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The major role of the kidneys is to remove waste products and purify blood. Besides this, the kidney plays an important role in removing extra water, minerals and chemicals; it also regulates water and minerals like sodium, potassium, calcium, phosphorus and bicarbonate in the body.
In patients suffering from chronic kidney disease (CKD), regulation of fluids and electrolytes may be deranged. Because of this reason even normal intake of water, common salt or potassium can cause serious disturbances in fluid and electrolyte balance.
To reduce the burden on the kidney with impaired function and to avoid disturbances in fluid and electrolyte balance, patients with chronic kidney disease should modify their diet as per the guidance of the doctor and the dietitian. There is no fixed diet for CKD patients. Each patient is given a different dietary advice depending on clinical status, the stage of kidney failure and other medical problems. Dietary advice needs to be altered for the same patient at different times.
The body needs calories for daily activities and to maintain temperature, growth and adequate body weight. Calories are supplied chiefly by carbohydrates and fats. The usual caloric requirement of CKD patients is 35 - 40 kcal/kg body weight per day. If caloric intake is inadequate, the body utilizes protein to provide calories. This breakdown of protein can lead to harmful effects such as malnutrition and a greater production of waste products. It is thus essential to provide an adequate amount of calories to CKD patients. It is important to calculate the caloric requirement according to a patient’s ideal body weight, and not current weight.
Carbohydrates are the primary source of calories for the body. Carbohydrates are found in wheat, cereals, rice, potatoes, fruits and vegetables, sugar, honey, cookies, cakes, sweets and drinks. Diabetics and obese patients need to limit the amount of carbohydrates. It is best to use complex carbohydrates from cereals like whole wheat and unpolished rice which would also provide fiber. These should form a large portion of the carbohydrates in the diet. All other simple sugar containing substances should form not more than 20% of the total carbohydrate intake, especially in diabetic patients. Non-diabetic patients may replace calories from protein with carbohydrates in the form of fruits, pies, cakes, cookies, jelly or honey as long as desserts with chocolate, nuts, or bananas are limited.
Fats are an important source of calories for the body and provide two times more calories than carbohydrates or proteins. Unsaturated or “good” fats like olive oil, peanut oil, canola oil, safflower oil, sunflower oil, fish and nuts are better than saturated or “bad” fats such as red meat, poultry, whole milk, butter, ghee, cheese, coconut and lard. Patients with CKD should reduce their intake of saturated fats and cholesterol, as these can cause heart disease.
Among the unsaturated fats it is important to pay attention to the proportion of monounsaturated and polyunsaturated fats. Excessive amounts of omega-6 polyunsaturated fatty acids (PUFA) and a very high omega-6/omega-3 ratio is harmful while low omega-6/omega-3 ratio exerts beneficial effects. Mixtures of vegetable oil rather than single oil usage will achieve this purpose. Trans fat containing substances like potato chips, doughnuts, commercially prepared cookies and cakes are potentially harmful and should be avoided.
Protein is essential for the repair and maintenance of body tissues. It also helps in healing of wounds and fighting against infection. Protein restriction (< 0.8 gm/kg body weight/day) is recommended for CKD patients not on dialysis to reduce the rate of decline in kidney function and delay the need for dialysis and kidney transplantation. Severe protein restriction should be avoided however because of the risk of malnutrition. Poor appetite is common in CKD patients. Poor appetite and strict protein restriction together can lead to poor nutrition, weight loss, lack of energy and reduction in body resistance, which increase the risk of death. Proteins with high biologic value such as animal protein (meat, poultry and fish), eggs and tofu are preferred. High-protein diets (e.g. Atkins diet) should be avoided in CKD patients. Likewise, the use of protein supplements and drugs such as creatine used for muscle development are best avoided unless approved by a physician or dietitian. However, once a patient is on dialysis, protein intake should be increased to 1.0 – 1.2 gm/kg body weight/day to replace the proteins lost during the procedure.
Why must patients with CKD take precautions regarding fluid intake?
The kidneys play a major role in maintaining the proper amount of water in the body by removing excess fluid as urine. In patients with CKD, as the kidney function worsens, the volume of urine usually decreases. Reduced urine output leads to fluid retention in the body causing puffiness of the face, swelling of the legs and hands and high blood pressure. Accumulation of fluid in the lungs (a condition called pulmonary congestion or edema) causes shortness of breath and difficulty in breathing. If this is not controlled, it can be life threatening.
What are the clues that suggest excess water in the body?
Excess water in the body is called fluid overload. Leg swelling (edema), ascites (accumulation of fluid in the abdominal cavity), shortness of breath, and weight gain in a short period are the clues that suggest fluid overload.
What precautions must CKD patients take to control fluid intake?
To avoid fluid overload or deficit, the volume of fluid should be recorded and followed as per the recommendation of the doctor. The volume o fluid permitted may vary for each CKD patient and is calculated on the basis of urine output and fluid status of each patient.
How much fluid is a chronic kidney disease patient advised to take?
Why must CKD patients maintain a record of their daily weights?
Patients should keep a record of their daily weight to monitor fluid volume in the body and to detect fluid gain or loss. The body weigh remains constant when the instructions regarding fluid intake are followed strictly. Sudden weight gain indicates fluid overload due to increase in fluid intake. Weight gain warns the patients about the need for more meticulous fluid restriction. Weight loss usually occurs as a combined effect of restriction of fluid and a response to diuretics.
Useful Tips to Reduce Fluid Intake
It is difficult to restrict fluid intake, but these tips will help you:
How does one measure and consume the prescribed amount of fluid per day?
