Module 5:

The Transition from Chronic Kidney

Disease (CKD) to Kidney Failure
The Diet Changes as CKD Develops and
Progresses to Kidney Failure
This professional development opportunity was created by the National Kidney Disease Education Program
(NKDEP), an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases of the
National Institutes of Health. With the goal of reducing the burden of chronic kidney disease (CKD),
especially among communities most impacted by the disease, NKDEP works in collaboration with a range
of government, nonprofit, and health care organizations to:
•raise awareness among people at risk for CKD about the need for testing;
•educate people with CKD about how to manage their disease;
•provide information, training, and tools to help health care providers better detect and treat CKD; and
•support health system change to facilitate effective CKD detection and management.

To learn more about NKDEP, please visit: http://www.nkdep.nih.gov. For additional materials from
NIDDK, please visit: http://www.niddk.nih.gov.

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 Meet our Presenters
Theresa A. Kuracina, M.S., R.D., C.D.E., L.N.

Ms. Kuracina is the lead author of the Academy of Nutrition and Dietetics’ CKD
Nutrition Management Training Certificate Program and NKDEP’s nutrition
resources for managing patients with CKD.

Ms. Kuracina has more than 25 years of clinical dietetics experience focused on
diabetes and CKD with the Indian Health Service (IHS). Until her retirement in 2017,
she served as a co-coordinator for a diabetes self-management education program at
the IHS Albuquerque Indian Health Center in New Mexico. For more than 9 years,
she has supported NKDEP with expertise regarding medical nutrition therapy for
diabetes and CKD patients, first as a member of the NKDEP’s Coordinating Panel
and more recently as a senior clinical consultant for the Program.

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 Meet our Presenters
Andrew S. Narva, M.D., F.A.C.P.

Dr. Narva is the Director of the National Kidney Disease Education Program
(NKDEP) at the National Institutes of Health. Prior to joining the NKDEP in 2006, he
served as Director of the Kidney Disease Program for the Indian Health Service
(IHS). Dr. Narva continues to serve as the Chief Clinical Consultant for Nephrology
for IHS and to provide care for patients at Zuni Pueblo through a telemedicine clinic.
Dr. Narva is a member of the American Board of Internal Medicine Nephrology
Subspecialty Board. He has served as a member of the Eighth Joint National
Committee (JNC 8) Expert Panel, the National Quality Forum Renal Steering
Committee, the Kidney Disease Outcomes Quality Initiative Work Group on Diabetes
in Chronic Kidney Disease, and the Medical Review Board of End Stage Renal
Disease Network 15.

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 Participants will be able to:

1. Identify the four treatment options for kidney failure.

2. Differentiate between the diet recommendations for

hemodialysis and peritoneal dialysis.

3. Associate intestinal dysbiosis in kidney disease as a factor

for inflammation in this population.

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An informed patient is better prepared
• Education may help patients to be successful in their self-
management efforts.

• People with kidney disease may see many providers.

Consistent messages are less confusing.

• You may not feel comfortable discussing treatment options,

however, they may ask you questions about the diet changes.

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Kidney disease education is a Medicare benefit

• Covers up to 6 sessions

• eGFR < 30

• Medicare Part B

• Requires referral like MNT

• Individual pays 20%, deductible applies

https://www.medicare.gov/Pubs/pdf/11454.pdf

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The topics include many of the ones
you already know about

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RENAL REPLACEMENT
THERAPY

Options

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Four options for treating kidney failure

• Renal replacement therapy (RRT)

1. Hemodialysis
 In-center or home, three times a week or more frequently
2. Peritoneal dialysis
 Daily, at home
3. Kidney transplantation

• No RRT
4. Supportive Care
 Active medical management

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Trends in ESRD prevalence by modality, 1996-2014

USRDS 2016

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Almost 90% of people initiating renal replacement
therapy start on hemodialysis
Trends in ESRD incidence by modality, 1999-2014

USRDS 2016

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Most people are not prepared for kidney failure
• People who are not prepared and need treatment do not
have much choice. They may start hemodialysis using a
temporary vascular access (catheter).

• In 2014, more than 80% of people started hemodialysis

with a temporary vascular access.

• Discuss treatment choices early with progressive kidney

disease.

• “Early” depends on the eGFR and the rate of decline.

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Coping with kidney disease and failure is challenging
• “I feel fine.”
 The signs and symptoms may not be obvious until kidney disease is
advanced.

