Cheese, dairy, dairy free alternatives and eggs
Dairy foods provide an important contribution to a balanced diet. They are a good source of calcium (see the section on Calcium, Phosphorus and Bone) and protein (see the section on protein intake for haemodialysis patients) however, they can also be a source of excess sugar, fat, potassium and phosphate.
Milk products are made into cheese, yoghurt and cream and within each of these, there are several variations. For example, it is possible to buy milk with different fat percentages or it can be used to make milky drinks such as chocolate milk. The nutritional content of these will vary such that some types of milk and its products may be of benefit to certain individuals with a kidney condition, whilst others will be of less value or even detrimental. Increasingly, non-dairy milk is becoming available.
The information below is designed for people who have a kidney condition and have been advised to be cautious with their diet.
Too much milk is discouraged in people with a kidney condition because it contains some potassium and phosphate (see sections on potassium and calcium, phosphorus and bone). A glass of milk (250mls) can contain approximately 15% of the daily potassium that a 70kg man can receive on a low potassium diet and 25% of the daily phosphate intake allowed. Therefore, milk should be limited to a maximum of 200mls per day.
Non-dairy milk can have variable quantities of phosphate and potassium. This is mainly due to additives such as tricalcium phosphate. So, ideally focus on unfortified, organic and/or unsweetened varieties. Rice, almond and oat milk are naturally low in phosphate and potassium. Soy milk is higher in phosphate and potassium, but still lower than dairy milk. Coconut milk is similar to dairy milk in phosphate but lower in potassium.
Non-dialysed patients with advanced chronic kidney disease and those undergoing maintenance haemodialysis or chronic peritoneal dialysis should be prescribed a dietary energy intake of 35 kcal/kg/day for patients who are <60 years of age and 30 kcal/kg for patients ≥60 years of age (1,2,3). Overweight or undernourished patients may need adjustments of energy supply. Carbohydrates equate to 50-60% of daily total energy intake and fat should account for 30-40%. Carbohydrates from sugars should be limited to less than 10% of energy intake, and higher polyunsaturated and monounsaturated fat consumption rather than saturated fatty acids, trans-fat and cholesterol are associated with more favourable outcomes (4). The KDIGO Clinical Practice Guidelines for Diabetes and CKD recommends that 40-45% of calories from carbohydrates should come from whole grains, fruit and vegetables  and the Kidney Disease Outcomes Quality Initiative (KDOQI)’s ‘Guidelines on Dyslipidemia’ recommends 20–30g/day of fibre . Patients treated with peritoneal dialysis absorb calories from the glucose in the dialysis fluid and this should be included in the calculation of dietary energy intake. Approximately 90% of the glucose is absorbed during dwells over 8h, and about 70% is absorbed during shorter dwells; therefore, the amount of carbohydrate absorbed in each exchange can be estimated (7). Replacing saturated with polyunsaturated fats may modulate hyperlipidaemia. In patients with hypercholesterolaemia, a diet including ≤30% of energy as fat, 10% saturated fatty acids and less than 300mg/day dietary cholesterol intake is recommended (8).
Resting energy expenditure (REE) is normal in stable maintenance chronic kidney disease and dialysis patients. During haemodialysis, studies have found an increase of 12-20% in the presence of co-morbidities, severe hyperparathyroidism, inflammation and poorly controlled diabetes (9,10,11,12). Decreased physical activity, leading to a reduction rather than an increase in total energy expenditure might have mitigated the increased REE (13).
Siren Sezer, Turkey
- Clinical Practice guidelines for nutrition in chronic renal failure.K/DOQI, National Kidney Foundation. Am J Kidney Disease 2000;35:S1-140
- Fouque D, Vennegoor M, ter Wee P et al. EBPG guidelines on nutrition. Nephrol Dial Transplant 2007;22 suppl 2:45-87
- Toigo G, Aparicio M, Attman PO,et al. Expert working group report on nutrition adult patients with renal insufficiency (part 2 of 2). Clin Nutr 2000;19:281-291
- Gang JK, Kalantar-Zadeh K, Goldstein-Fuchs J, Rhee CM. Review Dietary Approaches in the Management of Diabetic Patients with Kidney Disease.Nutrients 2017, 9, 824. doi:10.3390/nu9080824
- National Kidney Foundation (2007) KDOQI™ clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis 49(suppl 2):S1–S180
- Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group (2013) KDIGO clinical practice guideline for lipid management in chronic kidney disease. Kidney Int Suppl 3:259–305
- Wolfson M. Management of Protein and Energy Intake in Dialysis Patients J Am Soc Nephrol 1999;10: 2244–2247
- Toigo G, Aparicio M, Attman P-O etal (2000) (ESPEN) Expert Working Group report on nutrition in adult patients with renal insufficiency (part 1 of 2). Clin Nutr 19:197–207
- Neyra R, Chen KY, Sun M, Shyr Y, Hakim RM, Ikizler TA. Increased resting energy expenditure in patients with end-stage renal disease. JPEN J Parenter Enteral Nutr. 2003;27:36-42.
