphate intake
Sevelamer Hydrochloride Hyperphosphataemia Non-calcium, non-aluminium phos- Increased calcium absorption if taken
phate binder, ionic and hydrogen with calcium, diarrhoea, nausea, vom-
bonding of phosphate iting, dyspepsia, peripheral oedema,
decrease LDL, increase HDL
Sodium polystyrene sul- Hyperkalaemia Sodium and potassium exchange in Sodium and fluid retention, diarrhoea,
fonate the gut; potassium containing resin is nausea and vomiting, constipation, hy-
excreted in the stool pokalaemia, hypocalcaemia, hypomag-
nesaemia
Angiotensin converting Hypertension, renoprotection, Inhibits the production of angiotensin Hyperkalemia
enzyme (ACE) inhibitors heart failure (vasoconstrictor)
Slows the degradation of bradykinin
(vasodilator)
Avoid natural liquorice
Beta blockers Hypertension Adrenergic inhibitor, blocks sympa- Abdominal discomfort, flatulence, mask-
thetic effects on heart and results in ing if insulin-induced hypoglycaemia,
reduced arterial pressure and cardiac lowering of HDL-cholesterol, increase
output total-cholesterol and triglycerides
Alpha Blocker Hypertension Adrenergic-receptor blocking norepi- Modest lowering of LDL-cholesterol,
nephrine action dryness of mouth
Corticosteroids (Predni- Immuno-suppressant used Anti-inflammatory, immunosuppres- Hypertension, sodium and fluid
sone, Methylprednisolone during kidney transplantation sion retention, increased appetite weight
and treatment of many kidney gain, diabetes mellitus, dyslipidaemia,
diseases hypokalemia, hypocalcemia, osteoporo-
sis, osteonecrosis, hypophosphataemia,
protein hypercatabolism , urinary losses
of zinc, potassium, calcium, vitamin C
and nitrogen, gastrointestinal ulceration,
impaired wound healing, pancreatitis,
impaired growth in children
Cyclophosphamide Used to treat auto-immune Interfere with DNA replication Nausea, vomiting, diarrhoea, mouth
disorders sores, syndrome of inappropriate ADH

7
5.4 Patient education
(For specific patient treatment e.g. fluid, potassium, sodium and protein refer to patient education in CKD)
Patient education is only applicable when the patient is discharged and is taking in food orally. The patient education
guidelines are summarised in Table 7.

Table 7: Patient Education (AKI) General Guideline34

Treatment Conservative Dialysis (HD/CRRT)
Initial intervention (with- Follow-up (daily/as needed) Initial intervention (within Follow-up (daily/as needed)
Factor
in 72 hours of referral) 72 hours of referral)
Self-management Discuss the role and ef- Review and reinforce Discuss the role and effect Review and reinforce
skills fect of diet and medication self-management skills, of diet and medication on self-management skills,
on renal function. including daily intake and renal function and dialysis including daily intake and
output and relevant feedback treatment. output and relevant feedback
thereof. thereof.
The importance of blood Provide feedback on chang- The importance of blood Provide feedback on changes
pressure control and, if es in weight/nutritional sta- pressure control and, if rele- in weight/nutritional status,
relevant, blood glucose tus, blood pressure control. vant, blood glucose control. blood pressure control.
control.
Ensure optimal caloric, Recommend changes in Ensure optimal caloric, Recommend changes in
protein and nutrient intake nutrient intake that may protein and nutrient intake nutrient intake that may
e.g. sodium, potassium, improve outcome, depend- e.g. sodium, potassium, improve outcome, depending
phosphorous. ing on the stage of AKI e.g. phosphorous and vitamins on the stage of AKI e.g.
maintenance or recovery according to type of dialysis maintenance or recovery
stage. (HD / CRRT). stage and type of dialysis.
Basic dietary guidelines Provide specific mineral re- Basic dietary guidelines as Provide specific mineral re-
as indicated and reinforce striction guidelines according indicated and reinforce tem- striction guidelines according
temporary nature of rec- to lab results and reinforce porary nature of recommen- to lab results and reinforce
ommendations. temporary nature of recom- dations. temporary nature of recom-
mendations. mendations.
Discuss fluid intake and Review fluid status and Discuss dry weight, fluid Review fluid status and
restrictions, if indicated. recommendations. intake and fluid restrictions, recommendations.
as indicated.
Discuss laboratory results Discuss laboratory results Review dialysis adequacy
e.g. sodium, potassium, e.g. sodium, potassium, and changes in dialysis
phosphate, calcium, mag- phosphate, calcium, magne- modality.
nesium and the signifi- sium and the significance of
cance of thereof. thereof.
Discuss medicine-nutrient Review medication pre- Discuss medicine-nutrient Review medication
interactions as indicated. scribed, any changes and interactions as indicated. prescribed, any changes
medicine-nutrient interac- and medicine-nutrient
tions. interactions.
Implement nutritional plan Re-assess nutritional plan. Implement nutritional plan as Re-assess nutritional plan.
as per individual require- per individual requirements
ments i.e. oral intake, i.e. oral intake, enteral feed-
enteral feeding, intradia- ing, IDPN or TPN.
lytic parenteral nutrition
(IDPN) or TPN.
Assess comprehension of Assess comprehension of Assess comprehension of Assess comprehension of
education and projected education and projected education and projected education and projected
compliance. compliance. compliance. compliance.
Provide relevant educa- Provide and review Provide relevant educational Provide and review
tional material. Consider educational material during material. Consider exchang- educational material,
exchanges if renal func- hospitalisation and on es if renal function does not especially with changes
tion does not resolve. discharge. resolve. in dialysis modality during
hospitalisation and on
discharge.
Behavioural Identify short-term Reset short-term achievable Identify short-term achievable Reset short-term achievable
achievable goals. goals and review long-term goals. goals and review long-term
goals. goals.
Establish follow-up plan. Establish follow-up plan. Establish follow-up plan. Establish follow-up plan.

8
SECTION B: CHRONIC KIDNEY DISEASE (INCLUDING RENAL TRANSPLANT)

1. DEFINITIONS
Acute glomerulonephritis: A group of diseases characterised by inflammation of the capillary loops of the glomerulus.

Azotemia: The accumulation in the blood of abnormal quantities of urea, uric acid, creatinine, and other nitrogenous
wastes.

Chronic kidney disease: Abnormalities of kidney structure or function, present for more than three months with
implications for health and CKD is classified based on cause, GFR category, and albuminuria category.35

End-stage renal disease (ESRD): A disease characterised by the kidney’s inability to excrete waste products, maintain
fluid and electrolyte balance and produce hormones.

Erythropoietin (EPO): A hormone secreted chiefly by the kidney in the adult and by the liver in the foetus, which acts
on stem cells of the bone marrow to stimulate red blood cell production.

Glomerular filtration rate (GFR): The quality of glomerular filtrate formed per unit in all nephrons of both kidneys.

Nephritic syndrome: The syndrome of haematuria, hypertension and mild loss of renal function that results from acute
inflammation of the capillary loops of the glomerulus.

Nephrotic syndrome: A condition resulting from loss of the glomerular barrier to protein; characterised by massive
oedema, proteinuria, hypoalbuminemia, hypercholesterolemia, hypercoagulability, and abnormal bone metabolism.

Oliguria: The condition of having urinary volumes of less than 500ml/day.

Pyelonephritis: Bacterial infection of the kidneys.

Renal osteodystrophy: Metabolic bone disease as a complication of ESRD.

Uraemia: A clinical syndrome of malaise, weakness, nausea, vomiting, muscle cramps, itching, metallic mouth taste and
often neurological impairment, which is brought about by azotemia. 30

Prognosis / Classification of CKD:

Figure 2. Prognosis of CKD by GFR and albuminuria category (adapted from KDIGO 2012)35

Green- low risk (if no other markers of kidney disease, no CKD); Yellow- moderately increased risk; Orange - high risk; Red - very high risk

9
2. NUTRITIONAL ASSESSMENT
The nutritional assessment of the CKD patient is comparable to a routine nutrition assessment of normal individuals, but
with some modifications.

The ABCD (anthropometry, biochemistry, clinical and dietary) approach should be used when doing a nutritional
assessment as discussed below.

In patients receiving renal replacement therapy, the focus should be placed on body composition rather than on weight
loss in isolation to reduce metabolic demands on the kidney and as a result delay progression of ESRD. Thus BMI
should not be used in isolation, but rather with other anthropometric indicators like waist circumference.

2.1 Anthropometry36

2.1.1 Screening for over nutrition

Table 8. Classification of overweight and obesity by BMI, waist circumference and associated disease risk38

2.12 Screening for under-nutrition39,40

• Actual body weight < 85% of ideal body weight according to NHANES II.
• Unintentional weight loss ≥5% in 1 month or 7.5% in 3 months or ≥10% in 6 months, all considered significant
• BMI < 20kg/m2
• Subjective global assessment (SGA) is a mini-diagnostic examination using a standardized rating scale (Annexure
2). It has been recommended for routine monitoring of nutritional status changes. 39 Severe protein energy wasting
(PEW) is classified as a score of 1-2, whereas as moderate malnutrition is classified as 4-5.

2.2 Biochemistry
Selected nutrition-related laboratory parameters for haemodialysis and peritoneal dialysis are shown in Table
8, based on K/DOQI recommendations. 13

10
Table 9: Nutritional laboratory parameter outcome goals 32
Nutritional laboratory parameter Goal Outcome prevention focus
S-Sodium (mmol/L) 136-145 Fluid and blood pressure control
S-Potassium (mmol/L) 4.0-5.5 Cardiac arrhythmia and cardiac arrest
S-albumin g/L 35-52 Protein-energy malnutrition
S-Urea (mmol/L) 22-29 Protein intake
Malnutrition
Dialysis adequacy
Pre-dialyses S-creatinine (µmol/L) Pre ESKD 177-708 Malnutrition
Small patient on dialysis 708-1062
Large patient on dialysis 1328-1770
TCO2 (mmol/L) >22 Metabolic acidosis
Kt/V or urea reduction ratio >1.2 HD or >65% Dialysis adequacy
1.7 PD
S-Phosphate (mmol/L) 0.8-1.4 Soft tissue calcifications, bone disease
Maintain in the normal range Stages 3-5
0.78-1.42
S-Calcium (mmol/L) corrected 2.05-2.45 Soft tissue calcifications, bone disease
S-Calcium-phosphate product mmol2/L2 ≤5 or <4.4 Soft tissue calcifications , bone disease
PTH (ng/L) Stage 5: Hyperparathyroidism
2-9x normal range (normal range 1.5-7.6) Stage 3 -5
No optimal range
Transferrin saturation 20-50%
Serum Ferritin ( μg/L) 200-500

2.3 Clinical

Fluid overloading:
• oedema
• shortness of breath
• increased blood pressure
• oedematous gut, which could lead to irregular gut function
• swelling in legs and face
• need for oxygen
Uraemic symptoms:
• nausea, vomiting or dry retching
• anorexia
• taste changes
• bad smelling breath
• dizziness
• headaches
• irritable
• insomnia
• extreme exhaustion
• uraemic gut syndrome
Potassium symptoms:
• heart palpitations
• fainting
• heart attacks

Phosphate symptoms and side effects:

• itching
• red eyes
• body pains not related to gout
• CKD-MBD
• brittle bones
• regular bone breaks
• normal artery calcification
• hypertension
• nose bleeds

2.4 Diet history

Dietary intake assessment can be completed using traditional choices of diet recall, food diary, food frequency
questionnaires or food exchanges.