• “Why me?”
 Acceptance of any chronic illness including kidney disease takes
time for most people.
 Kidney disease may progress to kidney failure.

• Kidney “failure” or “end stage renal disease” sound scary.

 Grief, fear and depression are not uncommon.

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Dialysis involves diffusion of substances across a
semipermeable membrane
• Hemodialysis uses a dialyzer (artificial
kidney) as the membrane.

• Peritoneal dialysis uses the peritoneum as the

membrane.

• Substances diffuse down a gradient from

high to low concentrations and are removed.

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 Types of dialysis
HEMODIALYSIS (HD) Typical schedule
Traditional hemodialysis (in-center) 3-5 hours
3 days per week
Standard home hemodialysis 3-5 hours
3 days per week (or every other day)
Extended hours hemodialysis 6-10 hours
3-6 nights per week
Short daily hemodialysis 2.5-4 hours
5-7 days per week
PERITONEAL DIALYSIS (PD) Continuous
Continuous cycler-assisted (CCPD) Cycler is programmed to perform 3 to
5 exchanges during the night.
•Must know how to do manual
exchanges
Continuous ambulatory (CAPD) 4 to 6 exchanges per day (manual)

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Dialysis replaces only a fraction of
normal kidney function

• A normal kidney works “24/7.”

• Damaged kidneys (in CKD) still work

nonstop but at a reduced level.

• Hemodialysis is an intermittent treatment;

blood is filtered only during dialysis.

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Hemodialysis

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A vascular access is needed for hemodialysis

• Temporary access is usually a catheter placed in a

central vein.

• Permanent access types include arteriovenous (AV)

fistula or graft.

• Access is usually placed in the non-dominant arm.

• Protect blood vessels in both arms; avoid

venipuncture and IV catheter placement above the
wrist.

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An AV fistula is the preferred access

• The artery is connected to a vein.

• A fistula takes 2 to 3 months to mature
before it can be used. During maturation,
the vein dilates and thickens.
• A fistula is less likely to become infected
or clot, and provides better blood flow
rates.

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An AV graft is another option

• A synthetic tube connects the

artery and vein.
• A graft takes 2 to 3 weeks before it
can be used.
• Grafts are more likely to become
infected or clot than fistulas.

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Temporary access use should be minimized

• A venous catheter is inserted into a vein

in the neck, chest, or leg near the groin,
for short-term dialysis.
• This is only option when patient is not
prepared and needs immediate
hemodialysis.
• Catheters increase risk of infection,
clotting, and inadequate dialysis.
Catheter for temporary access
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The dialyzer is the artificial kidney

• Removal is based on size.

• Protein-bound substances are not usually removed.
• Amino acids are small enough to be dialyzed out
of the blood.
• Glucose is removed.
• Water-soluble vitamins are removed to some
degree.

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The hemodialysis prescription is individualized
• The goal is to achieve metabolic balance.
• Adequate dialysis depends on numerous factors
including:
 Type and size of the dialyzer
 Blood flow rate
 Dialysate composition (similar to normal serum levels)
 Sodium, potassium, calcium, bicarbonate
 Time

• Individual patient factors such as body size and diet.

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Home hemodialysis allows people do longer
or more frequent dialysis

• Increased dialysis allows a more normal

diet and fluid intake.

• Most dialysis centers require a trained

partner at home during treatment.

• Partner burn-out may be an issue.

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Peritoneal dialysis (PD) options
• PD requires surgery for catheter placement.

• PD is a continuous therapy providing a “steady state”

which may be better tolerated than intermittent
hemodialysis.

• Continuous ambulatory peritoneal dialysis (CAPD)

is done manually.

• Continuous cycler-assisted peritoneal dialysis

(CCPD) is automated.
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The peritoneal membrane is the semipermeable
“filter” in PD
• Dextrose is the most common osmotic
agent used in the dialysate.
• Osmotic gradient helps move water into
the peritoneal cavity.

• Clearance affected by:

 Concentration gradient
 Size
 Permeability of the peritoneal membrane

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The peritoneal dialysis exchange

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 PD prescription is individualized

• Dextrose solutions are used as osmotic agent.

 1.25%, 2.5%, 4.25% concentrations

• Exchanges are 2–3 liters in volume.

• Dwell time and number of exchanges vary

depending on peritoneal membrane
characteristics.