- Cuppari L, de Carvalho AB, Avesani CM, Kamimura MA, Dos Santos Lobao RR, Draibe SA. Increased resting energy expenditure in hemodialysis patients with severe hyperparathyroidism. J Am Soc Nephrol. 2004;15: 2933-2939.
- Avesani CM, Cuppari L, Silva AC, Sigulem DM, Cendoroglo M, Sesso R, et al. Resting energy expenditure in pre-dialysis diabetic patients. Nephrol Dial Transpl. 2001;16:556-565.
- Utaka S, Avesani CM, Draibe SA, Kamimura MA, Andreoni S, Cuppari L. Inflammation is associated with increased energy expenditure in patients with chronic kidney disease. Am J Clin Nutr. 2005;82: 801-805.
- Avesani CM, Trolonge S, Deleaval P, Baria F, Mafra D, FaxenIrving G, et al. Physical activity and energy expenditure in haemodialysis patients: an international survey. Nephrol Dial Transpl. 2012;27:2430- 2434.
In the early stages of kidney disease, it is not necessary to limit fluid intake.
If your kidney disease gets worse, your dietician or nephrologist will advise you on the amount of fluids to consume each day.
Reducing liquid consumption may be difficult for haemodialysis patients when it is recommended to increase this in end-stage renal failure. Due to the decrease in diuresis (amount of urine produced), water (and waste) is accumulated. It is therefore essential to remove the excess to avoid fluid overload causing fatigue to the heart. Reducing the consumption of liquids limits weight gain between dialysis sessions. Excessive weight gain between sessions can lead to a drop in blood pressure and significant fatigue after dialysis.
What are the recommendations?
They concern all fluids and not just water.
In case of diuresis: equivalent in volume to your diuresis plus 500 to 750ml of fluid.
In case of anuria: 500 to 750ml of fluids per day.
We tend to overestimate the water intake of food and wrongly stigmatise certain foods because of the specific juices it releases.
Overall, a day of food consumption (not counting the intake of liquids) equates to 1L of water.
Stanislas Trolonge, France
- Tea, coffee, chicory
- Still or sparkling water
- Soups and broths
- Sugary drinks
Tips to limit your liquid consumption
- Use smaller containers: a small cup instead of a larger one to reduce the amount of liquid consumed.
- To quench your thirst, suck ice cubes or frosted orange or lemon slices. Thus, you limit the intake of liquids.
- Some tablets or powders that need to be diluted can be swallowed with food, which avoids an additional intake of liquids.
- During hot weather, drink cool beverages or use a fan to cool off.
- Avoid overheated rooms. You can humidify the surrounding air by placing a water container on the radiator.
- Alcoholic or sweet drinks do not quench your thirst; they will make you even thirstier.
- As an aperitif, avoid drinks that require adding water (e.g. aniseed aperitif …).
Fruit and Vegetables
Fruit and vegetables are essential for health as they provide a range of vitamins and minerals as well as being an excellent source of fibre. They are also low in fat.
There are concerns that some fruit and vegetables are very high in potassium (see section on potassium). Taking this into consideration, some useful tips can be found below to help you decide which fruit and vegetables are best to consume and how to prepare them.
Fruit and vegetable juices tend to be very high in potassium and best avoided, as are soups made from vegetables.
Vegetables Cooking methods
Reducing the load of dietary potassium is recommended in case of, or to prevent, hyperkalaemia in CKD or dialysis. One of the strategies is cooking food. Fruit and vegetables are foods rich in potassium. Proper cooking methods significantly reduce the food’s potassium content once cooked.
Cooking by boiling in plenty of water lowers the potassium content of vegetables.