Why is a low sodium diet advised for patients with CKD?
Sodium in our diet is important for the body to maintain blood volume and to control blood pressure. Our kidneys play an important role in the regulation of sodium. In patients with CKD, the kidneys cannot remove excess sodium and fluid from the body so sodium and water build up in the body. An increased amount of sodium in the body leads to increased thirst, swelling, shortness of breath and increase in blood pressure. To prevent or reduce these problems, patients with CKD must restrict sodium intake in their diet.
What is the difference between sodium and salt?
The words sodium and salt are commonly used as synonyms. Common salt (table salt) is sodium chloride and contains 40% sodium. Salt is the principle source of sodium in our diet. But salt is not the only source of sodium. There are quite a few other sodium compounds in our food, such as:
How much salt should one take?
A typical daily intake of salt is about 10 to 15 grams (4-6 grams of sodium) per day. Patients with CKD should take salt according to the recommendation of the doctor. CKD patients with edema (swelling) and high blood pressure are usually advised to take less than 2 grams of sodium per day.
Which foods contain high amounts of sodium?
Foods high in sodium include:
Practical Tips to Reduce Sodium in Food
Why are CKD patients advised to restrict potassium in diet?
Potassium is an important mineral in the body that is needed for the proper functioning of muscles and nerves and to keep the heart beat regular. Normally, the level of potassium in body is balanced by eating potassium containing foods and removal of excess potassium in the urine. Removal of excess potassium in the urine may be inadequate in a patient with chronic kidney disease and can lead to the accumulation of a high level of potassium in the blood (a condition known as hyperkalemia). The risk of hyperkalemia is less in patients undergoing peritoneal dialysis compared to those on hemodialysis. The risk differs in both groups because the process of dialysis is continuous in peritoneal dialysis while it is intermittent in hemodialysis.
High potassium levels can cause severe muscle weakness or an irregular heart rhythm that can be dangerous. When potassium is very high, the heart can stop beating unexpectedly and cause sudden death. High potassium levels can be life threatening without noticeable manifestations or symptoms (and therefore it is known as a silent killer).
To avoid serious consequences of high potassium, CKD patients are advised to restrict potassium in diet.
What is normal potassium level in blood? When is it considered high?
The normal serum potassium (level of potassium in blood) is 3.5 mEq/L to 5.0 mEq/L.
When the serum potassium is 5.0 to 6.0 mEq/L, dietary potassium needs to be limited.
When the serum potassium is greater than 6.0 mEq/L, active medical intervention is needed to reduce it.
A serum potassium greater than 7.0 mEq/L is life threatening and needs urgent treatment such as emergency dialysis.
Classification of food according to potassium content:
To maintain proper control of potassium in blood, food intake must be modified as per the doctor’s advice. On the basis of potassium contents, foods are classified into three different groups (high, medium, and low potassium containing foods).
High potassium = More than 200 mg/ 100 gms of food
Medium potassium = 100 to 200 mg/ 100 gms of food
Low potassium = Less than 100 mg/ 100 gms of food
Foods with high potassium content
Foods with Medium Potassium Content
Foods with Low Potassium Content
Practical Tips to Reduce Potassium in Food
How does one reduce potassium content in vegetables?
Special tips for leaching potassium from potatoes
Why must CKD patients take a low phosphorus diet?
What foods containing high phosphorus should be reduced or avoided?
Foods containing high phosphorous include:
CKD patients generally suffer from an inadequate supply of vitamins during the predialysis period due to poor appetite, and an overly restricted diet in the attempt to delay progression of renal disease. Certain vitamins – especially water soluble vitamins B, vitamin C and folic acid – are lost during dialysis.
To compensate for inadequate intake or loss of these vitamins, CKD patients usually need supplementation of water-soluble vitamins and trace elements. High fiber intake is beneficial in CKD. Patients are therefore advised to take more fresh vegetables and fruits rich in vitamin and fibers while avoiding those with high potassium content.
For CKD patients daily food intake and water intake are planned and charted out by the dietitian in accordance with the advice of the nephrologist.
Diet plays a major role in prevention of many diseases and similarly in renal disease too.
DIET IN CKD
In a patient with CKD who has a persistently elevated creatinine, it has been proved that a low protein diet will slow the progression of disease and hence protein restriction to less than 0.8g/kg body weight is recommended of which > 50% should be of high biological value.
This however may put a patient at risk of malnutrition which becomes counter productive and patients doing unwell even after dialysis becoming unfit for transplantation.
Here diet is a double edged sword and hence follow you health care providers advice.
DIET IN DIALYSIS PATIENT
Here the patient is on dialysis because of End Stage Failure and there is no point called slowing the progression, the point of dietary protein restriction doesn't arise. Patients now need a very high protein rich diet to keep them well in dialysis and compensate for losses during these periods.
The recommended dietary protein per day is 1.2g/kg in Hemodialysis and 1.3g/kg in peritoneal dialysis.
Remember there needs to be restriction of phosphates in diet during all times of CKD on Dialysis or off it.
Simplifying restriction of protein is: avoid all kinds of meat intake including fish and prawn.
Avoid carbonated drinks.
In all patients avoid coconut water, fruits and fruit juices to prevent potassium accumulation as kidney is the only source of excretion and high potassium can lead to cardiac arrest
Restrict sodium intake to reduce edema and prevent fluid excess.
Fruits allowed in CKD are Apple, Papaya, guava & grapes.
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