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Can J Diabetes 38 (2014) 344e348

Contents lists available at ScienceDirect

Canadian Journal of Diabetes


journal homepage:
www.canadianjournalofdiabetes.com

Review

Nutrition for the Prevention and Treatment of Chronic Kidney


Disease in Diabetes
Dana Whitham RD, MSc *
Diabetes Comprehensive Care Program, St Michael’s Hospital, Toronto, Ontario, Canada

a r t i c l e i n f o a b s t r a c t

Article history: The prevention and treatment of chronic kidney disease (CKD) in diabetes through diet and lifestyle have
Received 18 March 2014 been a topic of much interest over the years. Consideration of the type and amount of carbohydrate,
Received in revised form protein and fat is required for optimal blood glucose control, for clinical outcomes related to renal
24 July 2014
function and for consideration of risk reduction for cardiovascular disease. Controversy has existed
Accepted 25 July 2014
regarding the clinical significance of a protein-controlled diet, not to mention the ideal recommended
intake in view of the benefits and risks. Furthermore, the level of CKD with which to implement dietary
Keywords:
changes should also be considered. This review seeks to provide guidance and clarity concerning the
protein
nephropathy
nutritional management of CKD in diabetes.
diabetes Ó 2014 Canadian Diabetes Association
sodium
nutrition r é s u m é

Mots clés : La prévention et le traitement de la néphropathie chronique (NC) à l’aide du régime alimentaire et du
protéine mode de vie lors d’un diabète ont suscité beaucoup d’intérêt au fil des années. La prise en considération
néphropathie du type et de la quantité de glucides, de protéines et de matière grasse est nécessaire à la régulation
diabète optimale de la glycémie, aux résultats cliniques liés au fonctionnement rénal ainsi qu’à la réduction du
sodium
risque de maladie cardiovasculaire. Une controverse existait concernant l’importance clinique d’un
nutrition
régime pauvre en protéines, sans parler de l’apport idéal recommandé eu égard aux avantages et aux
risques. De plus, le degré de NC pour la mise en pratique de changements au régime alimentaire devrait
également être considéré. Cette revue cherche à fournir des conseils et des précisions sur la prise en
charge nutritionnelle de la NC lors de diabète.
Ó 2014 Canadian Diabetes Association

Introduction promote optimal glycemic control. This review examines the life-
style factors that influence risk for and progression of CKD in dia-
Diet and lifestyle are key components of an interprofessional betes, notes the clinical recommendations for nutrition therapy and
approach to diabetes care. A treatment plan that encourages a provides guidance about how to achieve targets while managing
combination of self-management education, lifestyle and phar- both diabetes and CKD (Table).
macotherapy has been shown to be successful (1). Good nutrition
can help to control blood glucose, blood pressure and lipids,
Nutritionally Modifiable Risk Factors for Chronic Kidney
thereby slowing the onset and progression of complications that
Disease
include chronic kidney disease (CKD). Diets that reduce inflam-
mation and oxidative stress may also delay the progression of CKD
Poor glycemic control, hypertension and smoking are well-
in diabetes (2). Controversy surrounds recommendations for
known risk factors for CKD in persons with diabetes (3). There
low-protein diets in CKD in terms of the exact amount, when to
are several novel risk factors that are also amenable to dietary
implement any limitations and whether the benefits outweigh the
interventions, including obesity, hyperphosphatemia and advanced
potential risks. In more advanced CKD, the restrictions required as
glycation endproducts (AGEs).
part of a renal diet may conflict with the dietary strategies that
Obesity is associated with increased incidence of CKD (4,5), and
some experts estimate that up to 25% of cases of kidney disease
* Address for correspondence: Dana Whitham, RD, MSc, St Michael’s Hospital, 61
could be prevented through weight loss alone (6). Epidemiologic
Queen Street East, Toronto, Ontario M5C 2T2, Canada. studies report that obesity is independently predictive of CKD (3)
E-mail address: whithamd@smh.ca and that the link may occur through the physical compression of
1499-2671/$ e see front matter Ó 2014 Canadian Diabetes Association
http://dx.doi.org/10.1016/j.jcjd.2014.07.222
D. Whitham / Can J Diabetes 38 (2014) 344e348 345

