Chronic kidney disease (CKD) entails a gradual decline in kidney function. The kidneys play a crucial role in filtering wastes and excess fluids from the blood, which are subsequently eliminated through urine. As chronic kidney disease advances, there’s a risk of dangerous accumulations of fluid, electrolytes, and waste products within the body. During the initial phases of chronic kidney disease, symptoms may be minimal or absent, potentially leading individuals to be unaware of the condition until it has progressed significantly.

Having diabetes, high blood pressure, heart disease, obesity or a family history of kidney disease increases the risk for developing CKD. Controlling the medical condition and regular monitoring of blood and urine parameters specific for kidney function is essential for early detection of kidney disease.

Symptoms like fatigue, loss of appetite, frequent urination, blood in urine, water retention in ankles, feet or hand, itching indicate late stage of CKD.

Treatment strategy for chronic kidney disease involvesthe reduction in progression of kidney damage, by managing its underlying causes. If the progression of kidney damage persists, it can advance to end-stage kidney failure, where regular dialysis becomes crucial.

Dietary Guidelines for Individuals on Dialysis

Diet plays a critical role in the management of individuals undergoing dialysis by helping to maintain fluid balance, electrolyte levels, and nutritional status. While dialysis removes waste products from the blood, dietary modifications are necessary to minimize their production and prevent complications. Managing protein, fluid, sodium, potassium, and phosphorus intake is essential to prevent fluid overload, electrolyte imbalances, and malnutrition. Adhering to a healthy diet can improve overall health and quality of life for individuals on dialysis. It can reduce the risk of complications, improve energy levels, and enhance well-being.

General guidelines

Energy

• Dialysis patients need high calorie diet to ensure proper utilization of protein.Recommended energy intake is 35 kcal/kg/body weight if the patient is <60 years of age and 30 kcal/kg body weight if the patient is more than 60 year to meet body requirements and minimize tissue protein breakdown.
• It is recommended that 50%– 60% of total calories should come from carbohydrate, 30% of total calories should come from fat (saturated fats <7%), and the balance 20% of total calories should come from protein.

Protein

• Prior to initiation of dialysis, a low-protein diet (0.5-0.8gms/kg body weight)is advised to limit the amount of waste products in the blood.
• But this requirement increases during dialysis due to losses during the process.
• Failing to consume sufficient protein would result in breakdown of muscles tissue to get the necessary protein.
• Recommended intake 1.2 g/kg/body weight /day.Opt for high-quality protein such as egg white, fish, sea food&chicken. Although milk and milk productsprovide high quality protein but are also rich in phosphorus, so, limit its intake.
• To improve the protein quality, of plant protein, theratio of cereal to pulse in a cereal pulse preparation should be 4:1.
• Egg whites provide high biological value protein with low phosphorus and thus is a good addition for those who eat it.
• The bioavailability of phosphorus from plant-derived food is relatively low, usually <50%, and that from animal protein is 80%, therefore plant protein should be preferred.

In case, adequate protein intake is not met with the diet, a high protein, low electrolyte renal supplement may be given.

Fat

• Cardiovascular disease (CVD) is a major problem for patient undergoing dialysis.
• The National Institute of Nutrition (NIN 2010) recommends combination of either Rice bran oil/groundnut oil + mustard oil or

Rice bran oil/groundnut oil + soyabean oilor

Rice bran oil/groundnut oil + sunflower / safflower oil for cooking.

Control Sodium Intake

• Sodium and salt are closely related but not interchangeable terms.
• Sodium is an essential mineral and an electrolyte that plays a crucial role in various body functions.
• Salt, on the other hand, is a compound composed mainly of sodium chloride (NaCl). Sodium is a component of salt. In table salt (sodium chloride), approximately 40% of its weight comes from sodium.

