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Are You Getting What You Need?

Nutrition and ChronicKidney Disease (Stages 14)

www.kidney.org


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NATIONAL KIDNEY FOUNDATION2

* Your GFR number tells your doctor how much kidney func-tion you have. As chronic kidney disease progresses, yourGFR number decreases.

National Kidney Foundations

Kidney Disease OutcomesQuality InitiativeDid you know that the NationalKidney Foundations Kidney DiseaseOutcomes Quality Initiative (NKF-KDOQI) develops guidelines thathelp your doctor and health careteam make important decisionsabout your medical treatment? Theinformation in this booklet is basedon the NKF-KDOQI recommendedguidelines for anemia.

Stages of ChronicKidney DiseaseThere are ve stages of chronickidney disease. They are shown in

the table below. Your doctor deter-mines your stage of kidney diseasebased on the presence of kidneydamage and your glomerular ltra - tion rate (GFR) , which is a measureof your level of kidney function.

Your treatment is based on yourstage of kidney disease. Speakto your doctor if you have anyquestions about your stage ofkidney disease or your treatment.

Stages of Kidney DiseaseStage Description Glomerular Filtration

Rate (GFR)*1 Kidney damage (e.g., protein in the urine) with normal GFR 90 or above2 Kidney damage with mild

decrease in GFR 60 to 893 Moderate decrease in GFR 30 to 594 Severe reduction in GFR 15 to 295 Kidney failure Less than 15


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Why is good nutrition importantfor people with kidney disease?

Making healthy food choices isimportant to us all, but it is even

more important if you have chronickidney disease (CKD). Why? Goodnutrition gives you energy to:

n do your daily tasks

n prevent infectionn build muscle

n help maintain a healthyweight

n keep your kidney disease fromgetting worse.


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Will I need to change my diet if

I have kidney disease? There is no one eating plan thatis right for everyone with kidneydisease. What you can or cannoteat will change over time,depending on how much kidneyfunction you have and otherfactors, like having diabetes, forexample. Your doctor can refer you

to a dietitian with special trainingwho can teach you how to choosefoods that are right for you.

What are the basics of goodnutrition?

A healthy eating plan gives youthe right amount of:

n protein

n calories

n vitamins

n minerals.

You will need to choose foodsthat give you the right amountsof protein, calories, vitamins andminerals each day. This will helpto keep you healthy and fit. It mayalso help to keep your kidneydisease from getting worse.


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Why do I need protein?

Protein is an important nutrient.

Your body needs protein to helpbuild muscle, repair tissue andfight infection. But if you havekidney disease, you may need toclosely monitor the protein youeat to prevent protein wastes frombuilding up in your blood. This canhelp your kidneys work longer. Yourdoctor will tell you if you need to

limit how much protein you eat

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If you need help finding a dietitianwho specializes in kidney disease,you can ask your doctor for a referralor contact the American DieteticAssociation at 800.877.1600 ( www.eatright.org )


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each day. Decisions are based on

stage of kidney disease, the statusof nutrition, muscle mass, and otherfactors. It is important that yourprotein intake is not too low, either.Let the experts help you.

You get protein from:n red meats (beef, veal, lamb)

n pork

n poultry (chicken and turkey)n fish and other seafood

n eggs

n vegetables and grains.* Your dietitian can help you lea rnhow to maintain good nutrition,eat the right amount of protein

and help your kidneys too.

TIP

*This food list is not complete.

There are two kinds of proteins.Higher quality proteins are foundin animal products like meat,poultry, fish and eggs. They are theeasiest proteins for your body to use.Lower quality proteins are found

in vegetables and grains. A well-balanced diet for kidney patientsshould include both kinds of proteinsevery day.


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How many calories do I need?

Every person is different. Caloriesare like fuelthey provide yourbody with the energy you need tolive. They are important becausethey:

n help you stay at a healthybody weight

n give you energy to do yourdaily tasks and remain active

n help your body use the proteinin food to build muscles andtissues. (Without enoughcalories, your body will "waste"protein to provide you withenergy instead of using proteinto build your muscles andtissues.)

It is important to plan meals thatgive you enough calories eachday. Otherwise, your body maynot have the energy you need

to stay healthy. Your dietitian canhelp you do this. Some peoplemay be advised to eat morecalories. They may need to eatextra sweets like sugar, jam, jelly,hard candy, honey and syrup.Other good sources of caloriescome from fats such as soft (tub)margarine and oils like canola or

olive oil.


