Optimal Nutrition for Predialysis Chronic Kidney Disease

  • Rebecca Filipowicz
    Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; and VA Healthcare System and Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
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  • Srinivasan Beddhu
    Address correspondence to Srinivasan Beddhu, MD, 85 North Medical Drive East, Room 201, Salt Lake City, UT 84112.
    Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; and VA Healthcare System and Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
    Search for articles by this author
      Diet potentially plays a major role in the progression and complications of predialysis CKD. Moderate protein consumption along with a diet low in sodium might slow kidney disease progression. Increasing vegetable protein intake might decrease serum phosphorus, uremic toxins, and kidney damage. Because obesity might be an important factor in the increasing prevalence of CKD, dietary strategies targeting obesity might also benefit CKD progression. In those with more advanced CKD, dietary calcium and phosphorus restriction could minimize vascular calcification. Dietary fiber and vitamin D supplementation might also be important to decrease inflammation in CKD.

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        • Go A.S.
        • Chertow G.M.
        • Fan D.
        • McCulloch C.E.
        • Hsu C.Y.
        Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.
        N Engl J Med. 2004; 351: 1296-1305
      1. Eneanya AS, Lin J. Dietary factors and chronic kidney disease. Available at: Accessed November 30, 2012.

        • Brenner B.M.
        • Meyer T.W.
        • Hostetter T.H.
        Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease.
        New Engl J Med. 1982; 307: 652-659
        • Hostetter T.H.
        • Meyer T.W.
        • Rennke H.G.
        • Brenner B.M.
        Chronic effects of dietary protein in the rat with intact and reduced renal mass.
        Kidney Int. 1986; 30: 509-517
        • Walker J.D.
        • Bending J.J.
        • Dodds R.A.
        • et al.
        Restriction of dietary protein and progression of renal failure in diabetic nephropathy.
        Lancet. 1989; 2: 1411-1415
        • Zeller K.
        • Whittaker E.
        • Sullivan L.
        • Raskin P.
        • Jacobson H.R.
        Effect of restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes mellitus.
        New Engl J Med. 1991; 324: 78-84
        • Klahr S.
        • Levey A.S.
        • Beck G.J.
        • et al.
        The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group.
        N Engl J Med. 1994; 330: 877-884
        • Levey A.S.
        • Greene T.
        • Sarnak M.J.
        • et al.
        Effect of dietary protein restriction on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study.
        Am J Kidney Dis. 2006; 48: 879-888
        • Menon V.
        • Kopple J.D.
        • Wang X.
        • et al.
        Effect of a very low-protein diet on outcomes: long-term follow-up of the Modification of Diet in Renal Disease (MDRD) Study.
        Am J Kidney Dis. 2009; 53: 208-217
        • Cianciaruso B.
        • Pota A.
        • Bellizzi V.
        • et al.
        Effect of a low- versus moderate-protein diet on progression of CKD: follow-up of a randomized controlled trial.
        Am J Kidney Dis. 2009; 54: 1052-1061
      2. KDOQI Guidelines 2000: Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Available at: Accessed January 3, 2012.

      3. Institute of Medicine Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids Cholesterol, Protein, and Amino Acids (Macronutrients). The National Academies Press, 2005. Available at: Accessed January 3, 2013.

        • Wakefield A.P.
        • House J.D.
        • Ogborn M.R.
        • Weiler H.A.
        • Aukema H.M.
        A diet with 35% of energy from protein leads to kidney damage in female Sprague-Dawley rats.
        Br J Nutr. 2011; 106: 656-663
        • Jia Y.
        • Hwang S.Y.
        • House J.D.
        • et al.
        Long-term high intake of whole proteins results in renal damage in pigs.
        J Nutr. 2010; 140: 1646-1652
        • Halbesma N.
        • Bakker S.J.
        • Jansen D.F.
        • et al.
        High protein intake associates with cardiovascular events but not with loss of renal function.
        J Am Soc Nephrol. 2009; 20: 1797-1804
        • Lin J.
        • Fung T.T.
        • Hu F.B.
        • Curhan G.C.
        Association of dietary patterns with albuminuria and kidney function decline in older white women: a subgroup analysis from the Nurses' Health Study.
        Am J Kidney Dis. 2011; 57: 245-254
        • Wycherley T.P.
