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The Vegetarian Diet and Chronic Kidney Disease

By DaVita renal dietitian Chhaya Patel, MA, RD, CSR

What is a vegetarian?

A vegetarian is a person who follows a specific diet and has specific food choices which include plant foods such as vegetables, fruits, grains, legumes, soy, nuts and seeds. Vegetarians do not consume meat, but depending on what type of vegetarian they are, they may eat other products from animal sources.

There are a few reasons why people choose a vegetarian lifestyle. According to a survey conducted in 2000 by the RPG (Renal Dietitians Practice Group), most vegetarians follow this diet due to ethnic tradition, spiritual or religious reasons, concern for animals, health concerns or a lack of taste for meat.

Most vegetarians fall into one of the following categories:

  • Lacto-vegetarians- This group excludes eggs, but consumes milk and other dairy products in addition to plant foods.

  • Lacto-ovo vegetarians- This group consumes eggs, milk, dairy products and plant foods.

  • Pesco-vegetarians- This group eats fish for health reasons, in addition to eating plant foods, dairy products and eggs.

  • Vegan- This group consumes only plant foods and no animal products.

Can I be a vegetarian if I have chronic kidney disease?

If you are diagnosed with chronic kidney disease (CKD) and are a vegetarian you can continue the practice. You do not have to start eating meat because you have CKD or have started dialysis. In order to combine your vegetarian lifestyle with a renal diet, you will need to devise a meal plan to fit your nutritional needs. You should talk with a renal dietitian about kidney-friendly foods that are vegetarian-specific. Here are some things your dietitian may help with for your new diet:

  • Monitor your calorie intake to make sure you are getting enough calories.
  • Include vegetarian sources of protein and calorie supplements when needed.
  • Increase your phosphate binders that may be needed for meals and snacks.
  • Suggest a lower potassium dialysate for those on dialysis to control potassium levels.
  • Make sure your dialysis prescription is adjusted as needed for acceptable urea clearances.
  • Provide resources, recipes and renal education materials specific to your needs.

Food for a vegetarian, kidney-friendly diet

Vegetarian diets can meet the higher protein needs of a dialysis patient. Protein is made up of chains of amino acids, which are sometimes referred to as “the building blocks of life.” Plant foods contain most of the essential amino acids. Some plant foods, such as soy, are considered as complete protein foods because it provides all the essential amino acids. Some plant protein may lack one or more essential amino acids, but a variety of vegetarian foods combined throughout the day to provide adequate amounts of essential amino acids without consuming meat, eggs or milk. Plant protein can provide adequate protein into your kidney diet.

Protein enriched foods for vegetarians on a kidney diet may include:

  • Meat analogs (meat substitutes such as soy burgers, tofu, hot dogs and deli slices)
  • Soy products (tofu, tempeh)
  • Beans and lentils
  • Nuts and nut butters
  • Eggs and egg substitutes
  • Dairy products
  • Grains

The protein and nutrient content can vary for tofu products, soymilks and meat analogs.  It is important to check product labels for the specific nutrient content per serving (such as protein, sodium, potassium, phosphorus, etc.). Powder and liquid protein supplements may be an option for patients with unusually high protein needs or who are unable to meet their protein needs by food alone.

Eggs or egg substitutes are a source of HBV (high biological value) protein, also known as high quality protein. Lacto-ovo vegetarians can easily meet their HBV protein needs since they include eggs and dairy foods.

Benefits of being on a vegetarian diet with kidney disease

Plant protein sources have been shown to:

  • Decrease protein in the urine (proteinuria)
  • Slow the decline of glomerular filtration rate (GFR) and kidney blood flow
  • Result in less kidney tissue damage when compared to animal proteins
  • Reduce kidney cyst growth
  • Improve lipid (blood fat) profile of the blood

Modifying the source of protein rather than restricting the amount of protein may be effective in the dietary management of the patient with progressive kidney failure. Plant sources alone can provide high quality protein and adequate amounts of essential amino acids, if a variety of plant foods are consumed daily and energy needs are met.

Vegetarian diets may help slow down the progression of kidney disease without compromising nutritional needs. High protein consumption has long been shown to potentially have harmful effects on the kidney in those with pre-existing kidney disease.

The American Dietetic Association’s position on vegetarian diets states, “appropriately planned vegetarian diets are healthful, nutritionally adequate and provide health benefits in the prevention and treatment of certain diseases.”

Iron, calcium, zinc, vitamin D and B12 should not be a concern for vegetarians on dialysis. The renal vitamin that is prescribed for hemodialysis patients should contain vitamin B12 and zinc. All dialysis patients are regularly evaluated and prescribed calcium, vitamin D and intravenous (IV) iron by their doctors if and when they need it.