Table
Nutritional considerations for people with chronic kidney disease in Diabetes

CKD Stages 1-2 CKD Stages 3-4 ESRD Stage 5 (on dialysis)
Glycemic control Promote optimal glycemic control May require medication adjustment Assess for hypoglycemia
Assess for hypoglycemia
Calories and weight 23-35 kcal/kg BW/d or use HBE Hemo: 30-35 kcal/kg/day
23-35 kcal/kg/day for stage 3. 30-35 kcals/kg/day
Encourage 5%-10% weight loss if appropriate for stage 4. Encourage preservation of leanPD: 30-35 kcal/kg/day
body mass and nutritional status Encourage preservation of lean body mass and
nutritional status
CHO and sugar 45%-60% of energy <10% of calories from sugar 45%-60% of energy <10% of calories from sugar 45%-60% of energy
(as part of a mixed meal) (as part of a mixed meal) <10% of calories from sugar (as part of a mixed
meal)
Protein Encourage 0.8 g/kg/day 0.8g/kg/day with avoidance of intakes Hemo: 1.2 g/kg/day
>1.3g/kg/day PD: 1.2-1.3 g/kg/day
Fat saturated fat <30%-35% of energy <30%-35% of energy <30%-35% of energy
<7% of energy <7% of energy <7% of energy
Fibre 14-25 g/1000 kcal 14-25 g/1000 kcal 14-25 g/1000 kcal
Glycemic index Promote low GI grains, fruit, dairy products Encourage stepwise modifications in GI Encourage lower GI, renally appropriate choices
Watch overall carbohydrate content as GI of
diet changes
Fluid Usually unrestricted Usually unrestricted Hemo: 1L þ urine output
Watch for excessive thirst with hyperglycemia Watch for excessive thirst with hyperglycemia PD: Individualized
Watch for thirst caused by hyperglycemia
Educate on nonfluid sources of carbohydrate
for treatment of hypoglycemia
Sodium <2000 mg/day <2000 mg/day <2400 mg/day
Potassium Individualized restriction if hyperkalemia <2400 mg/d if hyperkalemia present Hemo: <2400 mg/day
present PD: Individualized
Phosphorus Individualized restriction if elevated serum 800-1000 mg/day Hemo: 800-1200 mg/day
levels PD: 800-1000 mg/day
Dietary patterns DASH/Mediterranean/Portfolio Progressing dietary restrictions limit patterns Progressing dietary restrictions limit patterns
based on protein content, potassium or based on protein content, potassium or
phosphorus. Modifications as required phosphorus. Modifications as required

CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; ESRD, end stage renal disease; GI, glycemic index; HBE, Harris Benedict equation; Hemo,
hemodialysis; PD, peritoneal dialysis.
Adapted from Whitham D, Sharma Parpia A. (37).