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CAPD requires 4 or more manual exchanges per day

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The cycler does 3–5 automated exchanges during the
night in CCPD

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Calories count in dextrose solutions
• Dextrose concentrations vary
 1.25%, 2.5%, 4.25%

• Bag sizes vary

 2-liter, 2.5-liter, 3-liter

• In CAPD, 60–70% is absorbed. The amount is

higher due to longer dwell times.

• In CCPD, 40–50% is absorbed.

Reference: McCann, 2009

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 Estimate of calories from CAPD
• Four exchanges of 2-liter bags with 1.5% dextrose
= 8 liters of 1.5% dextrose (grams dextrose/liter)
= 120 grams of dextrose

• 3.4 kcal/gram of dextrose

(120 grams of dextrose) x 3.4 = 408 calories

• 60–70% absorbed

• Total of about 250–290 calories are absorbed/day

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Kidney transplantation is a treatment, not a cure

• A deceased or living donor kidney is required.

• The transplant workup takes time; eligibility is

strict.

• Requires major surgery.

• Need to take medications daily, including anti-

rejection medication.

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A transplanted kidney is placed in the groin area

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A kidney transplant from a living donor may be better
than other treatments
Number (out of 100) alive at the end of time period by treatment

Preparing for Kidney Treatment You Have a Choice:

http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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Anti-rejection medications should be taken every day –
and may have side effects
Prednisone Mycophenolate Azathioprine

Weight gain Decreased blood counts Stomach upset

Hyperglycemia Diarrhea Muscle pain
Hypertension Upset stomach
Hyperlipidemia
Mood changes
Osteoporosis
Poor wound healing

High doses may be prescribed Take on a regular schedule 1 Take once or twice a day
right after the transplant hour before or 2 hours after after meals, about the same
occurs; dose may be reduced eating or drinking, about 12 time every day.
over time. hours apart.

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A few more anti-rejection medications
Tacrolimus Sirolimus Cyclosporine

Hyperglycemia Swelling Hypertension

Hypertension Hyperlipidemia Hyperlipidemia
Tremors, headaches Poor wound healing Tremors, headaches
Diarrhea Proteinuria Excess gum growth
Hair loss Excess hair growth
Trouble sleeping Hyperkalemia
Hyperkalemia Kidney toxicity
Hypophosphatemia
Kidney toxicity

Take on an empty stomach Take once a day, take it the Take on a regular schedule at
and regular schedule daily. same way, with or without the same time each day.
food.
Do not eat grapefruit or drink Do not take with grapefruit Do not eat grapefruit or drink
grapefruit juice. juice. grapefruit juice.

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The risk factors for new onset diabetes after
a kidney transplant include:
• Older age
• Ethnicity
 African Americans and Hispanics > Whites
• Family history of diabetes
• Weight
• Positive Hepatitis C
• Immunosuppressant medication
 Corticosteroids (prednisone)
 Tacrolimus > cyclosporine

• Remember: Medicare covers MNT for a period of 36

months post-transplant.
Ghisdal et al, Diabetes Care 2012:35:181-188

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Nutrition prescription: Transplant

• Transplant is a treatment, not a cure.

• May need a sodium restriction.

• May need to reduce calories to avoid weight gain.

• Food safety is very important.

• Medications may increase weight gain.

• Diabetes may be more difficult to manage.

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Supportive Care is active medical
management with no RRT

• Choosing whether to start RRT is the patient’s decision.

• Encourage patient to inform family.

• Without RRT, uremic toxins accumulate.

• Complications can be treated.

• Provide comfort and palliative care.

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CHOOSING A MODALITY

A brief look

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 Choosing a modality:
In-center hemodialysis
May be a choice for someone who:

•Can travel to a dialysis center 3 times a week for scheduled

treatments.

•Prefers trained staff to handle their treatments.

•Does not mind needle sticks.
•Is willing to follow a diet that includes numerous restrictions.
Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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 Choosing a modality:
Home hemodialysis
May be a choice for someone who:
•Wants to do their treatments at home.
•Has someone who is willing to be trained to help
them with treatments at home.
•Is willing to do treatments most days of the week.
•Has room for the machine and to store the supplies.
•Does not mind needle sticks and self-cannulation.
Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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Choosing a modality: Peritoneal dialysis
May be a choice for someone who:
•Has no contraindicating abdominal pathology.
•Wants to do their own treatments at home.
•Is willing to do treatments every day.
•Has room to store supplies at home.
CONSIDER:
•Diabetes may be harder to control due to the dextrose in
the dialysate.
•Body-image can be an issue for some. Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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Intra-peritoneal insulin may be an option

• Insulin is absorbed into the portal vein and the liver is

exposed to higher insulin levels than the periphery.
• Insulin may be injected into the bags of PD solution.
• The required dose may double or triple.
• Some insulin adheres to the bag and tubing.
• Lipids may be harder to control.

