Nutrition and Renal Disease
The kidneys’ job is to keep the body’s fluids, electrolytes, and
organic solutes in a healthy balance. Their functional units are the
million or so nephrons in the renal cortex which filter most
constituents of the blood other than red blood cells and protein,
reabsorb needed substances, secrete hydrogen ions to maintain acid-base
balance, and secrete wastes.
1
Urine formation consists of three basic processes: glomerular
filtration, tubular secretion, and tubular reabsorption. Several disease
conditions can interfere with these functions. Inflammatory and
degenerative diseases can involve the small blood vessels and membranes
in the nephrons. Urinary tract infections and kidney stones can
interfere with normal drainage, causing further infection and tissue
damage. Circulatory disorders, such as hypertension, can damage the
small renal arteries. Other diseases, such as diabetes, gout, and
urinary tract abnormalities can lead to impaired function, infection, or
obstruction. Toxic agents such as insecticides, solvents, and certain
drugs may also harm renal tissue.
Nephrotic Syndrome
In nephrotic syndrome, an injury to the glomerular basement membrane
causes an increased glomerular permeability, resulting in the loss of
albumin and other plasma proteins in the urine. Urinary protein losses
greater than 3-3.5 grams per day usually indicate nephrotic syndrome.
Although albumin synthesis in the liver is increased in nephrotic
syndrome, it is not enough to compensate for losses in the urine. The
loss of albumin leads to edema.
Low albumin levels also trigger cholesterol and lipoprotein synthesis
in the liver, resulting in hyperlipidemia. At the same time, hepatic
catabolism of serum lipoproteins is reduced and urinary excretion of HDL
is increased. These lipid abnormalities can be exacerbated by
medications often used to treat nephrotic syndrome, such as steroids,
diuretics, and anti-hypertensive agents.
Diet for Nephrotic Syndrome
A
well-planned diet
can replace lost protein and ensure efficient utilization of ingested
proteins through provision of adequate calories. Dietary changes can
also help control hypertension, edema, and hyperlipidemia, and slow the
progression of renal disease.
Protein: High-protein diets are not recommended as
they may encourage damage to the nephrons, leading to a progression of
renal insufficiency. Since albumin losses in nephrotic patients are due
to increased catabolism, rather than a reduction in protein synthesis,
low-protein diets, which decrease catabolism, may be more beneficial.
2
The optimal amount of dietary protein necessary to prevent protein
catabolism and progression of renal disease has not been established. A
common recommendation is 0.6 grams of protein per kilogram of ideal body
weight, adjusted depending on the glomerular filtration rate and
nutritional status, plus gram-for-gram replacement of urinary protein
losses.
A vegetarian diet, often used for lipid-lowering, also offers a
convenient way to provide adequate, but not excessive, protein. In a
1992 study, a group of 20 nephrotic syndrome patients were put on a
vegetarian diet for eight weeks. Protein intake averaged 0.7 grams per
kilogram per day, which was more appropriate to their needs than the
1.15 grams per kilogram provided in their usual diet.
3
Sodium and Fluid: A limit on sodium of 1-3 grams per
day is usually recommended to control edema and hypertension. Diuretics
may also be used. A fluid restriction is not warranted unless renal
failure occurs.
Lipids: A diet low in saturated fat and cholesterol,
combined with loss of excess weight, is recommended to reduce the risk
of cardiovascular disease. Many clinicians recommend limiting
cholesterol to less than 300 milligrams per day and fat intake to 30
percent of calories. However, research has shown that such
recommendations lead to only minimal lipid lowering. As noted in detail
in
Section 1,
low-fat vegetarian diets are much more effective for lipid control and
usually lead to the reversal of atherosclerotic disease.
Cholesterol-lowering drugs can be used adjunctively if needed.
An eight-week trial in 13 men and 7 women with hyperlipidemia and
nephrotic syndrome showed that a vegetarian diet significantly reduced
cholesterol, triglycerides, and phosphorus.
3
Energy: Calorie intake should be adequate to achieve
and maintain ideal body weight and maintain protein stores. Foods rich
in complex carbohydrates should provide the majority of calories.
Supplements: Patients with nephrotic syndrome are
often low in B vitamins and zinc, and can benefit from supplements. In
addition, since a significant portion of serum calcium is protein-bound,
it tends to be low when serum proteins are reduced. No modification is
routinely needed for potassium, but potassium losses due to secondary
hyperaldosteronism may require replacement.
4
The following clinical values should be monitored:
4
- Serum albumin and total protein
- Urinary protein
- Glomerular filtration rate
- Dietary protein, fat, and cholesterol
- Daily weights
-
Serum lipids
Acute Renal Failure
Acute renal failure, manifested by oliguria or anuria,
usually occurs suddenly and is often reversible. It is marked by a
reduction in the glomerular filtration rate and a modification in the
kidneys ability to excrete metabolic wastes.
