Diet and Nutrition Goals for People with Stage 3 Chronic Kidney Disease

There is no single kidney diet that fits everyone with kidney disease because the individual diet is determined by existing kidney function, lab values, body size, nutritional status and health history.

There are five stages of chronic kidney disease (CKD), based on glomerular filtration rate (GFR), a measure of the kidney’s ability to filter fluid and remove wastes from the blood. People with stage 3 CKD have a GFR between 30-59 ml/min, compared to a normal GFR of 90-120 ml/min. Once your GFR is determined, your doctor will establish a kidney diet prescription for you. Your dietitian will assess your current diet, weight history and appetite to decide daily nutrient targets and a meal plan to help you meet those targets.

What are the most important diet goals for stage 3 CKD?

In stage 3 CKD, the kidneys still function sufficiently to remove fluid, potassium and a moderate amount of waste. Adhering to diet goals includes the management of:

• Blood pressure
• Glucose
• Lipids
• Weight
• Vitamins
• Hormones
• Minerals

Managing waste in the blood is important in stage 3 CKD. Blood urea nitrogen (BUN) and creatinine are waste products that accumulate in the blood and are measured to assess kidney function. Normal values are:

• BUN: 10-20 mg/dL (3.6-7.1 mmol/L)
• Creatinine:
• 0.5-1.1 mg/dL (44-97 mmol/L) for women
• 0.6-1.2 mg/dL (53-106 mmol/L) for men

Changes that occur in the kidneys in stage 3 upset bone and mineral balance, causing the hormone called parathyroid hormone (PTH) to rise above normal. The Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines recommend measuring PTH, calcium and phosphorus after diagnosis and then every 12 months. The target ranges for stage 3 CKD are:

• PTH: 35-70 pg/mL (3.85-7.7 ppmol/L)
• Phosphorus: 2.7-4.6 mg/dL
• Calcium: 8.5-10.2 mg/dL

Which nutrients do I focus on for stage 3 kidney disease?

Calories

Adequate calories can either prevent weight loss if you are at a desirable weight or provide extra calories for weight gain if you are underweight. Making changes in your diet may cause weight loss, so weigh yourself and keep track to see if you need additional calories. If you are overweight or obese, you may find that diet changes help you lose weight. Your dietitian will determine a desirable weight and monitor your progress.

Fats and cholesterol

If you have cardiovascular disease or your blood cholesterol is high, unhealthy fats — such as saturated fats and trans-fats — should be replaced by poly- and monounsaturated fats from vegetable oil, canola oil and olive oil. A limit on high cholesterol foods is recommended.

Fluid

Fluid is not restricted in stage 3 CKD unless you experience fluid retention. Signs of fluid retention include sudden weight gain; shortness of breath; swelling in the feet, hands and face; and high blood pressure. These symptoms may indicate a decline in kidney function and decreased urine output.

Phosphorus

This mineral may be limited because reduced kidney function causes phosphorus to build up in your blood. This can impact bone and heart health. Based on calcium, phosphorus and PTH results, your stage 3 CKD diet may limit foods high in phosphorus. A diet with no more than 800 mg phosphorus can help. First, focus on avoiding foods with phosphate additives then adjust foods with naturally occurring phosphates, such as:

Cheese	Chocolate
Ice cream	Legumes
Milk	Nuts
Seeds	Yogurt

If PTH is higher than expected, a special active vitamin D pill may be prescribed to help lower it. Some patients may have low calcium levels and thus require a calcium supplement. Your doctor also may prescribe a nutritional vitamin D supplement if your vitamin D level is too low.

Potassium

Usually, potassium is not restricted in stage 3 CKD unless lab tests show potassium is too high. A high potassium level is typically related to potassium-sparing diuretics, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prescribed to reduce protein in the urine or other blood pressure management medications. Your doctor may make medication changes or prescribe a low-potassium diet. Reduce an elevated potassium level by avoiding some high-potassium foods; potassium chloride (found in salt substitute and many low-sodium processed foods); and limiting your daily servings of fruit, vegetables and milk. Some high-potassium foods include:

Bananas	Avocado
Cantaloupe	Honeydew
Legumes	Milk
Nuts	Potatoes
Seeds	Tomato products (juices, sauces, paste)
Yogurt

Your dietitian will assess your usual intake and provide instructions on ways to control your potassium.

Protein

The recommendation for protein intake in stage 3 is 0.8 g/kg body weight. This is the same as is recommended for a healthy adult and equals 55 g of protein a day for a person weighing 150 pounds or 68 kg. However, a healthy 150-pound American adult often eats more protein, averaging 88 g of protein a day. As you adjust your diet by incorporating recipes and meals with lower amounts of high-protein foods, you will find changing your protein intake is not difficult to do.

On a lower-protein diet, at least half of your protein comes from high-quality protein foods that contain all the essential amino acids (protein building blocks your body needs), such as:

Egg whites	Fish
Poultry	Meat
Milk (small amounts)	Yogurt (small amounts)
Cheese (small amounts)	Soy

In addition, nuts, seeds, legumes, grains and vegetables contain protein but may be missing some of the essential amino acids. For vegetarian and vegan diets, there is concern that higher amounts of phosphorus and potassium will be consumed and that there are inadequate amounts of essential amino acids. With the right meal plan, you can continue a vegetarian or vegan diet and stay well nourished. Vegetarians may find it easier than meat eaters to limit protein in their diet.

To estimate your protein goal based on 0.8 g/kg, divide your weight in pounds by 2.2, then multiply the answer by 0.8. The answer is your daily protein intake in grams.

Sodium

Limiting salt and high-sodium foods reduces high blood pressure, assists blood pressure medications to work more effectively and treats fluid retention. The sodium recommendation for stage 3 CKD is 1,000-4,000 mg/day based on blood pressure, fluid balance and the presence of other diseases that may affect sodium requirements. The average American consumes 3,700 mg of sodium a day. A good starting place for your stage 3 CKD diet is 1,500-2,000 mg/day or the amount recommended by your doctor or dietitian.

Sticking with your diet and nutrition goals

When you have stage 3 CKD, it’s important to know what your diet and nutrition goals are. Adhering to your doctor or dietitian’s kidney diet prescription could help slow the progression of the kidney disease and improve your quality of life.

Related articles on DaVita.com

• Hidden Phosphorus in Your Diet and How to Control It
• Seasoning the Low Sodium Way
• Top 15 Healthy Foods for People with Kidney Disease