        • Moran L.J.
        • Clifton P.M.
        • Noakes M.
        • Brinkworth G.D.
        Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials.
        Am J Clin Nutr. 2012; 96: 1281-1298
        • Toeller M.
        • Buyken A.
        • Heitkamp G.
        • et al.
        Protein intake and urinary albumin excretion rates in the EURODIAB IDDM Complications Study.
        Diabetologia. 1997; 40: 1219-1226
        • Nettleton J.A.
        • Steffen L.M.
        • Palmas W.
        • Burke G.L.
        • Jacobs Jr., D.R.
        Associations between microalbuminuria and animal foods, plant foods, and dietary patterns in the Multiethnic Study of Atherosclerosis.
        Am J Clin Nutr. 2008; 87: 1825-1836
        • Lin J.
        • Hu F.B.
        • Curhan G.C.
        Associations of diet with albuminuria and kidney function decline.
        Clin J Am Soc Nephrol. 2010; 5: 836-843
        • Lin J.
        • Judd S.
        • Le A.
        • et al.
        Associations of dietary fat with albuminuria and kidney dysfunction.
        Am J Clin Nutr. 2010; 92: 897-904
        • Knight E.L.
        • Stampfer M.J.
        • Hankinson S.E.
        • Spiegelman D.
        • Curhan G.C.
        The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency.
        Ann Intern Med. 2003; 138: 460-467
        • Patel K.P.
        • Luo F.J.G.
        • Plummer N.S.
        • Hostetter T.H.
        • Meyer T.W.
        The production of p-cresol sulfate and indoxyl sulfate in vegetarians versus omnivores.
        Clin J Am Soc Nephrol. 2012; 7: 982-988
        • Wu I.W.
        • Hsu K.H.
        • Lee C.C.
        • et al.
        p-Cresyl sulphate and indoxyl sulphate predict progression of chronic kidney disease.
        Nephrol Dial Transplant. 2011; 26: 938-947
        • Motojima M.
        • Hosokawa A.
        • Yamato H.
        • Muraki T.
        • Yoshioka T.
        Uremic toxins of organic anions up-regulate PAI-1 expression by induction of NF-kappaB and free radical in proximal tubular cells.
        Kidney Int. 2003; 63: 1671-1680
        • Niwa T.
        • Ise M.
        Indoxyl sulfate, a circulating uremic toxin, stimulates the progression of glomerular sclerosis.
        J Lab Clin Med. 1994; 124: 96-104
        • Sun C.Y.
        • Chang S.C.
        • Wu M.S.
        Uremic toxins induce kidney fibrosis by activating intrarenal renin-angiotensin-aldosterone system associated epithelial-to-mesenchymal transition.
        PLoS One. 2012; 7: e34026
        • Adijiang A.
        • Niwa T.
        An oral sorbent, AST-120, increases Klotho expression and inhibits cell senescence in the kidney of uremic rats.
        Am J Nephrol. 2010; 31: 160-164
        • Moe S.M.
        • Zidehsarai M.P.
        • Chambers M.A.
        • et al.
        Vegetarian compared with meat dietary protein source and phosphorus homeostasis in chronic kidney disease.
        Clin J Am Soc Nephrol. 2011; 6: 257-264
        • Scialla J.J.
        • Appel L.J.
        • Astor B.C.
        • et al.
        Estimated net endogenous acid production and serum bicarbonate in African Americans with chronic kidney disease.
        Clin J Am Soc Nephrol. 2011; 6: 1526-1532
        • Scialla J.J.
        • Appel L.J.
        • Astor B.C.
        • et al.
        Net endogenous acid production is associated with a faster decline in GFR in African Americans.
        Kidney Int. 2012; 82: 106-112
        • Raphael K.L.
        • Wei G.
        • Baird B.C.
        • Greene T.
        • Beddhu S.
        Higher serum bicarbonate levels within the normal range are associated with better survival and renal outcomes in African Americans.
        Kidney Int. 2011; 79: 356-362
        • Khan N.A.
        • McAlister F.A.
        • Rabkin S.W.
        • et al.
        The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II—Therapy.
        Can J Cardiol. 2006; 22: 583-593
        • Appel L.J.
        • Champagne C.M.
        • Harsha D.W.
        • et al.
        Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial.