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How do I get enough vitamins

and minerals?Do you know how most peopleget enough vitamins and mineralsto stay healthy? By eating awide variety of foods each day.However, if you have kidneydisease, you may need to limitsome foods that would normallygive you important vitamins and

minerals. If so, you may need totake special vitamins or mineralsinstead. Other tips:

n Take only the vitamins

and minerals your doctorrecommends, because somevitamins and minerals may beharmful to people with CKD.

n Check with your doctor beforetaking any herbal supplementsor medicines you can buywithout a doctors prescription.Some may be harmful to

people with kidney disease. Your doctor and dietitian will tellyou which are good choicesfor you.


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How will I know if I am getting

enough calories and nutrients? Your doctor will give you bloodtests and urine tests. These willhelp show whether or not you aregetting enough nutrients. You mayalso be asked to keep a fooddiary. Additionally, your dietitianmay interview you to find outabout the foods you eat. To learn

more about the tests your doctorand dietitian will use to checkyour nutrition, see page 25.

What if I don't want to eat or

don't like my food choices?As a person with CKD, it may bedifficult to get enough nutrientsfrom food, especially if you are

on a limited-protein diet. Manypeople with kidney disease alsofind it hard to eat enough calorieseach day. Nutritional supplementscan help you get the calories

TIPS

n Ask your doctor or dietitian whichtests will be used to check yournutritional health.

n Discuss the results of the tests withyour doctor or dietitian.


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and nutrients you need. Ask yourdietitian if they are right for you.Supplements can come in theform of liquid drinks, shakes, juices,bars, soups, cookies, puddingsand more. Many supplements are

available, but some nutritionalsupplements are made just forpeople with kidney disease,diabetes or kidney failure. Some

examples of supplements suitablefor people with kidney disease are:

n Renalcal

n

Suplena

with Carb Steady

.*If you have been taking asupplement for people withdiabetes, speak with your doctor

about whether you shouldcontinue taking it. Examples ofthese are:

n Boost Glucose ControlBeverage

n Glucerna shakes, cerealsor bars

n Nutren G lytrol

n Re/Gen Reduced Sugarformula

n Resource No Sugar AddedHealth Shake .*


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TIP

If you have diabetes and c hronickidney disease (CKD), ask your dieti-tian how to get the right amount ofcalories and keep your blood sugarin control. Adding sweet, high-caloricfoods to your meals may not be agood choice for you.

An example of a supplementfor a person with diabetes and

kidney disease is:n Suplena with Carb Steady .

Ask your doctor about whichdietary supplements that supplyextra calories, protein and nutrientswould be best. Examples are:

n Boost Plus Drinks, BoostSmoothie or Boost High-Protein Drinks

n Carnation Instant Breakfast Drinks

n Carnation Instant Breakfast

VHCn Enlive Drinks

n Ensure Shakes (Ensure Fiber,Ensure High-Calcium, Ensure

Plus)n Resource Breeze .*

Check with your doctor or dietitianbefore taking any supplement. *This list does not contain all available products.


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How will I know if I need anutritional supplement?

Your doctor and dietitian willtell you if you need to takenutritional supplements. Use onlythe supplements recommendedby your doctor or dietitian.Remember, not all people withkidney disease have the same

dietary needs. Depending onwhat you eat, you may needless protein, but someone elsemight need extra protein. Oryou may need extra calories,but someone else might needfewer calories. Your dietitianwill help you choose the rightsupplements for you.


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n most canned foods andfrozen dinners (unless they say"low sodium")

n processed meats like ham,bacon, hot dogs, sausageand deli meats

n salted snack foods like chipsand crackers

n canned or dehydrated soups

(like packaged noodle soup)n most restaurant foods, take-

out foods and fast foods.*

Your dietitian can teach you howto choose foods that are lowerin sodium. Learning how to readfood labels can help you choosefoods with less sodium.

TIPS

n Do NOT use salt substitutes unlessapproved by your doctor.

n Try fresh or dried herbs andspices instead of table salt toenhance the flavor of foods.When you limit salt, you mayhave to use more herbs andspices to get more flavor. Also,try adding a dash of hot peppersauce or a squeeze of lemon

juice for flavor.


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in your blood may also causecalcium to build up in your bloodvessels, heart, joints, muscles andskin where it does not belong.

This may cause serious problemssuch as:

n damage to the heart andother organs

n poor blood circulation

n bone painn skin ulcers.

To keep phosphorus at safe levelsin your blood, you may need tolimit phosphorus-rich foods. Youmay also need to take a type ofmedicine called a phosphatebinder . These binders are taken

with your meals and snacks. Yourdoctor will tell you if you needto limit high-phosphorus foods ortake phosphorus binders.


