Renal diet explained

A renal diet is a diet aimed at keeping levels of fluids, electrolytes, and minerals balanced in the body in individuals with chronic kidney disease or who are on dialysis. Dietary changes may include the restriction of fluid intake, protein, and electrolytes including sodium, phosphorus, and potassium.^[1] Calories may also be supplemented if the individual is losing weight undesirably.

The diet may help limit the buildup of waste products within the body and reduce strain on the kidneys, as well as reduce blood pressure and lower the risk of fluid build-up around the heart and lungs.^{[2] [3] [4] [5]} Phosphorus restriction can help maintain bone health, as phosphorus buildup in the blood results in the leaching of calcium from bones and subsequently an increased fracture risk.^[6] The evidence supporting uptake of a renal diet and a reduction in cardiovascular events and mortality is limited, but dietary interventions may increase health-related quality of life and estimated Glomerular Filtration Rate (eGFR) while lowering serum albumin and serum cholesterol levels.

The restrictiveness of a renal diet depends on the severity of the patient's kidney disease, and the diet should be undertaken with the advice of a dietician.^[7] Patients with comorbid conditions like diabetes may need to further alter their diets to meet the needs of those conditions simultaneously.

Who should be on a renal diet?

Diet modification is recommended in those diagnosed with CKD stage 3-5 or GFR <60 mL/min/1.73² that are NOT on dialysis. Those with eGFR greater than or equal to 60 mL/min/1.73² are recommended to follow the general population dietary recommendations (DASH diet).^[8]

Sodium

Sodium restriction in CKD has been studied and recommended in individuals w/ coexisting hypertension, volume overload or proteinuria. Sodium restriction to <2 g/day (<5 g/day of salt) has shown improved blood pressure control, improved volume control and reduced proteinuria.^{[9] [10] [11] [12]} High sodium intake of above 6g/day has been shown to increase rates of cardiovascular disease, stroke and overall mortality.^{[13] [14]}

• Condiments
• Canned vegetables/meats/fish/soups
• Cured or smoked bacon, sausage, meats
• Deli meats
• Frozen dinners
• Pickles
• Pizza
• Processed/packaged foods
• Seasonings
• Tomato sauces/marinades

Salt/sodium-free

Less than 5 mg of sodium per serving
Very low sodium	35 mg or less of sodium per serving
Low sodium	140 mg or less of sodium per serving
Reduced sodium	At least 25% less sodium than the regular product
Light or lite in sodium	At least 50% less sodium than the regular product
No salt added or unsalted	No salt is added during processing, but these products may not be salt/sodium-free unless stated

Potassium

Potassium management for individuals with CKD is variable and dependent on various factors including CKD stage/eGFR, serum potassium levels and concomitant use of potassium altering medications such as ACE inhibitors/ARBs. Potassium regulation requires an individualized approach with the assistance of a dietician and physician.

Avoid: High-potassium food!Fruits!Vegetables!Proteins!Dairy!Other

BananasOranges Raisins Avocado Coconut Figs Kiwi Mango Prunes Nectarines Cantaloupe

ArtichokesBaked beans Beets Brussels sprouts Chard Olives Potatoes Pickles Pumpkin Tomato Acorn squash Butternut squash

Beans (black/kidney/pinto) Lobster Salmon Sardines Scallops Whitefish

MilkIce cream Processed cheese Yogurt

ChocolatePeanuts Peanut butter Sports drinks

Low-potassium foods!Fruits!Vegetables!Proteins!Grain!Fluids!Snacks

ApplesBlueberries Cherries Dried fruits: apples, blueberries, cherries, coconut, cranberries Grapes Lychee Pear Persimmon Pineapple Plum Raspberries Strawberries Tangerines Watermelon

AsparagusBean sprouts Broccoli Cabbage Carrots Cauliflower Celery Cherry tomatoes Corn Cucumber Eggplant Green or wax beans Greens: collard, mustard, turnip Jicama Kale Leeks Lettuce Mushrooms Okra Onion Peas: green, sugar snap, snow Peppers: green, red, yellow, jalapeño Radish Spinach (raw) Squash: spaghetti, yellow Turnips Water chestnuts

BeansBeef Chicken Edamame Eggs (whole or egg whites) Fish Lamb Lentils Pork Tofu Turkey Veal Wild game