Pitfalls of being on a vegetarian diet with kidney disease

While people in the earlier stages of kidney disease are generally told to limit protein intake, dialysis patients require more protein because of protein loss during dialysis and increased body needs. It is more difficult for a vegetarian dialysis patient to consume enough protein and keep potassium and phosphorus controlled without using a protein supplement – this is especially true for those who are vegans, because no eggs or milk products are consumed.

Foods that cannot be eaten on a vegetarian, kidney-friendly diet

Vegetarians will need to limit certain foods with high amounts of sodium, phosphorus and potassium based on their kidney function and lab report, just like other chronic kidney disease patients.

Sodium restriction for vegetarians with kidney disease

Sodium content of some vegetarian foods can be high. The foods with high sodium content are usually processed, commercially-produced plant proteins. To reduce sodium intake, the use of high sodium foods such as meat analogs, salted nuts, miso, frozen entrees, marinated tofu products, savory snacks and meals in a cup should be limited. In comparison to meat, meat analogs have much higher sodium content and need to be limited.

Type of meat

Amount of protein

Amount of sodium

Meat, 1 ounce

7 grams

25 mg

Meat analog

7 grams

260 mg

Phosphate restriction for vegetarians with kidney disease

About 50 to 70 percent of phosphorus is absorbed in the body from a typical diet of both plant and animal-based foods. In general, phosphorus is higher in animal products than in plant-based foods. Much of the phosphorus in grains and legumes are in the form of phytic acid, the main storage form of phosphorus in many plant tissues. When phosphorus is stored in this form, it is ‘bound’ so phosphorus absorption is reduced to around 50 percent.

Legumes, nuts and seeds will need to be limited for patients with chronic kidney disease, if high potassium and phosphorus levels become an issue. Consumption of a vegetarian diet may require an increase in the number of phosphate binders for patients in end stage renal disease (ESRD) or on dialysis.

Potassium restriction for vegetarians with kidney disease

Fruits and vegetables are the primary source of potassium and may need to be limited for vegetarians with chronic kidney disease. Selecting the lowest potassium fruits and vegetables over higher potassium choices can help keep potassium levels down. Other foods high in potassium that vegetarians may use are soybeans, textured vegetable protein (TVP), soy nuts, soy flour, natto (soybean paste) and wasabi. With careful planning, some of these foods can be worked into a vegetarian diet. However, potassium amounts will need to be modified and levels monitored carefully by your renal dietitian.

Protein restriction for vegetarians with kidney disease

The protein quality of vegan protein sources is a concern for renal dietitians working with vegetarian patients. Soy has similar amino acids to that of meat or eggs, and is considered a HBV protein source. For this reason, renal dietitians recommend an acceptable soy-based product for vegetarian dialysis patients. Meat analogs are a significant source of protein. Many provide 10 to 24 grams of soy protein per serving. Select meat analogs that contain less than 200 mg of sodium per serving. It is important to look at nutrition labels for sodium content. In addition, the quality of protein is determined not only by the source of the protein, but also by the mixture of vegetable protein sources throughout the day. This means a meal plan for a vegetarian dialysis patient only needs to include foods from all the vegetarian food groups to meet recommended protein needs.

Beans and nuts are important sources of protein for the general vegetarian population who do not have chronic kidney disease. These foods are usually considered too high in potassium and phosphorus to be incorporated into a kidney patient’s diet who already consumes phosphorus from meat-based foods. But with careful dietary planning with your renal dietitian, certain beans and nuts can be included in the vegetarian meal plan.

Maintaining a healthy weight on a kidney-friendly, vegetarian diet

The key to maintaining a healthy weight is to continue adequate caloric intake through foods containing unsaturated fats and high carbohydrates as good sources of calories. This is recommended to all patients to help prevent cardiovascular disease (CVD), which is the number one cause of death among kidney disease patients.

Menu items for a vegetarian, kidney-friendly diet

DaVita.com features all types of delicious recipes for the kidney diet, including those that are vegetarian. Below are just a few of the kidney-friendly vegetarian recipes available. You can visit DaVita.com/Recipes and go to the Browse Tags section. Click on “All tags” and then “Vegetarian”, you will see a list of all the vegetarian recipes on the website. Each week more recipes are added, so check back often.

Breakfast

Lunch

Snack

Dinner

Dessert

Summary

The vegetarian diet does not have to stop when you have chronic kidney disease. A carefully planned, kidney-friendly diet can be developed by your renal dietitian. An appropriate mixture of plant protein foods with essential amino acids and an adequate calorie intake can help your body decrease its urea load. Whether you are a lacto-ovo vegetarian or a vegan, your dietitian can help you manage your diet while you still eat with your kidney health in mind.

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