Nutrition and Kidney Disease, Stages 1-4

Learn the basics!

 Nutrition and Chronic Kidney Disease
 Nutrition for Children with Chronic Kidney Disease

Most patients in the early stages of kidney disease need to limit the amount of sodium in their
diet. Some patients may be told to limit protein in their diet as well. The DASH diet is often
recommended for patients with kidney disease. Be sure to talk with your healthcare provider
about your specific nutrition needs.

 DASH Diet
 Enjoy Your Own Recipes Using Less Protein
 Sodium and Your CKD Diet: How to Spice Up Your Cooking

If your kidney disease gets worse, you may also need to limit potassium or phosphorus in your
diet. Talk with your healthcare provider about your specific nutrition needs.

 Potassium and Your CKD Diet

 Phosphorus and Your CKD Diet

Here are some additional resources to help you stay healthy with kidney disease through your
diet:

 Protein – Variety and Moderation is the Key

 Carbohydrate Counting with Chronic Kidney Disease
 How to Increase Calories in Your CKD Diet
 Cholesterol and Chronic Kidney Disease
 Dining Out With Confidence
 Use of Herbal Supplements in Kidney Disease
 Vitamins and Minerals in Kidney Disease
 What You Should Know About Good Nutrition
 Your Guide to the New Food Label
 Spice Up Your Diet
 Food Safety is a Must!
 Cookbooks for Kidney Patients
 Dairy and Our Kidneys
 Today’s leading health organizations are heartily endorsing the DASH Diet for the
informed health-conscious diner. The DASH (Dietary Approaches to Stop Hypertension)
Diet has been recommended by the National Kidney Foundation and approved by The
National Heart, Lung and Blood Institute, The American Heart Association, the Dietary
Guidelines for Americans, and also forms the basis for the USDA MyPyramid.
  Studies on the DASH have demonstrated that the DASH diet helps decrease blood
pressure, lowers the risk for heart disease, stroke and cancer, and reduces the risk of
kidney stone formation.
 The DASH Diet is rich in fruits, vegetables, low-fat dairy products, whole grains, fish,
poultry, beans, seeds, and nuts. It is low in salt and sodium, added sugars and sweets, fat
and red meats.
 Learn more about the DASH Diet
 Get tips to tackle the DASH Diet 
 Check out a sample 3-day DASH Diet Meal Plan, including recipes 
 The DASH diet is a recognized treatment for hypertension, heart disease, and kidney
disease. The DASH diet can slow the progression of both heart disease and kidney
disease. If you already have chronic kidney disease, you should speak with your doctor
and dietitian before starting any new diets as you may have special restrictions to
consider. The DASH diet should not be used by people on dialysis. Individuals on
dialysis have special dietary needs that should be discussed with a registered dietitian.
 Here’s the detailed DASH diet for a 2,000 calorie diet:

Food Group Daily Servings Serving Size

1 Slice bread
Grains1 6–8 1 oz dry cereal2
½ cup cooked rice, pasta, or cereal
1 cup raw leafy vegetable
Vegetables 4–5 ½ cup cut-up raw or cooked vegetable
½ cup vegetable juice
1 medium fruit
¼ cup dried fruit
Fruits 4–5
½ cup fresh, frozen, or canned fruit
½ cup fruit juice
Fat–free or low–fat milk and 1 oz milk or yogurt
2–3
milk products 1 ½ oz cheese
1 oz cooked meats, poultry, or fish
Lean meats, poultry, and fish6 or less
1 egg
1/3 cup or 1 ½ oz nuts
2 Tbsp peanut butter
Nuts, seeds, and legumes 4–5 per week 2 Tbsp or ½ oz seeds
½ cup cooked legumes (dry beans and
peas)
1 tsp soft margarine
1 tsp vegetable oil
Fats and oils 2–3
1 Tbsp mayonnaise
2 Tbsp salad dressing
1 Tbsp sugar
1 Tbsp jelly or jam
Sweets and added sugars 5 or less per week
½ cup sorbet, gelatin
1 cup lemonade
  1. Whole grains are recommended for most grain servings as a good source of fiber and nutrients.
2. Serving sizes vary between ½ cup and 1 ¼ cups, depending on cereal type. Check the product's Nutrition Facts label.

Plant-Based Diet and Kidney Health

Eating more plant-based foods such as vegetables and grains in place of animal-based foods such as red
meat may help prevent and slow the progression of chronic kidney disease, Type 2 diabetes, high blood
pressure, and heart disease.

