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Nutrition Tips For End-Stage Kidney Disease

Nina Ghamrawi, MS, RD, CDE
5
March 25, 2022

If you have end-stage kidney disease, this means that your kidneys are having trouble balancing certain minerals and filtering toxins from digestion. This can lead to loss of calcium from the bones, trouble with your heart rhythm, and severe pain and symptoms that affect your ability to do simple daily tasks. Whether you are on dialysis or not, having a healthy diet and reducing these symptoms may be a challenge. The kidneys are also fragile and complex, making your nutritional needs and diet restrictions vary from one week to the next. Keep reading to learn some great nutrition tips for end-stage kidney disease.

When you are experiencing kidney failure, or end-stage kidney/renal disease (ESRD) your kidneys are no longer able to filter the blood to keep your organs functioning correctly. This is the last stage of kidney disease (stage 5), where your kidneys are typically functioning at or below 10-15% of their typical ability, and the damage to the kidneys is now irreversible. People in stage 5 typically cannot live more than a few weeks without dialysis or a kidney transplant. You should note that when you have ESRD, your diet guidelines may fall into one of the 3 groups:

  1. You are not on dialysis yet.
  2. You are on hemodialysis.
  3. You are getting peritoneal dialysis.

Depending on where you are in your ESRD journey, your dietary restrictions of protein, potassium, and phosphorous may differ drastically.  

Diet Basics For Different Circumstances

If you have kidney disease (stage 3 or above), you are likely already seeing a dietitian, or are speaking with a nephrologist (or kidney specialist), and regularly drawing blood to watch your body’s levels of minerals and other indicators. Talk with your clinical team about how and how much to limit various food groups.

Not On a Dialysis Routine? Getting Peritoneal Dialysis? Getting Hemodialysis?
What’s Going On Your diet will likely be very strict. Your body is having trouble eliminating toxins and minerals from the blood, and your risk of toxicity, severe symptoms, and death is high, until you begin dialysis. While hemodialysis in a clinic every 2-3 days, peritoneal dialysis (PD) is done daily from your home or office. Because of this, the body does not build up as much potassium, sodium and fluid, so for most patients, the PD diet is less strict. Protein requirements are higher because more protein is lost through the peritoneal membrane. Hemodialysis is the technology functioning most similarly to the kidney. But because it is not exact, you will still need to rely on bloodwork to know.
How to Handle the Diet Protein (Keep it Low): 0.6-0.75g/kg body weight.
Minerals: Keep your intake of potassium, phosphorous and sodium low.
Protein (Keep it High): 1.2-1.4g/kg body weight.
Minerals: Intake will vary based on your bloodwork results, but oftentimes is less strict.
Protein (Regular or restricted amounts).
Minerals: Avoid foods high in sodium, potassium, and phosphorous.

Nutritional Food Groups In-Detail

There are 4 common minerals that kidneys must balance: potassium, sodium, phosphorous, and calcium. Apart from these, dietary protein also has a significant effect on the kidneys.

Too much of any of these 4 minerals can cause a backup of minerals in the blood, causing all kinds of symptoms related to mineral imbalance. You may also develop anemia, or low blood iron or B12 levels while on dialysis. While a diet high in minerals can cause an imbalance, too much dietary protein can be toxic. When protein is digested, a main product of digestion is uric acid - this is toxic in high amounts, so the kidneys naturally eliminate it. During end-stage kidney disease, a backup of uric acid can lead to a condition known as uremia, which is toxic, painful, and also deadly.

Protein:

Talk to your renal dietitian to help you know the exact amount depending on your needs.

  • Dietary sources: Protein doesn’t just come from meat. It is also in eggs, fish, shellfish, cheese, yogurt, milk, nuts, beans, and many other foods.
  • Caution: Protein comes from many places! Read all labels, and add it up. Get more protein from high density sources like meat, fish, and eggs, and less protein from plant-based foods. The plant-based foods are often higher in potassium, and require you to eat much more to reach your daily protein need.

Sodium:

  • Dietary sources: Canned foods, canned and frozen meals, cured and processed meats, sauces, salad dressings, pickles, soup stock, breads, cheese, and most spice mixes.
  • Caution: For all patients with kidney disease, the sodium restriction starts with the DASH diet recommendations, around 2300 mg sodium per day. While this is already difficult for most people, some patients may have more strict needs based on their bloodwork and health status. Talk to your doctor about your limit. If you don’t know it, use the above DASH guideline.

Potassium:

In all cases, limit dietary sources of potassium by avoiding foods that have high levels of it. When on dialysis, get regular blood tests to know if you need to further restrict dietary potassium, or add some back. Follow this link for a great article about potassium and its effects on the kidneys, with a complete list of foods containing high, medium, and low amounts of potassium. But for now, here’s a short list of foods to limit

Top Food Sources Highest in Potassium Adapted from the USDA Food Data Central Repository
Beet greens (and most other leafy greens) Salt substitutes and low-sodium foods that contain potassium additives
Avocado, cherimoya Bananas, guava, kiwi, passion fruit, jackfruit, soursop, mamey
Cantaloupe and honeydew Dried fruit
Legumes (beans and lentils) Milk and yogurt
Whole nuts and seeds Oranges and orange juice
Potatoes, yams, taro Pumpkin, acorn, and winter squash
Fish: Salmon, Snapper, Mahi-mahi, tilapia Tomato products (juices, sauces, paste)

Phosphorous:

Avoid foods below that are high phosphorous when you have ESRD and are not on dialysis, or if you are on dialysis and your doctor recommends to avoid them. Also read labels carefully, because finding added phosphorous is tricky: usually words in the ingredients list with “…phos…” in the name will be foods you should avoid.

Top Food Sources Highest in Phosphorous Adapted from the USDA Food Data Central Repository
Seafood: Clams, tuna (yellowfin), salmon, mackerel, haddock, shrimp, oysters Certain types of meats- pork chops, lean cured ham, pork tenderloin, pork ribs, chicken breast, lean ground turkey, beef skirt steak
Cheese Chocolate
Ice cream Legumes
Milk and yogurt Nuts and seeds
Soybeans, tofu
  • Caution: While many of the foods in this list are high phosphorous and may need to be avoided, some of them are also low potassium, or high in good quality protein. For most with ESRD, they can alternate between a low potassium and low phosphorous diet depending on their blood tests, and don’t always need to restrict both. This can seem confusing and contradictory, but that’s what makes the diet for kidney disease so complicated.

Takeaways

Talk with your renal dietitian or kidney specialist  to help you understand your bloodwork results, and manage the confusing changes in your dietary restrictions.