For individuals with CKD stages 3 and 4, you might start to experience poor appetite as the disease progresses, due to uremia (build-up of toxins in the kidneys), complications of CKD, or even other co-morbidities. Sustained loss of appetite and poor food intake may lead to malnutrition if it is not well-managed. Protein energy wasting (PEW), where your body’s protein and energy stores are being depleted, may occur and could lead to serious outcomes such as increased rates of hospitalization and other adverse effects.

If your appetite continues to be poor and you are losing weight, it is recommended that you speak with your doctor or dietitian for advice on how to increase your calorie intake.

Some general tips for increasing your calorie intake:

• Take small frequent meals during the day, instead of 2 or 3 large meals

• Limit fluids intake at main mealtimes to avoid feeling too full

• If your blood potassium or phosphorous levels are stable, you could stop or reduce your dietary restrictions

• Increase intake of foods that are higher in calories (i.e. higher in fat and/or sugar). For example: spread more butter or margarine on bread, opt for full-fat instead of low-fat dairy products, add avocado slices to sandwiches, use more oil in your cooking etc

• Consider taking oral nutritional supplements

• Take appetite stimulants if they are prescribed by your doctor

References

At CKD stages 3 and 4, as part of your treatment to slow down the progression of CKD, you may be advised by your doctor or dietitian to restrict your protein intake. Studies have shown that a high-protein diet may cause further damage to the kidneys and lead to uremia, whereas a low-protein diet might be more beneficial in preserving your kidney functions. A low-protein diet of 0.6-0.8g protein per kilogram body weight per day is often recommended in the management of CKD. For instance, for a 60kg person who has CKD stage 4, the recommended daily protein intake is 36-48g protein per day. Hence, your daily protein intake varies depending on your body weight.

If you are unsure of the exact amount or portion of protein you should be consuming, it is recommended that you speak with your dietitian for a diet plan. However, if your kidney functions (such as glomerular filtration rate (GFR), urea and creatinine levels) are stable, it may not be necessary with protein restrictions in the meantime.

References

At CKD stages 3 and 4, your kidneys might not be able to remove potassium as efficiently as it should, and build-up of potassium might occur over time. When potassium builds up, it may lead to weakness, nausea, and tachycardia (irregular, fast heartbeats).

If your blood potassium levels are within the ideal range, you are encouraged to continue your consumption of potassium-containing foods in moderation to ensure a healthy and balanced diet. However, if your blood potassium level increases progressively or is persistently high, your doctor or dietitian may advice you to follow a low-potassium diet. With a low-potassium diet, you should in general aim for potassium intake of not more than 2,000 – 3,000mg per day, or per your health professional’s advice.

References

At CKD stages 3 and 4, your kidneys may have some difficulties clearing excess phosphorus, and a build-up of phosphorus in your blood may lead to weak or brittle bones, increasing the risk of breakage. You may also experience itchy skin, as well as bone and joint pain.

If your blood phosphorus level is within the recommended range, you are encouraged to maintain it within this range by eating a healthy and balanced diet. However, if your blood phosphorus level increases progressively or is persistently high, your doctor or dietitian may advice you to follow a low phosphorus diet. With a low phosphorus diet, aim to keep your phosphorus intake at 800 – 1000 mg per day. Some tips to help you achieve this include limiting your intake of processed foods with phosphorus-based additives, and preparing home-cooked meals by using fresh ingredients.

As chronic kidney disease progresses to stages 3 and 4, your kidneys’ ability to filter and excrete sodium is impaired. Sodium holds onto water in your body and in excess, can lead to fluid retention. Fluid retention causes swelling in areas such as your limbs, face, or fluid build-up in your lungs, causing shortness of breath. Excessive sodium intake coupled with fluid retention also increases your blood pressure.

There is consistent evidence that blood pressure and volume control can be improved when sodium intake is limited to less than 2300mg/day.

Sodium is found in table salt and a variety of foods, including:

• Commercial condiments and seasonings such as sauces, gravy mix/granules, bouillon cubes or liquid stock, ready-made pastes, ketchup, flavoured salts (e.g. garlic, onion salt)

• Processed foods such as cold-cuts, sausages, cheese, canned foods, preserved foods (e.g. salted fish, anchovies), smoked/cured foods, instant noodles, canned/instant soups, savoury snacks and pastries, microwaveable or ready-to-eat meals, fast-food

• Sports or isotonic drinks, packaged vegetable juice

If possible, plan to have most of your meals home-cooked instead of eating out.

Tips to reduce your sodium intake when cooking at home:

• Use fresh ingredients such as fresh fish, poultry, meat, vegetables, and fruits instead of processed foods

• Choose plain frozen fish, meats, poultry or vegetables with no added salt

• Use vegetables such as lemon, lime, chilies, ginger, onions, garlic, mushrooms, curry leaves, cilantro, and spring onions to naturally enhance the taste of dishes instead of adding excessive salt

• Use herbs and spices such as pepper, cinnamon, cloves or turmeric to enhance the aroma and flavors of dishes instead of adding excessive salt

• Make your own stock and gravies using fresh ingredients instead of using commercial stock, canned soups, or instant gravies

• When grocery shopping, look out for products with “no salt”, “no added salt”, “reduced sodium”, “low-sodium”

• Read the Nutrition Information Panel and compare the sodium content (per 100g/100ml) between different products so that you may choose a lower sodium option

Tips to reduce sodium intake when eating out:

• Avoid finishing full portions of soups as these tend to be high in sodium (as well as fluids)

• Opt to leave out the gravy and sauces or ask for them to be served separately to avoid finishing all of it

• Avoid dipping your foods in additional sauces e.g. soy sauce, Hoisin sauce, ketchup, chili sauce

• Have a taste of your food before you add more salt or sauces as most dishes may already be tasty without the need to add more

• When having curries or stews, choose to consume ingredients such as proteins and/or vegetables and leave the gravy behind

• Opt for dishes that use mostly fresh ingredients such as fresh chicken, fish, meat and vegetables instead of processed foods such as fishballs, luncheon meat, sausages or preserved items (e.g. salted eggs, preserved vegetables and fish etc)

One of your kidneys’ functions is to regulate fluid balance in your body. This is done as your blood is filtered through your kidneys where excess water is removed and then excreted through urine. With the progression of chronic kidney disease, this function is impaired. You may notice fluid retention or swelling caused by fluid building up in areas such as your limbs, face or lungs, causing shortness of breath. Excess fluid can also increase your blood pressure and lead to heart problems due to an enlarged heart and weakened heart muscles.

Fluids include any food or beverage in liquid form. Beverages such as water, coffee, tea, milk, creamers, evaporated milk, fruit or vegetable juices, smoothies, soft drinks, cordials, syrups and alcohol are some examples of common fluids in our ordinary diets.

In addition, anything that melts into liquids such as ice cubes/chips, ice cream, sorbets/sherbets and popsicles also contribute to your fluid intake.

Foods that contain liquids such as soups, gravies, sauces, porridge, yoghurt, puddings, gelatine and jelly also contribute to your daily fluid intake. Fruits and vegetables naturally contain fluids as well to varying degrees. However, you should still include fruits and vegetables as part of a balanced diet if taken in the recommended portions.

How much fluid you need to restrict depends on your kidneys’ remaining function and other factors such as your urine output and signs of fluid retention. It is recommended to speak with your physician or dietitian to understand your body’s fluid balance and how much fluids you should be consuming each day.