Nutrition and Transplant

Learn the basics!
 Nutrition and Transplant

After a kidney transplant, your diet will still be an important part of maintaining your overall
health. If you were on dialysis before, you may find that this diet is easier to follow than the one
you followed when you were on dialysis. With a successful kidney transplant your body will be
able to keep a healthy balance the potassium and phosphorus in your body. However, your diet
may be affected by the medicine you need to prevent rejection of your transplant. It will be
important to eat a healthy, balanced diet and exercise regularly to keep you feeling great and
your kidney transplant working well. Be sure to talk with your healthcare practitioner or dietitian
about your individual diet needs. Here's some additional information on diet and nutrition after a
kidney transplant:

 Foods to Avoid After Transplant

 DASH Diet
 Metabolic Syndrome after Kidney Transplant – Are you at risk?
 Sodium and Your CKD Diet: How to Spice Up Your Cooking
 Carbohydrate Counting with Chronic Kidney Disease
 Cholesterol and Chronic Kidney Disease
 Herbal Supplements in Kidney Disease
 Vitamins and Minerals in Kidney Disease
 Good Nutrition: What You Should Know
 Food Labels
 Spice Up Your Diet
 Food Safety is a Must!

Nutrition and Transplant

Learn the basics!
  Nutrition and Transplant

After a kidney transplant, your diet will still be an important part of maintaining your overall
health. If you were on dialysis before, you may find that this diet is easier to follow than the one
you followed when you were on dialysis. With a successful kidney transplant your body will be
able to keep a healthy balance the potassium and phosphorus in your body. However, your diet
may be affected by the medicine you need to prevent rejection of your transplant. It will be
important to eat a healthy, balanced diet and exercise regularly to keep you feeling great and
your kidney transplant working well. Be sure to talk with your healthcare practitioner or dietitian
about your individual diet needs. Here's some additional information on diet and nutrition after a
kidney transplant:

 Foods to Avoid After Transplant

 DASH Diet
 Metabolic Syndrome after Kidney Transplant – Are you at risk?
 Sodium and Your CKD Diet: How to Spice Up Your Cooking
 Carbohydrate Counting with Chronic Kidney Disease
 Cholesterol and Chronic Kidney Disease
 Herbal Supplements in Kidney Disease
 Vitamins and Minerals in Kidney Disease
 Good Nutrition: What You Should Know
 Food Labels
 Spice Up Your Diet
 Food Safety is a Must!
Principle
Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across a
semi-permeable membrane. Diffusion is a property of substances in water; substances in water
tend to move from an area of high concentration to an area of low concentration.[7] Blood flows
by one side of a semi-permeable membrane, and a dialysate, or special dialysis fluid, flows by
the opposite side. A semipermeable membrane is a thin layer of material that contains holes of
various sizes, or pores. Smaller solutes and fluid pass through the membrane, but the membrane
blocks the passage of larger substances (for example, red blood cells, large proteins). This
replicates the filtering process that takes place in the kidneys when the blood enters the kidneys
and the larger substances are separated from the smaller ones in the glomerulus.[7]

Osmosis diffusion ultrafiltration and dialysis

The two main types of dialysis, hemodialysis and peritoneal dialysis, remove wastes and excess
water from the blood in different ways.[1] Hemodialysis removes wastes and water by circulating
blood outside the body through an external filter, called a dialyzer, that contains a semipermeable
membrane. The blood flows in one direction and the dialysate flows in the opposite. The
counter-current flow of the blood and dialysate maximizes the concentration gradient of solutes
between the blood and dialysate, which helps to remove more urea and creatinine from the
blood. The concentrations of solutes normally found in the urine (for example potassium,
phosphorus and urea) are undesirably high in the blood, but low or absent in the dialysis solution,
and constant replacement of the dialysate ensures that the concentration of undesired solutes is
kept low on this side of the membrane. The dialysis solution has levels of minerals like
potassium and calcium that are similar to their natural concentration in healthy blood. For
another solute, bicarbonate, dialysis solution level is set at a slightly higher level than in normal
blood, to encourage diffusion of bicarbonate into the blood, to act as a pH buffer to neutralize the
metabolic acidosis that is often present in these patients. The levels of the components of
dialysate are typically prescribed by a nephrologist according to the needs of the individual
patient.

In peritoneal dialysis, wastes and water are removed from the blood inside the body using the
peritoneum as a natural semipermeable membrane. Wastes and excess water move from the
blood, across the peritoneal membrane and into a special dialysis solution, called dialysate, in the
abdominal cavity.

Types
There are three primary and two secondary types of dialysis: hemodialysis (primary), peritoneal
dialysis (primary), hemofiltration (primary), hemodiafiltration (secondary) and intestinal dialysis
(secondary).

