What are the dietary protein restrictions and treatment recommendations for patients with Chronic Kidney Disease (CKD)?

Dietary Protein Recommendations for Chronic Kidney Disease

For adults with CKD stages G3-G5 who are metabolically stable, protein intake should be restricted to 0.8 g/kg body weight/day to reduce risk of CKD progression while maintaining nutritional status. 1

Protein Recommendations Based on CKD Stage and Dialysis Status

Non-Dialysis CKD Patients:

• CKD G3-G5 (without diabetes): 0.8 g/kg body weight/day 1
• CKD G3-G5 (with diabetes): 0.6-0.8 g/kg body weight/day 1
• Avoid high protein intake: >1.3 g/kg body weight/day in all CKD patients at risk of progression 1

Dialysis Patients:

• CKD 5D (hemodialysis or peritoneal dialysis): 1.0-1.2 g/kg body weight/day 1
• CKD 5D with diabetes: 1.0-1.2 g/kg body weight/day (may need higher levels if at risk of hypo/hyperglycemia) 1

Special Populations:

• Children with CKD: Do NOT restrict protein - target upper end of normal range for healthy children 1
• Older adults with frailty/sarcopenia: Consider higher protein and calorie targets 1

Very Low Protein Diet Option

For patients at high risk of kidney failure who are willing and able to comply:

• Very low protein diet (0.3-0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/day) 1
• Must be under close clinical supervision 1
• Can reduce risk of end-stage kidney disease/death and improve quality of life 1

Contraindications for Protein Restriction

• Metabolically unstable patients 1
• Children with CKD (risk of growth impairment) 1
• Patients with frailty or sarcopenia (may need higher protein intake) 1

Additional Dietary Recommendations

Sodium Intake:

• <2 g sodium/day (<5 g sodium chloride/day) 1
• Exception: Not appropriate for patients with sodium-wasting nephropathy 1

Energy Intake:

• 25-35 kcal/kg body weight/day based on individual factors 1

Diet Quality:

• Higher consumption of plant-based foods compared to animal-based foods 1
• Lower consumption of ultra-processed foods 1
• Mediterranean diet may improve lipid profiles 1
• Increased fruit and vegetable intake may decrease body weight, blood pressure, and net acid production 1

Implementation Considerations

Monitoring:

• Regular assessment by registered dietitian nutritionist 1
• Monitor appetite, dietary intake, body weight changes, biochemical data, anthropometric measurements 1
• Use 3-day food records (including dialysis and non-dialysis days when applicable) 1

Common Pitfalls:

1. Malnutrition risk: Protein restriction without adequate caloric intake can lead to protein-energy wasting 1
2. Poor adherence: Compliance with low protein diets is often unsatisfactory 2
3. Overrestriction: Very low protein diets (<0.3 g/kg/day) without supplementation have been associated with increased mortality 1
4. Ignoring comorbidities: Patients with diabetes may need different protein targets 1

Evidence Quality Considerations:

The evidence supporting protein restriction is mixed. While the KDIGO 2024 guidelines 1 recommend 0.8 g/kg/day for CKD G3-G5, a Cochrane review found that protein restriction has uncertain effects on kidney function decline and may make little difference to the risk of death and kidney failure in diabetic kidney disease 2. The benefits of protein restriction appear modest, while there are clinically important risks including malnutrition 1.

For optimal outcomes, protein restriction should be implemented with medical nutrition therapy provided by a registered dietitian nutritionist in close collaboration with the healthcare team 1.