Bagel (half)Bread loaf Cereal Corn tortilla Couscous English muffin (half) Old-fashioned or steel-cut oatmeal Pasta Pita (half) Quinoa Rice Rice cakes Slow-cook Cream of Wheat Slow-cook grits

100% fruit juices: apple, cranberry, grape, pineappleFresh-brewed coffee Fresh-brewed tea: black, herbal Fresh-squeezed lemonade Nectars: apricot, guava, mango, papaya, peach, pear Sodas: club, lemon-lime Water: sparkling, tap

All-natural fruit leatherAnimal crackers Applesauce Frozen fruit bars Fruit cocktail Homemade desserts: fruit pie or cobbler Italian ice Nuts, seeds and natural nut butters (2 tablespoons) Rice Krispies Treats® Sherbet Unsalted snacks: crackers, pita chips, popcorn, pretzels, tortilla chips

Phosphorus and calcium

Increased serum phosphate levels in CKD is associated with poor bone health, increased risk of cardiovascular events and mortality.^{[15] [16]} Although there isn't enough evidence that dietary restriction of phosphorus leads to decreased serum phosphorus, KDOQI recommends a maximum of 0.8 to 1 g/day intake restriction of dietary phosphorus.^[17]

Serum phosphate levels in CKD are heavily influenced by calcium and parathyroid hormone levels. In CKD,  the kidneys are unable to make adequate amounts of vitamin D, resulting in decreased calcium absorption. Low calcium leads to parathyroid hormone release, which moves calcium and phosphorus out of bones and into the blood. Therefore calcium supplementation in CKD patients results in decreased PTH and decreased phosphorus levels. KDOQI recommends a calcium intake goal of 800 to 1000 mg/day (diet and medications combined). Excessive calcium supplementation of 2000 mg/day for CKD patients may result in calcium deposition in other tissues leading to calcification.^[18]

Avoid: High-phosphorus foods!Protein!Grains!Dairy!Fluids

Pre-packaged or breaded meats and fishDeli meats Hot dogs Processed meats

BiscuitsMuffins Corn bread Pancakes Waffles

Processed cheesesCheese sauces Ice cream Milk Pudding Frozen yogurt

BeerHot cocoa Canned soup Some carbonated beverages, flavored waters and teas Milk Milkshakes Some protein shakes

Low-phosphorus foods!Protein!Grains!Dairy!Fruits

Fresh meats without breading or marinadesTurkey breast/thigh, skinless Chicken breast/thigh skinless Pork chop/roast Salmon Sea bass Shrimp Yellowfin

Flour tortillas: without baking powderWhite pita bread White bread Sourdough bread

Almond milkSour cream Soy milk Egg whites Cream cheese: 2 tablespoons Parmesan cheese: 2 tablespoons

AppleCherries Peach Pineapple Strawberries

Protein

A low protein diet for individuals with non-dialysis CKD has shown to lower the rate of CKD progression and electrolyte balance. Low protein diets of <0.8 g/kg/day have shown improved CKD management with reduced serum phosphorus, serum urea nitrogen and reduced protein in the urine.^{[19] [20] [21]} A very low protein diet (0.28 g/kg/day) is not recommended due to the possibility of malnutrition. The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) recommends a low protein diet of 0.55-0.6 g/kg/day but specific levels of protein intake varies for each individual and should be altered with the advice of a dietician and/or physician.^{[22] [23]}