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TIP

Using non-dairy creamers andrecommended milk substitutes inplace of milk is one way to lowerthe amount of phosphorus in yourdiet.

Calcium

Calcium is a mineral that isimportant for building strongbones. However, foods that aregood sources of calcium areoften also high in phosphorus.

The best way to prevent loss

of calcium from your bonesis to limit high-phosphorusfoods. You may also need totake phosphate binders andavoid eating calcium-fortifiedfoods. Your doctor may haveyou take a special form ofvitamin D as well to help keepcalcium and phosphorus levels

in balance and to preventbone disease. Do not takeover-the-counter vitamin D orcalcium supplements unlessrecommended by yourkidney doctor .


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Fluid

Most people with kidney diseasedo not need to limit the amountof fluids they drink if they arein the earlier stages of kidney

disease. [If you do not know yourstage of kidney disease, ask yourdoctor or contact the NationalKidney Foundation for additionalinformation (800.622.9010).]

If your kidney disease gets worse,your doctor will let you know ifyou need to limit fluids and how

much fluid is okay for you eachday. You also want to avoiddehydration, so let the expertshelp you plan.

TIPS

How do you know if your potassiumis normal? A simple blood test cancheck your potassium level. If it is notnormal, you may need to take:

n p otassium supplements

n special medicine to help getrid of too much potassium .

Take only the supplements yourdoctor recommends. Your dietitiancan help you plan a diet thatwill give you the right amount ofpotassium.


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What if I have diabetes?

You may need to make a fewchanges in your diet if you havediabetes and kidney disease.If your doctor says that youshould eat less protein, yourdiet may need to include morecarbohydrates or high-qualityfats to give you enough calories.Work with your dietitian to make

TIPS

n Learn to read food labels soyou know what you are eating.Reading labels can help youshop for foods with lower sodiumand to check for addednutrients that may not be bestfor you.

n Herbs, spices, table wine andspecial vinegar can be usedinstead of salt to make yourfood flavorful. Try purchasing orgrowing fresh herbs. Try addinga dash of hot pepper sauce or asqueeze of lemon juice for flavor.Ask your dietitian for a list ofherbs and spices that blend with

different types of foods.n Non-dairy c reamers can be used

in place of milk in cereals, coffeeand many sauces. This is a goodway to lower the amount of

phosphorus in your diet.


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a meal plan that is right for

you. Ask your doctor how oftento test your blood sugar level. Try to keep your levels undercontrol. Your dosage of insulin orother medications may need tochange if your kidney diseasegets worse. Contact your doctorif your blood sugar levels are toohigh or too low.

What if Im a vegetarian?

Most vegetarian diets are notrich in higher quality protein. Buteating a variety of foods andgetting enough calories canhelp. Without enough calories,your body will break down theprotein you eat to create energy

instead. If protein is broken down,more waste products have tobe removed by your kidneys.Ask about ways to check that


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the amount of protein you are

eating is right for you. Talk withyour dietitian about the bestsources of vegetable proteinwith lower amounts of potassiumand phosphorus. Your doctor ordietitian can check your bloodto make sure you are gettingthe right amount of proteinand calories.

What if I need helpplanning meals?

Your doctor can refer you to a

registered dietitian with specialtraining in kidney disease. Thisdietitian can:

n help you choose foods thatwill give you the right nutrientsin the right amounts

n explain why the diet changesyou need to make areimportant

n answer your questions.

TIP

Help from a dietitian is very important

for people with kidney disease. Youmay be eligible for reimbursement fornutrition counseling with a dietitianunder Medicare or under your healthinsurance plan.(See www.medicare.gov .)


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Where can I get more

information? You can speak to your doctor orother members of your healthcare team, or you can call theNational Kidney Foundation forinformation (800.622.9010). To learnmore about kidney disease, youmay also want to read some of thefree publications from the National

Kidney Foundation:

Brochures:n About Chronic Kidney

Disease: A Guide for Patientsand their Families (English 11-50-0160; Spanish11-50-0166)

n Diabetes and Chronic KidneyDisease (Stages 1 4) (English 11-10-0209;Spanish 11-10-0240)

n Dining Out with Confidence: A Guide for Kidney Patients (11-10-0405)

n GFR (Glomerular FiltrationRate): A Key to Understanding

How Well Your Kidneys AreWorking (11-10-1813)


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n Staying Fit with Kidney Disease(11-10-0502)

n Your Kidneys: Master Chemistsof the Bod y (11-10-0103).

