Plant-Based Diets in Kidney Disease
Management
Joan Brookhyser Hogan, RD, CSR, CD
The author is a consulting clinical dietitian in Gig Harbor, Washington.
A
s our awareness of chronic kidney
disease (CKD) rolls over into a
new era of bundling, improved
treatment options, and medicinal
choices, so our knowledge of nutrition and
its impact on disease management also
evolves. For decades, vegetarianism and
kidney disease has been seen as an oil-and-
water amalgamation. Dietitians have been
challenged to align diet recommendations
with vegetarian-type diets. Dietitians may
struggle with concerns that more plant-
based diets would be lacking in protein or
would be high potassium and phosphorus.
However, just as we have advanced in our
understanding of so many aspects of kid-
ney disease, we can now appreciate that a
plant-based diet can work to our patients
advantage and, by learning these advantages,
feel more comfortable with working these
foods into patient meal planning.
Although studies are small, several
support the idea that plant-based diets can
delay the progression of CKD, provide
endothelial protection, control high blood
pressure, and decrease proteinuria.1-10
These days, our dialysis patients seldom
die secondary to high potassium or uremia.
Many of our patients now face the same
diseases as the general population: heart
disease, cancer, and strokes.11 A plant-
based diet provides nutrients that not only
assist in kidney disease management but
also can provide an edge of protection
against costly, debilitating complications.8
Myths of a Plant-Based Diet
Poor-Quality Protein
It is now well documented that a plant-
based diet can provide as high a quality
protein diet as one that is animal based. In
1989 the International Food and Agriculture
Organization (FAO), the World Health
Organization (WHO), and the United
Sates Department of Agriculture (USDA)
adopted the Protein Digestibility-Corrected
DOI: 10.1002/dat.20594
Amino Acid Score (PDCAAS) as the offi-
cial assay for evaluation of protein qual-
ity.12 The PDCAAS takes into account a
proteins essential amino acid composition
corrected for digestibility and referenced
to a 2- to 5-year old human requirement.
This new method of evaluating protein
quality found that many plant proteins pro-
vide high-quality protein suitable to meet
adult requirements.
Too High in Potassium and
Phosphorus
Although animal proteins are lower in phos-
phorus when compared with plant-based pro-
teins, the phosphate in plant proteins is only
50% bioavailable, compared with animal
protein, including milk and cheese, which
is estimated to be 70% bioavailable. This
occurs because many plant-based proteins
are high in phytates, which bind phosphorus
and prevent its absorption.13
In general, the potassium-to-protein
ratio (mEq to mg) in legumes is higher
~7:7) than equal amounts of protein from
animal meats (~4:7). Legumes have the
advantage that they contain other nutrients
that can be of benefit to patients. Through
planning and education, legumes can be
safely included in the renal diet. For those
patients with potassium concerns, higher
potassium plant proteins such as seitan
or tofu can be replaced with nuts or soy
beans. Specific dried cooked beans higher
in potassium content can be replaced with
lower potassium choices. Examples include
navy or soybeans being replaced with lower
potassium beans such as lima or black-eyed
peas. If the patient is on hemodialysis,
lower dialysate potassium concentrations
may also be an option.
Lack of Options and Poor Taste
Plant proteins offer meals with whole
grains, dried cooked beans, soy, nuts and
seeds, and wheat glutenall of which can
add variety and taste to a patients diet.
Often, patients complain about diminished
taste for meats. Plant proteins offer options
that may be more tolerable for taste prefer-
ences. Tofu can adopt the flavor of other
foods and seasonings as well.
What a Plant-Based Diet Has
to Offer
Less Inflammatory Effect with
Anti-oxidant Protection
Patients with CKD are prone to an increase
in advanced glycation end products
(AGEs).14,15 An increase in proinflamma-
tory cytokines occurs.16 Renal patients are
at increased risk for inflammatory diseases
such as cardiovascular disease, atheroscle-
rosis, and stroke. Plant-based diets are a
source of anti-inflammatory components,
and can play a role in combating this
inflammation.16
The oxygen radical absorbance capac-
ity (ORAC) measure was developed by the
National Institutes of Health in the early
1990s. The ORAC score is a measurement
of the antioxidant capacity of food. The
higher the ORAC, the more a food has the
capacity to neutralize free radicals.17
Many fruits and vegetables have high
ORAC scores, but may be limited in a CKD
diet due to potassium content. However,
the diet can be designed to include high
ORAC foods while remaining within potas-
sium guidelines. Items with a high ORAC
include such foods as blueberries, black-
berries, broccoli and cabbage, and several
herbs and spices like cinnamon, rosemary,
tumeric, and pepper.
