NUTRITION AND CKD - SOME BASIC FACTS

Helping your kidneys to control body chemistry by eating a sensible diet is an early and important form of treatment for kidney failure. Being careful about what you eat can reduce the amount of fluid and waste build-up and help you feel better. The following substances feature in renal diets: protein, sodium, potassium, phosphate, fluids, fats and carbohydrates.

Why is nutrition so important?
When food is broken down in the stomach and intestines, waste is made. The kidneys remove the waste from the blood. If the kidneys are not working properly, the waste builds up in the bloodstream and you may feel weak, tired, and sick. The other balancing act the kidneys perform is the regulation of the body’s fluid balance. Some people with kidney disease may retain fluid, which leads to puffiness, swollen ankles, hands and feet and breathlessness.

Note: Advice on nutrition needs to be personalised and based on your individual kidney function. Your nephrologist can refer you to a renal dietician who will design a specific diet for your needs - contact Dietitians Association of Australia to find a local renal dietitian on1800 812 942. If you have seen a dietician, information below should not take the place of the diet prescribed for you.

Protein
Protein builds, repairs and maintains body tissue. It also helps to fight infections and heal wounds. Urea is a waste product, which is formed when the body breaks down protein. Your eating plan should be designed to provide enough protein for your body without causing urea to overload the kidneys.

Too little protein may cause:

• loss of muscle bulk and wasting
• weight loss
• lack of energy

Too much protein produces excess urea, which may cause:

• tiredness
• nausea and vomiting
• headaches
• a bad taste in the mouth
• bad breath
• poor memory and concentration

Foods high in protein include:

• meat, chicken, fish, eggs
• cheese, milk and other dairy foods (yoghurt, cheese)
• nuts, seeds and legumes

Sodium (salt)
Salt affects the amount of fluid the body retains. Salt also increases thirst, which can lead to drinking more fluid than your kidneys can remove and fluid retention. Too much fluid may cause high blood pressure, swelling of ankles, feet, hands and puffiness under the eyes and shortness of breath.

The amount of salt in your diet may need to be reduced so ask your doctor and dietician for advice. See Australian World Action on Salt and Health's Drop the Salt Campaign for some tips. Beware salt substitutes as some contain potassium instead of sodium. Foods high in salt include:

• processed foods e.g. ham, sausage and luncheon meats
• fast food e.g. pizza, pies, hamburgers, sausage rolls
• salty snacks e.g. pretzels, chips, salted nuts
• sauces and pickles
• salted seasonings e.g. stock cubes, celery and vegetable salts

Potassium
An essential mineral in the body which helps nerve endings and muscles work well.However, if the level of potassium is too high or low in the blood, it can cause an irregular heartbeat. In fact, potassium levels outside the normal range may cause the heart to stop. How much potassium can you have? This depends on your blood results as well as the amount of urine you are passing. Foods high in potassium include:

• dried fruit and fruit cake
• fruit and vegetable juices
• tomatoes, tomato pastes and purees
• tinned and homemade soups
• liqueurs, red wine, cider, stout, nuts and seeds
• bananas, avocados, apricots, rockmelons
• spinach, mushrooms
• dried peas, beans, baked beans
• potatoes, potato crisps, pumpkin
• chocolates, cocoa, liquorice
• stone fruits
• high fibre breakfast cereals, unprocessed bran

Tip for reducing potassium intake - cut vegetables into small pieces, soak them in a large volume of water for 1-2 hours before cooking, drain and cook normally. Alternatively, boil them and drain off the water. Not all fruits and vegetables have the same amount of potassium.Talk to your renal dietician about what diet is appropriate for your individual needs.

Phosphate and calcium
Minerals that help to keep your bones strong and healthy. When the kidneys are not working properly, high levels of phosphate accumulate in the blood. This can cause itching, painful joints and weak, and brittle bones.

The amount of phosphate allowed depends on your blood test results. Foods high in phosphate include:

• cola-based soft drinks e.g. Coca Cola and Pepsi
• nuts, seeds and peanut butter
• dried peas and beans and baked beans
• processed bran cereals
• sardines and fish pastes
• cheese, milk and other dairy products

Your doctor may prescribe phosphate binders. These bind the phosphate in your food so that it will pass out of your body. It is important to take phosphate binders with your meals and snacks. Phosphate binders include: Caltrate, Alutabs, Mylanta, Titrilac, Nephrex, Magmin or RenaGel.

Fluids
As kidney function worsens, the body can retain fluid so some people may need to limit their fluid intake. The recommended fluid intake will depend on your urine output, fluid build-up and blood pressure. The usual allowance is the urine output plus 600mls. Fluids include:

• water and ice cubes, tea, coffee, juices, milk and milk products, gravy, sauces and soups
• ice cream, jelly, custard, yoghurt

Tips for restricting fluids - sip small amounts throughout the day, use smaller cups and glasses, remember that foods containing fluids need to be included in your fluid allowance.