the kidneys, the activation of the renin-angiotensin aldosterone benefit to the progression of complications. Although not shown in
system (RAAS) or hyperfiltration (6). American guidelines for dia- humans, some animal-model studies have demonstrated a benefit
betes and CKD encourage attaining a normal body weight as a of antioxidant supplementation on vascular disease (11).
potential means of reducing risk (6). In summary, management of hyperglycemia, hypertension and
Recent observational studies have shown an association lipids and a more healthful dietary pattern that promotes an ideal
between serum phosphorus levels and rate of progression of CKD body weight plus balanced intake may be of benefit to minimizing
(7,8). The hypothesis is that dietary phosphorus intake leads to the progression of CKD in persons with diabetes.
calcification and vascular damage, although direct links have not
been demonstrated in clinical trials (7). Weight management
AGEs have been associated with both vascular damage (2) and
structural changes in the kidney, which may lead to the progression For those who are overweight, lifestyle therapy aimed at
of renal disease and to a higher prevalence of cardiovascular disease achieving and maintaining an ideal body weight may improve
in those with CKD (2). AGEs are a group of highly oxidant com- multiple risk factors for kidney disease, including blood glucose,
pounds also known as glycotoxins (9), which may be consumed in blood pressure, lipids and proteinuria (12e16). One systematic
the diet or may be produced as a part of normal metabolism. AGEs review found that for each kg of weight loss, there was a reduction of
accumulate in tissues, binding to and cross-linking proteins, 110 mg of proteinuria (17). Both body weight and waist circumfer-
thereby altering cell structure and function (9) as well as causing ence targets should be considered when setting goals. Waist
oxidative stress and inflammation (9). AGE formation is accelerated circumference is strongly associated with visceral fat in patients with
in states of high blood glucose and uremia (9). CKD (18) and carries a greater risk than does body mass index (1).
Dietary AGEs (dAGEs) are naturally found in uncooked animal- For overweight and obese people with stage 1 to 3 CKD
derived foods. Cooking, particularly frying, broiling and grilling at and diabetes, moderate weight loss of 5% to 10% of body weight
high temperatures, can lead to very significant increases in dAGE is recommended. Moderate reductions in energy intake (500 to
levels (10). Simple alterations of cooking methods have been shown 1000 kcal/day) combined with an increase in physical activity is the
to decrease serum levels of AGEs, oxidative stress, inflammation preferable weight-loss plan for this population (3,6). High-protein
and insulin resistance (9). In addition to the avoidance of very high diets, such as Atkins, Protein Power, South Beach, Sugar Busters
temperatures, the addition of moisture through either water or and Zone (defined as 20% of total daily calories from protein) are
marinades can reduce the formation of AGEs (9). not recommended. Higher protein intakes have adverse effects on
Prevention of oxidative stress may be important in many kidney hemodynamics and increase hyperfiltration, intra-
chronic diseases, including CKD. With conditions such as hyper- glomerular pressure and albuminuria. These deleterious effects are
glycemia and uremia, which lead to increases in oxidative stress, more pronounced in people with diabetes (6). Epidemiologic evi-
and a typical North American dietary pattern that promotes dence suggests an association between high-protein diets and the
oxidative stress and yet has insufficient antioxidants, it could be development of proteinuria in people with diabetes and hyper-
speculated that increasing the intake of antioxidants would be of tension and in women, a loss in kidney function (6).
346 D. Whitham / Can J Diabetes 38 (2014) 344e348