Preferable Fat Sources and
Increased Dietary Fiber
Animal proteins are sources of saturated fat
and have been associated with vascular dis-
eases. Plant proteins are low in total fat and
offer monounsaturated and polyunsaturated
fats, which have been associated with
cardioprotection. In addition, all animal
September 2011 Dialysis & Transplantation 407
 Plant-Based Diets

SEITAN WITH MARINADE How to Help Your Patient with

Gluten Balls
Plant-Based Food Choices
2 cups high gluten flour In a poll conducted by the Vegetarian
1 c water Resource Group in 2009, it was found that
6 c low sodium vegetable broth 3% of American adults did not eat red meat,
Marinade fish, or poultry, and a third of those did not
eat dairy, eggs, or honey. The same survey
1 tsp red wine vinegar found that 8% of American adults did not
1/2 tsp molasses eat red meat. As a result, the chances of
dash ground pepper having a patient who chooses to eat vege-
dash garlic powder tarian based on preference may be low, and
1/2 cup water a dietician may choose to encourage plant-
1/2 cup virgin olive oil based options for beneficial health reasons.
1/4 cup Dijon mustard This includes preventing the co-morbid
dash hot sauce conditions associated with kidney disease,
kidney disease progression, or possibly
To make the seitan, mix wheat gluten with water and stir until the wheat gluten mixture
becomes a ball. Knead for 5 minutes. Divide the dough into 2 equal balls. kidney disease itself.
The following are ways to add plant
In a large stockpot cover the gluten balls with 6 cups of broth. Bring to a boil and then protein:
turn down the heat and simmer for 1-1/2 to 2 hours. Remove from the heat and set Add cup dried cooked beans to a
aside to cool. Slice the dough into steaks and place in large baking dish.
meal per day. This can be added to a
Place the wine vinegar, molasses, ground pepper, garlic powder, water, olive oil, mustard and salad or soup or mixed into a pasta.
hot sauce in a blender until smooth. Pour over the seitan and marinate for at least 2 hours. Sprinkle cup nuts on salad or in
Slices of seitan can be used as a subsitute for animal meat and grilled over a charcoal cereal.
barbeque, on a stovetop, or even baked. If not used immediately, store the seitan in the Try high-protein grains such as quinoa,
broth in the refrigerator or drain and freeze. amaranth, or barley (see below).
Use tofu in place of cream cheese or
Makes 8 servings.
ricotta cheese in recipes, such as a
Nutritional information per serving: lasagna.
Calories: 150
Replace regular milk with an organic
soymilk.
Protein: 23 g Make a smoothie (see recipe below).
Total fat: <1 g Try seitan, a high-protein alternative
with a meaty taste. It can be replaced
Total carbohydrate: 7g
in any meat dish or sliced in sand-
Sodium: 222 mg wiches. See recipe below.
Potassium: 31 mg Add one low-potassium, high-ORAC
value food per day such as blueberries,
Phosphorus: 78 mg
cranberries, raspberries, or strawberries.
If potassium restriction is not needed,
products are devoid of fiber and the phy- ing butyrate-producing bacteria, which are encourage up to nine servings of fruits
tochemicals known to be protective to the important in maintaining epithelial cell and vegetables per day.
vascular system.18 One cup of whole grain health.20 Plant-based diets are naturally Add two or more healthier herbs to
rice adds 3.5 g of fiber and 5 g protein and high in the pre-biotics that are required for food every day, such as rosemary,
no fat.; cup of dried cooked kidney beans pro-biotic formation. Research has also garlic, oregano, turmeric, or sage.
adds 11 g of fiber and 7.5 g of protein, and found that vegetarians tend to have higher Encourage color. Many low-potassium
no fat. An average ounce of meat contains production of the metabolite equol, which fruits and vegetables are high in anti-
7 g of protein, no fiber, and up to 9 g of increases absorption of the isoflavone daid- oxidants (i.e., cabbage, beets, carrots,
saturated fat. zein found in soy.21 It is speculated that broccoli, peppers, yellow and green
increasing plant-based foods improves zucchini, green peas, broccoli, and
Gastrointestinal Health equol production through the benefits of cauliflower). D&T
Medications, stress, and disease affect the isoflavone content of soy. Soy has been
the gut flora. Since an estimated 70% of associated with many benefits in kidney References
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