Diabetes, Obesity and Metabolism, 2008

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 Choosing a modality: Kidney transplant
May be a choice for someone who:
•Is healthy enough for surgery that can last up to 4 hours.
•Has a living donor or can wait for a deceased donor kidney.
•Is willing to take anti-rejection medications every day for the rest
of their life.
•Understands that they will still need regular check-ups.
Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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People on RRT who have diabetes still need
comprehensive diabetes care
• Often people on dialysis or who have a transplant consider
their nephrologist to be their only doctor. They may not see
their primary care provider routinely.

• Keep in mind: They still need to have their eyes, feet, heart,
nerves, gums and teeth checked.

• As you educate them about the diet and treatment choices,

review the need for ongoing diabetes care.

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 The numbers can be improved
• In 2015, 34% of people with ESRD and diabetes received
comprehensive diabetes monitoring which included an
hemoglobin A1C, lipid test and a dilated eye exam

• 86.5% had at least one hemoglobin A1C test

• 71.8% had a lipid test

• 46.9% had a dilated eye exam

• In 2014-2015 flu season, about 72% had a flu shot USRDS 2017

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Supportive Care without dialysis or transplant
may be the choice for an individual who:

• Feels treatment will not improve their health.

• Feels they have done what they wanted to do

in life.
• Has family and friends who are in support of
this decision.
Preparing for Kidney Treatment You Have a Choice
http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/index.html

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 THE DIET

Discussing the options

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In-center hemodialysis is three times a week for
3 to 5 hours, leads to wider fluctuations

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Diet for home hemo may be more liberal due to
increased frequency of treatments

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PD is a continuous therapy – diet is a little more liberal

Dextrose in
dialysate
adds
calories

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Potassium restriction may be biggest difference
between HD and PD diets
Hemodialysis Peritoneal dialysis (PD)
(HD)
Calories (kcal/kg) INCLUDE dialysate calories
< Age 60 35 35
> Age 60 30 – 35 30 – 35

Protein (g/kg) 1.2 1.2 – 1.3

Sodium (mg per day) 2,300 2,300
Potassium (mg per day) < 2,400 3,000 – 4,000
adjust based on labs
Phosphorus (mg per day) 800 – 1,000 800 – 1,000
Fluids (cc per day) Urine output plus Urine output plus 1,000 cc
1000 cc
Calcium (mg per day) < 2,000 < 2,000
INCLUDE calcium-based binders NCM

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Complications continue into kidney failure
Fewer nephrons lead to Complication Evidenced by
Inadequate erythropoietin Anemia Low hemoglobin
Reduced urinary excretion of Hyperkalemia High potassium
potassium
Reduced urinary excretion of Metabolic acidosis Low serum bicarbonate
hydrogen ion
Inadequate activation of Bone disorders, soft • Low 25(OH) Vit D
vitamin D tissue and vascular • High serum
calcification phosphorus
• Abnormal calcium
• Abnormal parathyroid
hormone (PTH)

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 Complications and interventions

Complication Interventions may include:

Anemia • Erythropoiesis-stimulating agents
• Intravenous or subcutaneous iron
• Iron-based phosphate binders may impact iron levels.
• Ferric pyrophosphate citrate may be in HD dialysate.
Potassium • Hyperkalemia (hemodialysis) and hypokalemia
(peritoneal dialysis) are risk factors for mortality.
• Hemodialysis usually requires potassium restriction.
• Home hemodialysis may allow more liberal intake.
• Peritoneal dialysis means more liberal intake.

Metabolic acidosis • Dialysis treatments manage acid-base balance.

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 Complications and interventions
Complication Base interventions on serial assessments of phosphate, calcium, and
PTH levels (not the Ca x P product)
Mineral and • Phosphorus restriction may be prescribed for hyperphosphatemia.
bone disorders • Phosphate binders may be prescribed. Calcium-based binders
increase calcium load and their use may increase risk of vascular
calcification.
• Vitamin D (calcitriol) or vitamin D analogs may be prescribed to
correct deficiency.
• Use may decrease PTH, but may increase serum phosphate
and calcium levels.
• A calcimimetic may be prescribed to inhibit PTH secretion(targets
calcium-sensing receptors in the parathyroid gland).