The Academy of Nutrition and Dietetics (AND) recommends a restriction, for nutritional treatment of hypertension in people with
calorie intake of 23 to 35 kcal/kg BW/day in patients with CKD but diabetes because of its potent reductions in both blood pressure
without dialysis (19). Energy requirements in this population are and its effect on insulin resistance. Principles of the DASH diet
similar to those of healthy individuals; however, in more advanced include the use of whole grains, fruits and vegetables, and low-fat
stages of CKD, higher caloric intakes (30 to 35 kcal/kg BW/day) may dairy products. As a result, the diet is designed to be high in
be required to maintain nitrogen balance while also maintaining potassium and phosphorus and may be best suited to individuals
serum albumin and the anthropometric markers of normal nutri- with stage 1 to 2 CKD (26) and those without need for dietary
tional status. So, as the glomerular filtration rate (GFR) declines, restrictions to manage hyperkalemia.
caloric intake should increase toward the higher end of the range (6).
Regular monitoring to ensure that weight goals are attained is Carbohydrates and glycemic control
key to success. Assessment of fluid status and edema should be
considered when evaluating progress toward weight-loss goals. For most people with diabetes and CKD, the dietary strategies of
the Canadian Diabetes Association (CDA) that are aimed at reducing
Dietary fats hyperglycemia are appropriate (12). As kidney function declines
(CKD stages 4 and 5), both food choices and portions may have to be
Because people with CKD are at high risk for cardiovascular adjusted to meet the required restrictions in potassium and phos-
disease (20), lipid targets and dietary recommendations should phorus. Unfortunately, diets high in fibre and low in glycemic index
align with those of the Canadian Diabetes Association and Canadian are also commonly high in potassium and phosphorus. Neverthe-
Cardiovascular Society to reduce intake of alcohol, saturated and less, a higher fibre intake and the use of low-glycemic index foods
trans fatty acids, dietary cholesterol and simple sugars (12,21). should be encouraged within the constraints of the progressing
In people with CKD, substituting lean meats, poultry, fish and renal restrictions.
low-fat dairy products in place of high-fat animal-derived foods The first step in managing a diet for a person with diabetes and
will have little adverse impact on serum potassium or phosphorus. CKD is to ensure that the intake of carbohydrates is not excessive
However, care should be taken in recommending an increase in the for the caloric requirements and is within the recommended range
consumption of nuts, some sources of vegetable protein (soy and of 45% to 60% of total calories (27,28). A fibre intake similar to that
legumes) and certain sources of soluble fibre because these may of the general population (14 g/1000 kcal/day) (28) or slightly
exacerbate hyperkalemia. higher (15 to 25 g/1000 kcals/day) if achievable should be
Several guidelines recommend 2 to 3 servings of cold-water encouraged because it is unlikely to achieve fibre intakes at the
fatty fish weekly to increase omega-3 fatty acids. Omega-3 fatty high end of the CDA recommendations (50 g/day). Low-potassium
acids may have favourable effects on the progression of kidney fruits and vegetables, such as berries, pears, apples, green peas and
disease as evidenced by reductions in proteinuria, although trial green beans, as well as popcorn and cracked-wheat bread can be
data are limited (12,20). Supplementation of omega-3 fatty acids recommended to boost fibre intake. Those unable to achieve fibre
had no effect on cardiovascular disease in the Outcome Reduction goals through the diet can add natural tasteless fibre supplements
with Initial Glargine Intervention (ORIGIN) trial (22). (e.g. Benefibre) to their meals or fluids (6). In terms of the glycemic
No clinical studies have been conducted concerning the use of index (GI), low GI foods should be encouraged until a restriction in
plant sterols to lower cholesterol in patients with CKD, but they are dietary potassium limits their use. At that time, a stepwise
considered safe food additives, a dose of 2 g per day may lead to approach to restrictions would be recommended. Limiting high-
beneficial reductions in cholesterol for those not achieving targets. potassium, highly processed convenience foods, such as potato
chips, chocolate and granola bars, and refined breakfast cereals
Dietary sodium intake should be recommended. Most fruits and vegetables are low on the
GI index but range in potassium content. The second step toward
High dietary sodium intake is associated with high blood pres- managing postprandial glucose while following a potassium-
sure (23), worsening of proteinuria and a blunting of the response restricted diet would be to select fruits and vegetables that have
to agents that block the RAAS (24). Therefore, irrespective of blood lower potassium levels (see list above). Milk products, although
pressure, dietary sodium restriction should be a component of generally low on the glycemia index, should be encouraged initially
nutrition therapy for all patients with proteinuria, including those in amounts to meet the recommendations of the Canada Food
on RAAS blockade. The effect of the restriction may be more pro- Guide; however, as CKD progresses, recommended intakes may
nounced in those with pre-existing hypertension, older adults and need to be further reduced and calcium and vitamin D supplements
African Americans (24). considered. Modification of the intake of grains and starches would
The Kidney Disease Improving Global Outcomes (KDIGO) be the final step toward reducing potassium intake while main-
guidelines recommend a sodium restriction of less than 2000 mg taining targets in postprandial glucose. Grains lower on the GI
per day in people with stages 1 through 4 CKD (24) based on evi- index include parboiled rice, al dente pasta, cracked wheat and
dence that suggests that excess dietary sodium (4600 mg) affects sourdough breads.
proteinuria. The Canadian Hypertension Education Program (CHEP)
guidelines recommend limiting sodium intake to no more than Sweeteners
1500 mg of sodium per day for those younger than 50 years of age;
1300 mg for those between 50 and 70 years of age; and no more Nutritive and non-nutritive sweeteners (NNS) are considered
than 1200 mg for those over the age of 70 (25). Restricting sodium safe for use by people with diabetes and CKD when consumed in
intake to the recommended levels is often difficult to achieve in the acceptable intake ranges outlined by Health Canada. NNS,
practice, especially for those younger and more active individuals including acesulfame K, aspartame, stevia, sucralose and saccharin,
requiring larger caloric intakes. Nutrition counselling should focus are excreted unchanged in either urine or feces and as such do not
on processed and prepackaged foods (including canned soups and have any impact on serum potassium levels (29). Use of NNS may be
deli meats), meals taken outside of the home and bread products of importance for those with CKD and diabetes to manage the
that have high sodium content. overall glycemic load. This is especially important in situations
The Dietary Approaches to Stop Hypertension (DASH) diet is a where the necessity for dietary potassium restrictions has led to the
dietary pattern commonly recommended, along with a sodium use of foods lower in fibre or higher on the GI. Use of NNS to
D. Whitham / Can J Diabetes 38 (2014) 344e348 347

