Diet in chronic kidney disease (not on dialysis)
In CKD not on dialysis, give a low-protein diet (0.55-0.6 g/kg) with enough energy, and control sodium, potassium, phosphorus and fluid by blood results.
Aim and principles of the diet
Aim: To plan, prepare and calculate a diet for a man with stage 4 chronic kidney disease (CKD) who is not on dialysis. Principles: In CKD the kidneys slowly lose the ability to remove urea, potassium, phosphate, sodium and water. The diet aims to reduce uraemia, slow the damage and keep the patient well nourished. Protein is restricted to 0.55-0.6 g/kg/day (KDOQI 2020), because less protein means less urea; part of it comes from milk, curd or egg white. Energy must be adequate (25-35 kcal/kg): if it is low, the body breaks down its own protein and urea rises. Low-protein energy foods such as rice, sago, cornflour, sugar and oil fill the gap. Sodium is kept below 2.3 g a day for blood pressure and oedema. Potassium is limited (often to about 2 g a day, a common working figure; KDOQI 2020 sets no fixed number) when serum potassium is high, using low-potassium foods and leaching of vegetables. Phosphorus is limited to protect bone and blood vessels: dals, milk, nuts, colas and processed foods are high. Fluid = previous day's urine + 500 mL. Once the patient starts dialysis, protein is raised to 1.0-1.2 g/kg, because dialysis removes amino acids.
Nutrient prescription: Mr. C, 55 y, 170 cm, 60 kg, CKD stage 4, high potassium, urine 1 L/day
| Nutrient | Prescription | Basis and source |
|---|---|---|
| Ideal body weight | 63 kg | (170 − 100) × 0.9 |
| Energy | About 1900 kcal | 30 kcal/kg × 63 = 1890 (KDOQI 2020: 25-35 kcal/kg) |
| Protein | About 38 g | 0.6 g/kg × 63 = 37.8 (KDOQI 2020: 0.55-0.6 g/kg) |
| Sodium | Below 2.3 g | KDOQI 2020; no salt at the table, no salty foods |
| Potassium | About 2 g (about 51 mEq) | Common working limit when serum potassium is high; KDOQI 2020 gives no fixed figure, so adjust to the blood level |
| Phosphorus | About 800-1000 mg | KDOQI 2003 figure; KDOQI 2020 says adjust to serum phosphate |
| Fluid | About 1.5 L | Urine 1000 mL + 500 mL |
Foods to include and avoid
| Food group | Choose | Limit or avoid |
|---|---|---|
| Cereals | Rice, rice rava, idiyappam, sago, cornflour | Large amounts of whole grains and ragi (more phosphorus and potassium) |
| Protein foods | Measured milk, curd, egg white, a small portion of moong dal | Large dal portions, whole grams, large meat or fish portions |
| Vegetables | Leached low-potassium vegetables: bottle gourd, ridge gourd, cucumber, onion | Potato, yam, drumstick, spinach, amaranth, tomato, mushroom |
| Fruits | Apple, pear, pineapple, watermelon in measured portions | Banana, orange, sweet lime, tender coconut water, guava, dried fruits |
| Energy foods | Sugar, sago, cornflour, glucose, vegetable oils (limit sugar if diabetic) | None, unless diabetic |
| Others | Lemon and herbs for taste | Salt, pickles, papad, salt substitutes (potassium chloride), colas, packaged snacks |
Sample one-day menu: CKD stage 4, not on dialysis (Mr. C)
| Time | Menu | Approx. amount (raw) |
|---|---|---|
| 6.00 am | Tea | Toned milk 100 mL, sugar 10 g |
| 8.00 am | Rice rava upma with leached vegetables | Rice rava 60 g, vegetables 30 g, oil 8 g |
| 10.30 am | Apple | 100 g |
| 11.30 am | Lime water with sugar | Sugar 15 g in about 150 mL water |
| 1.00 pm | Rice, thin moong dal, leached bottle-gourd poriyal | Rice 100 g; moong dal 15 g; vegetables 100 g, oil 8 g |
| 4.00 pm | Sago payasam | Sago 30 g, toned milk 50 mL, sugar 15 g, ghee 3 g |
| 8.00 pm | Soft rice with egg-white curry (leached vegetables) | Rice 60 g; 2 egg whites, vegetables 70 g, oil 10 g |
| 9.30 pm | Cornflour custard with sago | Cornflour 20 g, sago 30 g, toned milk 50 mL, sugar 15 g |
Worked calculation: Mr. C's low-protein CKD diet
Mr. C, 55 years, 170 cm, 60 kg, has stage 4 chronic kidney disease, is not on dialysis, has a raised serum potassium and passes about 1 litre of urine a day. Find his IBW, energy, protein and fluid, and check the menu.
