Dietary Advice to Patients with Kidney Disease -Dr. Fayaz Ahmad Wani

Chronic kidney disease (CKD) is a global health problem affecting 850 million people  worldwide. One of the most important interventions in slowing down CKD progression is dietary  intervention. Studies have reported a malnutrition rate of around 18–75% among CKD patients,  which is associated with increased morbidities and mortality. As CKD advances, the requirement  and consumption of various nutrients alter considerably. Patients may find it perplexing that  dietary advice changes based on the CKD stages. 
The dietary guidelines now suggest that specific nutrient restriction is redundant unless  serum levels are abnormally elevated. Diet-related communication with patients and relatives  must be frequent, simple, and straightforward. 

Protein intake: A low protein diet (LPD), by reducing hyperfiltration at the glomerular bed, is  commonly recommended for slowing the progression of CKD. Implementing this advice requires  a full understanding of context and dietary habits of the patients. An Average Indian usually takes low (0.6–0.8 g/kg) protein diet daily. Avoiding common protein-containing items like pulses and  milk without proper dietary advice to meet the daily requirements leads to protein energy  malnutrition. Vegetarians may be allowed to continue their diet without restricting protein. The  shift from animal protein-based to plant-based diet is being increasingly recommended for its  pleotropic benefits on cardiovascular health. Plant-based diet could have a favorable effect on gut  microbiota, and may be better for control of nitrogen balance, acid–base metabolism, and bone  mineral disorders. 

Dietary fat: Patients typically develop dyslipidemia when GFR begins to decline. American Heart  Association (AHA) advises a total fat intake of 25–35% of total calories, monounsaturated fatty  acid (MUFA) up to 20%, and polyunsaturated fatty acids (PUFA) up to 10%, SFA not exceeding 7%,  trans fats at<1% of total calorie intake. The recommended combination of oils (groundnut or  sesame or rice bran + mustard oil/canola oil/soybean oil) suggested by the National Institute of  Nutrition 
Energy Intake: The KDOQI guidelines 2020 recommend an energy intake of 25–35 kcal/kg ideal  body weight in CKD patients based on age, gender, physical activity, weight, CKD stage,  comorbidity, and inflammation to maintain nutritional status. 

Fiber: CKD patients should not be deprived of the advantages of fiber in their diet, which also  helps in preventing constipation. A daily fiber intake of 25–30 g/day or more for CKD patients may  be suggested. 

Dietary Potassium: Hyperkalemia develops as GFR declines. Dietary modifications are now  recommended only to treat hyperkalemia and not as a preventative measure. Patients should be  advised to choose low-potassium fruits and vegetable.  

Phosphorus Intake: Dietary phosphorus restriction is challenging, especially for those on dialysis  needing a high-protein diet. Dietary phosphorus intake should be adjusted to maintain serum  phosphorus levels in the normal range. Beverages like colas, enhanced meats, frozen meals,  processed or spreadable cheeses, instant foods, and refrigerated bakery products are rich in  inorganic phosphorus > 90 % of which is bio-available. 

Dietary sodium and salt: A low salt diet is a cornerstone in CKD management, except in salt wasting kidney diseases. Guidelines recommend a sodium intake of <2.3 gms per day. 

Practical tips to reduce salt and sodium in daily diet: Gradually cutting back on salt over a few  weeks is crucial when cooking and preparing meals. Meals must be made using fresh ingredients  and either cooked without salt initially, then finished with the recommended amount later.

Fluid management: Urine output is usually normal in CKD stages 1 to 3. Fluid intake of 1.5–2 L/d  may be prescribed except in edematous patients. Fluid recommendations, however, vary based  on individual weight gain, blood pressure, residual renal function and a customized strategy is  required. Teaching patients to manage fluid intake and recognize symptoms of fluid overload is  advocated. 

Discuss with Your Dietitian: Everything that you eat and drink directly affects your kidneys.  Therefore, you should discuss the food items you should eat and the ones you should avoid. Your  dietician will work with you and chalk a plan according to your unique requirements, stage of  kidney disease, and any underlying health condition you may have.