Protein turns into waste once your body has used it, and your kidneys remove this waste from the blood, which is why a kidney clinic may ask you to hold protein down. Whether you have started dialysis tells you if that instruction, or the advice to eat more protein, is the one meant for you, and a registered dietitian can then work out the amount with you.
Less protein before dialysis, more once it starts
If you have not started dialysis, a letter from your kidney clinic asking you to eat less protein belongs to the stage you are in, because low-protein diets may be helpful before you start dialysis. Your kidney doctor or dietitian may advise a lower-protein diet based on your weight, the stage of your disease, how much muscle you have, and other factors, and you still need enough protein, so the amount is one to work out with them.
Some people with kidney disease may need moderate amounts of protein so waste does not build up in the blood. A moderate amount sits between two risks: too much leaves waste in your blood, and too little may lead to malnutrition, a condition in which your body does not get enough nutrients. Advice to eat more protein that is aimed at people in general, such as weight-loss advice, was not written with your kidneys in mind, so set it beside your clinic's letter and ask your kidney doctor or a dietitian which amount is yours. There is no single meal plan for everyone with kidney disease, and in the early stages you may have few limits on what you eat and drink.
Once you are on dialysis, the instruction reverses, because dialysis removes protein from the blood, by an amount that depends on the type of dialysis. You may need to eat more protein, and a high-protein diet with fish, poultry, pork or eggs at every meal may be recommended. People on dialysis should eat 8 to 10 ounces of high-protein foods each day. That figure is for people on dialysis only, so if you have not started, it is not a target for you.
If your kidney doctor has recommended a low-protein diet and you do not have a problem eating carbohydrates, you may replace the calories from protein with fruits, breads, grains and vegetables, which bring fiber, minerals and vitamins with them. Eating too little overall carries a risk of its own, since losing too much weight can make you sicker. If you find you do not feel like eating, talk with a dietitian or your kidney doctor about whether you are getting enough calories, from nutritious sources (see No appetite at all? Start by writing down one day of eating).
Reading your GFR and urine albumin results
Two results in your chart show how well your kidneys are working: your GFR, from a blood test, and your urine albumin, from a urine test. Blood and urine tests are the only way to know if you have kidney disease, and many people have no symptoms until it is very advanced, so feeling well is no guide to how far it has gone.
GFR stands for glomerular filtration rate, a measure of how well your kidneys filter your blood. It is estimated from the amount of creatinine in your blood, a waste product of the normal breakdown of muscle that rises as kidney disease gets worse. Albumin is a protein a healthy kidney keeps out of the urine, and a damaged kidney lets some of it pass. It can be checked with a dipstick, or measured as a urine albumin-to-creatinine ratio, UACR, which compares the albumin in your sample with its creatinine. The bands for the two tests:
| Result | What it means |
|---|---|
| GFR of 60 or more | in the normal range |
| GFR below 60 | may mean kidney disease |
| GFR of 15 or less | kidney failure, and most people below this level need dialysis or a kidney transplant |
| UACR of 30 mg/g or less | normal |
| UACR above 30 mg/g | may be a sign of kidney disease |
If you have albumin in your urine, your kidney doctor may want you to repeat the urine test one or two more times to confirm the results. Ask your kidney doctor what your own numbers mean for you, including which stage of kidney disease they point to, when they will be checked again, and how to keep your kidney health at its current level.
You cannot raise your GFR, but you can try to keep it from going lower, so numbers that have stayed the same for years are what treatment aims for: a GFR that stays the same, and urine albumin that stays the same or goes down, are how you can tell treatments are working. What you eat and drink may also affect how well your kidney disease treatments work.
Sodium, potassium and phosphorus, the changes besides protein
Other changes include sodium, potassium and phosphorus, because avoiding foods high in any of them may prevent or delay some health problems from kidney disease. How far you take each one depends on your stage and your blood results, and each hides somewhere different in food.