Double cooking is recommended for cooking vegetables, fruit and potatoes.
In practice, two saucepans of water will be boiled at the same time so as not to waste time.
Recommendation: If you peel vegetables (e.g. potatoes) before boiling, this will further increase the potassium loss.
The initial cooking of the food will take place in the first saucepan of water for 10 to 15 minutes. This cooking water should then be thrown away. The food will then be deposited in the second saucepan of boiling water to finish cooking. For additional flavour, food can be sautéed in a frying pan using fat, herbs and spices.
Ask your nephrologist or dietician for advice on the best choice of foods, recommended portions and recipes using these cooking techniques.
The table splits the vegetables into different portions depending on their potassium content. Following the table as a guide, it is, therefore, possible to combine slightly more low-potassium vegetables when preparing a meal. All the vegetables on the table are boiled unless otherwise stated. Potatoes are not included but should be boiled to lower their potassium content.
Lina Johansson, United Kingdom
Stanislas Trolonge, France
Nowadays, everyone knows that you have to move, even just a little, and that physical activity is a real medicine. Physical activity is a weapon against chronic diseases.
However, dialysis patients are generally very sedentary (1). This sedentary lifestyle is associated with excess mortality, whereas, conversely, physical activity has many benefits in terms of physical performance, quality of life, improved sleep, reduced anxiety, asthenia (2) and mortality reduction (3).
There are many obstacles related to practising physical activity, the time already spent on dialysis (12 hours per week excluding transport) is one of the main complaints received from patients (4). However, asthenia, chronic deconditioning, and from a clinical perspective, lack of means and/or competent staff are also contributing factors
In the case of patients with chronic kidney disease, physical activity must be supervised, at least initially, by a physical activity professional. He/she will be able to make a complete evaluation in order to establish the most suitable “prescription” of physical activity for each patient.
There are many ways to increase physical activity: predialysis exercise, participating in various group workshops or following a personalised programme at home. Activities in daily life are also a way to get moving: walking the dog, gardening, going on foot to the store to buy bread or doing the housework etc.
It is important to remember that any increase in physical activity, even minimal, may be beneficial, so we must move whenever possible! Do not hesitate to talk about physical activity with your doctor!
Catherine Lasseur, France
- Phenotypes influencing low physical activity in maintenance dialysis. Panaye M, Kolko-Labadens A, Lasseur C, Paillasseur JL, Guillodo MP, Levannier M, Teta D, Fouque D. J Ren Nutr. 2015 Jan;25(1):31-9.
- Physical activity in dialysis population: how and why to assess and establish a program? Kolko Labadens A, Lasseur C, Labat T, Trolonge S, Chauveau P. Nephrol Ther. 2014 Jun;10(3):151-8.
- Physical exercise among participants in the Dialysis Outcomes and Practice Patterns Study (DOPPS): correlates and associated outcomes. Tentori F1, Elder SJ, Thumma J, Pisoni RL, Bommer J, Fissell RB, Fukuhara S, Jadoul M, Keen ML, Saran R, Ramirez SP, Robinson BM. Nephrol Dial Transplant. 2010 Sep;25(9):3050-62. doi: 10.1093/ndt/gfq138. Epub 2010 Apr 13.
- Barriers to exercise participation among dialysis patients. Delgado C1, Johansen KL. Nephrol Dial Transplant. 2012 Mar;27(3):1152-7. doi: 10.1093/ndt/gfr404. Epub 2011 Jul 26.
Sodium, together with potassium and chloride, is one of the three major electrolytes in the body. Sodium contributes to the regulation of blood pressure and volume, the transmission of impulses for nerve function and muscle contraction.
The relationship between salt intake and blood pressure was discovered about 4,000 years ago when Chinese emperor Huang Ti drew a connection between salt and a “hardened pulse”. Today, salt is the most suspected environmental factor that may influence blood pressure and atherogenesis. The World Health Organisation recommends a reduction to < 2g/day sodium (5g/day salt) in adults, which helps to prevent blood pressure-related cardiovascular events and strokes (1).
Public awareness about the potentially adverse role of high sodium chloride consumption was first raised by a study in Finland that showed high sodium intake predicted mortality, particularly in males and overweight individuals during a 17-year follow-up (2).