See also

• List of diets

Notes and References

1. Web site: Diet - chronic kidney disease: MedlinePlus Medical Encyclopedia . 2022-03-23 . medlineplus.gov . en.
2. Hershey . Kristen . December 2018 . Renal Diet . The Nursing Clinics of North America . 53 . 4 . 481–489 . 10.1016/j.cnur.2018.05.005 . 1558-1357 . 30388974. 53272380 .
3. Akchurin . Oleh M. . February 2019 . Chronic Kidney Disease and Dietary Measures to Improve Outcomes . Pediatric Clinics of North America . 66 . 1 . 247–267 . 10.1016/j.pcl.2018.09.007 . 1557-8240 . 6623973 . 30454747.
4. Palmer . Suetonia C. . Maggo . Jasjot K. . Campbell . Katrina L. . Craig . Jonathan C. . Johnson . David W. . Sutanto . Bernadet . Ruospo . Marinella . Tong . Allison . Strippoli . Giovanni Fm . 2017-04-23 . Dietary interventions for adults with chronic kidney disease . The Cochrane Database of Systematic Reviews . 2017 . 4 . CD011998 . 10.1002/14651858.CD011998.pub2 . 1469-493X . 6478277 . 28434208.
5. Web site: Eating Right for Chronic Kidney Disease NIDDK . 2022-03-23 . National Institute of Diabetes and Digestive and Kidney Diseases . en-US.
6. Web site: Mineral & Bone Disorder in Chronic Kidney Disease NIDDK . 2022-03-23 . National Institute of Diabetes and Digestive and Kidney Diseases . en-US.
7. Web site: CDC . 2019-09-19 . Diabetes & Kidney Disease: What to Eat? . 2022-03-23 . Centers for Disease Control and Prevention . en-us.
8. Ikizler . T. Alp . Burrowes . Jerrilynn D. . Byham-Gray . Laura D. . Campbell . Katrina L. . Carrero . Juan-Jesus . Chan . Winnie . Fouque . Denis . Friedman . Allon N. . Ghaddar . Sana . Goldstein-Fuchs . D. Jordi . Kaysen . George A. . Kopple . Joel D. . Teta . Daniel . Yee-Moon Wang . Angela . Cuppari . Lilian . September 2020 . KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update . American Journal of Kidney Diseases. 76 . 3 Suppl 1 . S1–S107 . 10.1053/j.ajkd.2020.05.006 . 1523-6838 . 32829751. 221282344 . free .
9. Ikizler . T. Alp . Burrowes . Jerrilynn D. . Byham-Gray . Laura D. . Campbell . Katrina L. . Carrero . Juan-Jesus . Chan . Winnie . Fouque . Denis . Friedman . Allon N. . Ghaddar . Sana . Goldstein-Fuchs . D. Jordi . Kaysen . George A. . Kopple . Joel D. . Teta . Daniel . Yee-Moon Wang . Angela . Cuppari . Lilian . September 2020 . KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update . American Journal of Kidney Diseases. 76 . 3 Suppl 1 . S1–S107 . 10.1053/j.ajkd.2020.05.006 . 1523-6838 . 32829751. 221282344 . free .
10. Garofalo . Carlo . Borrelli . Silvio . Provenzano . Michele . De Stefano . Toni . Vita . Carlo . Chiodini . Paolo . Minutolo . Roberto . De Nicola . Luca . Conte . Giuseppe . 2018-06-06 . Dietary Salt Restriction in Chronic Kidney Disease: A Meta-Analysis of Randomized Clinical Trials . Nutrients . 10 . 6 . 732 . 10.3390/nu10060732 . 2072-6643 . 6024651 . 29882800. free .
11. Chen . Yanrong . Wang . Xiangyu . Jia . Yijie . Zou . Meina . Zhen . Zongji . Xue . Yaoming . June 2022 . Effect of a sodium restriction diet on albuminuria and blood pressure in diabetic kidney disease patients: a meta-analysis . International Urology and Nephrology . 54 . 6 . 1249–1260 . 10.1007/s11255-021-03035-x . 1573-2584 . 34671892. 239042207 .
12. McMahon . Emma J. . Campbell . Katrina L. . Bauer . Judith D. . Mudge . David W. . Kelly . Jaimon T. . 2021-06-24 . Altered dietary salt intake for people with chronic kidney disease . The Cochrane Database of Systematic Reviews . 2021 . 6 . CD010070 . 10.1002/14651858.CD010070.pub3 . 1469-493X . 8222708 . 34164803.
13. Malta . Daniela . Petersen . Kristina S. . Johnson . Claire . Trieu . Kathy . Rae . Sarah . Jefferson . Katherine . Santos . Joseph Alvin . Wong . Michelle M. Y. . Raj . Thout Sudhir . Webster . Jacqui . Campbell . Norm R. C. . Arcand . JoAnne . December 2018 . High sodium intake increases blood pressure and risk of kidney disease. From the Science of Salt: A regularly updated systematic review of salt and health outcomes (August 2016 to March 2017) . Journal of Clinical Hypertension (Greenwich, Conn.) . 20 . 12 . 1654–1665 . 10.1111/jch.13408 . 1751-7176 . 8030856 . 30402970.
