Dietary Recommendations for CKD Patients
Patients with CKD should adopt a plant-dominant diet with protein intake of 0.8 g/kg/day, sodium restricted to <2 g/day (<5 g salt/day), adequate energy intake of 30-35 kcal/kg/day, and mandatory referral to a renal dietitian for individualized monitoring. 1
Core Dietary Pattern
Emphasize plant-based foods over animal-based foods and minimize ultraprocessed foods. 1 The diet should be high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts, while lower in processed meats, refined carbohydrates, and sweetened beverages. 1, 2
Plant-dominant diets provide additional benefits beyond protein restriction, including improved metabolic acidosis control, reduced uremic toxin generation through favorable gut microbiome alterations, and lower cardiovascular risk. 3, 4
Protein Intake Guidelines
Standard Recommendations for CKD G3-G5 (Not on Dialysis)
Maintain protein intake at 0.8 g/kg body weight/day for metabolically stable adults with CKD stages 3-5. 1, 5 This target slows GFR decline without compromising nutritional status. 5
Avoid high protein intake exceeding 1.3 g/kg/day, as this accelerates CKD progression, increases albuminuria, and raises cardiovascular mortality risk. 1, 5
Very Low-Protein Diet Option
For patients at high risk of kidney failure who are willing, able, and metabolically stable, consider a very low-protein diet of 0.3-0.4 g/kg/day supplemented with essential amino acids or ketoacid analogs (total up to 0.6 g/kg/day) under close supervision. 1, 5 This approach requires mandatory dietitian oversight to prevent malnutrition. 6, 5
Never prescribe low or very low-protein diets in metabolically unstable patients or those hospitalized for acute illness. 1, 6
Special Population Adjustments
- Dialysis patients (hemodialysis and peritoneal dialysis): Increase protein to 1.0-1.2 g/kg/day to offset dialytic losses and catabolism. 1, 6, 2
- Older adults with frailty or sarcopenia: Consider higher protein and calorie targets to prevent muscle wasting. 1, 6
- Children with CKD: Do not restrict protein; target the upper end of normal range for age to promote optimal growth. 1
Sodium Restriction
Limit sodium intake to <2 g/day (equivalent to <90 mmol/day or <5 g salt/day) for all CKD patients. 1, 2 This target controls blood pressure and reduces cardiovascular risk. 2
Exception: Do not restrict sodium in patients with sodium-wasting nephropathy. 1
Energy Requirements
Ensure adequate caloric intake of 30-35 kcal/kg/day to prevent protein-energy wasting and maintain nitrogen balance. 2, 7 For patients ≥60 years, target 30-35 kcal/kg/day; for those <60 years, aim for 35 kcal/kg/day. 2
Inadequate energy intake forces the body to catabolize dietary and endogenous protein for energy, negating the benefits of protein restriction. 7
Phosphorus and Potassium Management
While specific targets vary by CKD stage and individual lab values, dietary education should address phosphorus (typically 500-700 mg/day for low-protein diets) and potassium restriction as needed. 1, 7 Plant-based diets may reduce hyperkalemia risk through improved bowel function. 3
Implementation Strategy
Refer all CKD patients to renal dietitians or accredited nutrition providers for individualized medical nutrition therapy. 1, 2 This is non-negotiable for successful dietary management. 5, 2
Dietitians should provide education on sodium, phosphorus, potassium, and protein adaptations tailored to CKD severity and comorbidities. 1
Consider cultural differences, food intolerances, food resource availability, cooking skills, comorbidities, and cost when recommending dietary options. 1
Monitoring Requirements
Monitor nutritional status at 1-3 month intervals including: 2
- Appetite assessment
- Dietary intake evaluation
- Body weight changes
- Biochemical markers (albumin, prealbumin)
- Anthropometric measurements
Watch for signs of protein-energy wasting, which increases morbidity and mortality. 6, 5
Critical Pitfalls to Avoid
Do not implement protein restriction without proper nutritional counseling and monitoring—this significantly increases malnutrition risk. 6, 5 Protein-energy wasting is associated with increased mortality. 6
Do not focus solely on protein restriction while ignoring overall diet quality. 6, 5 Address sodium, phosphorus, and potassium simultaneously, and emphasize plant-based food sources. 1
Use adjusted body weight for protein calculations, not fluid-overloaded weight. 5
Ensure much of the protein intake is of high biological value (e.g., 0.4 g/kg/day of the 0.6-0.8 g/kg/day target). 7