Its causes can be prerenal, intrinsic, and postrenal.
Prerenal causes include severe dehydration and circulatory collapse.
Causes intrinsic to the kidney include acute tubular necrosis,
nephrotoxicity, vascular disorders, and acute glomerulonephritis.
Obstructive (postrenal) causes include benign prostatic hypertrophy and
bladder or prostate cancer.1
The most common form of intrinsic renal disease is acute
tubular necrosis, accounting for about 75 percent of cases. Acute
tubular necrosis may be due to posttraumatic or surgical shock or to the
toxic effects of drugs, metals, or organic compounds.
Nutrition strategies in acute tubular necrosis vary
depending on its stage. During phase one, oliguria, less than 400
milliliters of urine is produced per day. This phase usually lasts one
to three weeks. Signs and symptoms include nausea, vomiting, fluid
overload, and elevation of BUN, creatinine, phosphorus, and potassium
levels. Dialysis may be needed during this stage to reduce acidosis,
control hyperkalemia, and correct uremia.
The diuretic phase of acute tubular necrosis lasts one
to two weeks, and is characterized by increased urine output and a
return of the ability to eliminate wastes. Fluid and electrolyte balance
should be monitored and replacements made as necessary. The
convalescent phase occurs over the next two to six months.1,2
Diet in Acute Renal Failure
Diet plays a critical role in the care of patients with acute renal
failure. Clinicians should plan diets with an eye toward the possibility
of uremia, metabolic acidosis, fluid and electrolyte imbalances,
infection, and tissue destruction. Nutritional support of dialysis will
be discussed below in the section on chronic renal failure.
Protein: A low-protein diet (0.5-0.6 grams per
kilogram) is recommended initially. Protein may be increased in the diet
as the glomerular filtration rate increases to normal. If dialysis is
initiated, the protein level may be increased to 1.0-1.5 grams per
kilogram per day if necessary to compensate for protein losses in the
dialysate.
Calories: Calorie needs are generally elevated (35-50
kilocalories per kilogram) in order to provide positive nitrogen
balance under stressful conditions. As protein is usually quite
restricted, calorie needs may be met by providing greater amounts of
carbohydrate and fat in the diet.
Sodium and Fluid: Sodium is restricted depending on
urinary excretion, edema, serum sodium levels, and dialysis needs.
During the oliguric phase, sodium may be restricted to 500-1000
milligrams per day, and fluid requirements are based on replacing losses
via urine, vomitus, and diarrhea, plus approximately 500 milliliters
per day.
Potassium: Potassium requirements vary depending on
hemodynamic status and the degree of hypermetabolism due to stress,
infection, or fever. High potassium levels are treated by dialysis or
with kayexalate, an exchange resin which substitutes sodium for
potassium in the gastrointestinal tract. During the oliguric phase,
potassium may be restricted to 1,000 milligrams per day.
3
Chronic Renal Failure
Approximately 90 percent of cases of end-stage renal disease are
attributable to diabetes mellitus, glomerulonephritis, or hypertension.
Kidney failure results in fluid and electrolyte imbalances, the build up
of nitrogenous wastes, and reduced ability to produce renal hormones.
The two treatment options are transplantation or dialysis.
1
Mild renal insufficiency is defined as 40-80 percent of renal
function. Moderate insufficiency is defined as 15-40 percent, and severe
renal insufficiency is below these figures.
2
Diet in Chronic Renal Failure
Low-protein diets may slow the progression of mild and moderate renal
insufficiency. Therapeutic diets using plant sources of protein are
more effective in delaying the progression of renal insufficiency,
compared to those using animal proteins.
5
Vegan (pure vegetarian) diets have been shown to provide
adequate protein. A study of 22 patients with mild renal failure
compared a vegan diet to a conventional low-protein diet. All patients
were followed for at least six months. There was no sign of protein
insufficiency and inorganic phosphorus levels remained normal.6
Dialysis Patients
Dialysis changes dietary needs. Patients undergoing typical
hemodialysis, involving about three treatments per week, follow diets
that are restricted in protein, sodium, potassium, phosphorus, and
fluid. Patients on continuous ambulatory peritoneal dialysis, involving
several dialysate exchanges per day, can be more liberal in protein,
sodium, potassium, and fluid intake.
Sodium: Sodium intake must be modified to prevent
hypertension, congestive heart failure, and pulmonary edema. Limiting
intake will help avoid thirst and maintain acceptable fluid balance.
Restrictions range from 1,000-3,000 milligrams per day with hemodialysis
and 2,000-4,000 milligrams per day for peritoneal dialysis. Major salt
sources are described below.
