October 21, 2015

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Options for nutritional intervention during pre-dialysis care

So you have just completed your annual visit to your doctor and he/she tells you that there is a little problem with your kidneys. He tries to explain what this means, but you find it confusing, especially since you have no symptoms. Then he tells you to "watch your protein intake and come back to see me in six months" His nurse gives you a brochure along with the phone number and name of a dietitian at the local hospital, just in case you want to learn about a "diet." Now you are really confused, wondering what this means for you and your future. Hopefully you follow up by making an appointment with the dietitian.

A diet to slow the progression of your renal disease is going to depend on your body size, state of nutrition and stage of kidney disease. There are six stages of chronic kidney disease. The stages of CKD are defined by the glomerular filtration rate (GFR). Normal GFR is more than 90 milliliters per minute.

The stages of kidney disease

Stage 1: GFR more than 90 with persistent protein in the urine

Stage 2: GFR 60-89 (mildly decreased)

Stage 3A: GFR 45-59 (mildly to moderately decreased)

Stage 3B: GFR 30-44 (moderately to severely decreased)

Stage 4: GFR 15-29 (severely decreased)

Stage 5: GFR less than 15- time for dialysis or transplant

There have been many studies over the years trying to establish if a "diet" could slow the progression of kidney disease. None of these studies could prove absolutely beyond a doubt that the diet could actually do this. But we have learned that a diet may decrease the symptoms, like nausea, vomiting, weakness and weight loss, which can accompany the later stages of kidney disease.

Renal dietitians have guidelines to follow when preparing information for people with kidney disease.

These are the goals:

Control blood pressure - 130/80

Control blood sugar, if you are diabetic- A1C less than 7

Control your protein intake, to decrease symptoms of kidney disease like nausea, vomiting and poor appetite

With Stage 1, 2 or 3 CKD, your protein intake may not be limited. ^1,2,3,4However, if you are at Stage 4 CKD, your dietitian may advise you to limit protein to 0.8 grams of protein per kilogram body weight. ^1,2,3,4

This is actually the same level recommended by the Dietary Reference Intakes (DRis) for a healthy diet for nor mal adults. The latest research suggests not eating a high protein diet if you have Stage 4 CKD. ^1,2,3,4

Limiting protein

All proteins are not created equally—some are high quality protein foods like meat, poultry, milk, cheese and eggs. Then there are the low quality protein foods found in nuts, vegetables, beans, peas and peanut butter.

Example: A 50 year old lady who weighs 154 lbs., (70 kilograms), with Stage 4 chronic kidney disease would need about 56 grams of protein a day. We eat much more protein than we need in the U.S. About half of the protein should come from high quality protein sources.^1,2,4

Potassium

Potassium is a mineral found naturally in most foods. Some patients need to restrict potassium and therefore must limit high potassium foods like bananas, melon, orange juice, tomato sauce, pomegranate juice, avocado, salt substitute, and potatoes. Some medications like ace inhibitors can raise the potassium level. But other patients may even have to take a potassium pill and eat high potas sium foods.

Phosphorus

Phosphorus is another mineral found naturally in many foods. It is also used as a preservative or additive in processed foods and in fast food. It is usually not on the label of the food product—but it must be listed, if it is an ingredient. Listing the exact amount is not required by law to be on the label. So we don't really know how much phosphorus we are consuming. With chronic kidney disease, too much phosphorus from our diet can cause serious problems with the heart and blood vessels. Avoid foods that have phosphoric acid or sodium phosphate and any ingredient that has PHOS on the label. Especially avoid eating fast food because it actually has preservatives and additives in it. Other high phosphorus foods include dark colas, (especially coke and diet coke), liver, sausage, chocolate and whole grains.

Milk (any kind) and dairy products like yogurt, pudding and ice cream contain large amounts of phosphorus. It is a good idea to start learning to use non-dairy foods like original Almond Breeze, which has only 20 milligrams of phosphorus in a cup. The daily allowance for phosphorus is 800 to 1,000 milligrams a day.^1,2,3,4 The goal is to keep your phosphorus level at 3.5 to 5.5 milligrams per deciliter.

Sodium

It is important to limit the sodium in the diet to less than 2000 mg a day. 1,2,3,4 It may be necessary to take 3-4 blood pressure medications to achieve good control. Fortunately, our government has made it mandatory to include the amount of sodium on the label of our food products. One teaspoon of salt (sodium chloride) has 2300 milligrams of sodium. A McDonald's Big Mac with Cheese has 1,070 milligrams of sodium.

Calories

It is very important to get enough calories in your diet to prevent mal nutrition. Calories come from carbohydrate, protein and fat. Since we may have limited the protein, the majority of calories will be coming from carbohydrate and fat. If you are diabetic, the amount of carbohydrate could also be

limited. However, it may be possible to increase the medications you take to control blood sugar to allow a little more carbohydrate in your diet. Fat has twice as many calories as protein and carbohydrate. So lots of margarine and or olive oil will provide lots of calories in the diet.

Sample Menu for Stage 4 CKD

Breakfast

1 scrambled egg in lots of margarine (margarine has no protein)

1 slice white bread toasted with lots of margarine and jelly (regular or diet)

Coffee with non-dairy like Original Almond Breeze and sugar or sugar substitute

Snack

12 grapes

Lunch

Large mixed green salad with 2 or 3 big strawberries cut up, 2 tablespoons blueberries, 1 tablespoon chopped pecans, 1 tablespoon chopped red onion, 2 tablespoons peeled, seeded and chopped cucumber with lots of extra virgin olive oil (no protein in olive oil) and white wine vinegar or balsamic vinegar

1 small roll or croissant with lots of margarine (no protein in margarine)

One cup (8 ounces) raspberry or mango sorbet (no protein in sorbet)

Iced tea with lemon and sugar and or sugar substitute

Dinner

5 ounces of grilled steak or roast chicken (5 ounces cooked weight, no bone – such as a small breast and a leg)

Medium baked potato (if you have no restriction in potassium) or 1 cup of cooked white rice if you have to restrict potassium. Lots of margarine

Small portion green beans, cauliflower, or carrots with lots of margarine

Coleslaw made with mayonnaise/vinegar/celery seasoning/black pepper

Yes, you can have dessert!

1/8 apple pie (or baked apple with a spoon of Cool Whip and 5 vanilla wafers if you are diabetic)

7 UP (regular or diet) -by Peggy Harum, RD, LDN

References

Kopple, JD, Massry SG, Kalantar-Zedeh K, eds, Nutritional Management of Renal Disease, 3rd ed. New York: Elsevier Academic Press. 2013

KDIGO CKD Work Group. KDIGO 2012 clini cal practice guideline for the evaluation and management of chronic kidney disease.

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease, Kidney Int. 2013:3 (Suppi):S1-S150

Am J Kidney Dis.2014;63:713-735. doi.10.1053/j.ajkd.2014.01.416.Epub 2014 March 16.