References: Melamed & Thadhani. Clin J Am Soc Nephrol 2012;7:358-365

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Clinical Indicators, 2016

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 Dialysis removes some phosphorus
Modality Phosphate removal Phosphate removal per
per session week
Hemodialysis 600-1,200 mg 1,800-3,600 mg
(in-center)
Nocturnal hemodialysis 600-1,200 mg 3,000-8,400 mg

Short daily hemodialysis Variable

Peritoneal dialysis 300-360 mg/day 2,100-2,520 mg

For comparison
NHANES data for average phosphorus intake: Men ≈1,600 mg day (range 1381-1747)
1,600 x 7 days = 11,200 mg phosphorus per week
Adapted from: Waheed et al. Neprhrol Dial Transplant 2013; 28:2961-2968;
USDA What We Eat in America, NHANES 2013-2014.
If 60% is bioavailable = 6,720 mg phosphorus per week
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Most protein-rich foods have phosphorus;
egg white is the exception
Food Amount P (mg)
Meat 1 ounce 65 More typical intake
6 ounces steak
Poultry 1 ounce 60
 390 mg phosphorus
Fish 1 ounce 73
Beans & peas 1/2 c. cooked 67 1 cup beans
 240 mg phosphorus
Egg 1 large 86
Phytates reduce absorption
Egg white* 1 large 5 Still high potassium
Nuts/seeds 1 ounce 65
2 egg whites
Milk/dairy 1 cup 232
 10 mg phosphorus
Soy products 1 ounce 103

https://www.cnpp.usda.gov/sites/default/files/usda_food_patterns/NutrientProfiles.pdf

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Take phosphate-binders with meals
TYPE EXAMPLES Other consideration
Calcium-based Calcium carbonate Soft tissue and vascular calcification
▪500 mg Ca/1,250 mg tablet may be a concern long-term.
Calcium acetate
▪169 mg Ca/667 mg capsule

Resin-based Sevalemer hydrochloride HCl may add to acid load.

Sevalemer bicarbonate
Rare earth metal- Lanthanum carbonate • Chew or crush tablet.
based • Mix powder with food, do not
dissolve in liquid.

Iron-based Sucroferric oxyhydroxide Limited impact on iron status.

≈ 500 mg iron/2,500 mg tab.
Monitor iron levels
Ferric citrate Increased risk of iron overload.
≈ 210 mg iron/tablet
Reference: Gutenkunst, JRN 2016;26(4):209-218

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Healthy Eating Patterns
• Colorful vegetables

• Whole fruit

• Whole grains (half)

• A variety of proteins

• Low-fat or non-fat dairy or substitute

• Oils

• Limit sodium, saturated and trans fats, sugars

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Tips for eating healthy in dialysis
• Prepare foods from scratch.

• Choose foods without food additives.

• Prepare foods without salt and if needed, add a small amount at the
table.

• Use liquid vegetable oil instead of solid fat.

• Eat protein-rich food with every meal.

• If serum potassium is high, use rice or noodles not potatoes

(hemodialysis).
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 For people who need to limit
potassium, the new label includes
potassium (in milligrams).

https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocume
ntsRegulatoryInformation/LabelingNutrition/ucm385663.htm
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Intestinal dysbiosis and kidney failure
• The composition of the microbiota may be altered in CKD and ESRD.
• Undigested proteins may enter the intestines leading to an increase in
proteolytic bacteria.
• Proteolytic bacteria ferment the protein and generate uremic toxins.
• Uremia leads to an influx of urea into the GI tract.
• Bacteria which have urease ferment urea into ammonia leading to increased
breath ammonia.
• People with CKD may have fewer saccharolytic bacteria due to reduced fiber
intake. These types ferment dietary fiber into short chain fatty acids.
References: Ramezani & Raj. J Am Soc Nephrol. 2014;25:657-670.
Ramezani et al. Am J Kidney Dis 2016;67:483-498.

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Dysbiosis and impaired intestinal barrier may be a
factor for systemic inflammation
• Colonic bacteria are the main source of pro-
inflammatory uremic toxins.

• The intestinal barrier may be altered in uremia.

• Increased intestinal permeability may allow uremic

toxins such as endotoxin to enter the bloodstream.