2.5 Urinary analysis:

• glucose
• protein
• urea and creatinine

11
3. NUTRITIONAL RECOMMENDATIONS FOR CKD 42, 43,
Table 10 summarises the macro and micro nutrient recommendations for CKD

Table 10: Nutritional recommendations for chronic kidney disease20,22,33,42, 43, 44,45,46,47,48
Requirements Conservative (non-dialysed) Hemodialysis Peritoneal dialysis Transplant
Protein(g/kg/d) 0.6 - 0.75 1.2 1.2-1.3 Initial:
At least 50% HBV At least 50% HBV At least 50% HBV 1.3 – 2.0
Stage 1-3: 0.75 10-12g amino acid loss
Stage 4-5: 0.6-.75 per dialysis session 5-15g protein loss per
Maintenance:
Nephrosis: 0.8-1.0 / 0.8 plus day
0.8-1.0
1.2 (urine protein loss) Chronic rejection (non-dial-
ysed)
0.6-0.8
Energy(kcal/kg) Initial:
30-35 30-35
30-35 30-35 Includes energy from Maintenance:
dialysate 25-30
Maintain desirable body
weight
NOTE: This energy intake is needed to ensure a positive nitrogen balance. Obese patients requires <35 kcal /kg/d, while underweight patients
would require more than 35kcal/kg/d.
Use actual weight if falls within the 95th-115th percentile of standard weight or adjusted if actual body weight falls <95th percentile (underweight) or
> 115th percentile (overweight/obese)these ranges,
Carbohydrates (% TE) 50-60 of total energy 50-60 of total energy 50-60 of total energy 50-60 of total energy
(complex) (complex) (complex) (complex)
Includes carbohydrates
from dialysate (see sim-
ple estimate formula)
Fat (% TE) 25-35 of total energy 25-35 of total energy 25-35 of total energy 25-30 of total energy
Cholesterol (mg/d) <300 <300 <300 <300
S/P/M/ ratio (%) <7: ≤10: ≤10 <7: ≤10: ≤10 <7: ≤10: ≤10 <7: ≤10: ≤10
Fibre(g/d) 20-30 20-30 20-30 20-30
Fluid (ml/d) Usually unrestricted with Output PLUS Monitored, Unrestricted unless indicated
normal urine output 500-750 1500-2000
Output PLUS New guidelines PLUS
500-750 1000ml
NOTE: Interdialytic weight gain should ideally not exceed 2-2.5kg or 4-4.5% of the dry weight.
Minerals Conservative Hemodialysis Peritoneal dialysis Transplant
Sodium (mg/d) 1000-4000 ≤ 1L urine 2000-4000 2000-4000 2000-4000
(Individualise) ≤ 1L urine 2000 (Individualise) (Individualise)
(Individualise)
Potassium (mg/d) 2000-3000 / 40mg/kg 2000-3000 / 40mg/kg 2000-4000 Unrestricted; unless hyperka-
1500-2700 if hyperkalaemic laemia

Calcium (mg/d) <2000 (<1500mg/d from <2000 (<1500mg/d from <2000 (<1500mg/d from 1200-1500
binders) binders) binders)
NOTE: Dietary calcium intake, including a calcium-based phosphate binder, should not exceed 2000mg/day to reduce the risk of hypercalcaemia
and vascular calcifications.
Phosphate (mg/d) 800-1000 / 800-1000 / 800-1000 / DRI
10mg/kg / <17 mg/kg 10-15mg/g Protein
10-12mg/g Protein 10-15mg/g Protein P-binders
P-binders P-binders
Magnesium (mg/d) 200-300 200-300 200-300 DRI, supplement if decreased
levels
Iron (mg/d) 10-18 (Individualise) 10-18 (Individualise) 10-18 (Individualise) DRI, individualise supplemen-
tation

12
 Requirements Conservative (non-dialysed) Hemodialysis Peritoneal dialysis Transplant
Zinc (mg/d) Individualise Individualise Individualise DRI
NOTE: Routine supplementation of Zinc, Selenium and Copper not recommended.
Thiamine (mg/d) 1.1-1.5 1.1-1.5 1.1-1.5 DRI
Riboflavin (mg/d) 1.8 1.1-1.3 1.1-1.3 DRI
Panthothenic acid 5 5 5 DRI
(mg/d)
Niacin (mg/d) 14-20 14-20 14-20 DRI
Pyridoxine (mg/d) 5 10 10 DRI
NOTE: Decreased levels of pyridoxine are associated with hyperhomocysteinaemia.
Vit B12 (μg/d) 2-3 2-3 2-3 DRI
Folate mg/d 1.0 1.0 1.0 DRI
NOTE: Vitamin B12 and Folate supplementation are required for normal erythropoiesis and an optimal response to the medications used to stimulate
erythropoiesis.
Vit C mg/d 60-100 60-100 60-100 DRI
NOTE: High doses of supplemented vitamin C of >200mg/day is not advised due to increased risk of oxalate deposition that may contribute to
vascular disease.
Vit A (μg/d) No supplementation No supplementation No supplementation DRI
NOTE: Vitamin A is known to accumulate during renal failure and therefore routine supplementation is not recommended during CKD.
Vit D (μg/d) Individualise Individualise Individualise DRI
NOTE: Consider Vitamin D supplementation for the treatment of osteomalacia and hyperparathyroidism.
Supplementation may be indicated.
Vitamin D: Individualise means we need to consider the patients calcium, phosphate and parathyroid hormone (PTH) levels, if need start at 0.25ug
of 25(OH)vitamin D and titrate upwards.
Vit E mg/d 0-15 (Individualise) 0-15 (Individualise) 0-15 (Individualise) DRI
NOTE: Vitamin E is known to accumulate during renal failure and therefore routine supplementation is not recommended during CKD. There is
controversy regarding the optimal vitamin E dose to be supplemented.
Vit K μg.d Individualise Individualise Individualise DRI
NOTE: The RDA for vitamin K is recommended except in cases with altered coagulant activity and long-term treatment with antibiotics.

Carbohydrates absorbed from the peritoneal dialysate should be taken into account when calculating the calorie
requirements. The ‘Simple Estimate Formulae’ can be used. 49, 50.
The Simple Estimate Formulae:
Estimate of calories absorbed from PD with 60% absorption rate50 (absorption rate ranges between 60-70%):
1.5% 1L = 15g X 3.4 = 51 X 60% = 31 kcal / L
2.5% 1 L = 25g X 3.4 = 85 X 60% = 51 kcal / L
4.25% 1L = 42.5g X 3.4 = 144.5 X 60% = 86.7 kcal / L
Concentration of dextrose absorbed27
Dialysate dextrose concentration Grams of dextrose/L kcal/L from dextrose kcal/L with CAPD (60%)*
1.50% 15g 51kcal 31kcal
2.50% 25g 85kcal 51kcal
4.25% 42.5g 144.5kcal 86.7kcal
*60% dextrose absorbed with CAPD
**each gram of dextrose = 3.4kcal
E.g. Energy/L x Total Volume

Note: In usual practice the dialysate bags are two litres in volume, used four times per day, giving eight litres in total per day.

13
Table 11: Nutritional recommendations for diabetic nephropathy45,51,52, 53,54,55,56
Requirements Conservative Hemodialysis Peritoneal dialysis
Protein (g/kg/d) 0.6-0.8 1.2 1.2-1.3
High biologic value protein % 50 (at least) 50 (at least) 50 (at least)
Energy (per day) H-Bakcal or 30-35 kcal/kg H-Bakcal or 30-35 kcal/kg H-Bakcal or 30-35 kcal/kg
Carbohydrates (%TE) 50-60 50-60 50-60
Fat (%TE) ≤30 ≤30 ≤30
Saturated fatty acids (% TE) ≤10 ≤10 ≤10
Polyunsaturated fatty acids (%TE) 6-8 6-8 6-8
Monounsaturated fatty acids (%TE) ≤15 ≤15 ≤15
Cholesterol (mg/day) <200 <200 <200
Fibre (g/d) 20-30 20-30 20-30
Fluid (ml/d) Output + (500-750) Output + (500-750) 1500-2000
Minerals Conservative Hemodialysis Peritoneal dialysis
Sodium (mg/d) <2300 2000-4000 2000-4000
Potassium (mg/d) 1500 - 2700 (restrict if raised) 2000-3000 2000-4000
Calcium (mg/d) <2000-2500 (including binder) <2000-2500 (including binder) <2000-2500 (including binder)
Phosphate (mg/d) 800-1000 / 10mg/kg / 800-1000 /<17 mg/kg 800-1000 / 10-15mg/g
10-12mg/g Prot P-binders 10-15mg/g Prot P-binders Prot P-binders
Iron (mg/d) 10-18 (Individualise supplemen- 10-18 (Individualise supplementation) 10-18 (Individualise
tation) supplementation)
Zinc (mg/d) 12-15 (male) 12-15 (male) 12-15 (male)
10-12 (female) 10-12 (female) 10-12 (female)
Selenium (μg/d) 55 55 55

NKF KDOQI: National Kidney Foundation Kidney Disease Outcome Quality Initiative
a
H-B: Harris Benedict Equation for determining Basal Energy Expenditure
TE: Total energy
All calculations are based on Ideal Body Weight
HBV: high biological value

3.1 Nutrition management of HIV/AIDS in CKD

• Individualised assessment and management
• Integrate specific nutrition challenges of HIV/AIDS with appropriate guidelines for CKD
o wasting
o lipodystrophy syndrome
o nausea, vomiting, anorexia
o diarrhoea
o malabsorption
o hormonal imbalances
o metabolic abnormalities
o side effects of medication
• Management
o individualise
o integrate guidelines for renal failure and HIV/AIDS
o energy 10 – 15% extra for HIV/AIDS, till 25% (with active weight loss) 30-35kcal/kg up to 45-50kcal/kg in
severely catabolic patients
o protein – to be individualised 1.2-1.5 g/kg22up to 2g/kg in severely catabolic patients. The lower range of
protein is for conservative patients that are not catabolic, increasing for dialysis and degree of acute illness
o Na – 2000-4000mg/day
o potassium – 2000-3000mg/day
o calcium – 1000-1500
o 10-12 mg/g of protein
o fluid- output plus 1000-1200ml
o iron – individualise to maintain iron stores
o be aware of nephrotoxic effects of anti-retroviral and tuberculosis medications

4. NUTRITIONAL INTERVENTION

Since protein-energy malnutrition has shown to be one of the most important risk factors for increased morbidity and
mortality, every effort should be made to preserve optimal nutritional status in CKD patients. Figure 3 summarises the
nutritional interventions for patients with CKD.
Refer to Annexure 1 for enteral formulation guidelines.

14
15
5. MONITORING

#
Practices vary amongst hospitals but minimum requirements should be according to internal hospital protocols.

5.1 Nutritional assessment, monitoring and follow-up

Table 12: Monitoring checklist for the hospitalised patient with chronic kidney disease (CKD) – conservative, RRT (HD and
CAPD) 27, 52
Parameter Frequency of assessment
Conservative RRT
Anthropometry
Weight Daily Daily
To monitor changes in fluid status. To monitor fluid, including pre- and post-dialysis weight.
*Biochemistry
Serum potassium, sodium Daily Daily
Serum urea and creatinine Daily Daily
Serum phosphorus, calcium and magnesium Weekly Weekly
Full blood count Weekly Weekly
Blood glucose Daily (if indicated) Daily (if indicated)
Serum albumin Weekly Weekly
Transferrin/RBS//Ferritin As needed As needed
CRP As needed As needed
Clinical
Signs and symptoms of oedema or dehydration Daily Daily
Stool output and consistency Daily Daily
Practices may vary amongst hospitals (guided by resources and costing) but minimum requirements should be according
to internal hospital protocols.

Table 13: Monitoring checklist for the out-patient with chronic kidney disease (CKD) – conservative, RRT (HD and CAPD) 27,
41, 57

Parameter Frequency of assessment

Conservative (pre-dialysis) RRT
Anthropometry
Weight 1- 3 monthly Monthly (PD) / 3x per week (pre- and post-HD)
BMI 1 -3 monthly 4 – monthly
SGA (subjective global assessment) 1 – 3 monthly 6 – monthly
Biochemistry #

Serum sodium 1 - 3 monthly 3 times a year

Potassium 6 times a year
Serum urea 1 - 3 monthly
Serum urea pre/post dialysis Monthly
Creatinine 1 - 3 monthly 3 times a year
Serum phosphorus 1 - 3 monthly 6 times a year
Serum calcium 1 - 3 monthly 6 times a year
Parathyroid hormone 3 times a year
Vitamin D Once a year
Bicarbonate (CO2 or HCO3) 6 times a year
White cell count and platelets 1 - 3 monthly Quarterly
Haemoglobin Monthly Monthly
Iron Quarterly
Ferritin Quarterly
Transferrin saturation Quarterly
Serum albumin 1 - 3 monthly Quarterly
Glucose (random) 2 times a year
HbA1C (diabetic patients only) 2 times a year
Lipogram fasting Once a year
Total cholesterol only Once a year

16
 Clinical
Signs and symptoms of oedema or dehydration 1 - 3 monthly Monthly
Stool output and consistency 1 - 3 monthly Monthly
Urine
Glucose 1 - 3 monthly As needed
Protein 1 - 3 monthly As needed

Practices may vary amongst hospitals (guided by resources and costing) but minimum requirements should be according
to internal hospital protocols.

