Chronic Kidney Disease (CKD) is a prevalent and severe complication arising from diabetes, significantly increasing the risk of cardiovascular disease and mortality compared to non-diabetic CKD patients. For individuals managing both diabetic kidney disease (DKD) and end-stage renal disease (ESRD), the importance of a well-structured dietary plan cannot be overstated. This article provides an overview of the current clinical practice guidelines and supporting evidence regarding the nutritional management of patients with DKD, emphasizing the specific needs of those undergoing dialysis.
Understanding the Interplay Between Diabetes, CKD, and Diet
The prevalence of diabetes is escalating globally, with a substantial portion of end-stage renal disease (ESRD) cases in the U.S. attributed to diabetes. The primary goals in managing DKD are stabilizing kidney function and preventing other end-organ complications through balanced nutritional therapy and appropriate pharmacological interventions aimed at optimizing glycemic status, lipid levels, and blood pressure. Managing both illnesses can be difficult alone, but can create even more stress when you have to manage both.
Nutritional Therapy in DKD Management
Nutritional therapy is a cornerstone of DKD treatment. The Centers for Disease Control and Prevention’s data shows that more than 35% of people aged 20 or older with diabetes have CKD. According to the End-Stage Renal Disease Incident and Prevalent Quarterly Update, approximately 37% of patients with ESRD have diabetes.
Current clinical practice guidelines do not fully address all aspects of dietary management due to existing controversies and knowledge gaps. Recommendations vary across the stages of DKD, reflecting the differential risk-to-benefit ratios of certain management strategies at varying levels of kidney function.
Evolving Guidelines for Dietary Management
In 2007, the National Kidney Foundation (NKF) Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guidelines for the Nutritional Management of Diabetes and CKD emphasized dietary protein restriction among DKD patients, recommending a target intake of 0.8 g/kg of body weight (BW)/day (approximately 10% of total caloric intake) for those with stages 1-4 CKD. In 2012, the Kidney Disease Improving Global Outcome (KDIGO) expert panel suggested maintaining dietary protein intake at 0.8 g/kg BW/day, avoiding levels above 1.3 g/kg BW/day, noting insufficient evidence to support long-term restriction below 0.8 g/kg BW/day.
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In 2014, a consensus conference by the American Diabetes Association (ADA), American Society of Nephrology (ASN), and NKF recommended a “usual level of dietary protein intake” of approximately 16−18% of total caloric intake for DKD patients.
Protein Intake: Balancing Act
Dietary protein requirements among diabetic patients without kidney disease are generally considered equivalent to those of the general population.
Protein Intake in the General Population
National Health and Nutritional Examination Survey (NHANES) data indicates that the average dietary protein intake of US adults is 1.34 g/kg of ideal body weight (IBW)/day or 1.09 g/kg of actual body weight (ABW)/day, exceeding the amount needed to avoid negative nitrogen balance (0.8 g/kg ABW/day).
Higher dietary protein intake was observed among men vs. women (1.36 vs. 1.25 g/kg IBW/day, respectively) and among Mexican-American and Latino participants vs. other racial/ethnic groups. Younger participants also showed incrementally higher protein intake compared to older individuals.
High Protein Diets and Renal Function
Type 2 diabetic patients may consume protein-rich foods to promote weight loss or avoid postprandial hyperglycemia. However, high protein diets may increase the risk of impaired renal function. High dietary protein intake increases glomerular filtration rates (GFRs) to excrete protein-derived nitrogen metabolites. Renal hemodynamic changes induced by excess protein intake may have deleterious consequences over time.
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Low Protein Diets (LPD) in DKD Management
The potential benefits and risks of a low protein diet (LPD) have been widely debated among patients with DKD. Many studies, including RCTs, have shown a beneficial impact of LPD upon trajectory of kidney function in this population. LPDs, often used with essential amino acids and ketoacids, may reduce proteinuria, uremic burden, metabolic derangements, and oxidative stress, potentially attenuating CKD progression and delaying dialysis initiation.
Conversely, other studies have not confirmed that LPDs favorably impact CKD trajectory. A Cochrane review of 12 RCTs concluded that LPDs showed a small but non-significant benefit upon slowing of eGFR decline. Variability in study populations, CKD stages, and treatment durations, along with unsystematic assessment of dietary adherence, may explain these conflicting results.