Fact Sheets:

Fact sheets can be found onlineat: www.kidney.org/atoz/

n How to Increase Calories in

Your CKD Dietn Phosphorus and Your

CKD Diet

n Potassium and Your CKD Diet

n Sodium and Your CKDDiet: How to Spice Up YourCooking

n Vitamins and Minerals inKidney Disease.

For further information, contactthe National Kidney Foundationtoll-free: 800.622.9010 or visit ourWeb site at www.kidney.org .Also, for our local Affiliates andDivisions visit www.kidney.org/about/offices.cfm


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You will be checked regularly by yourdoctor and dietitian to make sureyou are getting good nutrition. Sometests are:

n Physical Nutrition Exam

Your dietitian may give you anexam to check your body forsigns of nutrition problems. This

exam is called a Subjective Global Assessment (SGA). Your dietitianasks you questions about yourfood intake and looks at the fatand muscle stores in your body.

The dietitian notes: changes in your weight

changes in the tissues aroundyour face, arms, hands, shoul-ders and legs

your food intake

your activity and energy levels

problems that might interfere

with eating.n Dietary Interviews and Food

Diaries

Your dietitian will ask about whatyou eat. You might also be askedto keep a diary of everything youeat each day. Your dietitian wantsto see if you are eating the rightamount of protein, calories, vita-mins and minerals.

How is my nutritional

health checked?

Continued


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n Serum Albumin

Albumin is a type of protein in yourblood. It is checked by a bloodtest. If your albumin level is too low,it may mean you are not eatingenough protein or calories. Or, it

may mean that albumin is beinglost in the urine, in which caseeating more protein wont help. Ifyour albumin level continues to below, you have a greater chanceof getting an infection, not healingproperly, not feeling well, andbeing hospitalized. Your doctor ordietitian will tell you if you needextra protein.

n nPNA (normalized protein equiv-alent of nitrogen appearance)

Your nPNA estimates how muchprotein you are eating. It helps yourdoctor and dietitian check to see if

you are eating the right amount ofprotein. The nPNA result comes fromurine and blood tests.


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How can I be my own best

advocate? To strengthen and unify the voicesof all people affec ted by CKD,the National Kidney Foundationestablished an organizationcalled "People Like Us ."

Who has joined "People Like Us" ? This growing movement includes

individuals with CKD, transplantrecipients, donors, family membersand others who are learningabout and taking action on issuesthat affect their health. Through"People Like Us ," those who careabout kidney diseases have newpower. Together, they can usetheir voice in the public policy

process. They can join in decision-making about the best treatmentoptions for "people like us."

To join in the efforts of this strongand effec tive patient advocacyorganization, please visit www.nkfpeoplelikeus.org or call us at800.622.9010. You can also e-mail

us at [email protected]


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TIP

If you have questions or are unsureabout anything, write down yourquestions before you go to yourdoctor or nutritionist. Once you arethere, it is easy to forget what youwanted to talk about. Make sureyou ask what each test result meansand what your options are. Youneed to understand the treatment

plan. It is your health, so neverfeel uncomfortable about askinganything. Make sure you are involvedin the decision-making process foryour health.


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Questions to ask:n Do I need to limit how much proteinI eat?

___ Yes ___ No

If I do, how many grams of proteinshould I eat?

n How many calories do I need?

n How many ounces of fluid are best

for me?

n Is my potassium level too high ortoo low?

___ Yes ___No

n Do I need a nutritional supplement? ___ Yes ___ No

If I do, which one is best for me?


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n Should I take vitamins? ___ Yes ___ No

If I should, which ones should I take?

Other questions:


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Notes


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National Kidney Foundation30 East 33rd Street

New York, NY 10016800.622.9010

www.kidney.org

National Kidney Foundation The National Kidney Foundation (NKF) is dedicated to preventingkidney diseases, improving the health and well-being of individuals

and families affected by these diseases and increasing theavailability of all organs for transplantation.With local offices nationwide, the NKF provides early detectionscreenings and other vital patient and community services. TheFoundation conducts extensive public and professional education,advocates for patients through legislative action, promotes organdonation and supports kidney research to identify new treatments.In 2009 NKF launched a groundbreaking multifaceted collaborativeinitiative to END THE WA IT! for a kidney transplant in the UnitedStates in 10 years by using proven strategies to eliminate barriers todonation and institute best practices across the country.

The NKF relies on individual and corporate donations, foundationand government grants, membership and spec ial events to supportits range of programs, services and initiatives.

We proudly state that this pub lication is printed on recycled

pa per that c ontains 10% post-consumer waste. The p ap er

is also Forest Stewa rdship C ounc il (FSC) certified whichguarantees it is made from trees that c ome from c arefully

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