        J Am Med Assoc. 2003; 289: 2083-2093
        • Fodor J.G.
        • Whitmore B.
        • Leenen F.
        • Larochelle P.
        Lifestyle modifications to prevent and control hypertension. 5. Recommendations on dietary salt. Canadian Hypertension Society, Canadian Coalition for High Blood Pressure Prevention and Control, Laboratory Centre for Disease Control at Health Canada, Heart and Stroke Foundation of Canada.
        Can Med Assoc J. 1999; 160: S29-S34
        • Fujita T.
        Mineralocorticoid receptors, salt-sensitive hypertension, and metabolic syndrome.
        Hypertension. 2010; 55: 813-818
        • Yu W.
        • Luying S.
        • Haiyan W.
        • Xiaomei L.
        Importance and benefits of dietary sodium restriction in the management of chronic kidney disease patients: experience from a single Chinese center.
        Int Urol Nephrol. 2012; 44: 549-556
        • Hsu C.Y.
        • McCulloch C.E.
        • Iribarren C.
        • Darbinian J.
        • Go A.S.
        Body mass index and risk for end-stage renal disease.
        Ann Intern Med. 2006; 144: 21-28
        • Kramer H.J.
        • Saranathan A.
        • Luke A.
        • et al.
        Increasing body mass index and obesity in the incident ESRD population.
        J Am Soc Nephrol. 2006; 17: 1453-1459
        • Gelber R.P.
        • Kurth T.
        • Kausz A.T.
        • et al.
        Association between body mass index and CKD in apparently healthy men.
        Am J Kidney Dis. 2005; 46: 871-880
        • Evans P.D.
        • McIntyre N.J.
        • Fluck R.J.
        • McIntyre C.W.
        • Taal M.W.
        Anthropomorphic measurements that include central fat distribution are more closely related with key risk factors than BMI in CKD stage 3.
        PLoS One. 2012; 7: e34699
        • Burton J.O.
        • Gray L.J.
        • Webb D.R.
        • et al.
        Association of anthropometric obesity measures with chronic kidney disease risk in a non-diabetic patient population.
        Nephrol Dial Transplant. 2012; 27: 1860-1866
        • Iseki K.
        • Ikemiya Y.
        • Kinjo K.
        • Inoue T.
        • Iseki C.
        • Takishita S.
        Body mass index and the risk of development of end-stage renal disease in a screened cohort.
        Kidney Int. 2004; 65: 1870-1876
        • Kramer H.
        • Shoham D.
        • McClure L.A.
        • et al.
        Association of waist circumference and body mass index with all-cause mortality in CKD: The REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study.
        Am J Kidney Dis. 2011; 58: 177-185
        • Yamagata K.
        • Ishida K.
        • Sairenchi T.
        • et al.
        Risk factors for chronic kidney disease in a community-based population: a 10-year follow-up study.
        Kidney Int. 2007; 71: 159-166
        • Singhal A.
        Endothelial dysfunction: role in obesity-related disorders and the early origins of CVD.
        Proc Nutr Soc. 2005; 64: 15-22
        • Chagnac A.
        • Weinstein T.
        • Herman M.
        • Hirsh J.
        • Gafter U.
        • Ori Y.
        The effects of weight loss on renal function in patients with severe obesity.
        J Am Soc Nephrol. 2003; 14: 1480-1486
        • Cherney D.Z.
        • Sochett E.B.
        • Lai V.
        • et al.
        Renal hyperfiltration and arterial stiffness in humans with uncomplicated type 1 diabetes.
        Diabetes Care. 2010; 33: 2068-2070
        • Cherney D.Z.
        • Scholey J.W.
        • Miller J.A.
        Insights into the regulation of renal hemodynamic function in diabetic mellitus.
        Curr Diabetes Rev. 2008; 4: 280-290
        • MacLaughlin H.L.
        • Cook S.A.
        • Kariyawasam D.
        • Roseke M.
        • van Niekerk M.
        • MacDougall I.C.
        Nonrandomized trial of weight loss with orlistat, nutrition education, diet, and exercise in obese patients with CKD: 2-year follow-up.
        Am J Kidney Dis. 2010; 55: 69-76
        • MacLaughlin H.L.
        • Sarafidis P.A.
        • Greenwood S.A.