Quality and Source of Dietary Protein
In addition to quantity, the quality and characteristics of dietary protein intake have been a focus of investigation. Soy protein consumption as a replacement for animal sources of protein was associated with significant improvement in proteinuria compared with usual protein consumption. Higher red meat intake was associated with an increased risk of ESRD in a dose-dependent manner. However, varying sources of dietary protein may differentially impact CKD-related complications in DKD patients.
Higher consumption of vegetable protein sources among patients with advanced CKD may result in phosphate and potassium derangements. However, a higher proportion of dietary protein intake from plant sources was associated with lower mortality in those with eGFR < 60 mL/min/1.73 m2. Future studies are needed to determine the effect of protein type upon kidney function and other relevant outcomes in the DKD population.
Dietary Recommendations for Dialysis Patients with Diabetes
The guidelines and studies mentioned above do not generally apply to diabetic patients with ESRD receiving dialysis. ESRD patients are predisposed to protein catabolism and losses of protein and amino acids in the dialysate, dietary protein restriction may lead to protein energy malnutrition (PEW), a potent predictor of mortality in this population.
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Increased Protein Intake for Dialysis Patients
The National Kidney Foundation- Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) Guidelines for Dialysis Patients recommend higher dietary protein intake (>1.2 g/kg BW/day) compared to non-dialysis dependent CKD patients to counteract protein catabolism, dialysate amino acid and protein losses, and protein-energy wasting. Monitored liberalization of protein intake is needed to ensure adequate dietary intake and prevention of PEW in diabetic ESRD patients receiving dialysis.
It is important to eat a high protein food (lean meat, poultry, and pork, fish, eggs, or a meat alternative) at every meal, or about 8-10 ounces of high protein foods every day.
Caloric Intake
In the broader CKD population, including those who are non-dialysis and dialysis dependent, the NKF-KDOQI guidelines and the International Society of Renal Nutrition and Metabolism recommend a total energy intake of 30-35 kcal/kg BW/day, tailored to physical activity levels. In elderly patients who are sedentary, energy intake of 30 kcal/kg BW/day may be sufficient. Reduction of caloric intake by 500-750 kcal/day or an intake of 1200-1500 kcal/day in women and 1500-1800 kcal/day in men is recommended in patients with type 2 diabetes of overweight or obese status. The number of calories you should have are based on individual needs and your dietitian will work with you to determine the right number for you. Age, weight, height, sex, exercise level, and other factors are considered.
Managing Carbohydrates
Carbohydrates can be found in many foods such as fruits, milk, breads, desserts and many drinks. In addition to the need to watch protein intake, patients will need to pay more attention to the amount of carbohydrates (sugars) that they eat. All carbohydrate-containing foods ( e.g., bread, cereal, pasta, rice, starchy vegetables, fruits, juices, many sugar-free desserts) increase blood glucose levels. Therefore, the total amount of carbohydrates you eat will be balanced with your medicines and activity level.
Sodium and Fluid Intake
Sodium intake should be less than 2300 milligrams per day, which is equal to one teaspoon of salt. This means a lot more than not using a saltshaker, but also limiting foods with high levels of sodium listed on their nutrition facts label. Less sodium in the diet helps prevent fluid from building up between dialysis treatments and helps reduce thirst. Less sodium also helps keep your blood pressure within your goal range. People on in-center hemodialysis usually need a fluid restriction, but the amount depends on how much urine they still make. So, the restriction can range from one to two liters or more per day. Most people on home hemodialysis do not need a fluid restriction. A sudden increase in weight, along with swelling, shortness of breath, or a rise in your blood pressure may be signs that you are drinking too many fluids.
Potassium and Phosphorus Management
Limits on potassium in the diet are based on your specific blood levels. The potassium from meat and dairy products is absorbed more easily than from fruits, vegetables, legumes, nuts, and seeds. Therefore, it’s very important to keep track of your potassium levels. Phosphorus levels in the blood can become too high in kidney failure because Hemodialysis does not effectively remove phosphorus. The best way to improve your diet overall and to decrease your phosphorus load is to avoid processed foods and eating more plant-based healthy foods.
The Diabetes Dialysis Diet
The diabetes dialysis diet is specifically for patients who have stage 5 chronic kidney disease (CKD), also called end stage renal disease (ESRD), in addition to diabetes. Like the other dialysis diets, the diabetes dialysis diet is filled with nutritious foods. High-sugar foods increase blood glucose and therefore carbohydrate intake will be tightly controlled in order to manage your blood glucose levels.
Practical Strategies for Meal Planning
Putting together a meal plan that meets the needs of both dialysis and diabetes may seem difficult, but there are some practical strategies that you can use.