sweeten foods or for use in baking and low-sugar jams, jellies and Beyond quantity, the type of dietary protein may be important
yogurts may be appropriate and safe substitutions. to renal outcomes. High-biologic value proteins, which include
lean sources of fish, poultry, eggs, soy and legumes, should make up
Proteins between 50% and 75% of the protein intake (6). Diets that empha-
size plant sources of protein (soy, legumes and nuts) may be higher
The protein needs of people with diabetes are the same as those in potassium and phosphorus. In the Dietary Approaches to Stop
of the general population. Most adults consume, on average, Hypertension (DASH) trials, despite a relatively high protein intake
between 1.0 and 1.4 g/kg BW/day (12). In type 2 diabetes, meals (1.4 g/kg BW/day), blood pressure was significantly reduced by the
containing protein may assist with blood glucose management by intake of mainly vegetable sources of protein (whole grains, low-fat
enhancing insulin release (27,29,30) and promoting satiety. dairy products) along with fish and chicken. The DASH diet trials
Excessive dietary protein, however, causes hyperfiltration and the were not the only studies to demonstrate that there may be some
accumulation of uremic toxins (24) and dietary acids that may be benefit to limiting red meat (24). In the Nurses Health Study, the
detrimental to the progression of CKD. risk for end stage renal disease was greater in women who had
Although the adverse effects of excessive protein intakes are higher intakes of animal meat (24). Therefore, in people within
clear, the benefits of protein-restricted diets in CKD have long been stages 1 to 2 CKD, employing a patterned approach to intake, such
debated. This is the result primarily of the relatively poor quality of as the DASH diet, may be beneficial in terms of promoting
the studies and the reliance on surrogate endpoints, particularly appropriate types of proteins and carbohydrates and ultimately
albuminuria. Much of the data suggesting the benefits of protein may affect blood pressure, glycemia and proteinuria. A DASH
restriction came from studies conducted prior to the use of RAAS pattern can be continued until such time as limitations in potas-
blockade agents (31e33). sium or phosphorus intake are required or until the GFR falls below
A number of meta-analyses and a Cochrane review have been 30 mL/min/1.73m2. The practical implementation of achieving a
completed in attempt to summarize the available data. Based on 12 protein-controlled diet through nutrition therapy requires specific
studies, the Cochrane review concluded that there was a small but guidance by healthcare professionals and the avoidance of the
nonsignificant effect of low-protein diets on slowing diabetic word restriction. Specific guidance related to achieving the RDA of
nephropathy (34). 0.8 g/kg BW/day with a maximum of 1.3 g/kg BW/day would be
Pan and colleagues conducted a systematic review and meta- beneficial, especially for those with a GFR <30 mL/min/1.73m2.
analysis of randomized controlled trials evaluating lower protein When translating protein requirements into protein servings,
diets in people with diabetes, and the primary outcome was the use of actual or ideal body weight is recommended. After using the
rate of change of the GFR instead of the risk marker proteinuria formula of 0.8 g/kg BW/day, multiply by 0.5 to allow for at least 50%
(35). The actual intake in the low-protein diets averaged 0.91 g/kg of protein to come from high biologic sources. Divide the result by 7
BW/day as compared to a usual intake range of 1.27 g/kg BW/day. in order to determine the number of protein servings that would
Overall, the review found no improvement in kidney function, as come from meats and alternatives.
estimated by GFR, between low protein intake and usual intake.
The authors did conclude, however, that a significant decrease in Hypoglycemia and hyperglycemia
