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 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. 

Knowing your nutritional goals can help you have a better quality of life. 

Protein and stage 4 CKD 

On average, Americans consume 90 to 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. Half of your protein should come from high-quality sources that provide all the essential amino acids (e.g., eggs, milk, poultry, seafood, red meats, 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.  Ask your nephrologist or renal dietitian to calculate how much protein you should consume per day. 

Phosphorus and stage 4 CKD 

As kidney function decreases, phosphorus isn’t 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.  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. 

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

Potassium and stage 4 CKD  

If kidneys aren’t able to remove enough potassium to maintain normal blood levels in stage 4 CKD, you will need to limit high-potassium foods. Your doctor may prescribe a potassium restriction of 2,000 to 3,000 mg a day. 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

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. 

Sodium and stage 4 CKD 

Most kidney diets start with a goal of 1,500 to 2,000 mg per day or the amount recommended by your doctor or dietitian. 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. 

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 to 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. 

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. 

Stage 5 of Chronic Kidney Disease 

A person with stage 5 chronic kidney disease has end stage renal disease (ESRD) with a glomerular filtration rate (GFR) of 15 ml/min or less. At this advanced stage of kidney disease, the kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live. 

Symptoms of stage 5 CKD 

Symptoms that can occur in stage 5 CKD include: 

• Loss of appetite 
• Nausea or vomiting 
• Headaches 
• Being tired 
• Being unable to concentrate 
• Itching 
• Making little or no urine 
• Swelling, especially around the eyes and ankles 
• Muscle cramps 
• Tingling in hands or feet 
• Changes in skin color 
• Increased skin pigmentation 

Because the kidneys are no longer able to remove waste and fluids from the body, toxins build up in the blood, causing an overall ill feeling. Kidneys also have other functions they are no longer able to perform such as regulating blood pressure, producing the hormone that helps make red blood cells and activating vitamin D for healthy bones. 

If you are diagnosed with stage 5 CKD, you will need to see a nephrologist immediately. This is a doctor who is trained in kidney disease, kidney dialysis and transplant. The doctor will help you decide which treatment is best for you—hemodialysis, peritoneal dialysis (PD) or kidney transplant—and will recommend an access for dialysis. Your nephrologist will develop your overall care plan and manage your healthcare team. 

Dialysis treatments for people with stage 5 CKD 

Most people report feeling much better once they begin dialysis. As the toxins are removed from the blood medicines replace the functions the kidneys can no longer perform, they find they can enjoy a good quality of life. There are two types of dialysis treatments for people with stage 5 kidney disease. 

Hemodialysis: This treatment that can be done in a center or in a patient’s home with assistance from a care partner. A dialysis machine removes a small amount of a patient’s blood through a man-made membrane called a dialyzer, or artificial kidney, to clean out toxins that the kidneys can no longer remove. The filtered blood is then returned to the body. 

Peritoneal dialysis (PD): Unlike hemodialysis, PD is a needle-free treatment and a care partner is not required to to help assist during treatment. PD can be performed at home or at work. 

Kidney transplant is another treatment option 

If you wish to have a kidney transplant, tell your nephrologist. Your nephrologist will explain the process of how to get on a waiting list for a cadaverous kidney or how to find a living donor. 

When at stage 5 CKD, either dialysis or a kidney transplant is necessary to continue living. 

Changes in the diet for people with stage 5 CKD 

Once you begin dialysis, you will need to make changes in what you eat and drink. Your diet is a big part of your treatment, so you will be working with a dietitian who will coach you on how you should eat. Depending on the dialysis treatment you choose and your lab test results, your dietitian will help create a meal plan based on your individual requirements to keep you feeling your best. Your dietitian will explain what foods are restricted and which ones are recommended on the renal diet. 

A healthy diet for stage 5 CKD may recommend: 

• Including grains, fruits and vegetables, but limiting or avoiding whole grains and certain fruits and vegetables that are high in phosphorus or potassium 
• A diet that is low in saturated fat and cholesterol and moderate in total fats, especially if cholesterol is high or if you have diabetes or heart disease 
• Limiting intake of refined and processed foods high in sodium and prepare foods with less salt or high-sodium ingredients 
• Aiming for a healthy weight by consuming adequate calories and including physical activity each day within your ability 
• Decreasing calcium intake if necessary 
• Limiting fluid intake 
• Increasing protein intake to the level determined by the dietitian’s assessment of individual needs and to replace losses in the dialysis treatment 
• Taking special renal vitamins high in water soluble B vitamins and limited to 100 mg of vitamin C 
• Vitamin D and iron tailored to individual requirements 

Find a doctor when you have stage 5 CKD 

When a person learns he or she has stage 5 kidney disease, working with a nephrologist is necessary to ensure they have the right tools to treat their condition. 

 Source: https://www.davita.com/diet-nutrition/articles/advice/stage-4-kidney-disease-diet-focusing-on-nutrition, https://www.davita.com/education/kidney-disease/stages/stage-5-of-chronic-kidney-disease