Meal Planning and Food Journals
Following your meal plan will help keep blood sugar levels in your target range. With a CKD diet, you'll avoid or limit certain foods to protect your kidneys. You'll include other foods to give you energy and keep you nourished. A meal plan or a food journal are powerful tools that allow you to track exactly what and when you are eating.
The Exchange Method
A personal meal plan is developed with the help of your renal dietitian. You can make a serving exchange from a list of foods that have about the same nutritional value. Your dietitian or a certified diabetes educator can help you tailor a plan that works for you.
Carbohydrate Counting
This involves planning meals based on the total number of grams of carbohydrates you eat for that meal. You must be willing to keep track of the foods you eat and the carbohydrates you’ve been allowed. Reading and understanding food labels is very important and can help you manage this process.
Kidney-Friendly Foods
Below are just a few examples of foods a person with both diabetes and CKD can eat.
- Vegetables: kidney-friendly fruits like apples, grapes, peaches, and watermelon make a great snack anytime. Berries are especially beneficial for keeping diabetes in check because they are lower in sugar.
- Whole grains: High-fiber carbs like whole grain bread, whole grain pasta, brown rice, and even unsalted popcorn can be smart choices in moderation. Eating high-fiber foods helps keep your blood sugar within a normal range and prevents spiking.
- Proteins: Balance your meals with fresh protein choices such as chicken, fish, and eggs. Limit processed foods like deli meats or sausages because they are usually high in sodium and phosphorus.
- Unsaturated fats: Healthy fats like unsaturated fats can be good for you. Unsaturated fats typically come from plants and are found in vegetable oils, nuts, and peanut butter.
Diabetes- and Kidney-Friendly Meal Planner
Having diabetes and kidney-friendly eating plan will help you manage diabetes and CKD. By using the diabetes- and kidney-friendly meal planner, you can create balanced, nourishing meals that support your health. Start with a 9-inch plate and fill it with the following:
- Half Your Plate with Non-Starchy Vegetables: Choose options that have essential vitamins, minerals, and fiber. Examples include Broccoli, Cauliflower, Spinach, Asparagus, and Bell peppers.
- One Quarter of Your Plate with Starchy Vegetables and Grains: Starchy vegetables and grains will affect your blood glucose most but provide you with energy and nutrients. Choose whole grains when you can to be able to get more fiber in your meals. Examples include Quinoa, Brown rice, Whole wheat bread, and Barley.
- One Quarter of Your Plate with Lean Protein: Choose lean animal-based and plant-based proteins for lower calories and fats. By eating the right amount of protein, you can help keep your kidneys from working too hard after meals. Examples of lean proteins include Lentils, Beans, Tofu, Lean, skinless poultry (such as chicken or turkey breast), Fish and shellfish, and Eggs.
Key Nutrients to Monitor
People with CKD may avoid eating because they don’t feel hungry or because foods or beverages don’t taste the same. If you find that you don’t feel like eating, talk with a dietitian or health care professional to make sure you are getting enough calories and that the calories are from nutritious sources. Eating foods that have vitamins, minerals, and other nutrients and are minimally processed will help you reach your health goals.
- Protein: Helps you keep healthy blood protein levels for overall good health. Protein also helps keep your muscles strong, helps wounds heal faster, and keeps your immune system strong.
- Sodium: Less sodium in the diet helps prevent fluid from building up between dialysis treatments and helps reduce thirst. Less sodium also helps keep your blood pressure within your goal range.
- Potassium: Limits on potassium in the diet are based on your specific blood levels. When potassium in the blood is too high or too low this can cause heart problems and even death. Therefore, it’s very important to keep track of your potassium levels.
- Phosphorus: Phosphorus levels in the blood can become too high in kidney failure because Hemodialysis does not effectively remove phosphorus. This leads to weak bones and phosphorus binding with calcium to settle into blood vessels and the heart. Therefore, you may need to limit phosphorus in your diet, depending on your lab results.
- Fluids: People on in-center hemodialysis usually need a fluid restriction, but the amount depends on how much urine they still make.
- Calories: Calories give you energy from all the foods you eat and beverages you drink. An important goal is to get your calories from nutrient-dense foods, which means foods that have a lot of healthy nutrients for the number of calories you take in.
- Vitamins and Minerals: Vitamin and mineral needs are also specific to each person. Eating a wide variety of foods gives your body the vitamins and minerals it needs each day.
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