5.2 Complications related to dialysis treatment (HD and PD)

Many patients have pre-existing malnutrition prior to the initiation of dialysis, due to anorexia and uremia, altered taste,
metabolic acidosis, inflammation, and reduced dietary intake. Once dialysis therapy begins, uremic symptoms are
reduced and the diet is liberalised, some patients may show improved nutritional status.

Table 14: Examples of the effects of HD and PD on nutrition 27,57.

Effects of HD Effects of PD
Pre-existing malnutrition due to anorexia, uremia, metabolic Pre-existing malnutrition due to anorexia, uremia, metabolic acidosis
acidosis and inflammation as well as inflammation related to and inflammation as well as inflammation related to the dialysis
the dialysis procedure procedure
May induce catabolism which can result in malnutrition, in- May induce catabolism which may lead to malnutrition
creased susceptibility to infection and increased mortality
Protein 10-12 g lost through the dialysate Protein 5-15g lost through the dialysate
Water soluble vitamin losses Water soluble vitamin losses
Muscle cramps Reduced appetite and abdominal distension and delayed gastric
emptying
Dextrose absorbed from the bag contributes energy and carbohy-
drate, which needs to be accounted for in the diet prescription
Increased TG possibly due to the high dextrose content
Weight gain

5.3 Medication commonly used in chronic kidney disease (CKD) and possible side effects

Listed in this section are the commonly prescribed medication used in chronic kidney disease displaying their indication,
action and side-effects limited to nutrition and gastrointestinal function. It includes various diuretics, anti-hypertensive,
phosphate binders, immuno-suppressive medication etc.

Table 15: Medication commonly used in renal disease (CKD) and possible side effects30, 31,32,58
Medication Indication Action Nutritional side-effects
Furosemide Oedema, fluid overload Loop diuretic Urinary loss of potassium, zinc, magnesium,
calcium, sodium

Dehydration
Thiazide Diuretics Hypertension Powerful diuretic, prevent re-ab- Nausea, anorexia, hyponatraemia, hypokalae-
sorption of sodium, potassium, mia, hyperuricaemia, hyperglycaemia
chloride
Spirinolactone Hypertension, fluid over- Aldosterone antagonist, potassi- Hyperkalaemia, dry mouth, nausea, vomiting,
load um-sparing diuretic, which blocks gastritis, diarrhoea
exchange of sodium with potassium
and hydrogen
Calcium Hyperphosphataemia, Calcium supplement and phos- Constipation, increased Ca-P product, hyper-
hypocalcaemia phate binder. If used as a supple- calcaemia, calcium citrate increases aluminium
ment, do not use with food absorption, nausea and vomiting
Aluminium hydroxide Hyperphosphataemia Binds the phosphorus from ingest- Constipation, aluminium toxicity, increase
suspension ed food in the gut (Ca-P complex), thiamine requirements, impaired iron and folate
preventing absorption absorption

Take with meals while restricting

phosphate intake
Sevelamer Hydrochloride Hyperphosphataemia Non-calcium, non-aluminium phos- Increased calcium absorption if taken with cal-
phate binder, ionic and hydrogen cium, diarrhoea, nausea, vomiting, dyspepsia,
bonding of phosphate peripheral oedema, decrease LDL, increase
HDL

17
 Active Vitamin D (calcitriol, Hypocalcaemia, secondary Increase calcium absorption Increased absorption of aluminium and phos-
alfacalcidol) hyperparathyroidism phate, hypercalcaemia
Erythropoietin Anaemia of chronic kidney Recombinant human erythropoietin; Increased appetite, iron, folate and vitamin B12
disease support erythropoiesis deficiency, increased blood pressure
Sodium polystyrene sul- Hyperkalaemia Sodium and potassium exchange in Sodium and fluid retention, diarrhoea, nausea
fonate the gut; potassium containing resin and vomiting, constipation, hypokalaemia,
is excreted in the stool hypocalcaemia, hypomagnesaemia
ACE inhibitors (Enalapril, Hypertension, renoprotec- Inhibits the production of angioten- Hyperkalaemia
Captopril) tion, heart failure sin (vasoconstrictor)
Slows the degradation of bradykinin
(vasodilator)
Avoid natural liquorice
Beta blockers Hypertension Adrenergic inhibitor, blocks sympa- Abdominal discomfort, flatulence, masking if
thetic effects on heart and results insulin-induced hypoglycaemia, lowering of
in reduced arterial pressure and HDL-cholesterol, increase total-cholesterol and
cardiac output triglycerides
Alpha blocker Hypertension Adrenergic-receptor blocking nor- Modest lowering of LDL-cholesterol, dryness
epinephrine action of mouth
Iron Iron deficiency Support erythropoiesis Constipation, nausea, vomiting, altered taste,
dark stools
Corticosteroids (Predni- Immuno-suppressant used Anti-inflammatory, immuno-sup- Hypertension, sodium and fluid retention,
sone, methylprednisolone) during kidney transplanta- pression increased appetite weight gain, diabetes melli-
tion and treatment of many tus, dyslipidaemia, hypokalaemia, hypocalcae-
kidney diseases mia, osteoporosis, osteonecrosis, hypophos-
phataemia, protein hypercatabolism (PG),
urinary losses of zinc, potassium, calcium, vita-
min C and nitrogen, gastrointestinal ulceration,
impaired wound healing, pancreatitis, impaired
growth in children
Cyclosporine Immuno-suppressant Reduce IL-2 production, spare Hyperkalaemia, hypomagnesaemia, increased
T-suppressor cells, grapefruit uric acid levels, hyperlipidaemia, hyperglycae-
increases CsA blood levels – use mia, oedema and hypertension, anorexia and
with caution, be vigilant of medicine nausea, vomiting, diarrhoea (PG), gingival
interactions hypertrophy, bone resorption, gastro oesopha-
geal reflux disease, dysmorphia, nephrotoxicity
due to increased CsA levels
Muromonab-CD3 Immuno-suppressant Inhibits T-cell effector function Severe fluid retention, hypertension, pulmo-
nary oedema, nausea, vomiting, anorexia,
(Orthoclone OKT3) diarrhoea, abdominal gas/pain (PG)
Mycophenolate Immuno-suppressant Gastrointestinal (GI) bleeding, abdominal
pain, GI symptoms, hypertension, fluid
retention, hyperlipidaemia, hypophosphatemia,
hyperkalaemia (PG)
Sirolimus Immuno-suppressant Inhibits proliferation of immune cells Dyslipidaemia, impaired wound healing,
hypokalaemia
Azathioprine Immuno-suppressant Anti-proliferative Increased risk of infection, pancreatitis
Tacrolimus Immuno-suppressant Inhibits IL-2 synthesis and release Hyperglycaemia, hyperkalaemia, hypomag-
nesaemia, hypertension, gastrointestinal
disturbance
Statins (simvastatin, Dyslipidemia HMG-CoA Reductase inhibitors Diarrhoea, nausea, vomiting, constipation,
atorvastatin) fatigue, muscle pain, rhabdomyolysis, liver
failure

5.4 Patient education (chronic kidney disease)

Please refer to patient education general guides (Table 14). The renal diet is complex and it can be challenging to
educate patients, since some renal patients have low literacy levels when it comes to nutrition. Along with the nutrition
guidelines given, the emphasis should be placed on health communication, focusing on providing clear and simple
messages, not using medical jargon, using visual aids while focusing on one dietary aspect at a time and asking patients
to teach back what they were taught59.

5.4.1 Energy requirements

The energy intake of the patient must be sufficient to prevent protein from being used as an energy source. These
energy requirements are determined according to the recommended guidelines for acute renal failure (ARF) and CKD
and are usually high. In PD patients, the energy from the dextrose in the dialysate should be considered in calculations;
therefore, the energy supplied by the diet would be less.

18
It is often difficult to achieve high energy requirements due to either low protein intakes or symptoms of uremia. Therefore,
a slow but steady increase in energy requirements may be required. Oral supplementation may be needed, especially
in malnourished patients if oral intake is insufficient.

Guidelines to enhance or maintain energy intake, based on individual requirements, include the following:
• include as many appropriate complex carbohydrates as the meal plan allows. Include simple carbohydrates
within limits in the daily meal plan e.g. sugar, jam, sweets (clear boiled sweets, marshmallows, jelly babies,
peppermints) and cold drinks (carbonated beverages and avoid cola flavoured drinks) to help meet their nutritional
requirements (total energy). Avoid cola flavoured drinks as they are high in phosphate. Sports drinks may be
included to increase energy intake. Mageu can be used as an energy drink in moderation
• the energy density of foods can be increased by adding margarine to porridge and vegetables
• to prevent an increase in blood lipids and lipoproteins, fat in the diet should be derived as much as possible from
mono- and poly-unsaturated food sources. Cholesterol intake should be limited due to enhanced cholesterol
absorption in ESRD60

5.4.2 Protein requirements

A low protein diet is recommended for patients with ESRD (various requirements at different stages of renal failure),
because protein increases glomerular pressure and thus leads to accelerated loss of renal function61. At least 50 per cent
of the protein intake should be of high biological value (animal) protein e.g. milk, eggs, red meat, fish or chicken. For
vegetarian patients or patients who do not have access to animal protein, a diet that includes grains, legumes, seeds,
nuts and vegetables can still provide all the essential amino acids.62
Patients on HD/PD have higher protein requirements, due to the protein lost during the dialysis process. Protein losing
enteropathy also increases the requirements and should be accounted for according to the KDOQI guidelines.
5.4.3 Sodium restriction
A low sodium intake is necessary in patients with renal failure to control oedema and blood pressure. Low sodium foods
are classified as less than 120mg of sodium per 100g. Foods with a moderate sodium content (120-600mg per 100g)
should be used in moderation. High sodium foods (>600mg per 100g) should be avoided.
Take into consideration when flavours are added to products, the sodium content increases.
Guidelines for sodium restriction:
• avoid processed foods very high in sodium such as tinned foods (baked beans, pilchards in tomato sauce),
tomato sauce, chutney, meat extract, soya sauce, salted nuts, chips, instant soups, processed meats (viennas,
smoked meat, polony, ham, biltong)
• avoid adding salt to food, unless recommended by the dietitian
• salt replacements are not recommended as they contain potassium
• use low fat cottage cheese more often and limit processed cheese e.g. cheddar or gouda and feta cheese
• advise on the flavouring of food using limited salt, for example, season foods with garlic, onion, chilli, curry
powder, pepper, herbs and lemon juice
• the focus of lowering dietary sodium intake should be aimed at increasing whole food intake and limiting the intake
of processed food, convenience foods from stores and take-aways63.
• emphasis should be placed on reading labels
5.4.4 Fluid restriction
When fluid restriction is necessary, an intake equal to the daily urine volume plus 500ml should maintain water balance61
in a hot climate, an intake equal to daily urine plus 750ml may be needed.
Guidelines for fluid restriction:
• the following substances count as fluids and must be counted in the fluid allowance for the day: Cold rink, coffee,
tea, cream, ice cream, sorbets and ices, gelatin puddings or dishes, soup and gravies, yoghurt, drinking yoghurt,
custard, jelly, milk and milkshakes, wine and beer
• distribute the fluid intake evenly throughout the day
• suck on an ice cube
• chew sugar-free gum
• gargle with a mouthwash
• eat sweets within allowances
• use cold or cool liquids rather than room temperature
• freeze liquids – it takes longer to consume
• add lemon juice to water to make it more refreshing
• fluid restriction should be accompanied by a strict sodium restriction
5.4.5 Potassium (K) restriction
Depending on the level of renal function, the potassium intake of the patient may need to be reduced.
Guidelines for potassium restriction:
• individualise fruit and vegetable intake
• there are three different K lists for fruit and vegetables, low, moderate and high

