Review

Kidney Disease Diet for Patients Not on Dialysis

Author:

Anne Danahy, MS, RD, LDN

For patients with chronic kidney disease (CKD) but who are not on dialysis, it is useful to know some basic information before learning about their dietary needs.

For example, kidney function is sometimes expressed as the glomerular filtration rate (GFR). Normal GFR is 90 to 130 milliliters (mL)/minute. Blood urea nitrogen (BUN) is normally 5 to 25 mL/deciliter (dL). Urea is a product from the metabolism of protein. Normal kidneys maintain the BUN range of 5 to 25 mg/dL. When the kidneys begin to fail to eliminate urea in the urine, urea will build up in the blood, and BUN levels will increase.

The 5 stages of kidney disease, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), are:

▪ Stage 1—GFR is more than 90 mL/minute, with persistent protein in the urine

▪ Stage 2—GFR is 60–89 mL/minute, with persistent protein in the urine (mild disease)

▪ Stage 3—GFR is 30–59 mL/minute (moderate disease)

▪ Stage 4—GFR is 15–29 (severe disease)

▪ Stage 5—GFR is less than 15 or individual is on dialysis (kidney failure)

Approximately 14% of people in the United States have some stage of kidney disease. Many of these people have diabetes or high blood pressure. At present, about 460,000 people are on dialysis (Stage 5) (NIH NIDDK).

The National Kidney Foundation has suggested further guidelines for renal dietitians who are preparing and teaching special diets for persons with kidney disease. Specifically, if the amount of protein eaten is limited to the RDA, it may help alleviate the symptoms of uremia. These symptoms include nausea, vomiting, bad taste, and weight loss.Dietary Recommendations:

Protein

Restricting protein is not always beneficial until Stage 3 and Stage 4 of CKD. Protein guidelines are as follows:

  • 0.8 g/kg body weight/day, 60% high biological value (HBV) if GFR is >55 mL/minute
  • 0.6 g/kg body weight/day, 60% HBV if GFR is 25 to 55 mL/minute
  • HBV sources of protein include dairy products and meat

Calories

  • 35 calories/kg/day

This example shows you how to estimate the amount of protein needed in the diet:

Consider a man who is 57" tall and 150 pounds (68 kg)

  • 0.6 g × 68 kg = 41 g protein/day
  • 0.8 g × 68 kg = 54 g protein/day

The following list contains foods and their protein content:

  • 1 to 2 ounce chicken thigh=14 g protein
  • 8 fluid ounces skim milk=8 g protein
  • 1 egg=7 g protein
  • 1 cup cooked rice=4 g protein
  • 1 slice of bread=2 g protein
  • ½ cup corn=2 g protein

Potassium

Potassium usually is not restricted until urine output begins to decrease. The following foods are high in potassium:

  • Avocados
  • Bananas
  • Bran cereals
  • Chocolate
  • Dried peas and beans
  • Milk
  • Nuts
  • Orange juice
  • Oranges
  • Potatoes
  • Prune juice
  • Prunes
  • Papaya
  • Tomato juice
  • Tomato sauce

Sodium and blood pressure

High-sodium foods can increase blood pressure, which can in turn damage the blood vessels in the kidneys. High blood pressure is one of the major causes of kidney disease. Research on blood pressure and risk of death from CKD mortality indicates that maintaining blood pressure at or below 140/90 mm Hg reduces the risk of death in those with CKD (Ku et al., 2016). To achieve this, a person may need to take more than one drug.

The first line of high blood pressure medication is called an ACE inhibitor. This may improve the condition proteinuria or protein in the urine. This can affect both people with and without diabetes who have high blood pressure. Some individuals need a diuretic to help control high blood pressure. Other people need to add another blood pressure medication, such as an ARB (angiotensin reception blocker or angiotensin inhibitor).

Those with elevated blood pressure should also follow a low sodium diet (<1,500 mg/day), and avoid the following high-sodium foods:

  • Bacon
  • Canned soups
  • Cheese
  • Chinese food
  • Corn chips
  • Corned beef
  • Fast food
  • Ham
  • Pepperoni
  • Pickles
  • Pizza
  • Potato chips
  • Salt
  • Sausage
  • Soy sauce
  • Terriaki Sauce

Fluid restriction

The amount of fluid one can drink usually is not restricted until Stage 5 of CKD. The amount of urine the kidneys can make usually will not decrease until it is almost time to begin dialysis. This is called kidney failure, because eventually the kidneys fail to make urine.

Phosphorus

Phosphorus is a mineral found in almost all foods. Normal kidneys will balance the amount of phosphorus in the body. When the kidneys fail to eliminate phosphorus in the urine, phosphorus increases in the blood. This may begin as early as Stage 3 CKD. It becomes necessary to limit and/or avoid high-phosphorus foods.

Your patient’s physician may have them take a medication called a phosphate binder, such as Os-Cal®, PhosLo®, or Tums®, every time they eat. This medication will bind the phosphorus in the food and eliminate it in the stool. Control of phosphorus often is difficult for kidney failure patients.

High-phosphorus foods to eliminate include:

  • Beans (red, black, and white)
  • Black-eyed peas
  • Cheese
  • Chocolate/cocoa
  • Colas
  • Desserts made with milk (e.g. ice cream, pudding)
  • Lima beans
  • Liver and organ meats
  • Milk (all kinds)— recommend almond or rice milk instead
  • Nuts
  • Oysters
  • Sardines
  • Yogurt

Vitamins

Because the low-protein diet may lack some vitamins, special vitamins are recommended for persons with kidney disease. Regular multivitamins are not recommended. Suggestions include specific amounts of the B vitamins, including high doses of folic acid, and vitamin C. Also, a special form of vitamin D, calcitriol, sometimes is needed. Calcitriol helps prevent the bone disease that accompanies kidney disease. These vitamins require a prescription.

Diabetes and kidney disease

Many kidney disease patients have diabetes. Therefore, it is important to have good blood sugar control as indicated by daily glucose monitoring and regular A1c testing. The normal range for A1c is 4.5% to 6.5%.

Poor control of blood sugar contributes to the progression of kidney disease. To get enough calories when the diet is restricted in protein, it may be necessary to increase complex carbohydrates and healthy fats in the diet. Encourage patients to monitor their blood glucose closely when making these dietary changes, as they may need to increase medication to control their glucose.

References and recommended readings

  1. Kalantar-Zadeh K, Moore LW, Tortorici AR, Chou JA, St-Jules DE, Aoun A, Rojas-Bautista V, Tschida AK, Rhee CM, Shah AA, Crowley S. North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease. BMC Nephrology. 2016;17(1):90.
  2. Ku E, Gassman J, Appel LJ, Smogorzewski M, Sarnak MJ, Glidden DV, Bakris G, Gutiérrez OM, Hebert LA, Ix JH, Lea J. BP control and long-term risk of ESRD and mortality. Journal of the American Society of Nephrology. 2016. ASN-2016030326.
  3. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St Louis, MO: Saunders Elsevier; 2012.
  4. National Kidney and Urological Diseases Information Clearinghouse (NKUDIC). Kidney disease statistics for the United States. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/. Accessed February 16, 2018.
  5. National Kidney Foundation. About chronic kidney disease. Available at: http://www.kidney.org/kidneydisease/aboutckd.cfm. Accessed February 16, 2018.

Most Recent Review Date: March 7, 2018.