Diet Guide : Stage 1 To 4

nephroplus | July 21, 2016

By Mrinal Pandit, Chief Dietician, NephroPlus

Nutrition plays an important role in the well-being of an individual. And it becomes more crucial when it comes to special dietary needs. Diet control acts as a preventive medicine to delay the progression of diseases. In kidney disease as well, diet plays a vital role. Your Nutritionist can guide you about your nutrient needs and meals to be taken. Special attention should be given to the stage of kidney impairment and biochemical values.

Understand which stage are you in:
There are five stages of Chronic Kidney Disease (CKD). Depending upon the functioning of the kidneys your Nephrologist can decide which category you are in. The degree of kidney damage is measured by a test called Glomerular Filtration Rate (GFR). Your course of treatment and the diet depends on the stage of kidney failure.


Stages of Chronic Kidney Disease

Stage of kidney damage Description Glomerular Filtration Rate (GFR)
1 Kidney damage (e.g., proteine in the urine) with normal GFR 90 or above
2 Kidney damage with mild decrease in GFR 60 to 89
3 Moderate decrease in GFR 30 to 59
4 Severe reduction in GFR 15 to 29
5 Kidney failure Less than 15

Source: National Kidney Foundation

The progression of kidney damage can be interpreted by the value of GFR. The extent of Kidney damage and the GFR are inversely proportional to each other. The higher the GFR, lower is the kidney damage.

Nutritional Insight : The progression of kidney damage can be interpreted by the value of GFR. The extent of Kidney damage and the GFR are inversely proportional to each other. Higher the GFR, lower is the kidney damage.

How is Diet important in this stage?
From Stage 1 to Stage 4, the kidneys still perform their functions but the efficacy will be lower. With planned medical and nutritional therapy, you can decrease the burden on the kidney due to toxin overload. A good diet cannot completely stop the progression of disease but can surely delay it. A dietician can help you plan your menu as per your requirement A regular follow up with the Nephrologist and dietician is important as the diet will not be the same with each stage. Progression of disease may change the nutrient requirement.

How do I be sure that I am taking enough calories?
Intake of calories is important to overcome malnutrition. Albumin test can be a good marker to understand the nutritional status of an individual. Calorie needs can be manipulated based on Body mass index (BMI) and weight goals. Some people may require supplementation of calories by using commercial formulas while few have to cut down on extra dietary calories. Work with your dietician to make a plan to give you the right amount of calories.

ALARM: Ask for Professional Help If you experience any of the following:

•BMI below 18.5
•Low Albumin Levels

Nutritional Insight: Be careful while choosing nutritional supplements. The supplement should be clinically formulated to cater to the high calorie requirement and low protein needs of the patients. The formula should have low phosphorus and electrolyte content. Check with your Nutritionist to know which is the most suitable supplement for you.

How much protein do I need?
Proteins in the meal after digestion release nitrogenous waste. In this stage, the kidneys are partly functional so it may not clear all the nitrogenous waste. The intake of proteins should be optimal enough to take care of the body’s needs and prevent the accumulation of waste products. The protein requirement should be restricted to 0.6-0.8 gram per kg Ideal body weight.
For a 60 kg adult, the protein requirement will be between 36 g-48 g per day. A test-normalized protein equivalent of nitrogen appearance estimates the amount of protein intake. It can assist your dietician to check if you are eating the right amount of proteins.

ALARM: Ask for Professional Help if you have:

•Low Albumin Level
•Poor Skin Integrity
•Low Immunity

Nutritional Insight: Proteins are classified as first class protein and second class proteins. Meat, poultry, eggs and dairy products are first class proteins while proteins from plant origin tend to be of lower quality because of incomplete amino acids composition and are also known as second class protein. More than 50 % of the required protein should come from animal protein to achieve positive nutritional balance.

Do I have to restrict my Fat intake?
Fats are important sources of energy in meals. Fats and oil allowance will depend on your BMI and presence of any co-morbidities. Total fat consumption should not be restricted but the type of oil in the diet can be discussed with your dietician. Ask your dietician about good fat and the ration of PUFA: MUFA that is beneficial for your condition.

ALARM : Ask for Professional Help if you are:

•Over Weight
•Under Weight
•Have Vitamin Deficiency

How much should be my sodium intake?
Limit the content of sodium to 2000 mg per day. Sodium affects blood pressure and fluid retention. Healthy kidneys flush sodium out of the system. However, if your kidneys are not working well, salt may accumulate in the body and cause swelling of your ankle, fingers and eyes.
You can limit sodium intake by limiting table salt, processed foods, canned vegetables and fruits, soy sauce, chat masala, pickle, and salted biscuits. Learn to read food labels to know what you are eating. Herbs and spice can be used instead of salt.

ALARM : Ask for Professional Help if you have:

•Frequent thirst.
•Fluid overload
•High blood pressure

Nutritional Insight: Composition of some commonly available salts per 100 gm.

Brand Name Sodium content in gram Potassium content in gram 
Lona 29 38
Sendhav 38 5
Lite Salt 33.2 7.8
Common Salt 38.7 0

Do I need to restrict my Potassium?
Potassium is found almost in all vegetables and fruits. Wise selection of fruits and greens is important to avoid an emergency. Too much or too little potassium can be dangerous. Less than the normal limit can cause muscle cramping while excess can lead to heart attack. Few medications prescribed to control blood pressure can contribute to high potassium level to some extent. Discuss with your Nephrologist if strict diet control is not helping lower your blood potassium levels.

Potassium intake can be limited by leaching the vegetables, choosing low potassium fruits and pulses.