Hemodialysis
Main article: Hemodialysis

In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer,
exposing it to a partially permeable membrane. The dialyzer is composed of thousands of tiny
hollow synthetic fibers. The fiber wall acts as the semipermeable membrane. Blood flows
through the fibers, dialysis solution flows around the outside of the fibers, and water and wastes
move between these two solutions.[8] The cleansed blood is then returned via the circuit back to
the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer
membrane This usually is done by applying a negative pressure to the dialysate compartment of
the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to
dialysate and allows the removal of several litres of excess fluid during a typical 4-hour
treatment. In the United States, hemodialysis treatments are typically given in a dialysis center
three times per week (due in the United States to Medicare reimbursement rules); however, as of
2005 over 2,500 people in the United States are dialyzing at home more frequently for various
treatment lengths.[9] Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a
week, for 6 to 8 hours. This type of hemodialysis is usually called nocturnal daily hemodialysis,
which a study has shown it provides a significant improvement in both small and large molecular
weight clearance and decreases the need for phosphate binders.[10] These frequent long treatments
are often done at home while sleeping, but home dialysis is a flexible modality and schedules can
be changed day to day, week to week. In general, studies show that both increased treatment
length and frequency are clinically beneficial.[11]

Hemo-dialysis was one of the most common procedures performed in U.S. hospitals in 2011,
occurring in 909,000 stays (a rate of 29 stays per 10,000 population).[12]

Peritoneal dialysis

Schematic diagram of peritoneal dialysis

Main article: Peritoneal dialysis

In peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run through a tube
into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal
membrane acts as a partially permeable membrane.

This exchange is repeated 4–5 times per day; automatic systems can run more frequent exchange
cycles overnight. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried
out for a longer period of time the net effect in terms of removal of waste products and of salt
and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the patient,
often without help. This frees patients from the routine of having to go to a dialysis clinic on a
fixed schedule multiple times per week. Peritoneal dialysis can be performed with little to no
specialized equipment (other than bags of fresh dialysate).

Hemofiltration
Main article: Hemofiltration

Continuous veno-venous haemofiltration with pre- and post-dilution (CVVH)

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle.

The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A
pressure gradient is applied; as a result, water moves across the very permeable membrane
rapidly, "dragging" along with it many dissolved substances, including ones with large molecular
weights, which are not cleared as well by hemodialysis. Salts and water lost from the blood
during this process are replaced with a "substitution fluid" that is infused into the extracorporeal
circuit during the treatment.

Hemodiafiltration

Hemodiafiltration is a combination of hemodialysis and hemofiltration, thus used to purify the

blood from toxins when the kidney is not working normally and also used to treat acute kidney
injury (AKI).

Intestinal dialysis

Continuous veno-venous haemodiafiltration (CVVHDF)

In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is
digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is
eliminated in fecal waste.[13][14][15] An alternative approach utilizes the ingestion of 1 to 1.5 liters
of non-absorbable solutions of polyethylene glycol or mannitol every fourth hour.[16]

KIDNEY TRANSPLANTATION

Kidney transplantation is considered the treatment of choice for many people with severe chronic
kidney disease because quality of life and survival (life expectancy) are often better than in
people who are treated with dialysis. However, there is a shortage of organs available for
donation. Many people who are candidates for kidney transplantation are put on a transplant
waiting list and require dialysis until a kidney is available.

A kidney can be transplanted from a relative, an unrelated person (such as a spouse or friend), or
from a person who has died (deceased or cadaver donor); only one kidney is required to survive.
In general, organs from living donors function better and for longer periods of time than those
from donors who are deceased.

Some people with kidney failure are not candidates for a kidney transplant. Older age and severe
heart or vascular disease may mean that it is safer to be treated with dialysis rather than undergo
kidney transplantation. Other conditions that might prevent a person from being eligible for
kidney transplantation include:

●Active or recently treated cancer

●A chronic illness that could lead to death within a few years

●Dementia
●Poorly controlled mental illness

●Severe obesity (a body mass index greater than 40) (calculator 1 and calculator 2)

●Inability to remember to take medications

●Current drug or alcohol abuse

●History of poor compliance with medications or dialysis treatments

●Limited or no health insurance

Some people with human immunodeficiency virus (HIV) infection may be eligible for kidney
transplantation if their disease is well controlled.

People with other medical conditions are evaluated on a case-by-case basis to determine if
kidney transplantation is an option.

Advantages — Kidney transplantation is the treatment of choice for many people with end-stage
kidney disease. A successful kidney transplant can improve your quality of life and reduce your
risk of dying. In addition, people who undergo kidney transplantation do not require hours of
dialysis treatment. Ideally, patients who are eligible to get a kidney transplant do so before ever
starting on dialysis.

