What are the recommendations for diet and Dapagliflozin (Forxiga) in a patient with chronic kidney disease (CKD) stage 3 or 4, impaired renal function, and potential type 2 diabetes?

Diet and Dapagliflozin in CKD Stage 3-4

For patients with CKD stage 3-4 taking dapagliflozin, maintain a protein intake of 0.8 g/kg/day, limit sodium to <2 g/day (<5 g sodium chloride), and follow a balanced diet high in vegetables, fruits, whole grains, and plant-based proteins while avoiding processed meats and refined carbohydrates. 1

Protein Intake Recommendations

• Maintain protein intake at 0.8 g/kg body weight per day for patients with CKD stages 3-4 not on dialysis 1
• Do not restrict protein below 0.8 g/kg/day, as clinical trial evidence has not shown improved kidney outcomes with lower intake 1
• Higher protein intake (>1.3 g/kg/day or >20% of daily calories) should be avoided, as it is associated with increased albuminuria, faster kidney function decline, and cardiovascular mortality 1

Sodium Restriction

• Limit sodium intake to <2 g/day (equivalent to <90 mmol/day or <5 g sodium chloride/day) 1
• Sodium restriction is particularly important as kidney function declines, since sodium retention leads to increased blood pressure, accelerated kidney function decline, and higher cardiovascular event risk 1
• This recommendation is consistent across international cardiovascular disease prevention guidelines 1

Overall Dietary Pattern

The primary dietary advice should emphasize a balanced, healthy diet that is:

• High in: vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts 1
• Lower in: processed meats, refined carbohydrates, and sweetened beverages 1

This dietary pattern addresses the complex nutritional requirements of patients with both diabetes and CKD, which often conflict with recommendations for either condition alone 1

Physical Activity

• Undertake moderate-intensity physical activity for at least 150 minutes per week cumulative duration, or to a level compatible with cardiovascular and physical tolerance 1
• Physical inactivity has been associated with adverse clinical outcomes in patients with diabetes and CKD 1

Specific Considerations with Dapagliflozin

Volume Status and Sodium

• Dapagliflozin causes urinary glucose excretion of approximately 70 grams per day, which also results in increased urinary volume 2
• Assess volume status before initiating dapagliflozin and correct volume depletion if present 3, 2
• The sodium restriction recommendation (<2 g/day) becomes even more critical when taking dapagliflozin, as the medication's diuretic effect combined with dietary sodium restriction requires careful monitoring to prevent excessive volume depletion 3

Sick Day Management

• During acute illness with reduced food and fluid intake, temporarily discontinue dapagliflozin 3
• Hold dapagliflozin during fever, vomiting, or diarrhea to prevent diabetic ketoacidosis and volume depletion 3
• Withhold dapagliflozin for at least 3 days before major surgery or procedures requiring prolonged fasting 3, 2

Potassium Considerations

• Individualize dietary potassium based on serum potassium concentrations, as urinary potassium excretion may be impaired with reduced eGFR 1
• This is particularly important for patients on renin-angiotensin-aldosterone system inhibitors, which are typically used alongside dapagliflozin 1

Common Pitfalls to Avoid

• Do not reduce protein intake below 0.8 g/kg/day thinking it will provide additional kidney protection—evidence does not support this, and it may lead to malnutrition 1
• Do not ignore sodium restriction even though dapagliflozin has diuretic effects—the combination of medication and dietary sodium restriction provides optimal blood pressure and kidney protection 1
• Do not continue dapagliflozin during acute illness when oral intake is reduced, as this significantly increases the risk of volume depletion and ketoacidosis 3

Monitoring Requirements

• Assess renal function prior to dapagliflozin initiation and periodically thereafter 3, 2
• Monitor volume status carefully, especially in patients on concurrent diuretics or with low systolic blood pressure 3
• For CKD stage 3, laboratory evaluations are generally indicated every 6-12 months; for stage 4, every 3-5 months 1