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Stage 4 Kidney Disease Diet: Focusing on Nutrition

Disclaimer: This article is for informational purposes only and is not intended to be a substitute for medical advice or diagnosis from a physician.

When you have stage 4 chronic kidney disease (CKD), your diet goals should help minimize symptoms and help you maintain adequate nutrient intake to prevent weight loss and malnutrition.

Kidney function is severely decreased to only 15-29 percent of normal function in stage 4 CKD. Protein waste, toxins and minerals build up in the body and lead to uremia with symptoms such as nausea, vomiting, loss of appetite, abnormal taste, bad breath, nerve and sleep problems, difficulty concentrating and fatigue. Fluid retention due to a decrease in urine output may also occur in stage 4.

Knowing your nutritional goals can help you have a better quality of life when you have stage 4 CKD.

Protein and stage 4 CKD

On average, Americans consume 90-100 grams of protein a day, but our bodies only need about 46 (for women) to 56 grams (for men) of protein.

The Kidney Disease Outcome Quality Initiatives (K/DOQI) Nutrition Guidelines suggest that a protein intake of 0.6 grams per kg of body weight may be beneficial when glomerular filtration rate (GFR) drops below 25, or approximately 25 percent remaining kidney function. Ask your nephrologist or renal dietitian to calculate how much protein you should consume per day. Half of your protein should come from high-quality sources that provide all the essential amino acids (eggs, milk, poultry, seafood, red meats or soy).

This lower-protein diet is thought to have a protective effect on the kidneys. However, it also brings the risk of protein malnutrition, with muscle wasting and low albumin levels. Work with your dietitian to help monitor your nutritional status as well as the effectiveness of the diet.

Phosphorus and stage 4 CKD

As kidney function decreases, phosphorus is not removed from your body efficiently and can build up in the blood. At the same time, calcium is not absorbed well from your food, leading to low blood levels. In response, parathyroid hormone (PTH) production increase and causes a release of calcium and phosphorus from your bones. The loss of calcium and phosphorus from your bones causes bones to weaken and the increase of phosphorus and calcium in your body can cause calcifications in your heart, blood vessels and other soft tissues within your body. This can affect the bones, heart and blood vessels. Based on your lab results for phosphorus, calcium and PTH, your stage 4 CKD diet may include a phosphorus restriction of 800-1,000 mg daily.

If you are reducing protein, you will automatically limit phosphorus because high-protein foods contain a significant amount of phosphorus. Your main emphasis may be to avoid foods with phosphate additives, which are easily absorbed from the digestive track into the bloodstream. Check food ingredient lists for any type of phosphorus additive (phosphoric acid, hexametaphosphate, triphosphate, etc.). Many beverages and processed foods have these additives.

Other high-phosphorus foods to limit include:

Cheese

Chocolate

Ice cream

Legumes

Milk

Nuts

Seeds

Yogurt

High phosphorus may be treated with a diet low in phosphorus and phosphorus binders, medications that prevent the phosphorus in your food from being absorbed into the blood stream. If you have low calcium levels, a calcium supplement also may be required. However, total calcium intake may be limited to no more than 2,000 mg/day. If your PTH level is high, a special, calcitriol, the active form of vitamin D may be prescribed to help lower it. Your doctor also may prescribe a nutritional vitamin D supplement if your vitamin D level is too low.

The goals for phosphorus, calcium and PTH in stage 4 CKD are:

  • Phosphorus: 2.7-4.6 mg/dL
  • Calcium: 8.5-10.2 mg/dL
  • PTH: 70-110 pg/mL

Potassium and stage 4 CKD 

Potassium restriction may or may not be required in stage 4 CKD. If kidneys are not able to remove enough potassium to maintain normal blood levels in stage 4 CKD, you will need to limit high-potassium foods. If lab tests show potassium is too high, your doctor may prescribe a potassium restriction of 2,000-3,000 mg a day. A high potassium level may also be related to angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) prescribed to reduce protein in the urine, potassium-sparing diuretics or other blood pressure management medications and your doctor may make medication changes. To reduce high potassium, limit intake of high-potassium foods, and avoid foods with added potassium chloride. Many salt substitutes and low sodium foods contain potassium chloride. Your meal plan may limit your daily servings of fruit, vegetables and milk.

Some high-potassium foods to limit or avoid include:

Avocado

Bananas

Cantaloupe and honeydew melon

Dried Fruit

Legumes

Milk

Nuts and seeds

Oranges and orange juice

Potatoes

Pumpkin and winter squash

Tomato products (juices, sauces, paste)

Yogurt

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

Sodium and stage 4 CKD

Blood pressure medications work more effectively when you limit salt and high-sodium foods. A low-sodium diet may be prescribed to help treat fluid retention and control thirst if you are on a fluid intake limit. The sodium recommendation for stage 4 CKD is 1,000-4,000 mg/day based on fluid balance, blood pressure and other diseases that may affect sodium requirements. The average American consumes 3,700 mg of sodium a day. Most kidney diets start with a goal of 1,500-2,000 mg per day or the amount recommended by your doctor or dietitian.

Calories and stage 4 CKD

When you make changes in your diet, your calorie intake may decrease, resulting in undesirable weight loss. Decreasing your protein intake alone can result in 200-400 fewer calories a day. Weigh yourself and track your weight weekly to see if you need more calories. Ask your dietitian to help with setting realistic weight goals depending on your current weight. An increase in healthy fats and some concentrated carbohydrates may be recommended to boost calorie intake.

Supplemental drinks may also be recommended to help ensure adequate calorie intake. Your dietitian will provide information on the best products to meet your diet goals.

Fluid and stage 4 CKD

If you start to retain fluid in stage 4 CKD, you may need to limit the amount of liquids you consume. Signs of fluid retention include swelling in the feet, hands and face; sudden weight gain; shortness of breath; and high blood pressure. These symptoms may indicate decreased urine output as kidney function declines.

A better quality of life on a stage 4 kidney disease diet

The diet for stage 4 CKD can reduce buildup of minerals and waste and may help delay the need for dialysis or kidney transplant. Maintaining good nutritional status, while following the kidney diet for stage 4 CKD, is extremely important. You can plan meals and track your protein and mineral intake using the DaVita Diet Helper meal planner. Regularly visiting your doctor and dietitian, self-monitoring of weight and appetite and knowing your lab results will help you stay healthier while managing stage 4 CKD.

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