19
• patients should be educated to choose mostly from the low to moderate K group, however they do not have to
completely exclude the high K group, especially if their K levels are within range and they are on PD, which has
a higher K requirement
• refer to Annexure 3 for the new Renal exchange list of South Africa62
• cooking methods and food preparation, such as leaching, boiling and chopping of vegetables and legumes, can
aid in decreasing the potassium content
• leach potassium out of high-potassium vegetables by soaking vegetables in water before cooking, discarding
the water used for soaking, boiling the vegetables in water and then discarding the water used for boiling as well
• if the potassium level of a patient is high, avoid foods with over 250mg potassium per serving and limit the daily
intake to 1500-2700mg2
• generally, milk is limited to one portion for the day, due to the high potassium and phosphate content, however
more can be allowed on an individual basis
• the focus of lowering dietary potassium intake should be aimed at increasing whole food intake and limiting the
intake of processed food, convenience foods from stores and take-aways63.
• take note that processed foods may contain an increase in potassium salt substitutes in an effort to decrease
sodium content, regulated by legislation

5.4.6 Phosphate restriction

• Phosphate levels are usually high in renal failure patients due to altered bone metabolism.
• Patients should be educated about organic and inorganic phosphates and the bioavailability of phosphates from
these sources.
• Meat and dairy products are the main animal sources of organic phosphate, found in membrane phospholipids
and phosphoproteins, whereas in vegetable sources legumes, whole grains and nuts, it is found as phytate.
• The bioavailability from animal sources are 40 to 80 per cent. This can be higher if Vitamin D is present, vegetables
have an absorption rate of 20 to 40 per cent, because most of the phosphate is found as part of phytate, which
must be hydrolysed by phytase to be absorbed. Phytase is not found in the small intestine, which reduces
absorption further.
• Inorganic phosphate is not found in foods in their natural state, but is usually added. They are mainly additives
used to preserve food to improve palatability and shelf life of foods. The bioavailability is 90 per cent from the
inorganic phosphate, which is the highest absorption rate of the phosphate types. Not all foods are labelled with
phosphate content, which makes it more difficult to identify.63.
• Patients must be educated on limiting high phosphate meats e.g. cheese, eggs, sardines, pilchards or bacon to
one exchange a day. Legumes and wholegrains are allowed (even though high in phosphate, the phosphate in
legumes has reduced bioavailability)64,65. Legumes would include peanut butter, soya beans, baked beans, lentils,
dried beans and peas. Wholegrains would include breads, cereals and other wholegrain starches.
• The most suitable meat exchanges would come from the low phosphate meat groups including beef, lamb,
chicken, fish, lean mince, low fat cottage cheese or tuna.
• Milk and dairy products are limited to one portion per day, due to the high potassium and phosphate content.
• Always check that patients are taking their phosphate binder correctly, i.e. chewing it in the middle of meals (not
before/after eating).
• The focus of lowering dietary phosphate intake should be aimed at increasing whole food intake and limiting the
intake of processed food, convenience foods from stores and take-aways63.
• Emphasis should be placed on reading labels.
5.4.7 Fibre and the gut microbiome
Gut dysbiosis has recently been implicated in affecting the gut micriobiota in CKD patients. This is due to the altered
gut bacteria because of low fibre intake, which favours proteolytic fermentation instead of saccharolytic fermentation.
This increases uremic toxins (p-cresyl sulphate, indoxyl sulphate and trimethylamine oxide (TMNO), which causes the
progression of renal disease or worsens uremia as well as promoting inflammation.66 Saccharolytic fermentation is
achieved by adequate fibre in the diet. Studies have shown a reduction in urea and creatinine in CKD patients with fibre
interventions67.
• It is important to obtain sufficient fibre from a variety of sources, including soluble and insoluble fibres from fruit,
vegetables and especially wholegrains.
• The phosphates in wholegrains have low bio-availability so it may be included within the portion control of the diet.
• Patients can be advised about fruits and vegetables, encouraging low to moderate potassium sources, however
high sources do not have to be completely excluded.
• Although prebiotic supplements, synbiotics and probiotic studies have shown some benefit in the gut microbiome,
it is not recommended at this stage due to insufficient evidence for its adverse effects. Most of these studies have
been small. It is recommended that more research be done to understand the effects of diet, prebiotics, synbitoics
and probiotics on the symbiotic environment and its relation to kidney function. 68.

20
5.5. Transplant patient education

Please refer to the patient education general guidelines (Table 16) for additional information.
The post-transplant nutrition management can be divided into several phases; however, emphasis will be placed on
the immediate post-transplant and intermediate to late post-transplant phase.

5.5.1 Early post-transplant phase

In the early post-transplant phase in an uncomplicated surgery, the main emphasis is to manage fluid balance, electrolytes
and acid-base balance. The stress of surgery and the effects of high doses of steroids on nutrient metabolism necessitate
increased energy and protein requirements. The main goals are to promote wound healing, prevent infections and
provide adequate protein and energy to promote visceral protein stores and to correct electrolytes69. Potassium needs
to be monitored very carefully and patients should be advised to avoid high potassium fruits and fruit juices for the first
week post-transplant (depending on patient’s potassium levels). Certain immuno-suppressant medication has the effect
of increasing potassium levels. Other symptoms may include diarrhoea, constipation, nausea and vomiting and needs
to be managed accordingly.

5.5.2 Intermediate to late post transplant phase

• In the intermediate to late transplant phase, the goals are to prevent the complications of immuno-suppressant
medications, such as obesity, diabetes, hypertension, bone disease, hyperlipidaemia, hyperkalaemia and
malnutrition.57.
• Dietary advice should focus on healthy diet advice and to avoid restrictions from pre-transplant diets.
• Diet, exercise and lifestyle modification has an important role to play in the reduction of insulin resistance, which
can have harmful consequences, and to improve transplant outcomes69.

5.5.3 Advice on discharge

Successful transplant patients should be counseled as follows:

• explain to patients why their dietary requirements have now changed and counsel them on appropriate healthy
eating
• explain the need for adequate protein and why they should not follow a low protein diet
• counsel patients on following a low fat diet, with particular focus on low fat and cholesterol. Omega 3 fatty acids
and the use of plant stanols and sterols can be beneficial43
• discuss the importance of maintaining a healthy body weight
• patients should be warned that they have an increased risk of glucose intolerance and diabetes due to steroid
use. Refined carbohydrates should be reduced and replaced with high fibre foods instead
• normal potassium requirements should apply once potassium levels have stabilised and normalised, and
depending on the ongoing use of cyclosporine and blood levels
• salt should be used sparingly, while if low magnesium levels are present, supplementation and dietary food
sources rich in magnesium should be recommended e.g. green leafy vegetables, nuts, seeds and whole grains
• include calcium rich foods in the diet e.g. low fat dairy products and vegetables e.g. broccoli to improve bone
mineral density
• fluid restriction is usually not indicated
• exercise and lifestyle modification advice should be discussed
• place emphasis on hygiene principles and food safety

21
Figure 4: Patient education flow diagram27, 61, 69

22
Table 16: Patient education (CKD) - general guide31
Treatment Conservative Dialysis (HD/PD)
Initial intervention (within Follow-up (3-4 weeks/ Initial intervention (within Follow-up (within 1 month)
Factor first month of referral) as needed) and quarterly first month of referral) and six month intervention
intervention
Self-management Discuss the role and effect Review and reinforce Discuss the role and effect Review and reinforce
skills of diet and medication on self-management skills, of diet and medication on self-management skills,
renal function. including a diet history and renal function and dialysis including a diet history and
relevant feedback thereof. treatment. relevant feedback thereof.
The importance of blood Provide feedback on chang- The importance of blood Provide feedback on changes
pressure control and, if es in weight/nutritional sta- pressure control and, if rele- in weight/nutritional status,
relevant, blood glucose tus, blood pressure control. vant, blood glucose control. blood pressure control.
control and slowing the
progression of renal failure.
Discuss optimal caloric, Recommend changes in Discuss optimal caloric, Recommend changes in nu-
protein and nutrient intake nutrient intake that may protein and nutrient intake trient intake that may improve
e.g. sodium, potassium, improve outcome. e.g. sodium, potassium, outcome.
phosphorous. phosphorous and vitamins
according to type of dialysis
(HD/PD).
Basic dietary guidelines for Provide specific mineral re- Basic dietary guidelines for Provide specific mineral re-
renal failure, and for diabe- striction guidelines according ESKD, and for diabetes, striction guidelines according
tes, include timing of meals to laboratory results. include timing of meals and to laboratory results.
and snacks if indicated. snacks if indicated.
Discuss fluid intake and Review fluid status and Discuss dry weight and fluid Review fluid status and rec-
restrictions, if indicated. recommendations. restrictions, if indicated. ommendations.
Discuss laboratory results Discuss laboratory results Review dialysis adequacy.
and the significance and the significance thereof.
thereof.
Discuss the use and effect Review the appropriate use Discuss the use and effect Review the appropriate use of
of phosphate binders. of phosphate binders. of phosphate binders. phosphate binders.
Discuss medicine-nutrient Review medication pre- Discuss medicine-nutrient Review medication pre-
interactions as indicated. scribed, any changes and interactions as indicated. scribed, any changes and
medicine-nutrient interac- medicine-nutrient interactions.
tions.
Assess comprehension of Assess comprehension of Assess comprehension of Assess comprehension of
education and projected education and projected education and projected education and projected
compliance. compliance. compliance. compliance.
Provide relevant education- Provide and review educa- Provide relevant educational Provide and review educa-
al material, renal exchang- tional material. material, renal exchanges tional material, especially with
es or diabetes exchanges or diabetes exchanges (if changes in dialysis modality.
(if appropriate). appropriate).
Behavioural Encourage exercise as Assess activity and changes Encourage exercise as Assess activity and changes
part of a healthy lifestyle, if in recommendations. part of a healthy lifestyle, if in recommendations.
appropriate. appropriate.
Identify short-term achiev- Reset short-term goals and Identify short-term achiev- Reset short-term goals and
able goals. review long-term goals. able goals. review long-term goals.
Establish follow-up plan. Establish follow-up plan. Establish follow-up plan. Establish follow-up plan.

Table 17: Patient education (transplant) - general guide31

Treatment Acute phase Chronic phase

Initial intervention Follow-up (daily/as Initial intervention (1-2 months post Follow-up (6 months/as
Factor (within 72 hours of needed) transplant) needed)
referral)
Self-management Discuss the role and Review and reinforce Determine previous dietary instruction Review and reinforce
skills effect of diet and medica- self-management skills, and practices. self-management skills,
tion in transplantation. including changes in med- including daily intake
ical status and therapies and output and relevant
e.g. medication, dialysis. feedback thereof.
The importance of blood Provide feedback on Review changes in nutritional status, Provide feedback on
pressure control and, if changes in weight/nutri- blood pressure control and blood changes nutritional status,
relevant, blood glucose tional status, blood pres- glucose control. blood pressure and glu-
control. sure and blood glucose cose control.
control.

23
 Discuss optimal caloric, Recommend changes Ensure optimal caloric, protein and Recommend changes
protein and nutrient in nutrient intake that nutrient intake and the use of vitamin/ in nutrient intake that
intake and vitamin/min- may improve outcome, mineral supplementation, depending may improve outcome,
eral supplementation as depending on tolerance of on tolerance of oral intake or changes depending on tolerance
indicated. oral intake or changes in in appetite. of oral intake or changes
appetite. in appetite or chronic
rejection.
Basic dietary guidelines Basic dietary guidelines Specific dietary guidelines as indicat- Provide specific dietary
as indicated and rein- as indicated to improve ed to improve outcome. guidelines according to
force temporary nature of outcome. laboratory results, pres-
recommendations based ence of diabetes, medi-
on medical condition and cine-nutrient interactions,
laboratory results. episodes of rejection and
reinforce temporary na-
ture of recommendations
where applicable.
Discuss fluid intake and Review fluid status and Discuss fluid intake and fluid Review fluid status and
restrictions, if indicated. recommendations. restrictions, if indicated. recommendations.
Discuss laboratory Review laboratory results Discuss laboratory results e.g. sodi-
results e.g. sodium, and relevant changes. um, potassium, phosphate, calcium,
potassium, phosphate, magnesium, lipid profile and the
calcium, magnesium and significance thereof.
the significance thereof.
Discuss medicine-nu- Review medication Discuss medicine-nutrient interactions Review medication,
trient interactions as prescribed, any changes as indicated. especially any changes
indicated, especially and medicine-nutrient in immuno-suppressant
immuno-suppressant interactions. medication prescribed,
medication. and medicine-nutrient
interactions.
Implement nutritional Re-assess nutritional plan Implement nutritional plan as per Re-assess nutritional plan
plan as per individual for adequacy and appro- individual requirements. for adequacy and appro-
requirements. priateness. priateness.
Assess comprehension Assess comprehension of Assess comprehension of education Assess comprehension of
of education and project- education and projected and projected compliance. education and projected
ed compliance. compliance. compliance.
Provide relevant educational material. Provide and review
educational material, es-
pecially if presenting with
chronic rejection.
Behavioural Identify short-term Reset short-term achiev- Identify short-term achievable goals. Reset short-term achiev-
achievable goals. able goals. able goals and review
long-term goals.
Encourage exercise as part of a Assess activity and
healthy lifestyle. changes in recommenda-
tions.
Establish follow-up plan. Establish follow-up plan. Establish follow-up plan. Establish follow-up plan.

