15.3: Plan Nutritional Strategies to Impact Renal Wellness

Learning Objectives

By the end of this section, you should be able to:

• 15.2.1 Prioritize the hypotheses of nutritional habits that optimize renal wellness.
• 15.2.2 Generate solutions to optimize renal wellness utilizing nutritional habits.

Planning Nutrition Goals

The nurse should consider a client’s current renal system when planning nutritional goals; therefore, plans will vary accordingly. For the client with healthy kidneys, the goals of nutrition should focus more on dietary needs for comorbidities, including limiting sodium, trans fats, saturated fats, and alcohol; eating appropriate amounts of protein; and maintaining adequate fluid balance.

When creating nutritional plans for clients with compromised kidneys, the nurse should collaborate with a renal dietician and consider all laboratory test values. The plans for these clients should focus on limiting fluid intake, potassium, phosphorus, sodium, trans fat, saturated fats, magnesium, and proteins, while increasing calcium. Note that at the start of dialysis, slightly different restrictions apply.

The Healthy Renal System Goals

The nurse should direct clients with a healthy renal system and no comorbidities to consider nutritional goals for renal wellness. A good starting point is to use the MyPlate portioning method with every meal (de Bellefonds, 2021). In addition, it is important to limit sodium intake to no more than 2300 mg/day. Because the majority of sodium intake comes from processed foods and not table salt, encourage clients to avoid pre-processed foods or, at minimum, choose no-sodium or low-sodium options.

MyPlate

MyPlate pictorially represents healthy portion sizes of different food groups in a nutritionally sound diet. This tool is useful as a good starting point for any healthy client trying to improve their nutritional intake to maintain health.

Clients should also be aware of protein intake because protein byproducts are filtered through the kidneys. Clients should eat enough protein to maintain overall health, but not consume too much because the kidneys will have to work extra hard.

The nurse should encourage the client to choose complex carbohydrates such as whole grains, fruits, vegetables, lentils, and beans over simple carbohydrates such as sweetened beverages, packaged foods, and desserts (de Bellefonds, 2021). Heart health is important to kidney health, so limiting saturated fats and avoiding artificial trans fat is recommended. The client should consider limiting, or even eliminating, their alcohol intake. Alcohol is a waste product that the kidneys need to filter out, making it less efficient to filter out other things during this time; alcohol is also dehydrating, which affects the kidneys’ ability to regulate the body’s hydration status.

Another factor the nurse should consider is any comorbidities a client has. For example, a client who has a healthy renal system but has hypertension or diabetes is at much higher risk for developing CKD. Dietary goals should include foods that will keep these pathologies under control, as well as include nutrients that support renal health once a client has developed CKD.

Special Considerations: Fads for Weight Loss—Dangers to Renal System Health

Diets that promote excessive or reduced intake of specific nutrients, such as protein or carbohydrates, can be dangerous because they limit many nutrients and promote disease. For example, diets with excess red meats and saturated fats may cause heart disease; diets high in protein can lead to intraglomerular hypertension that may cause renal hyperfiltration, glomerular injury, and proteinuria, which could lead to CKD (Gang-Jee, et al., 2020). Well-known diets that require extreme nutritional changes include Atkins, Keto, Dukan, Montignac, Scarsdale, Stillman, and the Zone.

Goals for Clients with CKD

Clients with CKD need to follow the preceding guidelines, but they also have more restrictions. For clients who have CKD and diabetes and/or hypertension, the following restrictions are also required in addition to their original nutritional plan dictated by their comorbidity, categorized by stage Table 15.2.

Table 15.2 Nutrient Intake for Clients with CKD, Dependent on Stage of Failure (source: National Kidney Foundation, 2023a)

Stage	GFR	Function	Water Intake	Nutrient Intake
1	≥ 90 mL/ min/1.73 m^2	Working well. Client is unaware of deficiencies.	Increase water intake.	Consume low-fat and low-sodium diet.
2	60–89 mL/ min/1.73 m^2	Still functioning. Client may be asymptomatic or show signs of hypertension.	High water intake.	Continue low-fat and low-sodium diet. Add foods higher in calcium and magnesium.
3A	45–59 mL/ min/1.73 m^2	Decrease in function, with kidneys starting to decline. Client will have hypertension. Client may have anemia, fatigue, anorexia, malnutrition, and bone pain.	Continue high water only if no edema or heart failure present. If client has heart failure or edema, restrict fluids.	Continue with low-fat and low-sodium diet and food options that are high in calcium and magnesium. If heart failure or edema is present, restrict foods with phosphorus, potassium, and protein, limiting proteins that are plant-based or from lean meats.
3B	30–44 mL/ min/1.73 m^2
4	15–29 mL/ min/1.73 m^2	Severe decline in kidney function; may need dialysis. Client will have hypertension, anemia, malnutrition, altered bone metabolism, edema, metabolic acidosis, hypocalcemia, an elevated BUN and creatinine. Client may have uremia and azotemia.	Restrict fluids.	Restrict intake of fat, sodium, potassium, phosphorus, and magnesium. Increase intake of calcium. If not yet on dialysis, restrict protein. If dialysis has been started, increase protein.
5	< 15 mL/ min/1.73 m^2	End-stage renal disease (ESRD). Client will have complete kidney failure in which all other symptoms are present and worsened. Client will have azotemia with overt uremia and require dialysis or renal transplantation to survive.	If on dialysis, follow stage 4 recommendations. If recipient of a kidney transplantation, follow regular healthy diet.	If on dialysis, follow stage 4 recommendations. If recipient of a kidney transplantation, follow regular healthy diet.

Identifying Challenges to Nutritional Goals

Many barriers exist for clients with CKD—the more advanced the disease, the higher the likelihood that a client will, either deliberately or accidentally, not follow a nutritional plan. The nutritional plan for clients with CKD restricts fluids, fat, sodium, phosphorus, protein, magnesium, and potassium and increases calcium, which presents many challenges, especially before transplantation. The nurse should counsel the client on the following:

• Restricting fluids can be extremely difficult; the kidneys will excrete more urine if unable to concentrate solutes in smaller urine amounts. The client will then become extremely thirsty because they are losing much more water than they are permitted to drink each day.
• Sodium and phosphorus are not only found in certain fresh items but are also added to many processed foods as preservatives. Processed foods are much cheaper and more readily available to clients with busy lives, so it is more difficult to avoid these types of foods. Fast foods—prepared foods that are readily available—are not only extremely high in both sodium and phosphorus, but also in fat content. The nurse should counsel the client to limit their fast-food intake to only once or twice a week
• The client with CKD also needs to understand how to combine plant protein sources in the right amounts and types to replace proteins easily found in meat. Although lean meat protein sources are acceptable, options tend to be more expensive.
• The challenge faced when limiting magnesium is that many food sources high in magnesium are high in plant proteins, which can replace meat proteins, making selections more limited. Another difficult balance to achieve with magnesium is that many high calcium foods that need to be increased are also high in magnesium.
• Lastly, potassium is found naturally in a variety of fresh and healthy food choices. Many foods that the client was taught to eat before they had CKD to manage hypertension, diabetes, or any number of other comorbidities, will be ones they now have to avoid due to high potassium content. Potassium is the opposite of most other foods on the list—it is high in fresh food options and low in processed food options.