1 teaspoon salt = 2,300 mg sodium

3/4 teaspoon salt = 1,725 mg sodium

1/2 teaspoon salt = 1,150 mg sodium

1/4 teaspoon salt = 575 mg sodium

• Excess sodium can lead to fluid retention, swelling, higher blood pressure, and strain on the heart. So restrict sodium intake to <2000 mg/day.
• Patients with limited residual renal function and uncontrolled hypertension should restrict its use to 1500 mg/day.
• Reducing sodium in your diet helps you control high blood pressure. It also keeps you from being thirsty, and prevents your body from holding onto extra fluid.
• Sodium is found in large amounts in table salt and in foods that have added table salt.
• Use minimal salt in cooking and avoid adding salt at the table.
• Avoid foods high in sodium: seasonings like soy sauceand garlic or onion salt; most canned, packaged and processed foods; processed meats like ham, bacon, sausage, and cold cuts; salted snack foods, like chips, salted biscuits, namkeensandcrackers;pickles, papads and chutneys.
• Sodium is also found in foods containing

Ajinomoto(Monosodium glutamate – MSG)

Baking soda – Sodium bicarbonate

Preservatives -Sodium nitrate or sodium benzoate

• Do not use salt substitutes because they contain potassium which also needs to be restricted.
• While shopping
• Check all labelsto see how much salt or sodium, the foods contain (the label may mention salt or sodium or both).
• In packaged foods look for those with less than 100 milligrams (mg) of salt per serving.
• Look for these words on food labels: low-sodium, no salt added

sodium-free, sodium-reduced, unsalted.

• If salt is listed in the first five ingredients, the item is probably too high in sodium to use.
• To cut down on sodium opt for fresh fruits, vegetables, and fresh / dried herbs and spices to enhance flavour without relying on salt.
• Spices and herbs that can be used as an alternative to salt are bay leaves, coriander leaves, vinegar, ginger, garlic, onion, red chilli, dry mustard, nutmeg, rosemary, sage, thyme etc.

Watch Potassium intake

• Potassium levels can rise between dialysis sessions, so limit your intake of high-potassium foods. Potassium intake should be2000-2750 mg/d.
• Limit high-potassium foods

Fruits – Banana, avocado, orange, mango, melon, water melon

Tomato & its products – tomato, tomato juice, tomato ketchup

Green leafy vegetables – spinach, mustard leaves, bathua, chulai

Root vegetables – potato, radish, turnip, beetroot

Other vegetables – lotus stem pumpkin, mushroom, french beans, broad beans, amla, singhara, karela, jack fruit, drumstick

Chocolate

Legumes

Nuts – almond, cashew, coconut, groundnut, pistachio, walnut

Dried fruits and seeds.

• Avoid fruit / vegetable juice, coconut water and vegetable soups.
• Discard the juice/syrup from tinned fruits, canned vegetables and meat before consuming.
• Salt substitutes are made of potassium chloride and should not be used.
• Brown rice, whole-grain bread, and other foods made with whole-wheat flour and bran have higher potassium and should be restricted.
• Choose fruits like peaches, grapes, pears, apples, strawberries, cherries, pineapple, plum, guava and papaya.
• Choose vegetables like broccoli, cabbage, carrots, cauliflower, capsicum, corn, lauki, parwal,tori, tinda, zucchini and cucumber.
• All vegetables should be peeled before cooking. Vegetables should be boiled rather than steamed, pressure cooked, microwaved or stir-fried to reduce their potassium. Use a large volume of water to boil them and discard the water. Ensure all vegetables are cut into small pieces before boiling. When making a stir fry, try to make sure that all vegetables are par-boiled.
• White rice, pasta, bread, plain noodles, couscous and other products made with white or corn flour are low in potassium.
• Protein foods such as meat, fish, eggs, and milk are also high in potassium but are essential for good health. Eat them as part of a main meal but avoid eating extra as snacks. Almond milk, buttermilk, soy milk, cottage cheese, cream, cream cheese, tofu can be included.
• Leaching potassium from foods:

Soaking foods in hot water for 5-10 minutes reduce potassium.

Reduction in potassium by leaching green leafy vegetables is 40-49%, other vegetables 30-39 % and root vegetables 10-20 %.

• Serum levels of potassium should be monitored regularly during dialysis. If serum potassium levels are in normal range then intake of fruits and vegetables can be increased to provide adequate fibre.