24
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27
7. ANNEXURES
ANNEXURE 1: Enteral product formulation

Enteral product formulations Definition

Renal-specific formulas These formulas include those with adapted macro- and
*Low/high protein low electrolytes micronutrient compositions to the needs of a specific
*According to treatment disease (including digestive and metabolic disorders)
Energy dense formula
Low sodium feed 2kcal/ml; 3g/100ml Protein; 78mg/100ml Sodium,
112mg/100ml Potassium

ANNEXURE 2: Subjective global assessment (SGA)

1) Weight change over past two weeks and last six months
• weight gain, no change, mild weight loss (>0.5kgs but <1kg)
• moderate weight loss (>1 kg but <5%)
• severe weight loss (>5%)

2) Change in dietary intake

• no change or slight change for a short duration
• intake borderline and increasing
• intake borderline or poor and decreasing

3) Presence of GI symptoms
• few intermittent or no symptoms
• some symptoms for >2 weeks or severe symptoms that is improving
• symptoms daily or frequently >2 weeks

4) Functioning state
• no impairment in strength/stamina or mild to moderate loss and now improving
• mild to moderate loss of strength/stamina in daily activity or severe loss but now improving
• severe loss of strength/stamina or bed ridden

5) Subcutaneous loss of fat

• little or no loss
• mild-moderate in all areas
• severe loss in some or most areas

6) Muscle wasting
• little or no loss
• mild-moderate in all areas
• severe loss in some or most areas

7) Oedema
• little or no oedema
• mild-moderate oedema
• severe oedema
Minimum score = 7
Maximum score = 49
1-14 - Well nourished
15-35- Mild to moderate malnourishment
36-49- Severe Malnourishment
Adapted from: Tapiawala, S, Vora, H, Patel, Z, Badve, S, Shah B. 2006. Subjective global assessment of nutritional status of patients with chronic
renal insufficiency and end stage renal disease on dialysis. JAPI.(54):923-926.

28
 ANNEXURE 3: South African renal exchange lists (updated 2012)
Meat and Meat Substitute Exchanges – High Phosphate (> 100 mg)
350 kJ, 7 g Prot, 5 g Fat, 0 g CHO, 120 mg PO4, 55 - 430 mg Na, 90 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Low in Sodium (55 mg)

Canned fish, pilchards in brine 3055 30g 1 heaped DSP 162 6 1.6 0 115 156 126

Canned fish, pilchards in tomato sauce 3102 30g size of small matchbox 159 5.6 1.6 0.2 105 111 126

Canned fish, sardines in oil 3104 30g 1 large / 2 small 253 7.4 3.5 0 147 152 119

Canned fish, sardines in tomato sauce 3087 30g 1 large /2 small 220 4.9 3.6 0.2 110 124 102

Cheese, Cheddar 2722 30g size of small matchbox 494 7.4 9.7 0.5 160 146 25

Cheese, Gouda / Edam / Swiss 2723 30g size of small matchbox 473 7.2 9.5 0.1 170 153 21

Cheese, Mozzarella, grated 2790 30g 2 heaped TBS 350 5.8 6.5 0.7 111 112 20

Cheese, Ricotta 2793 70g 507 7.9 9.1 2.1 111 59 74

Egg, boiled or poached 2867 55g 1 extra-large 339 6.9 5.7 0.7 106 69 54

Liver, chicken, simmered 2970 30g 1 liver 190 7.3 1.7 0.3 94 15 42

29
Liver – sheep / lamb, fried 2955 30g size of small matchbox 290 7.7 3.8 1.1 128 37 106

Liver, beef, fried 2920 30g size of small matchbox 265 8 2.4 2.4 138 32 109

Macaroni and cheese, white sauce(WM,HM) 3301 90g 1 heaped LS 642 6 8.4 12.9 112 151 78

Oysters, canned 3068 80g 12 oysters 224 5.7 2 3.1 111 90 183

High in Sodium (430 mg)

Bacon, cured, fried / grilled 2906 30g 3 rashers 702 9.2 14.8 0 101 479 146

Cheese, Blaauwkrantz / Roquefort 2726 30g size of small matchbox 460 6.5 9.2 0.6 118 543 27
Cheese, Camembert 2758 30g size of small matchbox 373 5.9 7.3 0.2 104 253 56
Cheese, Parmesan, grated 2762 20g 2 heaped DSP? 376 8.3 6 0.7 161 372 21

Pizza with cheese, tomato & olives, 3353 80g 2 wedges 834 7.2 9.4 19.8 128 456 120

TO BE RESTRICTED
Brains (High phosphate)
Cheese spread/wedges (High phosphate, sodium)
Feta (High phosphate, sodium)
Marmite, Bovril (High phosphate, sodium, potassium)
Nuts, all types (High phosphate, potassium)
Dried fish (Bokkems) (Extremely high in sodium; phosphate not known)
Fish paste (Extremely high in sodium; phosphate not known)
 Meat and Meat Substitute Exchanges – Low Phosphate (< 100 mg)
350 kJ, 7 g Prot, 5 g Fat, 0 g CHO, 65 mg PO4, 55 - 430 mg Na, 90 mg K
Food Item Code Portion   Energy Protein Fat CHO PO4 Na K
    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Low in Sodium (55 mg)
Beef stew, with vegetables 3020 60g ~¼ cup 323 6.9 3.7 3.3 53 24 117
Bobotie, regular mince 3023 40g 1 heaped TBS 332 5.8 3.1 6.5 57 161 153
Calamari, fried 3099 30g 8 med rings 214 5.4 2.3 2.3 75 92 84
Canned fish, mackerel, canned 3113 30g size of small matchbox 227 6 3.4 0 81 57 58
Canned fish, tuna in brine, drained 3054 30g 1/4 cup 139 7.7 0.2 0 49 101 71
Canned fish, tuna in oil, drained 3093 30g 1/4 cup 239 8.7 2.5 0 93 106 62
Chicken, cooked without bones 2963 30g 1 small drumstick 200 8.8 1.4 0 59 18 76
Cheese, Brie 4312 30g 416 6.2 8.3 0.1 56 189 46
Chicken, giblets, cooked, simmered 2998 30g size of small matchbox 185 7.8 1.4 0 69 17 47
Chicken stew no skin, with vegetables 4378 60g ~ ¼ cup 266 6.9 2.1 3.3 60 20 114
Cottage cheese, low fat 2729 60g 2 heaped TBS 221 6.3 2.4 1.5 68 97 111
Cottage pie, lean mince, WM, HM 3009 50g 2 heaped DSP 296 7.3 3.1 3 58 26 137
Crab, fresh, cooked 3065 30g 2 TBS 123 6.1 0.5 0 62 84 97
Lobster (crayfish), cooked 3069 30g 172 7.9 0.6 0.9 69 68 94
Duck roasted meat and skin 2995 45g 1 drumstick / 1TBS 618 8.6 12.8 0 70 27 92
Fish, fatty (butterfish, herring), grilled 3082 30g size of small matchbox 246 6.9 3.5 0 91 35 126
Fish, medium fat (snoek), grilled / steamed 3089 30g size of small matchbox 194 8.5 1.4 0 95 32 148

30
Fish, medium fat, battered/crumbed, fried in oil 3084 30g size of small matchbox 285 7.6 4.2 0 85 28 133

Fish, white, battered fried in oil 3094 30g size of small matchbox 302 6.7 4.2 1.8 76 26 115

Fish, low fat, fried in oil 3060 30g size of small matchbox 231 6.3 3.4 0 57 28 92

Goat, roasted 4281 30g size of small matchbox 172 8.1 0.9 0 60 26 122

Hare, stewed 4328 30g 1 heaped DSP 241 9 2.4 0 75 12 63

Kidneys, beef simmered 2923 30g 3 heaped TBS 168 7.7 1 0 92 40 54

Kidneys, sheep / lamb, braised 2956 30g 1 kidney 161 7.1 1.1 0 87 45 53

Lasagne, lean mince, cheese source (LFM, HM) 3440 75g 1 heaped LS 505 7.9 4.5 11.6 82.5 67.5 91.5

Meatball, lean mince, without egg 2966 30g 1 small meatball 265 8.3 2.9 0.9 56 29 87

Meat, cooked without bones, beef 4370 30g size of small matchbox 357 8.2 5.9 0 50 28 83

Minced meat, mutton, cooked 3041 30g 3 level DSP 345 7.4 5.9 0 60 24 102

Mopanie worms, canned 4284 60g 257 8.5 2.2 0.4 74 140 139

Mopanie worms, dried 4250 15g 259 8.5 2.2 0.4 75 142 141

Mussels, black / blue, boiled 3085 30g 10 mussels 209 7.1 1.4 2.2 86 111 80

Mutton, leg roasted, meat and fat 2947 30g 1 thin slice 314 7.7 5 0 57 20 94

Mutton, leg and shoulder braised, lean 3036 30g 1 heaped DSP 270 10.1 2.6 0 62 21 78
 Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Mutton stew, with vegetables 2916 60g ~ ¼ cup 416 7.4 6 3.3 56 22 111

Ostrich, cooked 4283 30g 1 heaped DSP 168 7.6 1.1 0 77 16 97

Patty, beef, grilled 2984 40g 1 small 458 9.8 7.9 0 63 31 118

Perlemoen / Abalone, fried 3078 30g 1 slice 232 5.9 2 3.3 NA 177 26

Pork leg, roasted 2958 30g 1 thin slice 332 8 5.3 0 79 18 106

Pork loin, braised 3044 30g size of small matchbox 244 8.9 2.5 0 54 19 110

Shrimps / prawns, cooked 3070 30g 1 heaped TBS 119 6.3 0.3 0 41 67 55

Spaghetti bolognaise, lean mince 3388 75g 1 heaped LS 425 7.7 2.3 11.3 64.5 16.5 120

Spleen, sheep / lamb braised 4340 30g size of small matchbox 188 8.9 1.4 0 72.3 17.4 74.4

Turkey, roasted, meat only 2981 30g size of small matchbox 205 8.8 1.5 0 64 21 89

Veal, chuck, cooked 4331 30g size of small matchbox 247 8.8 2.6 0 66 30 99

Veal, breast, cooked 4356 30g size of small matchbox 290 7 4.6 0 58 35 91

Venison, roasted, fine 2913 30g 1 heaped DSP 190 9.1 1 0 68 16 101

High in Sodium (430 mg)

31
Ants, flying dried 4333 15g 373 5.7 7 0.9 91 295 71

Biltong / dried sausage, beef 3021 20g 6 slices 340 6.6 5.1 1.8 81 443 119

Chicken pie 2954 70g 1 small square 1119 4.8 17.4 22.5 50 270 71.4

Chicken liver pate 2922 50g 413 6.8 6.6 3.3 87.5 193 47.5

Corned meat, beef, canned 2940 30g 2 thin slices 290 5.9 4.5 1.5 33 302 41

Frankfurters 2937 60g 1 Frankfurter 790 6.8 17.5 1.6 52 672 100

Ham, cooked, 15cm X 9cm 2967 30g 1 thin slice 223 5.2 3.2 0.9 74 395 99.6

Meat pie, steak ‘n kidney 2957 90g 1 wedge 1350 8.3 20.6 25.7 76.5 356 88

Offal – beef 3003 50g 337 7.9 5.5 0 51 271 79

Pastrami, turkey 4343 40g 4 thin slices 228 7.4 2.5 0.7 80 418 104

Polony/cold meat, beef and pork, 10 cm diam 2919 60g 4 thin slices 776 7 17 1.7 55 611 108

Pork sausages, thin, grilled 2932 30g 10 cm piece 452 5.9 9.4 0.3 55 388 108

Salami / Russians, 5cm diam 2948 30g 5 thin slices 512 6.9 10.3 0.8 43 558 113

Sausage, beef and pork / Boerewors, thick, grilled 2931 60g 10 cm piece 974 8.3 21.8 1.6 64 483 113