Fluid: Fluid consumption should be controlled to
avoid congestive heart failure, pulmonary edema, hypertension, and
swelling of the legs and feet. Fluid allowances are 1,000-1,5000
milliliters per day and are based on urine output and type of dialysis.
Protein: Protein requirements range from 1.1-1.5
grams per kilogram, depending on the type of dialysis used and the
patient’s nutritional status. It is important to ensure sufficient
protein to maintain visceral protein stores, but to avoid excesses that
could lead the accumulation of nitrogenous waste products in the blood
(uremia).
Phosphorus: Kidney failure causes high levels of
phosphorus to build up in the blood and disrupts calcium/phosphorus
balance. Elevated phosphorus levels can lead to metastatic calcification
(soft tissue calcification), secondary hyperparathyroidism, and renal
osteodystrophy. Recommended intakes usually range from 800-1,000
milligrams per day with hemodialysis and less than 1,200 milligrams per
day with periotoneal dialysis.
Potassium: Potassium restrictions depend on serum
potassium levels, the type of dialysis, medications, and residual renal
function. Patients on hemodialysis are usually restricted to 2,000-3,000
milligrams per day to prevent hyperkalemia between treatments. Patients
on peritoneal dialysis may follow a more liberal dietary potassium
intake, as potassium is lost in the dialysate solution during daily
exchanges.
Kidney Stones
About 12 percent of Americans develop a kidney stone at some point in
their lives. Stones usually result from the crystallization of calcium
(which originally came in foods or supplements) and oxalate, a part of
many plant foods. Some people have a tendency to lose excessive amounts
of calcium or oxalate through their kidneys, and they have a greater
likelihood of a stone.
7-10 Kidney stones can also form from
uric acid, which is a breakdown product of protein, or from struvite
(ammoniomagnesium phosphate) or cystine.
The prevalence of kidney stones is three times higher in men than
women, and is higher among Caucasians than Asians or African Americans,
for reasons that are not clear. They are especially likely to strike
between the ages of 40 and 60.
Nutritional steps are important in preventing stones and can also
help prevent recurrences, which is important given that 30-50 percent of
people diagnosed with a renal stone have a recurrence within five
years.
Preventing stones is like keeping a salt crystal from forming in a
glass of salty water. You can either reduce the concentration of salt or
add more water. Epidemiologic studies have shown that certain parts of
the diet help reduce the amount of calcium that filters into the urine.
It is a simple matter to put these factors to work clinically.
| WHAT’S IN A STONE? 7 |
| Calcium oxalate |
72% |
| Uric acid |
23% |
| Ammoniomagnesium phosphate (struvite) |
5% |
| Cystine |
<1% |
Protective Foods
Certain parts of the diet clearly help reduce the risk. The first is no surprise.
Water. Water dilutes the urine and keeps
calcium, oxalates, and uric acid in solution. In research studies,
those subjects whose total fluid intake (from all sources) over 24 hours
was roughly 2.5 liters, the risk of a stone was about one-third less
than that of subjects drinking only half that much.7 (They do
not need to drink 2.5 liters of water per day; rather this is the total
fluid consumption, including juices, soups, etc.) Patients need to
understand that their thirst sense can lag behind their hydration
status, and they may need to develop a routine for extra water
consumption.
High-Potassium Foods. A study of 46,000
men conducted by Harvard University researchers found that a high
potassium intake can cut the risk of kidney stones in half. Potassium
helps the kidneys retain calcium, rather than sending it out into the
urine. Potassium supplements are not generally necessary. Rather, a diet
including regular servings of fruits, vegetables, and beans supplies
plenty of potassium.
Calcium. Although most stones contain
calcium, the calcium in foods does not necessarily contribute to stones.
Calcium supplements taken between meals may increase the risk of
stones, because about 8 percent of any extra dietary calcium passes into
the urine.9,11 On the other hand, calcium consumed with
meals has the opposite effect, reducing the risk of stones. The reason,
apparently, is that calcium binds to oxalates in foods and holds them in
the digestive tract, rather than allowing them to be absorbed.
Caffeine. Caffeinated beverages reduce
the risk of stones. Caffeine’s diuretic effect causes the loss of both
water and calcium, but the water loss is apparently the predominant
effect. Similarly, alcoholic beverages are associated with a reduced
risk of kidney stones, again presumably due to a diuretic effect. This
is not a compelling reason to drink either coffee or alcohol, but their
diuretic actions do present this advantage.