• Circulating endotoxin may activate pro-

inflammatory cytokine production.
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Other factors that may mediate systemic
inflammation in ESRD
• Accumulation of pro-inflammatory oxidized LDL coupled with HDL
deficiency

• Higher numbers of monocytes which produce cytokines and reactive

oxygen species (ROS)

• Impaired inhibitory activity of T lymphocytes

• Iron overload via intravenous iron

• Inflammatory cytokines may directly suppress appetite in peritoneal

dialysis.
Reference: Vaziri Semin Nephrol. 2016:36:112-118.

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 The food groups with fiber

• Vegetables and fruit vary in potassium content.

• Boiling potatoes and tubers removes enough potassium.

Leaching, or soaking, in water is not required.

• Legumes are rich in protein, potassium and phosphorus

(and have the most fiber).

• Canned items tend to be lower in potassium as potassium

leaches out into the liquid.
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Preparation impacts potassium in vegetables
Generally speaking, potassium contents vary, when cooking:
•Canned < boiled < baked or roasted
•Frozen boiled < fresh boiled
•Boiled < microwaved
•Smaller pieces < larger pieces (chopped vs. spears)

Generally speaking, for raw vegetables:

•Smaller pieces < larger pieces (grated vs. chopped)
•Juice has more based on comparable serving size (also counts as fluid)

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 Tips for vegetables and hyperkalemia
• Choose lower potassium vegetables.
• Buy frozen vegetables without added sauces.
 Some frozen Asian stir fry mixes may have added soy sauce.
• Boil vegetables instead of microwaving them.
• Choose no-added salt canned vegetables, drain and rinse.
• Drain and rinse regular canned vegetables to lower sodium (and maybe some potassium).
• Top sandwiches with veggies such as green leaf lettuce, sliced cucumbers, grated carrots,
and others.
• Add grated carrots and zucchini to meatloaf or meatballs.
• Top tacos with green cabbage and lettuce.
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 Tips for fruit and hyperkalemia
• Choose lower potassium fruit.
• If a higher potassium fruit is preferred, eat a small amount.
• Canned fruits have less potassium than fresh. Drain and
rinse.
• Dried fruit has more potassium than fresh or canned.
• Use peeled fruit for fruit salad.
• Although the fruit “nectars” are lower in potassium, they
have added sugar and are low in fiber.
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 Whole grains
• Whole grains have more potassium and phosphorus.

• Cereal and bread may be a source of sodium.

• Convenience or instant-type items may have sodium or other

additives.

• Use the Nutrition Facts labels to compare products and choose the
ones with less sodium.

• Phosphorus in whole grain yeast bread may be more bioavailable

due to the phytase in the yeast.
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 Plant-based food groups and minerals
Food Sodium Phosphorus Potassium
Vegetables Regular canned > no Dried beans and peas >> Fresh > frozen > canned
added salt, fresh or most other types
frozen (no sauce)
* Read labels to compare brands Pickled have more
Fruit Very little Very little Fresh > frozen > canned
↑ means higher amounts

Grains Instant* > regular Oat > corn, rice, wheat Oat > corn, rice, wheat
Whole > refined
Cereal Varies, read the label Bran > refined Bran > refined
Fortified* > unfortified

Bread Varies, read the label Corn > wheat Whole wheat > white

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 The food groups without fiber
• Meat, poultry, and fish contribute to potassium and phosphorus intake.

• Use items that are not canned or enhanced or have added solution
(sodium).

• Dairy foods are high in sodium, protein, phosphorus, potassium, and

fluid (milk).

• Use foods without food additives, if possible.

• Use liquid oils instead of solid fats in food preparation.

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 Minerals in protein foods
Food Sodium Phosphorus Potassium
Meat Canned > fresh Avoid “enhanced” products Stewed < baked or fried
Processed ↑, deli ↑ (Na and P)

Poultry Canned > fresh Avoid added solution or broth Stewed < baked or fried
* Read labels to compare brands Avoid added solution

↑ means higher amounts Fish Canned > fresh Contributes to intake Contributes to intake
Ready to heat > fresh

Egg Egg white < egg sub. Egg white < egg sub. Egg white < egg sub.

Soy Fermented tofu > tofu Tofu >> fermented tofu Tofu >> fermented tofu
Convenience items ↑*

Nuts and Salted > lightly salted > Contributes to intake Contributes to intake
seeds unsalted

Milk Protein fortified ↑ Protein fortified ↑ Protein fortified ↑

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 Eating out and kidney disease

• Restaurants and fast foods tend to be higher in sodium.

• Salad dressing portions tend to be large.

• Smaller, single items are still high in sodium.