Disadvantages — Kidney transplantation is a major surgical procedure that has risks both during
and after the surgery. The risks of the surgery include infection, bleeding, and damage to the
surrounding organs. Even death can occur, although this is very rare.

After kidney transplantation, you will be required to take medications and have frequent
monitoring to minimize the chance of organ rejection; this must continue for your entire lifetime.
The medications can have significant side effects.

HEMODIALYSIS

In hemodialysis, your blood is pumped through a dialysis machine to remove waste products and
excess fluids. You are connected to the dialysis machine using a surgically created path called a
vascular access, also known as a fistula or graft. Sometimes, a catheter inserted into a large vein
in the neck is used for hemodialysis treatments, although it is better to have a fistula or graft.
This allows blood to be removed from the body, circulate through the dialysis machine, and then
return to the body.

Hemodialysis can be done at a dialysis center or at home. When done in a center, it is most
commonly done three times a week and takes between three and five hours per session. In-center
hemodialysis can also be done with an overnight treatment three times per week. Home dialysis
is generally done three to six times per week and takes between 3 and 10 hours per session
(sometimes while sleeping). More detailed information about hemodialysis is available
separately. (See "Patient education: Hemodialysis (Beyond the Basics)".)

Advantages — It seems that neither hemodialysis nor peritoneal dialysis have clear advantages
over the other in terms of survival. The choice between the two types of dialysis is generally
based upon other factors, including your preferences, home supports, and underlying medical
problems. You should begin with the type of dialysis that you and your doctors think is best,
although it is possible to switch to another type as circumstances and preferences change.

Disadvantages — Low blood pressure during treatments is the most common complication of

hemodialysis and can be accompanied by lightheadedness, shortness of breath, abdominal
cramps, nausea, or vomiting. Treatments and preventive measures are available for these
potential problems. In addition, the access can cause a blood stream infection or get clogged up
and need surgery or other procedures to open it up.

Many patients who receive hemodialysis in a center are either unable to work or choose not to
work due to the time required for travel and the dialysis treatments. Sometimes, nighttime
overnight hemodialysis treatments in a dialysis facility may make it easier to both work and have
hemodialysis.

PERITONEAL DIALYSIS

Peritoneal dialysis is typically done at home. To perform peritoneal dialysis, the abdominal
cavity is filled with dialysis fluid (called dialysate) through a catheter (a flexible tube). The
catheter is surgically inserted into the abdomen near the umbilicus (belly button). (See "Patient
education: Peritoneal dialysis (Beyond the Basics)".)

The fluid is held within the abdomen for a prescribed period of time (called a dwell), usually
several hours. The lining of the abdominal cavity (the peritoneal lining) acts as a membrane to
allow excess fluids and waste products to diffuse from the bloodstream into the dialysate. The
used dialysate in the abdomen is then drained out and discarded. The abdominal cavity is then
filled again with fresh dialysate solution. This process is called an exchange.

Peritoneal dialysis treatments may be done by hand four to five times during the day or by using
a machine (called a cycler) while you sleep. Some people use a cycler at night and also do one or
two exchanges during the day.

Advantages — Advantages of peritoneal dialysis compared with hemodialysis include more

uninterrupted time for work, family, and social activities. Many people who use peritoneal
dialysis are able to continue working, at least part time, especially if exchanges are done during
sleep.

Disadvantages — People who use peritoneal dialysis must be able to understand how to set the
equipment up and use their hands to connect and disconnect small tubes. If you cannot do this, a
family or household member may be able to do it.
Disadvantages of peritoneal dialysis include an increased risk of hernia (weakening of the
abdominal muscles) from the pressure of the fluid inside the abdominal cavity. In addition, you
can gain weight, and you have an increased risk of infection at the catheter site or inside the
abdomen (peritonitis), although this is quite rare.

WHICH THERAPY IS BEST FOR ME?

Kidney transplantation is the optimal treatment for most patients who do not have one of the
reasons to be ineligible for transplant that were mentioned above (see 'Kidney transplantation'
above). Patients who are not candidates for kidney transplantation or who must wait for a kidney
can usually be treated with either hemodialysis or peritoneal dialysis.

Choosing between peritoneal dialysis and hemodialysis is a complex decision that is best made
by you, your doctor, and often other family members or caregivers after careful consideration of
a number of important factors.

For example, hemodialysis involves rapid changes of the fluid balance in the body and cannot be
tolerated by some patients. Some patients are not suitable candidates for kidney transplantation,
while others may not have the home supports or abilities needed to do peritoneal dialysis. Your
overall medical condition, personal preferences, and home situation are among the many factors
that should be considered. It is possible to switch from one type of dialysis to the other if
preferences or conditions change over time.