        • Campbell K.L.
        • Hall W.L.
        • Macdougall I.C.
        Compliance with a structured weight loss program is associated with reduced systolic blood pressure in obese patients with chronic kidney disease.
        Am J Hypertens. 2012; 25: 1024-1029
        • Ezequiel D.G.
        • Costa M.B.
        • Chaoubah A.
        • de Paula R.B.
        Weight loss improves renal hemodynamics in patients with metabolic syndrome.
        J Bras Nefrol. 2012; 34: 36-42
        • Morales E.
        • Valero M.A.
        • Leon M.
        • Hernandez E.
        • Praga M.
        Beneficial effects of weight loss in overweight patients with chronic proteinuric nephropathies.
        Am J Kidney Dis. 2003; 41: 319-327
        • Daviglus M.L.
        • Greenland P.
        • Stamler J.
        • et al.
        Relation of nutrient intake to microalbuminuria in nondiabetic middle-aged men and women: International Population Study on Macronutrients and Blood Pressure (INTERMAP).
        Am J Kidney Dis. 2005; 45: 256-266
        • Riley M.D.
        • Dwyer T.
        Microalbuminuria is positively associated with usual dietary saturated fat intake and negatively associated with usual dietary protein intake in people with insulin-dependent diabetes mellitus.
        Am J Clin Nutr. 1998; 67: 50-57
        • Lin J.
        • Curhan G.C.
        Associations of sugar and artificially sweetened soda with albuminuria and kidney function decline in women.
        Clin J Am Soc Nephrol. 2011; 6: 160-166
        • Chertow G.M.
        • Raggi P.
        • Chasan-Taber S.
        • Bommer J.
        • Holzer H.
        • Burke S.K.
        Determinants of progressive vascular calcification in haemodialysis patients.
        Nephrol Dial Transpl. 2004; 19: 1489-1496
        • Ganesh S.K.
        • Stack A.G.
        • Levin N.W.
        • Hulbert-Shearon T.
        • Port F.K.
        Association of elevated serum PO(4), Ca x PO(4) product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients.
        J Am Soc Nephrol. 2001; 12: 2131-2138
        • Kalantar-Zadeh K.
        • Kuwae N.
        • Regidor D.L.
        • et al.
        Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients.
        Kidney Int. 2006; 70: 771-780
        • Block G.A.
        • Hulbert-Shearon T.E.
        • Levin N.W.
        • Port F.K.
        Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic hemodialysis patients: a national study.
        Am J Kidney Dis. 1998; 31: 607-617
        • Guerin A.P.
        • London G.M.
        • Marchais S.J.
        • Metivier F.
        Arterial stiffening and vascular calcifications in end-stage renal disease.
        Nephrol Dial Transplant. 2000; 15: 1014-1021
        • Noori N.
        • Kalantar-Zadeh K.
        • Kovesdy C.P.
        • Bross R.
        • Benner D.
        • Kopple J.D.
        Association of dietary phosphorus intake and phosphorus to protein ratio with mortality in hemodialysis patients.
        Clin J Am Soc Nephrol. 2010; 5: 683-692
        • Levin A.
        • Bakris G.L.
        • Molitch M.
        • et al.
        Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease.
        Kidney Int. 2007; 71: 31-38
        • Pires A.
        • Adragao T.
        • Pais M.J.
        • Vinhas J.
        • Ferreira H.G.
        Inferring disease mechanisms from epidemiological data in chronic kidney disease: calcium and phosphorus metabolism.
        Nephron Clin Pract. 2009; 112: c137-c147
        • Eddington H.
        • Hoefield R.
        • Sinha S.
        • et al.
        Serum phosphate and mortality in patients with chronic kidney disease.
        Clin J Am Soc Nephrol. 2010; 5: 2251-2257
        • Kovesdy C.P.
        • Anderson J.E.
        • Kalantar-Zadeh K.
        Outcomes associated with serum phosphorus level in males with non-dialysis dependent chronic kidney disease.
        Clin Nephrol. 2010; 73: 268-275
        • de Boer I.H.
        • Rue T.C.
        • Kestenbaum B.
        Serum phosphorus concentrations in the third National Health and Nutrition Examination Survey (NHANES III).
        Am J Kidney Dis. 2009; 53: 399-407
        • Antoniucci D.M.