• Double meat means more sodium, phosphorus and

potassium.

• Some items have PHOS additives.

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Processed and fast foods may have more additives
Breakfast Amount P (mg) K (mg) Na (mg)

Pancake, plain, prepared from recipe 4 inch 60 50 167

Pancake, white flour, complete 4 inch 127 66 239

Pancake, whole-wheat, incomplete 4 inch 164 123 252

Hotcake (fast food) One (of 3) 129 86 178

Egg, white, raw, fresh 1 large 5 54 55

Egg, whole, hard boiled 1 large 86 63 62
Egg substitute, liquid or frozen, fat-free ¼ cup 43 128 119
Scrambled egg (fast food) One (of 2) 133 71 98

Reference: http://www.nal.usda.gov/fnic/foodcomp/search/

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Enhanced and fortified foods may have phosphorus,
potassium and sodium
Amount P (mg) K (mg) Na (mg)
Pork, tenderloin, roasted 100 g 267 421 57
(3 oz.) 227 358 48
Pork, enhanced tenderloin, roasted 100 g 316 567 231

Soymilk, original and vanilla, unfortified 1 cup 126 287 124

Soymilk, all flavors, fortified with calcium 1 cup 151 156 90

Soymilk, chocolate, unfortified 1 cup 124 347 129

Orange juice ½ c. 21 248 1
Orange juice, fortified with calcium * ½ c. 59 * 222 2

* Phosphorus content varies among brands, depending upon calcium

compound used (calcium phosphate, calcium citrate, etc.).

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Check the nutrition apps you recommend

• Do they include:
 fiber content?

 potassium content?

 phosphorus content?

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 Summary: Treatment options
• Discuss the options early to allow time for the patient to adjust and make a
decision.

• The diet will change with dialysis, more protein is needed to replace the losses.
• Hemodialysis has the most restrictive diet.
• Peritoneal dialysis calories add up.
• Transplant requires daily immunosuppressant medication.
• All the options—including supportive care—still require medications.
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 And last…

BUT NOT LEAST

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What about physical activity and exercise?
• People with kidney disease tend to be less active and have reduced physical
functioning and performance.
• Physical inactivity is associated with increased mortality in both CKD and
kidney failure.
• Results from studies about exercise training and dialysis patients suggest this
training may reduce CVD risk.
• Although data is limited, recommending activity may be beneficial.
• Obtain clearance from the primary care provider.
• Hypoglycemia may develop, counsel appropriately.
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 OTHER RESOURCES

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 NIDDK links for kidney failure (patients)
Kidney Failure
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure
Choosing a Treatment for Kidney Failure
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/
choosing-treatment

Hemodialysis
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/
hemodialysis
Home Hemodialysis
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/
hemodialysis/home-hemodialysis
Eating & Nutrition for Hemodialysis
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/
hemodialysis/eating-nutrition
https://www.niddk.nih.gov/health-information/kidney-disease

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 NIDDK links for kidney failure (patients)
Peritoneal Dialysis
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-
failure/peritoneal-dialysis

Kidney Transplant
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-
failure/kidney-transplant

Financial Help for Treatment of Kidney Failure

https://www.niddk.nih.gov/health-information/kidney-disease/kidney-
failure/financial-help-treatment

https://www.niddk.nih.gov/health-information/kidney-disease

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 Reference: http://nkdep.nih.gov/resources.shtml

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Slide 88 of 93
 References
Ghisdal L, Van Laecke S, Abramowicz MJ, Vanholder R, Ambramowicz D. New-onset diabetes after renal transplantation.
Diabetes Care. 2012;35:181–188.

Hanafusa N, Tessema Lodebo B, Kopple JD. Current uses of dietary therapy for patients with far-advanced CKD. Clinical Journal
of the American Society of Nephrology. 2017; 12(7):1190–1195.

Handelman GJ, Levin NW. Guidelines for vitamin supplements in chronic kidney disease patients: what is the evidence?
Journal of Renal Nutrition. 2011;21(1):117–119.

Ikizler TA. Optimal nutrition in hemodialysis patients. Advances in Chronic Kidney Disease. 2013;20(2):181–189.

Johansen KL, Painter P. Exercise in individuals with CKD. American Journal of Kidney Diseases. 2011;59(1):126–134

Karaboyas A, Zee J, Brunelli SM, et al. Dialysate potassium, serum potassium, mortality, and arrhythmia events in hemodialysis:
results for the dialysis outcomes and practice patterns study (DOPPS). American Journal of Kidney Diseases.
2016;69(2):266–277.
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 References
Malliputtu SK, He JC, Uribarri J. Role of advanced glycation endproducts and potential therapeutic interventions in dialysis patients.
Seminars in Dialysis. 2012;25(5):529–538.