14. Strazzullo . Pasquale . D'Elia . Lanfranco . Kandala . Ngianga-Bakwin . Cappuccio . Francesco P. . 2009-11-24 . Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies . BMJ (Clinical Research Ed.) . 339 . b4567 . 10.1136/bmj.b4567 . 1756-1833 . 2782060 . 19934192.
15. Newsome . Britt . Ix . Joachim H. . Tighiouart . Hocine . Sarnak . Mark J. . Levey . Andrew S. . Beck . Gerald J. . Block . Geoffrey . June 2013 . Effect of protein restriction on serum and urine phosphate in the modification of diet in renal disease (MDRD) study . American Journal of Kidney Diseases. 61 . 6 . 1045–1046 . 10.1053/j.ajkd.2013.01.007 . 1523-6838 . 23415016.
16. Palmer . Suetonia C. . Hayen . Andrew . Macaskill . Petra . Pellegrini . Fabio . Craig . Jonathan C. . Elder . Grahame J. . Strippoli . Giovanni F. M. . 2011-03-16 . Serum levels of phosphorus, parathyroid hormone, and calcium and risks of death and cardiovascular disease in individuals with chronic kidney disease: a systematic review and meta-analysis . JAMA . 305 . 11 . 1119–1127 . 10.1001/jama.2011.308 . 1538-3598 . 21406649. 10453/117870 . free .
17. Ikizler . T. Alp . Burrowes . Jerrilynn D. . Byham-Gray . Laura D. . Campbell . Katrina L. . Carrero . Juan-Jesus . Chan . Winnie . Fouque . Denis . Friedman . Allon N. . Ghaddar . Sana . Goldstein-Fuchs . D. Jordi . Kaysen . George A. . Kopple . Joel D. . Teta . Daniel . Yee-Moon Wang . Angela . Cuppari . Lilian . September 2020 . KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update . American Journal of Kidney Diseases. 76 . 3 Suppl 1 . S1–S107 . 10.1053/j.ajkd.2020.05.006 . 1523-6838 . 32829751. 221282344 . free .
18. Spiegel . David M. . Brady . Kate . June 2012 . Calcium balance in normal individuals and in patients with chronic kidney disease on low- and high-calcium diets . Kidney International . 81 . 11 . 1116–1122 . 10.1038/ki.2011.490 . 1523-1755 . 3352985 . 22297674.
19. Rhee . Connie M. . Ahmadi . Seyed-Foad . Kovesdy . Csaba P. . Kalantar-Zadeh . Kamyar . April 2018 . Low-protein diet for conservative management of chronic kidney disease: a systematic review and meta-analysis of controlled trials . Journal of Cachexia, Sarcopenia and Muscle . 9 . 2 . 235–245 . 10.1002/jcsm.12264 . 2190-6009 . 5879959 . 29094800.
20. Yan . Bingjuan . Su . Xiaole . Xu . Boyang . Qiao . Xi . Wang . Lihua . 2018 . Effect of diet protein restriction on progression of chronic kidney disease: A systematic review and meta-analysis . PLOS ONE . 13 . 11 . e0206134 . 10.1371/journal.pone.0206134 . 1932-6203 . 6221301 . 30403710. 2018PLoSO..1306134Y . free .
21. Hahn . Deirdre . Hodson . Elisabeth M. . Fouque . Denis . 2020-10-29 . Low protein diets for non-diabetic adults with chronic kidney disease . The Cochrane Database of Systematic Reviews . 10 . 10 . CD001892 . 10.1002/14651858.CD001892.pub5 . 1469-493X . 8095031 . 33118160.
22. Menon . Vandana . Kopple . Joel D. . Wang . Xuelei . Beck . Gerald J. . Collins . Allan J. . Kusek . John W. . Greene . Tom . Levey . Andrew S. . Sarnak . Mark J. . February 2009 . Effect of a very low-protein diet on outcomes: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study . American Journal of Kidney Diseases. 53 . 2 . 208–217 . 10.1053/j.ajkd.2008.08.009 . 1523-6838 . 18950911.
23. Ikizler . T. Alp . Burrowes . Jerrilynn D. . Byham-Gray . Laura D. . Campbell . Katrina L. . Carrero . Juan-Jesus . Chan . Winnie . Fouque . Denis . Friedman . Allon N. . Ghaddar . Sana . Goldstein-Fuchs . D. Jordi . Kaysen . George A. . Kopple . Joel D. . Teta . Daniel . Yee-Moon Wang . Angela . Cuppari . Lilian . September 2020 . KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update . American Journal of Kidney Diseases. 76 . 3 Suppl 1 . S1–S107 . 10.1053/j.ajkd.2020.05.006 . 1523-6838 . 32829751. 221282344 . free .