        • Yamashita T.
        • Portale A.A.
        Dietary phosphorus regulates serum fibroblast growth factor-23 concentrations in healthy men.
        J Clin Endocrinol Metab. 2006; 91: 3144-3149
      4. Sigrist M, Tang M, Beaulieu M, et al. Responsiveness of FGF-23 and mineral metabolism to altered dietary phosphate intake in chronic kidney disease (CKD): results of a randomized trial. Nephrol Dial Transplant. [Epub ahead of print]. doi: 10.1093/ndt/gfs405.

        • Yilmaz M.I.
        • Sonmez A.
        • Saglam M.
        • et al.
        FGF-23 and vascular dysfunction in patients with stage 3 and 4 chronic kidney disease.
        Kidney Int. 2010; 78: 679-685
        • Kanbay M.
        • Nicoleta M.
        • Selcoki Y.
        • et al.
        Fibroblast growth factor 23 and fetuin A are independent predictors for the coronary artery disease extent in mild chronic kidney disease.
        Clin J Am Soc Nephrol. 2010; 5: 1780-1786
        • Gutierrez O.
        • Januzzi J.
        • Isakova T.
        • et al.
        Fibroblast growth factor 23 and left ventricular hypertrophy in chronic kidney disease.
        Circulation. 2009; 119: 2545-2552
        • Gutierrez O.M.
        • Mannstadt M.
        • Isakova T.
        • et al.
        Fibroblast growth factor 23 and mortality among patients undergoing hemodialysis.
        N Engl J Med. 2008; 359: 584-592
        • Shuto E.
        • Taketani Y.
        • Tanaka R.
        • et al.
        Dietary phosphorus acutely impairs endothelial function.
        J Am Soc Nephrol. 2009; 20: 1504-1512
        • Kusano K.
        • Segawa H.
        • Ohnishi R.
        • Fukushima N.
        • Miyamoto K.
        Role of low protein and low phosphorus diet in the progression of chronic kidney disease in uremic rats.
        J Nutr Sci Vitaminol (Tokyo). 2008; 54: 237-243
        • Murtaugh M.A.
        • Filipowicz R.
        • Baird B.C.
        • Wei G.
        • Greene T.
        • Beddhu S.
        Dietary phosphorus intake and mortality in moderate chronic kidney disease: NHANES III.
        Nephrol Dial Transplant. 2012; 27: 990-996
        • Barsotti G.
        • Cupisti A.
        • Morelli E.
        • et al.
        Secondary hyperparathyroidism in severe chronic renal failure is corrected by very-low dietary phosphate intake and calcium carbonate supplementation.
        Nephron. 1998; 79: 137-141
        • Chertow G.M.
        • Burke S.K.
        • Raggi P.
        Treat to Goal Working Group. Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients.
        Kidney Int. 2002; 62: 245-252
        • Spiegel D.M.
        • Brady K.
        Calcium balance in normal individuals and in patients with chronic kidney disease on low- and high-calcium diets.
        Kidney Int. 2012; 81: 1116-1122
        • Spiegel D.M.
        • Brady K.
        Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation.
        Am J Kidney Dis. 2000; 35: S1-S140
        • Krishnamurthy V.M.R.
        • Wei G.
        • Baird B.C.
        • et al.
        High dietary fiber intake is associated with decreased inflammation and all-cause mortality in patients with chronic kidney disease.
        Kidney Int. 2012; 81: 300-306
        • Dobnig H.
        • Pilz S.
        • Scharnagl H.
        • et al.
        Independent association of low serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels with all-cause and cardiovascular mortality.
        Arch Intern Med. 2008; 168: 1340-1349
        • Chonchol M.
        • Scragg S.R.
        25-Hydroxyvitamin D, insulin resistance, and kidney function in the Third National Health and Nutrition Examination Survey.
        Kidney Int. 2007; 71: 134-139
        • Mehrotra R.
        • Kermah D.A.
        • Salusky I.B.
        • et al.
        Chronic kidney disease, hypovitaminosis D, and mortality in the United States.
        Kidney Int. 2009; 76: 977-983
      5. NKF KDOQI Guidelines: Prevention and treatment of vitamin D insufficiency and vitamin D deficiency in CKD patients. Available at: Accessed November 30, 2012.