Caution!! Use of salt substitute is recommended only after Nephrologist/Dietician’s advice as substitutes are high in potassium.

ALARM : Ask for Professional Help if you have:

•Hyperkalemia (high potassium levels in the blood)
•Muscle cramps
•Abnormal heart beat

Nutritional Insight: According to a new study in the Journal of Food Science that explored the effects of leaching and boiling on levels of potassium and other minerals in potatoes found that boiling cubed or shredded samples reduced potassium levels by 50 percent and 75 percent, respectively.

Is Phosphorus harmful for my body?
Phosphorus works with calcium and Vitamin D to keep bones healthy and strong. In stage 3, kidneys do not clear extra phosphorus. High phosphorus in blood pulls calcium from the bone and makes them fragile. It may also cause calcium to build up in the blood vessels, joints muscles and joints where they don’t belong.
Depending on the phosphate levels your doctor may prescribe phosphate-binders. This avoids unnecessary phosphorus in the body. A phosphate binder can be helpful, but you will still need to watch how much phosphorus you eat. Phosphorus restriction of 800 mg per day can help.

Active Vitamin D supplementation may be required to maintain calcium and phosphate levels.

ALARM : Ask for Professional Help if you have:

•Dry Skin
•Skin Ulcers

Nutritional Insight: Phosphate binders are effective only when they  are taken along with the meal as it works by preventing phosphorous to be absorbed in the blood stream when the food is being digested. The time of ingestion of binders is very important for its efficacy.

How much should be my fluid intake?
In early stages of CKD, kidneys make moderate urine. Fluid restriction will depend on the GFR and urine output. Extra fluid can also build up around your lungs and make it hard to breathe. A Doctor can guide you about the allowance of fluid depending on the progression of kidney damage.

ALARM : Ask for Professional Help if you have:

•Shortness of Breath

How do I manage thirst?
Managing thirst becomes a skillful task when the allowance of fluid is limited. Fluids like weak Tea, Milk, Buttermilk, Kanji, Lime water etc. can be restricted or liberally allowed depending on the urine output. If the fluid allowance is stringent, few tips that will help reduce fluid intake:

  • Drink water only when thirsty.
  • Drink water out of a bottle that has a measured amount put in it.
  • Use ice cubes or ice chips.
  • Use small cups and glasses to drink.
  • Use sour candy or gum to moisten your mouth.
  • Gargle with mouthwash when you are thirsty. Do Not Swallow!!

Understanding Household measures?

It becomes necessary to know the household measures to ensure prescribed amount of intake suggested by you nutritionist.

1 vegetable bowl = 150 g
1 cup, medium = 120 ml
1 soup bowl = 250 ml
1 glass = 200ml
1 tea spoon = 5 g
1 table spoon = 15 g

How do I manage Anemia?
Your kidneys make an important hormone called erythropoietin (EPO).The formation of EPO goes down with the partial to permanent loss of kidney function. Low EPO levels cause your red blood cell count to drop and anemia to develop. Not everyone with anemia will show symptoms. If you have kidney disease, you should test your hemoglobin level regularly to assess anemia.
Unfortunately, oral dietary intake of iron does not play major role in elevating the hemoglobin (Hb) level as iron given intravenously does. So even if high iron content foods are ingested in the diet it will not make much change in Hb level. Your Nephrologist will treat you with erythropoiesis stimulating agents (ESAs) and iron supplementation.

Nutritional Insight: ESA replaces the function of EPO, which is less in people with kidney failure. Your body needs Iron to make Red blood cells (RBC), without iron ESA will not work well. A cover of iron supplementation with ESA will help your reach the desired Hemoglobin level.

What lifestyle changes do I need?
The prevalence of heart disease is high with people with CKD. As a precautionary measure dietary and life style modifications are advisable. It is better to maintain your ideal body weight. A regular exercise regimen can help you achieve desired body weight.
Regular aerobic exercise can help you maintain blood pressure, Lower LDL and triglyceride, maintain blood glucose level, increase muscle mass.

Nutritional Insight: A study shows 12 months of moderate exercise training was able to improve physical function, aerobic capacity and quality of life in patients with CKD. Another study reveals that an exercise program that includes a supervised and home-based training phase is effective, adhered to, and safe in patients with CKD.

Can I take over the counter drugs?
Always talk to your Nephrologist before taking any new medication. With normal kidney few medicines work well but it may not be always same for you. Some medicines can build up in your body and cause harm if kidneys are impaired. Consult your doctor for type of medicine, dosage and substitution to prevent further damage the kidneys.

Can I take Herbal medicine?
Not much research supporting the use of herbal medicine is available in CKD, so not much can be said about it. Speak to your Nephrologist before starting herbal medication as it may interfere with other prescribed medication and decrease its efficacy. It may also lead to some unwanted side effects.

What is Diet Diary?
You may not always able to recall what you have eaten the previous day. A Diet Diary helps you track the food you take throughout the day. It allows your dietician to understand your dietary regime, calorie intake, protein, micro nutrients and pin point if any food group which is restricted for you. A regular follow up will make you understand if anything has to be changed or added in your diet. The diet diary will allow you to spot at a glance any shortchanged food groups that could be potentially depriving you of important nutrients. Writing down Diet Diary makes you more responsible and accountable for every bit you eat.

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  • It seems I am in Stage 2 CKD so am reading up on it. This article I like a lot – maybe because I have lived in India and Nepal!!

  • Pl advice for revive from GLOMERULAR rate 61 ml/min/1.73 m2