Fats and Carbohydrates
Maintaining a healthy weight is important for everyone. If protein has been restricted in your diet, your energy and kilojoule requirements may need to be met by increasing the amount of fats (polyunsaturated and/or monounsaturated) and carbohydrates that you eat. Otherwise you will lose weight, which is undesirable.

If haemodialysis commences, your protein restriction will be lifted as some proteins are lost from the body during dialysis. As your feeling of well being and appetite improves, you will find it easier to incorporate a greater variety of foods to meet your requirements. Your renal dietician can help you to plan a new diet to suit your individual needs.

Nutrition and CKD - points to remember

• Your nutritional care plan needs to be personalised and based on your kidney function.
• Ask questions until you understand your diet.
• You may need to measure foods and fluids; for greater accuracy, measure with a cup or scale.
• Take your medication as prescribed.
• Organise reviews and follow-up with your renal dietician.
• Be aware of and note your trends in body weight, blood pressure and blood values.
• Inform your doctor or dietician if you are losing weight or have any concerns about your diet.
• Following your suggested nutritional care plan may not treat or cure your kidney problem, but it could help you reduce some of the symptoms, and improve your general feeling of wellbeing.

RECOMMENDED RENAL DIET WEBLINKS
For quality information via external websites

• A to Z of a renal diet and nutrition Extensive info and recipes NKF (USA)
• Back on the Menu Kidney Health Australia's recipe book for a restricted low potassium diet
• Bush Tucker in Kidney Failure and Diabetes Guide to 'Bush Tucker' foods, when you have CKD
• Chapter 10 - Thinking about food and drink from KHA's Living with Kidney Failure 7th edition
• Culinary Kidney Cooks - USA Lots of great recipes to help make your meals appetising
• DaVita - Diet and Nutrition Helpful advice on kidney diets and so much more!
  • CKD Non Dialysis diet diagnosed with early stage of CKD - designed to help your kidneys keep as much of their remaining function for as long as possible
  • Diet Helper Kidney-friendly meals: easy to plan, prepare, track via online dialysis diet tool
  • Diet and nutrition basics in CKD and Food analyser
  • Fluid control for kidney disease patients on dialysis
  • Recipe ideas for a renal diet and how to cook them Video
  • Renal Diet Recipes Practical delicious recipes for a varied diet *Haemodialysis diet *Peritoneal dialysis diet *Transplant diet *Diabetic dialysis diet *Potassium, phosphorous and dialysis diet
• Dietitians Association of Australia Hotline 1800 812 942
• Eating Out: A Guide for Chronic Kidney Disease Patients Renal Resource Centre NSW
• Healthy Eating on a Renal Diet Extensive cookbook for people with kidney disease USA
• Just the Facts on Fluid and Dialysis
• Kidney Diet Tips Kidney Foundation of Canada (Northern Alberta and Territories)
• Kidney Foundation of Canada - Fact Sheets Overview of nutrition, recipes & diet for CKD
• Kidney Kitchen NKF USA - look for extensive Renal Recipe listing
• Kidney Patient Guide UK Excellent diet section for kidney patients
• Kidney Patient News - Renal Diet
• Kidney Times - The Recipe Box Selection of recipes for tasty meals for those with CKD
• List of cookbooks for Renal Diets NKF USA - Extensive list of resources, buy online
• Living Well on Dialysis NKF (USA) Very detailed online renal diet resource
• Low Protein Diets Brochure - Renal Resource Centre Australia
• Nephron Information Centre - Arizona Dietetic Project Managing nutrition for kidney disease
• PKD Health Notes US based - Nutrition and cooking tips for those with CKD - great recipes too
• Rediscovering Food & Flavours UK - TV Chef Lawrence Keogh, Roast & BBC’s Saturday Kitchen and Renal Dietician, Diane Green help you move away from bland low phosphate diets
• Renal Diet - How to make it work advice New Zealand Kidney Foundation
• The Renal Gourmet What to cook when your kidneys quit
• Renal Nutrition Recipe Corner Northwest Kidney Centres USA

Food composition, standards, guidelines - to support nutrition for all stages of CKD and post transplant

• Asian database of food standards for many Asian cultural foods (values may differ for local food content)
• KHA-CARI Guidelines - Nutrition and growth in kidney disease Published guidelines specifically on *Vitamins in pre-dialysis patients *Complimentary medicine and pre-dialysis patients *Nutrition in kidney transplant recipients
• iKidneyDiet - an iTunes application Clever mobile phone app which gives levels for the 3 Ps - Potassium, Phosphorous, Protein - when watching intake for a renal diet. Some USA products are noted.
• Food composition and standards for Australia and New Zealand
• International food composition tables for a truly global list of foods
• NEMO = Nutrition Education Materials Online QLD Dietitians Assoc of Australia - Renal
• USA food standards and database American products etc (values may differ for local food content)