- IBW = (170 − 100) × 0.9 = 63 kg.
- Energy = 63 kg × 30 kcal/kg = 1890, about 1900 kcal (KDOQI 2020: 25-35 kcal/kg).
- Protein = 63 kg × 0.6 g/kg = 37.8, about 38 g (KDOQI 2020: 0.55-0.6 g/kg).
- Fluid = urine 1000 mL + 500 mL = 1500 mL a day, counting tea, lime water, payasam and custard.
- Approximate values used (kcal and g protein per 100 g raw unless stated; rounded from Indian food composition tables, mainly IFCT 2017 and the older Nutritive Value of Indian Foods; a few, such as toned milk, are estimates): toned milk 60 and 3 per 100 mL; sugar 400; rice 355 and 8; mixed vegetables 30 and 1.5; oil/ghee 900; apple 60 and 0.3; moong dal 325 and 24; sago 350 and 0.2; egg white 17 kcal and 3.5 g per piece; cornflour/custard powder 350 and 0.3.
- Cereals (rice 220 g, sago 60 g, cornflour/custard powder 20 g): 1061.0 kcal, 17.8 g protein.
- Pulses (moong dal 15 g): 48.8 kcal, 3.6 g protein.
- Milk and milk products (toned milk 200 mL): 120.0 kcal, 6.0 g protein.
- Egg white (2 egg whites): 34.0 kcal, 7.0 g protein.
- Vegetables (mixed vegetables 200 g): 60.0 kcal, 3.0 g protein.
- Fruits (apple 100 g): 60.0 kcal, 0.3 g protein.
- Oil and ghee (oil/ghee 29 g): 261.0 kcal.
- Sugar (sugar 55 g): 220.0 kcal.
- Energy = 1061.0 + 48.8 + 120.0 + 34.0 + 60.0 + 60.0 + 261.0 + 220.0 = 1864.8 kcal.
- Protein = 17.8 + 3.6 + 6.0 + 7.0 + 3.0 + 0.3 = 37.7 g.
- Compare with the prescription: energy 1864.8 ÷ 1900 × 100 = 98%; protein 37.7 ÷ 38 × 100 = 99%.
- Most of the protein comes from rice (17.6 g), milk (6 g) and egg white (7 g); sago, cornflour, sugar and oil add energy with almost no protein.
- Each group is rounded to one decimal and the totals are the sums of those rounded figures; all values are approximate.
IBW 63 kg; prescription about 1900 kcal, 38 g protein and 1.5 L fluid. The menu gives about 1865 kcal (98%) and 38 g protein (99%).
Preparation and serving tips, and result
- Leach vegetables: peel, cut small, soak in warm water (about 10 times their volume) for at least 2 hours, then boil in plenty of fresh water and throw that water away.
- Weigh the dal, milk and egg white; they carry most of the protein, potassium and phosphorus.
- Serve drinks in a small marked cup; sucking a small ice cube or a lemon slice eases thirst, and the ice counts as fluid.
- Use sugar, sago, cornflour and oil generously for energy (unless the patient is diabetic) so the low-protein diet does not cause weight loss.
- Result: The CKD diet gives about 1865 kcal and 38 g protein within 1.5 L fluid, with leached vegetables and no added salt, meeting Mr. C's prescription.
In the diet kitchen, the CKD tray needs three extra jobs: leaching the vegetables in the morning, cooking without salt, and weighing the dal, milk and egg white so protein stays near the prescribed grams. Ward staff must know the fluid allowance, because tea, soup and payasam all count.
Short answer: “What protein intake is advised in CKD stage 4 not on dialysis?” 0.55-0.6 g/kg/day (KDOQI 2020) with adequate energy (25-35 kcal/kg); e.g. 63 kg × 0.6 = 38 g.
Short answer: “Why must energy be adequate on a low-protein diet?” Otherwise the body breaks down its own protein for energy, which raises urea and causes muscle loss.
Structured question: “Explain the dietary principles in chronic kidney disease not on dialysis.” Low protein 0.55-0.6 g/kg with some milk, curd or egg white; energy 25-35 kcal/kg from cereals, sago, sugar and oil; sodium below 2.3 g; potassium limited if high (low-potassium foods, leaching); phosphorus limited (dals, milk, nuts, colas); fluid = urine + 500 mL; protein raised to 1.0-1.2 g/kg once on dialysis.
CKD = 'three Ps and an S, but plenty of E': low Protein, Potassium and Phosphorus, low Sodium, plenty of Energy, and fluid = urine + 500.