Problem Foods
Animal Protein. Animal proteins cause
calcium to be leached from the bones and excreted in the urine where it
can form stones. Diets rich in animal proteins also increase uric acid
excretion. In a controlled research study, published in the American Journal of Clinical Nutrition,
research subjects on a diet eliminating animal protein had less than
half the calcium loss that they had on their baseline diet.12
The Harvard study mentioned earlier found that even a
modest increase in animal protein, from less than 50 grams to 77 grams
per day, was associated with a 33 percent increased risk of stones in
men.7 The same is true for women. The Nurses’ Health Study, a
long-term study of health factors in a large group of women, revealed
an even greater risk of stones from animal protein than was found in
previous studies in men.9
The association between animal proteins and stones
probably relates both to the amount of protein they contain and to their
content of the sulfur-containing amino acids. In particular, the sulfur
in cystine and methionine is converted to sulfate, which tends to
acidify the blood. As a part of the process of neutralizing this acid,
bone is dissolved, and bone calcium ends up in the urine. Meats and eggs
contain two to five times more of these sulfur-containing amino acids
than are found in grains and beans.11,13
Between 1958 and the late 1960s, there was a sharp
increase in the incidence of kidney stones in Great Britain. During that
period, there was no substantial change in the amount of calcium or
oxalate-containing foods consumed. However, the consumption of
vegetables decreased, and the use of poultry, fish, and red meat
increased. Statistical analyses showed a strong relationship between the
incidence of stones and animal protein consumption.14
Sodium. Sodium increases the passage of calcium through the kidney and increases the risk of stones.9 When people cut their salt (sodium chloride) intake in half, they reduce their daily need for calcium by about 160 milligrams.15
Plants of any kind—grains, vegetables, legumes, and
fruits—contain almost no sodium at all unless it is added during canning
or other processing. Dairy products and meats contain more salt than
plant products, and table salt, frozen meals, and canned and snack foods
are the highest-sodium food products. For more information, see the
sodium/potassium chart in
Section 5.
Sugar. Sugar accelerates calcium losses through the kidney.16
In the Nurses’ Health Study, those who consumed, on average, 60 grams
or more of sugar (sucrose) per day had a 50 percent higher risk of
stones than those who consumed only about 20 grams.9
| SUGAR IN COMMON FOODS (grams) |
| Candy bar (2 ounces) |
22-35 |
| Cookies (3) |
11-14
|
| Corn flakes (1 cup, 28 grams) |
2 |
| Frosted corn flakes (1 cup, 41 grams) |
17 |
| Crackers (5) |
1 |
| Fruit cocktail (1/2 cup, 124 grams) |
14 |
| Grape jam (1 tablespoon) |
13 |
| Ice cream (1/2 cup, 106 grams) |
21 |
Soda (12 ounces)
|
40 |
| White bread (2 slices) |
1 |
| Source: package information |
Climate. Kidney stones are also more
common in warm climates, presumably because perspiration leads to
dehydration and a more concentrated urine, and because sunlight
increases the production of vitamin D in the skin which, in turn,
increases calcium absorption from the digestive tract.17
Surprisingly, oxalate-rich foods, such as chocolate,
nuts, tea, and spinach, are not associated with a higher risk of renal
stones,7 nor is vitamin C, even though it can be converted to
oxalate. A large study of men taking vitamin C supplements found that
they had no more kidney stones than men who do not take them.8
Helping Patients Avoid Kidney Stones
Here are simple steps to help your patients avoid kidney stones.
- Encourage patients to drink plenty of water or other fluids, staying ahead of their thirst.
- Diets including generous amounts of vegetables, fruits, and beans are rich in potassium and very low in sodium.
- If you prescribe calcium supplements, encourage patients to take them with meals, rather than between meals.
- Encourage patients to avoid animal products. Their proteins and sodium content increase the risk of stones.
-
Patients should keep salt and sugar use modest.
Cranberry Juice: An Old Remedy Is Clinically Tested
Cranberry juice has long been used as a folk remedy for urinary infections. A 1994 report in the Journal of the American Medical Association
showed that it does indeed have at least a preventive effect. In a test
involving 153 elderly women in Boston, half the subjects drank 300
milliliters (about one and one-quarter cups) of cranberry juice cocktail
each day, using the same bottled beverage that is commonly sold in
grocery stores.18 The other subjects consumed a drink that looked and tasted like cranberry juice, but had no real juice in it.
Over the next six months, urine samples were collected
and tested for signs of bacteria. The women consuming cranberry juice
had only 42 percent as many urinary infections as the control group. The
number of cases that had to be treated by antibiotics was also only
about half, which is a real advantage, since antibiotics can sometimes
lead to yeast infections and other problems. It takes about four to
eight weeks for the preventive effect to be seen.
The explanation for the effect of cranberry juice is
probably not an acidification of the urine, because the placebo drink
also reduced urinary pH. Rather, cranberries contain a substance that
stops bacteria from being able to attach to cells, and this is probably
true whether the cranberry juice reaches the bacteria in the digestive
tract or the urinary tract. Substances that interfere with bacterial
adhesion have also been found in blueberry juice, but not in orange,
grapefruit, pineapple, mango, or guava juice.
