For individuals with CKD stage 5 (non-dialysis), 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

At CKD stage 5, 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 5, 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.

As your glomerular filtration rate (GFR) declines, which is also an indication of the progression of your CKD, this might in turn affect your appetite and cause a reduction in your food intake. Poor appetite is also associated with uremia, when the kidneys are unable to remove the “waste” accumulated in the body over time. Protein energy wasting (PEW), where your body’s protein and energy stores are being depleted, is a state of metabolic and nutritional imbalance common in CKD individuals and is associated with muscle wasting and frailty.

It is important to increase your caloric intake when facing poor appetite due to your kidney disease progression. Over time, loss of appetite will lead to weight loss and adverse clinical outcomes such as poor immunity and increased hospitalization.

Some general tips for increasing your calorie intake:

Small meals across the day

Eating smaller but more frequent meals, such as 2 to 3 snacks on top of your regular meals, might be more beneficial than 3 regular big meals.

Increase your intake of foods higher in calories

For individuals with only CKD and no other co-morbidities, there are more liberal ways to manage poor appetite. You could increase your intake of foods that are higher in calories (i.e. higher in sugars and/or fat), also known as “free” foods. For example, you can try adding more fat during meal preparation such as adding oil to your cooking or salads, or adding a thicker spread of margarine on your bread or crackers. Choosing full-fat dairy products instead of low-fat versions is another alternative. Adding honey/sugar/syrup to your beverages, bread, pancakes or oats can be another way to increase caloric intake without affecting your portion intake significantly. Having some candies, gum drops or jelly in between meals are also good for increasing caloric intake, especially for those without blood sugar concerns. If your appetite is fine but you need to limit protein, try loading up on carbohydrate foods such as rice, bread and pasta (opt for the refined ones as they are lower in potassium and phosphate).

Comorbidities and caloric intake

However, if you have other comorbidities such as diabetes, or heart disease in addition to CKD, there might be more dietary caution when increasing your caloric intake due to poor appetite. For instance, if you have underlying high cholesterol or heart disease, be mindful and opt for choices lower in saturated fats instead, such as sunflower oil and soft margarine.

Oral nutritional supplements

Instead of plain water, opt for higher-calorie beverages such as oral nutritional supplements. They might also be good meal replacements if you have early satiety levels, and may be easier to manage if you prefer drinking instead of eating during meal or snack times.

Protein intake

Despite having CKD, it is essential that you achieve the minimum daily protein requirement needed for your body functions. Poor appetite and oral intake can result in sub-optimal protein consumption. Hence, try to ensure you meet your protein intake at main mealtimes where possible.

Boosting visual appeal of food

Using a variety of foods/vegetables, presented in smaller portions, may be more visually appealing than large meals when dealing with poor appetite. Serving foods in colourful utensils might also be helpful in stimulating your hunger and appetite.

References

At CKD Stage 5, your kidney function is impaired, and build-up of potassium will occur over time. When potassium builds up, it results in weakness, nausea, and tachycardia (irregular, fast heartbeats). If needed, your doctor might prescribe you some medications to aid in the control of your blood potassium level. However, if your blood potassium level increases progressively or remains persistently high, you may need 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 potassium per day, or per your health professional’s advice.

While following a low-potassium diet, it is still important to eat well and avoid the risk of excessively low blood potassium level (hypokalaemia). If you are unsure which foods may be lower or higher in potassium, these tables may be helpful.

References

At CKD stage 5, your kidneys are not able to remove excess phosphorus efficiently, and a build-up of phosphorus in your blood may lead to weak and brittle bones, increasing the risk of breakage. You may also experience itchy skin, as well as bone and joint pain.

Your doctor may prescribe you with phosphate binders, which are medications that help to reduce the phosphorus absorbed by your body from the foods you eat. Take them as suggested by your doctor or dietitian.

If your blood phosphorus level remains within the recommended range, no restriction is needed but you are encouraged to adjust your daily food intake to maintain your phosphorus level within the recommended range. However, if your blood phosphorus level increases progressively or is persistently high, phosphorus restriction may be needed. 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.

At CKD stage 5, your kidneys’ ability to filter excess 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 a variety of foods other than table salt. Other sources of sodium include:

• 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

References

At CKD stage 5, your kidneys’ remaining function is very minimal or your kidneys are completely not able to work. At this point, your kidneys are not able to remove excess fluids efficiently hence you may have reduced urine output or none. If you have not started on or are not undergoing dialysis treatment, it is therefore more crucial to control your fluid intake to minimize fluid retention.

Symptoms of fluid retention include:

• Swelling caused by fluid build-up in your face, arms and feet or legs

• Shortness of breath due to fluid build-up in the lungs

• Increased blood pressure

• Heart problems due to an enlarged heart and/or weakened heart muscles

How much fluid you need to restrict depends on factors such as weight gain, urine output and signs of fluid retention. It is advisable to speak with your physician or dietitian to understand your body’s fluid balance and how much you should be taking each day.

References