Smoked fish – Haddock 3061 30g size of small matchbox 140 7.6 0.3 0 75 229 125

Vienna sausage, beef and pork, canned 2936 70g 2 large 799 7.2 17.6 1.4 34 667 71
 Meat and Meat Substitute Exchanges – Legumes
350 kJ, 7 g Prot, 5 g Fat, 15 g CHO, 120 mg PO4, 55 - 430 mg Na, 245 mg K
Food Item Code Portion   Energy Protein Fat CHO PO4 Na K
    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Low in Sodium (55 mg)
Biryani, with lentils, ghee, no meat/ potato 3194 150g 2 heaped LS 980 6.6 6.9 33 125 5 224

Biryani, with lentils, oil, no meat/potato 3193 150g 2 heaped LS 980 6.6 6.9 33 125 3 224

Dried beans, cooked, kidney / white 3183 90g 3/4 cup 453 7 0.4 12.3 100 2 457

Dried beans, cooked, sugar 3205 90g 3/4 cup 553 6.4 0.5 17.6 110 12.6 331

Dried peas, cooked 3177 90g 3/4 cup 464 7.5 0.4 13.7 89 2 326

Lentils, cooked 3203 90g 2/3 cup 455 7.7 0.2 12.3 116 5 243

Lentils split, cooked 3179 90g 2/3 cup 459 8.1 0.4 13.1 162 2 332

Peanut butter, smooth style 3485 30g 2 level DSP 786 7.4 15 4.4 97 143 216

Peanuts, roasted, unsalted 3452 30g 1 med handful 778 7.9 14.8 3 155 2 205

Soup mix, dried, 4-in-1, raw 3175 50g 766 7.5 1.1 29.3 128 12 NA

Soya beans, cooked 3188 50g 4 level TBS 392 8.3 4.5 2.4 123 1 258

Tofu, fried 3209 50g 609 8.6 10.1 4.7 144 8 73

Tofu, raw, (soybean curd) 3202 100g 348 8.1 4.8 0.7 97 7 121

32
High in Sodium (430 mg)

Baked beans, canned in tomato sauce 3176 90g 2 heaped TBS 482 4.3 0.5 16.1 94 357 266

Toppers, cooked 3196 140g 3/4 cup 584 8.1 2.4 17.9 141 552 346

TO BE RESTRICTED

Salted peanuts (High in sodium)

 Milk Exchanges
325 - 835 kJ, 4 g Protein, 5 - 10 g Fat, 10 - 20 g CHO, 110 mg PO4, 65 mg Na, 185 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Low to Moderate in Energy (325 kJ), Fat (5 g) and Carbohydrate (10 g)
Buttermilk (cultured) 2713 125g/125 ml 1/2 cup 280 4.1 3.5 4.8 110 126 200
Custard, wm (with custard powder) 2716 125g/125 ml 1/2 cup 475 4.0 4 15.1 108 55 185
Custard, low fat (with custard powder) 2779 125g/125 ml 1/2 cup 411 4.1 2.4 14.8 106 53 180
Custard, skim (with custard powder) 2717 125g/125 ml 1/2 cup 330 4.3 0.3 14.5 121 60 198
Maas / Amasi / Sour milk 2787 125g/125ml 1/2 cup 338 4.1 4.6 5.6 116 89 238
Melkkos / - snysels wm (no sugar) 2733 135g 1/2 cup 458 5.3 4.9 10.9 128 68 204
Milk, evaporated, full fat, unsweetened 2715 60g/60ml ~1/4 cup 320 4 4.1 5.8 140 64 152

Milk, low fat / 2% fat, fresh 2772 125g/125ml 1/2 cup 266 4.1 2.5 6.1 111 58 190
Milk, low fat powder (vit A, B, D, E, folate
2825 10g 1 heaped DSP 163 3.4 0.6 5 97 54 179
added)
Milk powder, blend, medium fat, (Numel) 2794 15g 1 heaped TBS 254 4.2 1.7 7 126 76 234

Milk, skim, fresh 2775 125g/125ml 1/2 cup 186 4.3 0.3 6.1 126 65 208

Milk, full fat / whole, fresh 2718 125g/125ml 1/2 cup 328 4.0 4.3 6 113 60 196

Nesquik, powder (+ 100ml wm) 2830 10g powder 1 heaped DSP 437 3.3 3.6 14.6 96 49 172

Ovaltine powder, no sugar (+ 100ml wm) 2754 10g powder 1 heaped DSP 299 3.6 3.7 6.0 102 54 177

33
Soya milk, plain 2737 125g/125ml 1/2 cup 186 3.5 2.4 0.6 61 15 176

Soya milk, fortified 4351 125g/125ml 1/2 cup 260 3.3 3.3 5 44 49 113

Yoghurt, low fat, flavoured, drinking,

2756 125g/125ml 1/2 cup 396 3.9 1.6 15.9 101 59 163
sweetened
Yoghurt, low fat, plain 2734 125g/125ml 1/2 cup 318 5.4 2.4 8.1 138 83 243
High in Energy (835 kJ), Fat (10 g) and Carbohydrate (20 g)
Baked custard, wm (egg), plain 2724 125g/125ml 1/2 cup 605 5.8 5.4 18.3 124 71 161

Baked custard, low fat(egg), plain 2785 125g/125ml 1/2 cup 563 5.8 4.1 18.4 123 69 158
Baked custard, skim (egg), plain 2745 125g/125ml 1/2 cup 505 5.9 2.5 18.4 133 75 170
Ice cream, kulfi 4323 100g 1764 5.4 39.9 11.5 150 76 240

Ice cream sorbet (8% fat) 3491 80g/125ml 2 scoops 598 2.6 7 17.4 80 61 136

Ice cream (regular 10 % fat) 3483 80g/125ml 2 scoops 694 2.8 8.8 18.9 84 64 159

Ice cream (rich 16 % fat) 3519 80g/125ml 2 scoops 832 2.8 13 17.9 76 45 127

Ice cream, soft serve (13 % fat) 3518 135g 1 med cone 1253 5.5 17.6 30 157 82 239

Milk, condensed, full fat, sweetened 2714 50g 2 level TBS 691 4.0 4.4 27.2 127 64 186

Milk ice (frozen on stick) 3530 100g 601 3.9 4.3 22.1 99 80 202

Milk shake, vanilla, purchased 2788 125g/125ml 1/2 cup 600 4.9 3.8 22.1 144 119 229

Pancake / Crumpet, plain, wm, sun oil 3238 70g 1 pancake 808 4.4 11 19 78 34 102
 Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Sweets, chocolate coated bar 3997 55g 1 lunch bar 1089 2.8 12.4 34.3 80 91 157

Sweets, chocolate, Kit kat 4024 50g 1 medium 1076 4.0 13.3 30.3 95 54 165

Sweets, chocolate, milk 3987 50g 1/2 X 100g slab 1151 4.3 15.3 30.1 120 60 210

Sweets, chocolate, white 4023 50g 1/2 X 100g slab 1160 4.7 16.1 28.7 115 55 175

Yoghurt, frozen 4324 75g 1/2 cup 515 3.0 4.2 18.2 97 65 158

Yoghurt, wm, curry spice (khuri) 2786 125g/125ml 1/2 cup 520 5.3 7.3 8.8 131 73 265

TO BE RESTRICTED

Chocolates with coated nuts, raisins (high in potassium, sodium and phosphate)

Dark chocolates - Albany (high in potassium and phosphate)

High protein milk drinks e.g. drinking chocolate powder (high in phosphate)
Puddings, instant (very high in phosphate)

*Creamer, non-dairy powder (cremora, coffee-mate) - only 10 g/d (kJ, Prot, 4 G Fat, 6 g CHO, 42 mg PO4, 18 mg Na, 81 mg K)

34
 Starch Exchanges – Low Potassium (< 100 mg)
350 - 835 kJ, 2 g Protein, 0 - 10 g Fat, 20 g CHO, 40 mg PO4, 70 mg Na, 50 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Low to Moderate in Energy (350 kJ), and / or Fat (0 g)

Barley, pearl cooked 3368 75g 3 heaped TBS 397 2 0.4 17.9 41 7 70

Brown bread / rolls (fortified) 3211 30g 1 slice / 1 roll 309 2.7 0.4 13 28 194 68

Crumpets (wm, sunflower oil) 3238 25g 1 crumpet 289 1.6 3.9 6.7 28 12 37
Jelly 3983 120g ~ 1/2 cup 320 1.4 0 17.4 1 6 6
Maize meal cooked, crumbly porridge 3401 50g 1 heaped TBS 410 2.4 1.0 21 50 3.5 64
Maize meal cooked, soft porridge 3399 200g 2 heaped LS 400 2.4 1 21 80 8 44
Maize meal cooked, stiff porridge 3400 100g 1 heaped LS 520 2.8 1.1 27 80 7 71
Maize, rice cooked (white) 3250 100g 2 heaped LS 424 2.2 0.2 21.5 15 1 28
Maize, samp cooked (white) 3280 100g 1 heaped LS 424 2.2 0.2 21.5 15 1 28
Maltabella, cooked 3241 200g 5 heaped TBS 356 2.2 0.6 17 52 NA 86
Oats, cooked 3239 110g 1 heaped LS 307 1.9 1.8 10.6 85 2 63
Pasta, cooked 3262 40g 1 heaped TBS 236 1.9 0.3 10.7 22 0.4 12
Pearl wheat, cooked 3249 60g 2 heaped TBS 229 1.9 0.3 9.4 24 2 41
Provita biscuits 3235 20g 3 biscuits 354 2.3 1.7 14.4 35 142 41

35
Puffed rice - sweetened (cocopops) 3372 30g 1 cup 486 1.6 0.1 26.5 42 227 26
Puffed wheat, plain 3325 15g 1 cup 247 2.2 0.2 11.4 53 1 52
Pumpernickel bread 3283 25g 1 slice 282 2.1 0.4 11.5 40 145 48
Rice, brown, cooked 3315 90g 3 heaped TBS 422 2.3 0.8 19.2 75 5 39
Rice, white, cooked 3247 75g 3 heaped TBS 398 2 0.2 20.6 35 2 29
Scone, plain 3237 25g 1 small scone 401 2 4 12.5 27 77 32
Scone, whole-wheat (hm / wm) 3320 25g small 383 2.7 3.9 9.4 64 73 75
Tasty wheat, cooked 3240 100g 1 heaped LS 220 1.5 0.2 11 17 1 17
White bread / rolls* (fortified) 3210 30g 1 slice / 1 med roll 311 2.6 0.4 13.8 29 196 64
Whole-wheat bread / rolls 3212 30g 1 slice / 1/2 roll 325 2.5 0.6 13.3 53 114 64
High in Energy (835 kJ) and / or Fat (10 g)

Apple tart, short crust 3224 75g 1 large wedge 700 2 5.9 25.4 23 115 84

Baked cheese cake, egg and cream 3293 50g 1 small wedge 867 2.7 16.2 12.7 48 155 55

Banana loaf (wm, hm) 3333 40g 1 cm slice 562 1.9 4.4 21 26 84 84

Beskuit, whole-wheat, buttermilk (hm) 3255 30g 1 rusk 597 2.7 6.2 16.8 65 130 77

Boerbeskuit 3364 30g 2 small pieces 530 2.7 2.3 22.6 50 34 62

Butter cake, plain (wm, hm) 3288 50g 1 small piece 754 2.6 6.2 27.9 37 119 41

Buttermilk rusk, white, commercial 3329 30g 1 rusk 569 2.4 4.5 20.6 50 164 61
 Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Carrot cake, plain (egg, sun oil) 3392 50g 1 med wedge 791 2.1 9.9 22.3 82 157 48

