Nephrotic syndrome is not a specific disease but a collection of symptoms stemming from conditions like diabetes, glomerular disorders, minimal change disease (MCD), or focal segmental glomerulosclerosis. It occurs when the kidney's glomeruli become inflamed and permeable, allowing proteins and other large molecules to pass into the urine. Minimal Change Disease (MCD) is a disorder affecting the glomeruli that can lead to nephrotic syndrome, especially in young children. While diagnosis typically involves urine analysis, managing symptoms often requires dietary adjustments.
Understanding Nephrotic Syndrome and MCD
Several medical terms are associated with nephrotic syndrome:
- Proteinuria: Protein in the urine, often indicating kidney impairment.
- Albuminuria: Specifically, albumin in the urine, resulting from damage to the kidney's filtration barrier. Moderately increased albuminuria is defined as urine albumin measuring between 30 to 300 grams per day.
- Hypoalbuminemia: Decreased albumin in the blood, often due to increased albumin loss in the urine.
- Hyperlipidemia: An abnormal increase of lipids in the blood.
- Glomerular filtration rate (GFR): GFR estimates kidney function by calculating blood creatinine levels with urine protein levels.
MCD primarily affects young children under 5, accounting for 80 to 90% of nephrotic syndrome cases in this age group, while only 10 to 15% of nephrotic syndrome cases in adults are MCD. A kidney biopsy revealing little or no change to the glomeruli confirms MCD.
Dietary Goals for Managing Nephrotic Syndrome
Dietary changes are crucial for avoiding kidney damage and managing nephrotic syndrome symptoms, such as high blood pressure, fluid retention, and elevated blood lipids. The primary goals include:
- Controlling protein intake
- Monitoring sodium intake
- Balancing electrolytes
- Promoting heart health
- Maintaining adequate vitamin D levels
Dietary Recommendations
Protein Intake
Avoid a high-protein diet, as it can worsen urinary protein loss and potentially damage nephrons, leading to renal insufficiency. Individual protein needs should be similar to those recommended for each CKD stage. A low to moderate protein intake is recommended, depending on kidney health. The recommended protein intake for nephrotic syndrome is about 1 gram per kilogram of body weight per day, or 0.45 grams per pound per day, but this may vary. Plant-based proteins, such as beans and nuts, are easier on the kidneys because they produce less acid than animal proteins.
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Sodium Intake
Limit total salt intake to manage blood pressure and reduce fluid retention. Current suggestions for sodium restriction vary from less than 2 mEq/kg/day to a "no added salt diet". The Pediatric Nephrology Clinical Pathway Development Team proposes a one-to-one ratio of 1 mg of sodium for each calorie (kcal) to adequately restrict sodium intake. Aim for under 400 mg of sodium per meal (150 mg per snack).
Foods to limit or avoid due to high sodium content:
- Processed foods
- Cheese
- Canned goods
- Salted snacks (chips, nuts, pretzels, popcorn)
- High-sodium meats (bologna, ham, bacon, sausage, hot dogs)
- Frozen dinners and entrées
- Pickled vegetables
- Salted bread
Seasonings and condiments to avoid:
- Worcestershire sauce
- Bouillon cubes
- Olives
- Pickles
- Soy sauce
- Ketchup
- Mustard
- Barbecue sauce
- Hot sauces
- Steak sauce
- Low-calorie salad dressings
- Cocktail sauce
Low-sodium alternatives:
- Herbs and spices
- Vinegar
- Lemon juice
- No- or low-sodium seasoning blends
- Fresh garlic or garlic powder
- Fresh onion or onion powder
Fluid Intake
Fluid restriction is generally not recommended unless there is significant hyponatremia, massive anasarca, or oliguric renal failure. All foods that are liquid at room temperature, such as milk, juice, yogurt, ice cream, and soup, should be counted towards fluid intake.
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Potassium
Potassium is vital for muscle function, including the heart. The amount of potassium you need depends on how well your kidneys are working and your medications. Potassium from animal foods is absorbed at a higher rate than potassium from plants. Elevated blood sugars can also increase potassium levels.
Phosphorus
As kidney function declines, phosphorus can build up in the blood, weakening bones. If needed, limit foods high in phosphorus, such as dairy products, organ meats, colas, deli meats, and processed foods with phosphate additives. Avoid processed foods that have additives with "PHOS" in the ingredients list.
Calcium
Foods high in calcium are often also high in phosphorus. Your dietitian or healthcare provider will tell you if you need to limit calcium. Before taking any over-the-counter vitamin D or calcium supplements, talk to your healthcare provider.
Heart-Healthy Diet
With an increased risk of hyperlipidemia, total dietary fat should be evaluated. Children over 2 years old should follow the Cardiovascular Health Integrated Lifestyle Diet (CHILD-1): fats should be restricted to <30% of total daily calories, saturated fats to <10%, and cholesterol consumption to <300 mg/d, while simultaneously increasing the consumption of healthier fats, such as monounsaturated, polyunsaturated, and omega-3 fatty acids. Children who also present with hyperlipidemia should follow the CHILD-2 diet plan, which further limits the intake of saturated fats to <7% and cholesterol to <200 mg/d.
Foods to include:
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- Lean meats (poultry, fish, shellfish)
- Dried beans
- Peanut butter
- Soybeans
- Fresh or frozen fruits (apples, watermelons, pears, oranges, bananas)
- Fresh or frozen vegetables (green beans, lettuce, tomatoes)
- Low-sodium canned vegetables
- Potatoes
- Rice
- Whole grains
- Unsalted snacks (potato chips, nuts, popcorn)
- Cottage cheese
- Tofu
- Milk
- Butter or margarine
- Healthy oils, such as sunflower oil, coconut oil, canola oil, and olive oil
Vitamin D
Tracking vitamin D levels is important because of its many roles in the body. Serum vitamin D levels should be routinely monitored in children with NS starting at the time of diagnosis.
Additional Dietary Tips
- Prepare meals at home: Restaurant meals often have higher salt content.
- Read food labels: Check sodium content before purchasing food items.
- Cook with healthy oils.
- Remove salt from the dinner table.
- Choose fresh or low-sodium canned vegetables.
- Consider the DASH Diet: The DASH (Dietary Approaches to Stop Hypertension) 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.
Supplements
Doctors recommend that people taking steroid medications for nephrotic syndrome should also take vitamin D or calcium supplements, as steroid medications can affect bone health. Some supplements, such as herbal supplements, may be harmful to the kidneys. Consult a doctor before taking any supplements.
Potential Complications of Untreated Nephrotic Syndrome
If left untreated, complications of nephrotic syndrome include:
- Blood clotting
- High blood cholesterol
- High blood triglycerides
- Malnutrition
- Weight loss
- Vitamin D and calcium deficiency
- High blood pressure
- Kidney failure
- Chronic kidney disease
- Infection due to loss of antibodies in urine
The Role of Plant-Based Diets
Compared with protein from plant sources, animal protein has been associated with an increased risk of end-stage kidney disease in several studies. Plant-based diets are nearly acid neutral, while the dietary acid load in a Standard American Diet is derived mostly from animal sources such as meats, eggs, and cheeses.
Case Study: Minimal Change Disease and Plant-Based Diet
A 44-year-old man diagnosed with minimal change disease experienced severe protein loss, hypertension, and worsening kidney function despite steroid and immunosuppressant treatment. After adopting a plant-based diet, exercising, and losing weight, he regained his quality of life and surpassed his pre-kidney disease physical activity levels.
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