References
1. Mahan LK, Arlin M. Krause’s Food, Nutrition, and Diet Therapy. W.B. Saunders, Philadelphia, 1992.
2. The American Dietetic Association. Handbook of Clinical Dietetics, second edition. Yale University Press, 1992.
3. D’Amico G, Gentile MG, Manna G, et al. Effect of vegetarian soy diet on hyperlipidemia in nephrotic syndrome. Lancet. 1992;339:1131-1134.
4. The American Dietetic Association. Manual of Clinical Dietetics, fifth edition. American Dietetic Association, Chicago, 1996.
5. Gretz N, Meisinger M, Strauch M. Does a low protein diet really slow down the rate of progression of chronic renal failure? Blood Purif. 1989;7:33:33-38.
6.
Barsotti G, Morelli E, Cupisti A, Meola M, Dani L, Giovannetti S. A
low-nitrogen, low-phosphorus vegan diet for patients with chronic renal
failure. Nephron. 1996;74:390-394.
7. Curhan GC, Willett WC,
Rimm EB, Stampfer MJ. A prospective study of dietary calcium and other
nutrients and the risk of symptomatic kidney stones. N Engl J Med. 1993;328:833-838.
8. Curhan GC, Willett WC, Rimm EB, Spiegelman D, Stampfer MJ. Prospective study of beverage use and the risk of kidney stones. Am J Epidemiol. 1996;143:240-247.
9.
Curhan GC, Willett WC, Speizer FE, Spiegelman D, Stampfer MJ.
Comparison of dietary calcium with supplemental calcium and other
nutrients as factors affecting the risk for kidney stones in women. Ann Int Med. 1997;126:497-504.
10.
Soucie JM, Thun MJ, Coates RJ, McClellan W, Austin H. Demographic and
geographic variability of kidney stones in the United States. Kidney Int. 1994;46:893-899.
11. Lemann J. Composition of the diet and calcium kidney stones. N Engl J Med. 1993;328:880-882.
12.
Remer T, Manz F. Estimation of the renal net acid excretion by adults
consuming diets containing variable amounts of protein. Am J Clin Nutr. 1994;59:1356-1361.
13.
Breslau NA, Brinkley L, Hill KD, Pak CYC. Relationship of animal
protein-rich diet to kidney stone formation and calcium metabolism. J Clin Endocrinol. 1988;66:140-146.
14.
Robertson WG, Peacock M, Hodgkinson A. Dietary changes and the
incidence of urinary calculi in the U.K. between 1958 and 1976. J Chron Dis. 1979;32:469-476.
15.
Nordin BEC, Need AG, Morris HA, Horowitz M. The nature and significance
of the relationship between urinary sodium and urinary calcium in
women. J Nutr. 1993;123:1615-1622.
16. Lemann J Jr, Adams ND, Gray RW. Urinary calcium excretion in human beings. N Engl J Med. 1979;301:535-541.
17.
Soucie JM, Coates RJ, McClellan W, Austin H, Thun MJ. Relation between
geographic variability in kidney stones prevalence and risk factors for
stones. Am J Epidemiol. 1996;143:487-495.
18. Avorn J,
Monane M, Gurwitz JH, Glynn RJ, Choodnovskiy I, Lipsitz LA. Reduction of
bacteriuria and pyuria after ingestion of cranberry juice. JAMA. 1994;271:751-754.
Foodservice Update
Healthy Tips and Recipes for Institutions from The Vegetarian Resource Group
Menu Selection
for Vegan Renal Patients
By Chef Nancy Berkoff, RD, EdD
A proper renal diet is extremely important for patients with chronic kidney failure. Many
health care professionals have shown that a
carefully planned vegetarian diet is adequate in managing
chronic kidney failure.
It is vital that a renal patient's food and fluid intake
be overseen by a nephrologist and a registered dietitian
familiar with vegan diets. These professionals can help
manage kidney disease with appropriate vegan food
and fluid choices. The information in this article is not
designed to replace consultation with medical doctors
and registered dietitians. This article provides general
guidelines and information about vegan diets that can
be used in menu planning for people with chronic kidney
disease, stage 2 or 3, in conjunction with consultation
with health care professionals who treat people
with kidney disease.
In kidney disease, nutrition management focuses
on decreasing waste products built up from digested
foods. The goals for planning a vegan renal diet, as
for any other renal diet, are to:
- Obtain the appropriate amount of protein to meet
protein needs while minimizing waste products
in the blood
- Maintain sodium, potassium, and phosphorus
balance
- Avoid excessive fluid intake to prevent overload
- Ensure adequate nutrition
The information provided in this article is meant as
a very general guideline for patients that have at least
40-50 percent normal kidney function (chronic kidney
disease, stage 2 or 3) and who are not currently receiving
dialysis. For patients with lower kidney function
or who are receiving dialysis, very individual diet planning
must be done. All renal patients need to be closely
monitored, with regular blood and urine testing.