Chocolate éclair with cream filling 3268 50g 1 med 802 2.1 11.9 19 37 75 44

Commercial cookies with filling 3217 30g 2 cookies 611 1.5 5.6 21.9 25 67 36

Commercial cookies, plain 3216 30g 3 biscuits 579 2.2 4 22.7 25 123 42

Corn flakes, plain 3243 40g 1 cup 642 3.10 0.1 33.2 20 484 42

Cream crackers 3230 25g 3 crackers 507 2.4 4.1 17.1 28 152 30

Doughnut, plain 3232 45g 1 small 793 2.7 9.8 21.2 36 104 39

Ginger bread (hm) 3253 40g 1 cm slice 662 2.1 5 25.4 29 127 54

Koeksister 3231 60g 1 large 869 1.6 5.6 37.2 25 NA NA

Madeira cake, commercial 3291 50g 2 thin slices 866 2.7 8.5 29.2 60 190 60

Mosbolletjies 3426 40g 1/2 big 554 2.3 2.6 23.8 26 25 34

Noodle salad 3336 95g 1/2 cup 817 3.1 12.3 17.6 39 79 56

Popcorn, sugar coated / candied 3359 100g 2 cups 2165 2.1 20 77.6 58 56 75

36
Rice crispies 3252 40g 1 cup 642 2.6 0.1 34.7 56 529 40

Roti with butter 3356 50g 15 cm diam small 1096 2.4 18.7 20.8 29 186 35

Roti with oil 3358 50g 15 cm diam small 1245 2.3 22.8 20.7 23 1 29

Samoosa, mutton filling 3355 40g 1 small 1000 2.0 22.4 7.2 25 13.2 48

Shortbread (butter) 3296 25g 2 pieces 550 1.6 6.8 15.4 20 60 25

Sweetcorn fritter 3254 50g 2 small 876 2.8 15 15.4 58 124 100

Tipsy tart 3323 60g 1 med wedge 729 1.8 2.6 34.3 25 25 83

Vetkoek 3257 60g 1 small 914 4.3 10.6 25.4 52 16 47

 Vegetable Exchanges – Low Potassium (< 120 mg)
90 kJ, 1 g Prot, 0 g Fat, 2 g CHO, 20 mg PO4, 20 mg Na, 75 mg K

Food Item Code Portion  Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Artichoke, globe / French, cooked 3944 30 g 62 1.1 0.1 1.7 26 29 106

Broccoli, cooked 3701 75g 1/2 cup 89 1.7 0.2 1.1 37 3 91

Cabbage Chinese, boiled (pre-tsai) 4109 65g 1/2 cup 46 0.5 0.1 1.2 14 7 90
Cabbage, cooked 3756 70 g 1/2 cup 73 0.7 0 2.2 17 14 81
Cabbage, raw 3704 40 g 1/2 cup 54 0.6 0 1.7 13 12 69
Celery, cooked 3774 20 g 1 heaped DSP 14 0.1 0 0.3 5 6 55
Celery, raw 3829 10 g 1 stick 8 0.1 0 0.2 2 4 38

Chicory (witloof), raw 3947 50g 2 heaped TBS 44 0.5 0.1 0.5 13 1 106

Coleslaw, commercial 3707 50g 1/2 cup 328 0.8 5.6 3.9 18 135 90
Coleslaw, mayonnaise, raisins 3705 50g 1/2 cup 302 0.8 5.5 4.3 17 87 86
Cucumber, raw, English 4119 50 g 5 med slices 31 0.4 0.1 1 14 6 84

Leek, cooked 3833 100 g 1/2 cup 150 0.8 0.2 6.6 17 10 87

Lettuce, shredded 3723 40 g 1/2 cup 27 0.4 0 0.7 11 3 68

37
Mixed vegetables (carrot, corn, peas, beans) 3727 75 g 1/2 cup 201 1.7 0.4 6.2 38 26 109
Mixed vegetables(carrot, cauliflower, beans) 4265 75 g 1/2 cup 98 1.1 0.2 2.2 29 25 101
Onion, cooked, whole 3773 50 g 2 small or 1 med 96 0.5 0.1 4.4 15 7 81
Onion, raw 3755 30g 2 slices 58 0.3 0 2.6 10 5 54

Peas, fresh, cooked 3719 50g 2 heaped TBS 182 2.7 0.4 4 31 7 104

Peas, frozen, cooked 4146 50g 2 heaped TBS 176 2.6 0.4 2.7 46 4 54

Peas, mangetout, cooked 3717 25g 10 small pods 46 0.5 0 1.6 13 0 36

Pepper, chili 3977 5g 1 heaped TSP 12 0.1 0 0.2 3 0 17
Pepper, sweet, green, raw 3733 25 g 4 med slices 26 0.2 0 0.8 6 2 44
Pepper, sweet, red, raw 3734 25g 4 med slices 33 0.2 0.1 1.1 5 1 44

Pepper, sweet, yellow, raw 4153 25g 4 med slices 33 0.3 0.1 1.4 6 1 53

Pumpkin, summer, marrow 4179 110g 1/2 cup 64 0.1 0 1.9 2 2 47

Radish, raw 3745 50 g 2 large radishes 45 0.3 0.3 1 9 12 116

Sambal, tomato, onion 4272 50g 82 0.4 0.1 3.7 13 4 99

Sou sou (Chayote), cooked 4166 50g 49 0.4 0.1 1.3 11 0 68

Sweetcorn, cream style, canned 3726 65 g 1/4 cup 212 1 0.2 10.1 31 172 81

Sweetcorn, whole kernel, canned 3942 50 g ~1/4 cup 156 1 0.2 7.3 26 107 82

Tomato ketchup / sauce 3139 25g 1 level TBS 120 0.3 0.1 6.2 10 146 116
 Vegetable Exchanges – Moderate Potassium (120 – 200 mg)

90 kJ, 1 g Prot, 0 g Fat, 2 g CHO, 20 mg PO4, 20 mg Na, 150 mg K

Food Item Code Portion  Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Asparagus, cooked (green) 3695 90g 1/2 cup 100 2.1 0.3 1 49 0 191

Amaranth leaves, boiled 3980 50g 56 1 0.1 0.6 19 2 123

Beetroot, cooked with skin (flesh only) 3698 50 g 1/2 med 108 1 0 4 18 30 145

Beetroot leaves, cooked 3914 20g 1 large DSP 30 0.5 0 0.5 8 48 182

Brinjal, cooked (including skin) 3700 90 g 1/2 cup 94 0.6 0 2.9 21 4 160

Brussels sprouts, cooked 3703 80 g 1/2 cup 120 2.2 0.1 1.8 46 7 187

Calabash / Gourd (white), boiled 4212 100g 120 0.6 0 3.7 13 2 170

Carrot salad, pineapple, orange juice 3710 65g 1/2 cup 124 0.5 0 5.1 12 11 142

Carrots, cooked, rings 3757 80 g 1/2 cup 130 0.7 0.1 4.2 23 23 125

Carrots, raw, grated 3709 50g 1/2 cup 85 0.5 0 3.2 12 12 121

Cauliflower, cooked 3716 80 g 1/2 cup 75 1.1 0.1 1.7 23 5 134

38
French salad (lett, tom, cuc), no dressing 3921 70g 1/2 cup 55 0.6 0.1 1.7 19 5 130

Green beans, cooked, long pieces 3696 65 g 1/2 cup 89 1.2 0.1 1.7 24 3 168

Kalahari truffle, raw 4195 50g 191 2.1 1.8 0.4 71 2 145

Mushroom, raw, sliced 3842 45g 1/2 cup 60 1 0.1 1.2 36 5 132

Pumpkin, summer, patty pan, sliced 4181 100g 3 heaped TBS 81 1 0.2 1.4 28 1 140

Pumpkin, winter, white, cooked 4164 105g 1/2 cup 97 0.7 0.1 3 18 2 165

Pumpkin, winter, hubbard, cooked 4177 105g 1/2 cup 142 0.7 0.1 5.9 20 2 165

Spinach, cooked (Swiss chard) 3913 90 g 1/2 cup 121 2.4 0.3 1.8 32 129 159

Sweetcorn, cooked 3725 65 g 1/4 cup 345 2.1 0.8 14.5 67 11 162

Tomato, raw 3750 80g 1 small 73 0.7 0.2 2.3 20 4 185

Turnip, cooked 3911 90 g 1/2 cup 89 0.6 0.1 2.6 17 45 122

Waterblommetjies, fresh (boiled) 4194 100g 95 0.7 0 2.1 25 20 131

Watercress, raw 3954 50g 41 1.2 0.1 0.4 30 21 165

 Vegetable Exchanges – High Potassium (> 200 mg)
90 kJ, 1 g Prot, 0 g Fat, 2 g CHO, 20 mg PO4, 20 mg Na, 270 mg K
Food Item Code Portion  Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Amadumbe, tuber, boiled, flesh only 4087 50g 300 0.3 0.1 15 38 8 242

Amadumbe / taro, leaves, steamed 4089 50g 65 1.4 0.2 1 14 1 230

Bamboo shoots, raw 4095 50g 55 1.3 0.2 0.6 27 3 234

Marog, cooked 8302 50g 100 2 0 3.8 18 8 310

Mixed vegetables, canned 4264 140g 1/2 cup 277 2.9 0.1 9.7 46 532 294

Mushroom, cooked, whole 3729 90 g 1/2 cup 120 2.1 0.2 2.4 66 9 239

Okra, boiled 3939 100g 1/2 cup 162 1.9 0.2 4.7 56 5 322

Pumpkin leaves, boiled 4205 50g 56 1.4 0.1 0.4 40 4 219

Pumpkin, summer, gem, cooked 3760 90g 1/2 large 87 0.5 0.1 3.2 19 1 232

Pumpkin, winter, butternut, cooked 3759 105g 1/2 cup 247 1.6 0.1 11 45 2 288

Spinach, small leaf, boiled 3761 90g 1/2 cup 114 2.7 0.3 1.3 50 63 419

Spinach, small leaf, raw 4167 50g 62 1.5 0.2 0.4 25 40 279

39
Tomato and onion stew, with sugar 3910 75g 1 heaped LS 129 0.8 0.2 5.3 24 7 203

TO BE RESTRICTED

Gherkins/pickled cucumber (High sodium and potassium)

Pickled onion (High sodium)
Waterblommetjies canned (High sodium)
 Fruit Exchanges – Low Potassium (< 120 mg)

250 kJ, 0,5 g Protein, 0 g Fat, 10 g CHO, 15 mg PO4, 5 mg Na, 95 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Fresh Fruit (Raw)
Apple, skin 3532 100g 1 small 267 0.2 0.1 13 7 4 99
Cherry 3542 50g 2 heaped DSP 137 0.6 0.1 6.7 10 3 118
Granadilla (without peel) 3545 20g 1 med 90 0.4 0.1 2.6 7 0 62
Kumquat 3630 50g 6 med 149 0.5 0.1 4.9 10 3 98
Lemon, with peel 3577 70g 1/2 med 149 0.8 0.2 4.2 11 2 102
Litchi 3632 50g 6 litchis 164 0.4 0.1 8.6 10 2 112
Melon, wild 3678 60g   64 0.8 0.1 2.4 14 21 14
Mulberries 3634 50g   103 0.7 0.2 4.1 19 5 97
Pear 3582 100g 1 small 305 0.3 0.2 14.4 9 4 85
Pineapple 3581 40g 2 med slices 99 0.2 0 4.8 2 0 64

Plum 3570 50g 1 med 116 0.4 0.1 5.5 9 2 86

Prickly pear 3571 50g 1 small 139 0.5 0.2 5.3 10 1 72
Strawberry 3573 50g 4 med 79 0.4 0.2 3 14 2 85
Youngberry 4236 50g 122 0.4 0.2 3.8 10.5 0 98
Dried Fruit
Apple, dried, raw 3600 25g 5 rings 287 0.2 0.1 14.3 9.5 22 113
Dates, dried, raw 3543 10g 2 dates 130 0.2 0.1 6.6 4 0.3 65

40
Pear, dried, raw 3585 12g 1 half 148.5 0.3 0.1 7.5 7 0.5 64
Fruit Juice
Apple juice, Ceres / Liquifruit 3606 125 ml 1/2 cup 288 0.1 0 16.6 9 3 113
Apricot juice, Liquifruit 3610 125 ml 1/2 cup 279 0.4 0 15.3 14 3 85
Grape juice, Ceres / Liquifruit 3690 125ml 1/2 cup 304 0.1 0.1 17.4 14 5 53
Guava juice, Ceres / Liquifruit 3629 125 ml 1/2 cup 260 0.3 0.1 14.4 11 8 81
Litchi juice, Ceres 3684 125 ml 1/2 cup 274 0.1 0 15.9 14 5 59