| Mineral | What too much of it can do | Some places it hides |
|---|---|---|
| Sodium | makes your blood hold on to fluid, which can cause high blood pressure and swelling and puts stress on your kidneys and heart | packaged, prepared and restaurant foods, canned foods, some frozen foods, most processed meats, and snacks such as chips and crackers |
| Potassium | too little or too much in your blood can cause heart and muscle problems, and with too much, dangerous heart rhythms may result | fruits and vegetables, salt substitutes, foods with potassium chloride on the ingredient list, and the liquid in canned fruits and vegetables |
| Phosphorus | can harm your blood vessels and make your bones thin, weak and more likely to break, and high levels can cause itchy skin and bone and joint pain | additives in packaged and processed foods and drinks, such as deli meats and flavored drinks, and protein-rich foods such as meat, dairy products and beans |
For sodium, read the % Daily Value on the Nutrition Facts label: 20% or more means the food is high in sodium, and 5% or less means it is low. Draining and rinsing canned vegetables, beans, meats and fish with water takes off extra salt. Many people with kidney disease need to limit sodium more than other adults do, and your kidney doctor or dietitian can set your own limit based on your kidney health. Cutting sodium helps you control high blood pressure, and it also keeps you from being thirsty and stops your body holding on to extra fluid (see Why your prescriber needs your home blood pressure log).
Salt substitutes are not for people with kidney disease, because they contain potassium, and most herbs can flavor food in place of salt. Fruits and vegetables contain large amounts of potassium, so ask your kidney doctor or dietitian which fruits and vegetables to choose, and which to limit or avoid. If your potassium level is high, your kidney doctor may recommend limiting foods with potassium chloride on the ingredient list, which some packaged foods use in place of salt, and draining canned fruits and vegetables and throwing out the liquid, which is often high in potassium. Serving size counts as well: a large serving of a lower-potassium food may have more potassium than a small serving of a higher-potassium food.
Phosphorus additives are the primary source of phosphorus for many people, and foods and drinks with added phosphorus may push your blood level up more than foods that contain it naturally. On the ingredient list, look for the word phosphorus, or for words containing PHOS, such as phosphoric acid, disodium phosphate and monosodium phosphate. Some packaged meats and poultry have phosphorus added, so ask someone who works in the meat department to show you which do not. Your body also absorbs more phosphorus from animal foods, such as meat and poultry, than from plant foods, such as beans and seeds, and even in the early stages of kidney disease, phosphorus levels in the blood can get too high. Your kidney doctor can check your potassium and phosphorus levels with a blood test, so ask whether yours have been checked and what they showed.
Who sets your amounts, and how a dietitian's counseling can be covered
Your kidney doctor or a registered dietitian sets the amounts. If you are enrolled in Medicare and have kidney disease, Medicare will cover medical nutrition therapy, which is nutrition counseling from a registered dietitian. Two conditions come with that coverage: you need a written referral from a doctor, and the counseling must come from a registered dietitian. Ask your kidney doctor for a written referral to a registered dietitian who can help with your diet for kidney disease. Some dietitians specialize in diets for people with kidney disease, and a dietitian can also fit the diet around your other health needs.
You can also find a registered dietitian who specializes in kidney disease through the Academy of Nutrition and Dietetics online. With other health insurance, check your insurance company's website or call your insurer's customer service line to find out whether it pays for some or all of the counseling. If you have neither insurance nor Medicare, ask your kidney doctor what a dietitian's services cost; they may be able to connect you with organizations that help cover the cost of nutrition counseling.
How much to drink, and when fluid is an emergency
In the early stages of kidney disease, you do not need to limit the fluid you drink, but as it gets worse, or once you are on dialysis, you will need to watch how much liquid you take in. Your kidney doctor or a dietitian, and your dialysis nurse once you are on dialysis, will tell you how much to drink each day.
Once you are on dialysis, fluid can build up in your body between sessions, and too much fluid will lead to shortness of breath, an emergency that needs immediate medical attention: phone 911, or have someone take you to an emergency room straight away. Whether or not you are on dialysis, phone your kidney doctor's office if you notice any swelling in your face, arms, legs or abdomen.
If you are signing up with NicoCares for weight care, list your kidney disease, your latest GFR and urine albumin, and your clinic's protein instruction in the medical history it asks for, because your answers are read by a doctor licensed in the state where you live, and that doctor decides, on clinical grounds, whether to treat you. Once you are a patient, ask your care team how a dietitian's amounts fit with your weight care; their replies arrive in Spruce, a separate app whose sign-up link reaches you by email. Those replies have no set time, so phone your kidney doctor's office about swelling, and call 911 for shortness of breath on dialysis.