Vegan Protein
Renal patients need to limit the amount of protein
in their daily diets. For this reason, the protein in the
diet needs to be high-quality protein. Very generally,
depending on individual ability and needs, 0.8 gram
of protein per kilogram of body weight is recommended
per day. This translates to approximately 2 ounces of
pure protein per day for a 140-pound person.
High-quality vegan protein for renal patients includes
tofu, peanut butter (no more than two Tablespoons
Vegan Foods That Provide Approximately
7 Grams of Protein Per Serving
|
| Protein Source |
Serving Size |
Seitan (wheat gluten)
Beans, dried/cooked
Tofu, firm
Tofu, regular
Tempeh
Nut Butters |
1 oz.
½ cup
1/3 cup
⅔ cup
¼ cup
2 Tablespoons |
per day), tempeh, and beans. Soy meats, such as textured
vegetable protein (TVP) or vegan ground round,
are high in quality protein but are also high in sodium,
phosphorous, and potassium, which need to be limited.
Soy protein has been found to assist in minimizing
some complications from kidney disease. Patients should
have at least one serving of soy a day, such as soymilk,
tofu, or tempeh. Again, it is a balancing act for renal
menus - a small amount of soy each day may be beneficial,
but too much can be harmful.
Here are some tips for including soy products on
your vegan renal menu:
- Mash a few Tablespoons of regular tofu with
croutons and seasonings to 'extend' the tofu and
decrease the amount of protein served.
- Add small chunks of regular tofu-rather than
animal protein-to soups, stews, and stir-fries.
- Use silken tofu instead of vegan mayonnaise in
salad dressings, sandwich fillings, and sauces.
- Crumble up regular tofu, add a spicy seasoning
(without salt), and quickly sauté to top rice or
pasta, or use as a filling for a taco or burrito or
to top a pizza crust.
Beans and nuts are good sources of high-quality protein.
However, they can be high in phosphorus and
potassium, so the amounts served need to be carefully
calculated. Try to use dried beans or beans frozen without
salt. Canned beans, even lower sodium beans, are
usually high in sodium.
A way to balance potassium intake is to include
needed protein (which may be high in potassium)
and then to select fruits and vegetables that are lower
in potassium.
Sodium
Some vegetarian foods can be very high in sodium.
Here are suggestions for avoiding excess sodium
on the menu:
- Avoid using ready-to-eat foods, such as frozen
meals, canned soup, dried soups, or packaged
vegetable broths.
- Use miso very sparingly.
- Use lower-sodium soy sauces very sparingly, as there
is still a lot of sodium in these soy sauces.
- Limit soy- and rice-based cheeses.
- Amino acid preparations, such as Bragg's Liquid
Aminos, can be very concentrated in protein,
potassium, and phosphorus; if the patient wants
to include these types of products, they will need
to be calculated into the daily intake.
- Read the labels for vegan meats (such foods as tofu
hot dogs and veggie burgers) or other canned or
frozen soy products.
- Read the labels for seasoning mixtures to avoid
excess sodium.
Potassium
Potassium may not need to be strictly restricted unless
the function of the kidney decreases to less than 20
percent. Routine blood testing is the best way to know
a patient's potassium requirements. Approximately
two-thirds of dietary potassium comes from fruits,
vegetables, and juices. The easiest way to limit potassium
would be to limit fruit and vegetable selections
based on the level of potassium in the patient's blood.
Higher Potassium Foods
|
Textured vegetable protein (TVP)
Soy flour
Nuts and Seeds
Cooked dried beans or lentils
Cooked dried soybeans
Tomato products (sauce, pureé)
Potatoes
Raisins
Oranges, bananas, cantaloupe, or honeydew melon |
¼ cup
2 Tbsp
¼ cup
1/3 cup
1 cup
¼ cup
½ cup
¼ cup
½ cup
|
A common limitation is five servings of fruits and
vegetables per day.
A potassium serving size is generally:
- 1/2 cup fresh fruit, canned fruit, or juice
- 1 cup fresh vegetables
- ½ cup cooked vegetables
If a patient would like several servings of protein,
alternative protein selections may be needed to keep
potassium levels from going too high. This will mean
using more tofu and seitan, rather than beans or textured
vegetable protein (TVP), at every meal. Blackstrap
molasses, spinach, Swiss chard, beet greens, and prunes
are very high in potassium and may need to be limited
or avoided.