Melamed ML, Thadhani RI. Vitamin D therapy in chronic kidney disease and end stage renal disease. Clinical Journal of the American
Society of Nephrology. 2012; 7:358–365.

Nakanishi T, Hasuike Y, Nanami M, Yahiro M, Kuragano T. Novel iron-containing phosphate binders and anemia treatment in CKD: oral
iron intake revisited. Nephrology Dialysis Transplantation. 2016; 31:1588–1594.

Pluznick JL. Gut microbiota in renal physiology: focus on short-chain fatty acids and their receptors. Kidney International. 2016;
90:1191–1198.

Preparing for Kidney Treatment: You have a choice. http://ckddecisions.org/wp-content/themes/jhm/flipbook/Prepared2/HTML/files/

assets/basic-html/page1.html Accessed October 14, 2017

Ramezani A, Massy ZA, Meijers B, Evenepoel P, Vanholder R, Raj DS. Role of the gut microbiome in uremia: a potential therapeutic
target. American Journal of Kidney Diseases. 2016;67(3):483–498.

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 References
Ramezani A, Raj DS. The gut microbiome, kidney disease, and targeted interventions. Journal of the American Society of Nephrology.
2014;25:657–670.

Ritter CS, Slatopolsky E. Phosphate toxicity in CKD: the killer among us. Clinical Journal of the American Society of Nephrology.
2016;11:1088–1100.

Sirich TL. Dietary protein and fiber in end stage renal disease. Seminars in Dialysis. 2015;28(1):75–80.

Torlen K, Kalantar-Zadeh K, Molnar MZ, Vashistha T, Mehrotra R. Serum potassium and cause-specific mortality in a large peritoneal
dialysis cohort. Clinical Journal of the American Society of Nephrology. 2012;7:1272–1284.

U.S. Department of Agriculture, Agricultural Research Service. 2017. Total Nutrient Intakes: Percent Reporting and Mean Amounts of
Selected Vitamins and Minerals from Food and Beverages and Dietary Supplements by Gender and Age, What We Eat in America,
NHANES 2013-2014. www.ars.usda.gov/nea/bhnrc/fsrg Accessed December 5, 2017

United States Department of Agriculture Center for Nutrition Policy and Promotion. USDA Food Patterns.
https://www.cnpp.usda.gov/sites/default/files/usda_food_patterns/NutrientProfiles.pdf

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 References
U.S. Department of Health and Human Services. Centers for Medicare & Medicaid Services.  Your Medicare Coverage: Kidney
disease education. Available from:  https://www.medicare.gov/coverage/kidney-disease-edu.html
Accessed June 22, 2018

United States Renal Data System. 2016 USRDS annual data report: Epidemiology of kidney disease in the United States. National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2016. U.S. Renal
Data System website. https://www.usrds.org/2016/view/Default.aspx Accessed June 21, 2017.

Vaziri ND. Safety issues in iron treatment in CKD. Seminars in Nephrology. 2016;36:112–118.

Vaziri ND, Zhoa Y, Pahl MV. Altered intestinal microbial flora and impaired epithelial barrier structure and function in CKD: the
nature, mechanisms, consequences and potential treatment. Nephrology Dialysis Transplantation. 2016;31:737-746.

Waheed AA, Pedraza F, Lenz O, Isokova T. Phosphate control in end-stage renal disease: barriers and opportunities. Nephrology
Dialysis Transplantation. 2013; 28:2961-2968.

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 Other Resources

National Kidney Disease Education Program. Chronic kidney disease (CKD) and diet: assessment,
management and treatment. Treating CKD patients who are not on dialysis. An overview
guide for dietitians. Revised April 2015. National Kidney Disease Education Program
website. https://www.niddk.nih.gov/health-information/communication-programs/nkdep/
identify-manage-patients/professional-education/chronic-kidney-disease-nutrition.

National Kidney Disease Education Program. Eating right for kidney health tips for people with
chronic kidney disease (CKD). Revised June 2014. NIH publication 14–7405. National
Kidney Disease Education Program website.
https://www.niddk.nih.gov/-/media/Files/Health-Information/Communication-Programs/
NKDEP/eating-right-508.pdf

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