Mango juice, Ceres 3683 125 ml 1/2 cup 268 0.1 0 15.5 11 3 39
Mango and orange juice, Liquifruit 3681 125 ml 1/2 cup 291 0.4 0.1 16.4 15 3 94
Orange juice, Ceres, Liquifruit 3638 125ml 1/2 cup 273 0.4 0.1 15.1 16 5 119
Peach juice, Ceres 3687 125 ml 1/2 cup 273 0.5 0.1 15.1 11 4 110
Strawberry juice, Liquifruit 3654 125 ml 1/2 cup 261 0.4 0.1 14.6 15 4 66
Canned or Cooked Fruit
Apple, fresh, stewed with sugar 3603 120g 1/2 cup 509 0.4 0.5 25.7 10 1 106
Fruit salad, canned in syrup 3580 140g 1/2 cup 491 0.4 0.1 26.2 13 8 112
 Food Item Code Portion   Energy Protein Fat CHO PO4 Na K
    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Litchi, canned in syrup 3631 125g 1/2 cup 395 0.5 0 22.1 15 3 94
Peach salad, curried/atchar/pickles 3693 45g 1 heaped TBS 153 0.3 0 8 9 2 61
Peach, canned in syrup 3567 125g 1/2 cup 394 0.6 0.1 21 13 6 104
Pear, canned in syrup 3583 130g 1/2 cup 410 0.3 0.1 21.8 13 7 107
Pineapple, canned in fruit juice 3647 90g 1/2 cup 249 0.4 0.1 13.4 5 1 110
Pineapple, canned in syrup, pieces 3648 90g 1/2 cup 332 0.2 0.1 19 6 1 94

Fruit Exchanges – Moderate Potassium (120 – 200 mg)

250 kJ, 0,5 g Protein, 0 g Fat, 10 g CHO, 15 mg PO4, 5 mg Na, 170 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Fresh Fruit (Raw)

Apricot 3534 50g 2 small 79 0.4 0.1 3.3 13 2 160

41
Gooseberry 3622 50g 10 berries 125 1 0.4 3 20 0.5 137
Grapefruit 3546 100g half 165 0.7 0.1 6.9 16 3 134
Guava 3551 50g 1 small 145 0.4 0.2 3.9 12 0.5 132
Mango 3556 100g quarter 303 0.6 0.2 15.3 11 1 164
Melon, green 3575 60g 3 cm wedge 115 0.4 0.1 5.4 13 7 162
Minneola, peeled 4227 100g   201 0.7 0.2 9.3 19 2 177
Naartjie / Tangerine 3558 100g 1 med to large 230 0.9 0.2 10 15 5 139
Pawpaw, cubes 3563 100g 4 heaped TBS 186 0.4 0.1 8.6 7 7 192
Canned or Cooked Fruit
Fruit cocktail, canned in fruit juice 3664 140g 1/2 cup 337 0.6 0 17.1 25 7 168
Fruit cocktail, canned in syrup 3665 140g 1/2 cup 451 0.6 0.1 24.1 15 8 123
Gooseberry, canned in syrup 3621 130g 1/2 cup 686 0.7 0.3 36 30 4 157
Grapefruit, canned in fruit juice 4215 125g 1/2 cup 109 0.5 0.1 4.8 10 6 121
Grapefruit, canned in syrup 3547 125g 1/2 cup 345 0.8 0.1 18.8 13 3 161
Guava, canned in syrup 3553 105g 1/2 cup 385 0.4 0 17.1 12 7 126
Mango, canned in syrup 3633 125g 1/2 cup 449 0.4 0 25.1 13 4 125
Peach, canned in fruit juice 3640 125g 1/2 cup 288 0.5 0 14.9 26 6 194
Pear, canned in fruit juice 3643 130g 1/2 cup 256 0.4 0 12.4 16 5 125
 Fruit Exchanges – High Potassium (> 200 mg)

250 kJ, 0,5 g Protein, 0 g Fat, 10 g CHO, 15 mg PO4, 5 mg Na, 240 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Fresh Fruit (Raw)

Avocado 3656 40g quarter 408 0.7 9.4 0.8 13 1 233

Banana, peeled 3540 100g 1 large 382 1.4 0.4 18.8 20 1 241
Fig 3544 100g 2 large figs 353 1.2 1 13.5 20 4 237
Grapes 3550 100g 1 small bunch 300 0.7 0.1 14.7 19 2 215
Kiwi fruit 3660 100g 1 fruit 294 1 0.5 13 26 2 253
Marula, peeled 4241 100g 248 0.5 0.4 12.1 12 2 317
Melon, tsama 4246 100g   80 0.4 0 2.7 5 2 267
Melon, orange flesh 3541 60g 3 cm wedge 104 0.5 0.1 4.9 8 10 226
Num num 3679 100g   325 0.7 1.2 6.5 26 10 261

Orange 3560 120g 1 small 274 1 0.1 11 23 1 211

Peach 3565 100g 1 small 196 0.7 0.1 8.6 17 4 201
Watermelon 3576 200g 1 med wedge 276 1.8 0.2 11.8 10 8 274

42
Dried Fruit

Apricot, dried, raw 3536 20 g ~ 6 halves 227 0.7 0.1 11 23 2 276

Currants, dried 3662 30g 3 heaped DSP 388 0.9 0.2 20 30 5 270

Dried fruit sweets 3995 40g 3 large sweets 553 0.6 0.1 29.6 21 5 214

Fig, dried, raw 3557 40g 2 figs 484 1.2 0.5 22 27 4 285

Peach, dried, raw 3568 25g 2 halves 283 0.9 0.2 13.1 30 2 249

Prune, dried, raw 3596 30g 3 prunes 339 0.8 0.2 17 24 1 224

Raisins, seedless 3552 30g 2 heaped DSP 411 1 0.2 22 29 5 242

Fruit Juice
Orange juice, fresh 3561 125ml 1/2 cup 245 0.9 0.3 12.8 21 1 250

Tomato juice, Ceres 3976 125ml 1/2 cup 166 1.0 0.1 7.1 1.3 32.5 294
Canned or Cooked Fruit
Apricot, canned in syrup 3535 135g 1/2 cup 402 0.5 0.3 21.5 15 12 201

Apricot, canned in fruit juice 3607 135g 1/2 cup 273 0.8 0 13.6 30 5 243

TO BE RESTRICTED
Guava roll, dried (high potassium)
 Sugar Exchanges

155 kJ, 0 g Prot, 0 g Fat, 10 g CHO, 0 mg PO4, 0 mg Na, 10 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)

Chewing gum 3993 10g 2-5 sweets 162 0 0 9.5 0 0 0

Coconut ice 4011 20g 1 med piece 381 0.3 2.6 15.9 8 5 22

Fruit gums 4000 10g 2 sweets 152 0.1 0.2 8.6 0 6 36

Golden syrup 3988 10g thinly spread 135 0 0 7.9 2 27 24

Honey 3984 10g thinly spread 140 0 0 8.2 1 1 5

Jam / Marmalade 3985 10g thinly spread 120 0 0 6.9 2 2 9

Marshmallow 4001 10g 1 sweet 140 0.2 0 8 1 4 1

Peppermints 4004 10g 3 sweets 177 0.1 0.1 10.2 0 1 0

Sugar, brown 4005 10g ~ 2 TSP 164 0 0 9.6 2 3 34

Sugar, white 3989 10g ~ 2 TSP 170 0 0 10 0 0 0

43
Super C sweets (129 mg vit C / 10g) 4022 10g 2 sweets 177 0.1 0.1 10.2 0 1 0

Sweets, hard boiled or soft jelly type 3986 10g 2 small sweets 160 0 0.1 9.3 1 2 0

TO BE RESTRICTED
Assorted chocolates (high in protein, potassium, sodium and phosphate)
Chocolate coated bars/nuts/raisins (high in protein, potassium, phosphate and sodium)
Dark/bittersweet chocolate (high in protein, potassium and phosphate)
Fudge/toffee (high in protein, potassium, sodium and phosphate)
 Fat Exchanges

160 kJ, 0 g Prot, 5 g Fat, 0 g CHO, 0 mg PO4, 45 mg Na, 0 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Butro 3523 5g 1 level TSP 152 0 4.1 0 1 41 1

Butter, salt added 3479 5g 1 level TSP 152 0 4.1 0 1 41 1

Butter, salt free 3529 5g 1 level TSP 152 0 4.1 0 1 1 1

Cream, fresh, 20% fat 3481 15g 1 level TBS 154 0.4 3.8 0.5 11 6 17

Ghee 3525 5g 1 level TSP 185 0 5 0 0 0 0

Holsum 3516 5g 1 level TSP 185 0 5 0 NA NA NA

Lard 3495 5g 1 level TSP 185 0 5 0 0 0 0

Margarine, light (soft) 3521 10g 2 level TSP 302 0 8 0.1 0 153 1

Margarine, med fat (PUFA) 3496 10g 2 level TSP 306 0 8.3 0 0 40 1.0

Margarine, plain, brick 3484 5g 1 level TSP 149 0 4 0 0 40 0

Mayonnaise 3488 10g 1 heaped TSP 217 0.1 5.4 0.9 3 76 1

44
Mutton tallow 3497 5g 1 level TSP 185 0 5 0 NA NA NA

Oil, sunflower, olive oil 3507 5g 1 TSP 185 0 5 0 0 0 0

Olives, ripe / canned / pitted 3658 25g 5 Olives 130 0.2 2.7 0.8 1 218 2

Orley whip 3492 15g 1 level DSP 148 0 3.9 0 2 6 2

Salad cream 3489 10g 1 heaped TSP 148 0.1 3.3 1.5 4 96 4

Salad dressing, French 3487 5g 1 level TSP 121 0 3.2 0.3 1 0 1

Salad dressing, low fat 3505 30g 2 DSP 175 0.3 3.9 1.6 0 142 1

Sandwich spread 3552 10g 2 level TSP 165 0.1 3.4 2.2 NA NA NA

TO BE RESTRICTED
Nuts, salted (High in phoshate, sodium and potassium)
Nuts, unsalted (High in phosphate and potassium)
 Drink Exchanges

10 - 300 kJ, 0 g Protein, 0 g Fat, 5 g CHO, 5 mg PO4, 10 mg Na, 20 mg K

Food Item Code Portion   Energy Protein Fat CHO PO4 Na K

    Grams/ml Measure (kJ) (g) (g) (g) (mg) (mg) (mg)
Energy Drinks (300 kJ)

Cold drink, carbonated 3981 250ml 1 med glass 438 0 0 25.8 8 17.5 2.5

Cold drink, squash, diluted 3982 250ml 1 med glass 298 0 0 17.5 2.5 12.5 10

Liqueur 4040 25ml 1 liqueur glass 360 0 0.1 11.6 1.5 2 7.5

Liqueur, with cream 4055 25ml 1 liqueur glass 346 0,7 3.9 5.2 13 23 8

Lucozade 4007 125ml 1/2 med glass 383 0 0 22.5 5 35 2.5

Mahewa / Magou 4056 125ml 1/2 cup 199 1.0 0.4 9.8 48 0 23

Sherry, dry / med, Vermouth 4043 50ml 1 sherry glass 225 0,1 0 2.1 4.5 4.5 46

Sherry, sweet / port, Muscadel 4032 50ml 1 glass 291 0,1 0 5.9 4.5 4.5 46

Spirit/Brandy/Gin/Whiskey/Cane/Vodka/Rum 4035 50g 1 tot 522 0 0 0 2 0.5 1

Energade NA 125ml 1/2 cup 150 0 0 9 NA 46 6

45
Powerade NA 125ml 1/2 cup 156 0 0 9.4 0 28 21

Game NA 125ml 1/2 cup 153 0 0 9.5 19 31 6

Non-Energy Drinks (10 kJ)

Coffee, brewed, instant 4037 180 ml 1 tea cup 16 0.2 0 0.7 2 3.6 97

Cold drink, artificially sweetened / diet squash 3999 250ml 1 med glass 7.5 0.3 0.0 0.3 25 27.5 2.5

Tea, Ceylon, brewed 4038 180ml 1 tea cup 9 0 0 0.5 1.8 5.4 67

Tea, herbal 4053 180ml 1 tea cup 5 0 0 0.4 0 2 16

Tea, rooibos 4054 180ml 1 tea cup 5 0 0 0.4 NA 5.4 7.2

TO BE RESTRICTED
All types of beer (high in phosphate, potassium)
Ciders, sweet (high in potassium)
Cola drinks e.g. Coke, Pepsi (high in phosphate)
Wine (high in potassium)
46
National Department of Health
Civitas Building
Cnr Thabo Sehume and Struben Streets
Pretoria
0001

Switchboard: 012 395 8000