According to the meta-analysis by Feng J He et al, a modest reduction in salt intake for four or more weeks causes a significant fall in blood pressure in both hypertensive and normotensive individuals, irrespective of sex and ethnic group (3).
The exaggerated blood pressure response to dietary salt intake affects approximately 50% of hypertensive patients and 25% of normotensive adults (4).
The risk of salt sensitivity increases with age, the presence of obesity or diabetes and a decline in renal function. Guidelines from the KDIGO (in ‘Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease’) recommend lowering salt intake to 90mmol (2g) per day of sodium (corresponding to 5g of sodium chloride) in adults unless contraindicated (5).
Salt restriction is not recommended in patients with salt-wasting nephropathies and those prone to hypotension and volume contraction. In the early stages of chronic kidney disease, increased salt intake contributes to the prevalence of hypertension and proteinuria. For the same amount of salt intake, patients with kidney disease show a higher hypertensive response than those with normal renal function (6).
Dietary salt excess may also attenuate the antihypertensive and antiproteinuric effects of antihypertensive drugs (7,8).
Although there is some evidence that salt ingestion could attenuate kidney damage independent of blood pressure, the data searching for the association between dietary sodium restriction and the progression of kidney disease and mortality is not supportive (9).
From a historical perspective, salt was primarily used to preserve food. In industrialised countries, most sodium intake comes from salt added during food processing. Convenience foods such as fast food, frozen dinners, packaged side dishes, sauces, snacks, ready-made soups, cheese and pastry may be high in sodium. Salt might have been added to processed food like meat, bread and cereals to retain moisture and enhance flavour. Restaurant meals and fast food may also contain high amounts of salt.
Tips to decrease sodium intake:
- Prepare meals from fresh food.
- Try to use fresh poultry, fish and meat rather than canned, smoked or processed products.
- Avoid fast foods, frozen dinners and canned foods.
- Use sodium-free seasonings to add flavour to your food instead of salt including herbs, spices, garlic, shallots, parsley, onion and lemon juice.
- Check the sodium content on food labels for sauces, snacks etc. A daily value of 20 per cent or more means the food item is high in sodium.
- Look for terms like sodium-free or salt-free, low, reduced, or no salt or sodium; or unsalted or lightly salted on labels.
- Beverages might contain added sodium, so check the ingredients.
- Baked food may include salt, therefore consume bread products low in sodium or without any added salt.
- Dietary salt or low-salt foods may contain salt substitutes rich in potassium so check for their potassium content.
- Rinsing with water will decrease the sodium, potassium and phosphorus in canned food, beans, meats and fish; so rinse with water.
Siren Sezer, Turkey
Sodium and fluid intake in dialysis patients
Sodium accumulation is one of the consequences of renal failure, resulting in increased water intake, an increase in the extracellular volume and a rise in blood pressure (10). Strict volume control is associated with improved control of hypertension and prolonged survival in those on haemodialysis (11,12).
The ability of patients with kidney disease to detect or taste salt in food is often impaired (13). This may contribute to high levels of sodium in the body due to an increase in dietary consumption.
The kidney patient on a high sodium diet might complain about thirst, oedema and shortness of breath. Reducing dietary sodium intake will help to control blood pressure and fluid intake. In these patients, effective management of hypertension requires normalisation of sodium balance and volume excess through reaching the ideal dry weight (14,15).
Sodium intake in renal transplant patients
Reducing sodium intake is also recommended for patients with kidney transplants. In hypertensive kidney transplant patients, low sodium intake combined with antihypertensive therapy results in significantly decreased blood pressure versus those on therapy without sodium restriction (16).
The issue of high salt intake in chronic kidney disease patients resembles that of blood glucose control in diabetics. Gaining a self-management approach and autonomy in dietary habits should be an absolute priority in patients’ lives.
Remember: one teaspoon of salt has about 2,300mg of sodium, which is the recommended amount for the entire day!
Vitamins do not contain any calories. They serve the great functions of life (Vitamin A helps our sight, Vitamin D the bones and the B vitamins help the nervous system and hematocrit etc …).
We classify them into two groups:
- Fat-soluble vitamins that are soluble in fats: Vitamins A, D, E and K.
- Water-soluble vitamins that are soluble in water: Vitamins C, B1, B3 or PP, B5 or Pantothenic acid, B6, B8 or Biotin, B9 or Folic acid and B12.
Philippe Chauveau, France