Phosphorus
Depending on the extent of an individua's kidney
disease, phosphorus may need to be restricted. Foods
high in phosphorus include bran cereals, wheat germ,
whole grains, dried beans and peas, colas, beer, cocoa,
and chocolate drinks. For more information about
high phosphorus foods, see
www.kidney.org/atoz/
atozitem.cfm?id=101. Dried beans and peas and
whole grains are high in phosphorus, but because
of their high phytate content, they may not cause
phosphorus in the blood to be elevated as much as
would be expected. Individual monitoring by the
health care provider is necessary to determine the
appropriate level of dietary phosphorus.
Adequate Nutrition
A vegan diet can be lower in calories and higher in
fiber than an animal-based diet. This is great news
for healthy patients. However, for vegan renal patients,
we need to ensure that there is no weight loss or loss
in nutritional status. Here are some tips for adding
more calories to a vegan renal diet:
- Make shakes with soymilk, tofu, rice milk, and
non-dairy frozen dessert. Some patients, especially
those with very limited kidney function, may need
to use unfortified soymilk or rice milk and unfortified
soy yogurt.
- Use more oils, such as olive oil in cooking. Drizzle
flaxseed oil on food after it is cooked, or mix with
salad dressing and serve over lettuce.
- Provide frequent small meals if patients feel full
very quickly.
- Even though sugar is not the best selection in a
diet, for a renal patient who needs extra calories,
sorbet, vegan hard candy, and jellies may be added.
Additional Ideas When Planning
Vegan Renal Menus
- Avoid using salt or salt substitutes. Use herb mixtures,
such as Mrs. Dash, or mixtures you create
yourself with fresh or dried herbs.
- If you need to use canned broths, purchase the
lowest-sodium version possible.
- Use fresh or frozen (without salt) fruits or vegetables
when possible.
- Lower potassium fruits and veggies include wax
beans, green beans, kiwi, watermelon, onions,
head lettuce and Romaine lettuce, bell peppers,
pears, and raspberries.
- Lower phosphorus foods include sorbet, unsalted
popcorn, white bread and white rice, hot and cold
rice cereals, pasta, cold corn-based cereal (such as
Corn Flakes and Corn Chex), Cream of Wheat
hot cereal, and grits.
Sample Menu to Get You Started
|
Breakfast
- Cream of Wheat or cream of rice cereal
with a small serving of fresh or thawed
frozen peaches and cinnamon
- White toast with a choice of two fruit jellies
- Pear cocktail
Mid-Morning Snack
- Popcorn tossed with a very small amount
of nutritional yeast
- Sparkling water with lemon and lime
- Raspberry popsicle
Lunch
- Angel hair pasta topped with chopped mushrooms,
broccoli, and nutritional yeast
- Tossed green salad with chopped bell peppers
(red, yellow, and green for color) and silken
tofu salad dressing
|
- Garlic bread made with fresh chopped garlic
and olive oil
- Sorbet served with cookies
Mid-Afternoon Snack
- 1 small tofu taco on flour tortilla
- Sparkling water with a kiwi slice
Dinner
- Stir-fried seitan or tempeh tossed with onions
and cauliflower, served on a bed of herbed rice
- Onion dinner roll served with nonhydrogenated
vegan margarine
- Chilled watermelon slices
Evening Snack
|
Icy Smoothie
(Serves 4)
- 2 cups soft silken tofu
- 3 cups ice
- 2 Tablespoons coffee powder or green tea
powder
- 2 teaspoons vanilla extract
- 2 Tablespoons rice syrup
Place all ingredients in a blender
and process until smooth and
thick. Serve immediately.
| Total calories per serving: 109 |
Fat: 3 grams |
| Carbohydrates: 13 grams |
Protein: 6 grams |
| Sodium: 24 milligrams |
Fiber: <1 gram |
| Potassium: 255 milligrams |
Phosphorus: 75 mg |
Hot Spiced Cereal
(Makes approximately 1 quart or
four 1-cup servings)
- 4 cups water
- 2 cups cream of rice or other hot rice
- cereal, grits, or Cream of Wheat
- 1 teaspoon vanilla extract
- ¼ cup maple syrup
- 1 teaspoon powdered ginger
Bring water to a boil in a medium
pot. Whisk in cereal and lower
heat. Continue to stir until mixture
is smooth. Reduce to a simmer.
Stir in remaining ingredients. Allow to cook, stirring, until
desired texture is attained.
| Total calories per serving: 376 |
Fat: <1 gram |
| Carbohydrates: 85 grams |
Protein: 5 grams |
| Sodium: 7 milligrams |
Fiber: <1 gram |
| Potassium: 166 milligrams |
Phosphorus: 108 mg |
Lemon Hummus
(Makes approximately 1 pint)
This spread is higher in phosphorus
and potassium than other spreads,
but it is a good source of protein.