proteinuria was observed in those who ingested the lower protein
diet. Reductions in proteinuria have also been seen in other studies The risk for hypoglycemia, especially in those using insulin or
involving dietary protein intakes at the recommended dietary insulin secretagogues, increases with declining renal function. In
allowance (RDA) level (6). In a more recent study, a protein- those with later stages of CKD, altered drug metabolism may affect
controlled diet limited to 0.89 g/kg BW/day was shown to reduce the clearance of certain medications. Uremic factors, including
the risk for progression to end stage renal disease with more gastroparesis, poor appetite, fatigue and taste changes, compound
pronounced benefits in individuals with diabetes (36). Of particular the risk. Furthermore, reduced kidney mass impairs renal gluco-
interest is that this study was conducted in people with type 1 neogenesis and can predispose an individual toward hypoglycemia.
diabetes who were treated with an angiotensin-converting enzyme Treatment of hypoglycemia should follow CDA guidelines (12), but
inhibitor, indicating that the effect of controlling protein intake care should be taken to avoid hyperkalemia (by using higher
closer to the RDA in early stages of CKD in diabetes may be additive potassium treatment options such as orange juice) and fluid over-
to current treatment recommendations. In the only large-scale load. Fast-acting carbohydrates that are suitable for those with
randomized controlled trial to date, the Modification of Diet in renal impairment include dextrose tablets, hard candies, honey
Renal Disease (MDRD) Study (33), a lack of effectiveness of protein- and non-cola regular pop instead of commonly recommended
restricted diets (defined as less than the RDA of 0.8 g/kg BW/day) treatments such as juices or cola beverages.
was found. With declining renal function, fluid control may become an
Based on this information, the CDA (12) recommends that in issue. Adherence to fluid restrictions may be more difficult in
people with CKD, intakes should be targeted to the RDA of 0.8 g/kg situations of hyperglycemia. When a fluid restriction is warranted,
BW/day. Both the Academy of Nutrition and Dietetics (AND) (19) patients should be educated to maintain optimal glucose control
and the Kidney Disease Outcomes Quality Initiative (KDOQI) (6) and to control thirst with alternate strategies such as using lime
guidelines also recommend intakes in the 0.8 to 0.9 g/kg BW/day and lemon wedges, ice chips and sugar-free gums or candies.
range for those with CKD and diabetes. Counselling to avoid under-
consumption or excessive consumption of protein is recom- Summary
mended. Excessive intakes are generally defined as a diet that
contains 20% or more total calories derived from protein. The 2012 Living with either CKD or diabetes is a challenge. For patients
KDIGO (24) guidelines recommend that protein intake should be with diabetic nephropathy, acceptance and adherence to the diet is
maintained at 0.8 g/kg BW/day with avoidance of intakes above often limited because the restrictions required by the renal diet
1.3 g/kg BW/day for those individuals at risk for progression. Upon may contradict previous dietary recommendations for diabetes.
review of the evidence, the KDIGO working group concluded that in Poor adherence places patients at risk for acute complications, such
CKD with diabetes, there was no convincing evidence that long- as fluid overload, hyperkalemia, hyperphosphatemia and malnu-
term low protein intakes (<0.8 g/kg BW/day) were beneficial in trition, not to mention the potential worsening of CKD. Adherence
slowing the progression of CKD. is best achieved through collaboration with a registered dietitian to
348 D. Whitham / Can J Diabetes 38 (2014) 344e348

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