Nutrition and Renal Disease
Autor: claudia lulkin | Publicado: 2016-10-19T06:49:00-07:00




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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
&lt;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.
References1. 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.











    
  





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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


Small soymilk shake








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: &lt;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: &lt;1 gram


Carbohydrates: 85 grams
Protein: 5 grams


Sodium: 7 milligrams
Fiber: &lt;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&amp;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




Renal Support Network - KidneyTalk Podcast: What You Need to Know

Nancy Berkoff is The Vegetarian Resource
Group's Food Service Advisor. She is
the author of Vegan in Volume.