- 2 cups cooked garbanzo beans
- 1/3 cup tahini
- ¼ cup lemon juice
- 2 minced garlic cloves
- 1 Tablespoon olive oil
- ½ teaspoon paprika
- 1 teaspoon parsley flakes
Place garbanzo beans, tahini,
lemon juice, and garlic in a
blender or food processor. Blend
until smooth. Transfer mixture to
a serving bowl. Drizzle olive oil
over the mixture. Sprinkle with
paprika and parsley. Serve with
pita triangles or unsalted crackers.
| Total calories per serving: 72 |
Fat: 4 grams |
| Carbohydrates: 7 grams |
Protein: 3 grams |
| Sodium: 4 milligrams |
Fiber: 2 grams |
| Potassium: 88 milligrams |
Phosphorus: 75 mg |
Corn and Cilantro Salsa
(Serves 6-8)
This is an unusual twist on the
usual salsa recipe.
- 3 cups fresh white or yellow corn cut
from the cob
- ½ cup chopped cilantro
- 1 cup chopped sweet onions (such as
Vidalia or Maui)
- ½ cup chopped fresh tomato
- 4 Tablespoons lemon or lime juice
- ¼ teaspoon dried oregano
- 2 teaspoons chili powder or red pepper
flakes
Place corn in a medium-sized
bowl. Add remaining ingredients
and mix well. Cover and refrigerate
for at least one hour prior to
serving.
| Total calories per serving: 89 |
Fat: 1 gram |
| Carbohydrates: 21 grams |
Protein: 3 grams |
| Sodium: 9 milligrams |
Fiber: 3 grams |
| Potassium: 270 milligrams |
Phosphorus: 72 mg |
Mushroom Pockets
(Serves 6)
Here's a tasty vegetarian version
of soft tacos.
- 2 Tablespoons water
- 2 Tablespoons lemon or lime juice
- 1 Tablespoon vegetable oil
- 2 minced garlic cloves
- 1 teaspoon ground cumin
- 1 teaspoon crushed dried oregano
- 3 cups thinly sliced fresh mushrooms,
such as portobello caps, white button,
or brown crimini
- 1 cup thinly sliced bell pepper
- ½ cup chopped scallions (white parts only)
- 3 Tablespoons shredded vegan soy cheese
- Six 7-inch flour tortillas
In a large bowl, mix water, juice,
oil, garlic, cumin, and oregano.
Add mushrooms, peppers, and
scallions. Stir to coat. Allow to
marinate for at least 30 minutes.
If desired, this can be done the
day before.
Heat a large saut&3acute; pan. Sauté
vegetable mixture with marinade
until the peppers and scallions are
soft, approximately 5-7 minutes.
Allow to continue cooking until
most of the liquid has evaporated.
While veggies are cooking,
wrap tortillas in a paper towel and
heat in a microwave, or wrap in
foil and heat in a 350-degree oven.
Place each tortilla on a plate.
Spoon on vegetable mixture and
top with cheese.
| Total calories per serving: 147 |
Fat: 5 grams |
| Carbohydrates: 23 grams |
Protein: 4 grams |
| Sodium: 262 milligrams |
Fiber: 1 gram |
| Potassium: 267 milligrams |
Phosphorus: 64 mg |
Fruit Cobbler
(Serves 8)
- 3 Tablespoons melted nonhydrogenated
vegan margarine
- 1 cup all-purpose unbleached flour
- ¼ teaspoon salt
- 1 teaspoon baking powder
- ½ cup rice milk
- 3½ cups pitted fresh cherries*
- 1¾ cups white vegan sugar, divided
- 1 Tablespoon cornstarch
- 1 cup boiling water
Preheat oven to 350 degrees.
In a medium-sized bowl,
combine margarine, flour, salt,
baking powder, and rice milk
and mix just to combine.
In a separate bowl, toss cherries
with ¾ cup sugar and place
cherries in the bottom of an
8-inch square pan. Place dough in small pieces over cherries to
cover cherries in an even pattern.
In a small bowl, combine
remaining sugar and cornstarch.
Whisk in boiling water. Pour
cornstarch mixture over the dough.
Bake for 35-45 minutes or until
bubbly. Serve warm or cold.
Note: You can use thawed frozen
pitted cherries; peeled and cored
fresh pears; or fresh or thawed
frozen raspberries to replace a
part of or all of the fresh cherries.
| Total calories per serving: 315 |
Fat: 5 grams |
| Carbohydrates: 68 grams |
Protein: 2 grams |
| Sodium: 170 milligrams |
Fiber: 2 grams |
| Potassium: 159 milligrams |
Phosphorus: 87 mg |
Nancy Berkoff is The Vegetarian Resource
Group's Food Service Advisor. She is
the author of
Vegan in Volume.