Limit Phosphorus

• Restrict dietary phosphorus to 800–1000 mg/day to address high phosphate levels.
• If phosphate levels remain high for long, they leach calcium out of bones resulting in osteoporosis.
• High level of phosphorus may also cause calcium phosphorus crystals to build up in your joints, muscles, skin, blood vessels, and heart resulting in aching joints and muscles and hardening of blood vessels increasing the risk of heart disease.
• Phosphorus from plant foods is less absorbed than phosphorus from animal foods.
• Use boiling as the preferred initial cooking method. Discard the boiling water. Boiled food may be stir fried or oven roasted with little oil and spices.

• Restrict foods rich in phosphorus:

-Dairy products such as milk, processed cheese, yogurt, ice cream, and pudding

-Dry fruits, nuts, peanut butter& seeds

-Processed foods & meat with phosphorus-containing food additives

-Cereals containing bran&nuts

-Organ meat, Shellfish

– Cold drinks, drinking chocolate, malted drinks, beer and wine

• Since dairy products are naturally high in both calcium and phosphorus, substitutes such as Almond Milk, Soy Milk and non-dairy creamer are recommended.
• Some dairy foods which are lower in phosphorous, include: cottage cheese, feta cheese, cream cheese, parmesan and blue cheese.

Fluid restriction and controlling thirst

• Fluid is any food or beverage that is liquid at room temperature.eg, water, tea, coffee, milk, ice, sodas, juices, frozen desserts such as ice cream, sherbet, gravy and soups.
• Fluid management is the most important and complex intervention in dialysis patient.
• Limiting fluid intake between dialysis treatments is very important because most people on dialysis urinate very little. Without urination, fluid will build up in the body and cause too much fluid in the heart and lungs.
• Usually 400 to 500ml (basal losses) plus the urine output in 24hours is recommended. This would roughly come to around 750–1500 mL/day.
• Tips to restrict fluid intake

-Use a measuring jug / bottle to manage intake

-Use a smaller cup

-Sip instead of gulping down fluid

-Drink only when thirsty, rather than out of habit

-Suck sugar free mints / chewing gum

• Tips to keep from becoming thirsty include:
• Rinsing mouth whenever thirsty.
• Freezing some juice in an ice cube tray and eating .it like a fruit-flavored ice pop (you must count these ice cubes in your daily amount of fluids)
• Staying cool on hot days.

Vitamin and Mineral Supplements:

• A daily supplement of water-soluble vitamins and minerals are usually given as these are lost in the dialysate and thrown by leaching methods of cooking in pulses and vegetables. 

Managing constipation

Constipation is a common problem for people on dialysis in part due to fluid restrictions and a low potassium diet which limits the types and amount of fibre in the diets.A stool softener / laxative may be prescribed for the same.

Sample Menu Plan

1500 Kcal Vegetarian Meal Plan

Early Morning – 2 Threptin biscuit + ½ cup Tea (1 tsp sugar)

Breakfast – Suji / oats Upma / Poha withvegetables – 1 big K   + 200 ml almond/soy milk / 2 Idli + ½ K sambhar + green chutney + 200 ml almond/soy milk / 2 toast with green chutney + 40 gm paneer/ tofu + ½ cup tea / 2 stuffed roti (cabbage / methi/ gobhi/ matar) with green chutney+ 200 ml almond /soy milk / 2 small dosa + green chutney +1/2 K sambhar + 200 mlalmond/ soy milk / 2 Tbsp cornflakes + 200 ml almond/soy milk / oats porridge with 200 ml almond/soy milk

(½ tsp oil for cooking + 1 tsp sugar)

Mid-morning –   Fruit – 1 medium Peach/ pear/ apple / Plum / Guava / Papaya (150 gm)/ Fresh Pineapple (100gm) / grapes – 15

Lunch – 2 Chapati / 1 K rice / 1 K veg Pulao + ½ K dhuli dal + 50 gm tofu / ½ K curd + 1 K vegetable preparation (Ghia/ tinda/ torai /parwal / bhindi / aloo methi / aloo gobhi / aloo matar (with leached potato) / broccoli/ cabbage

(1.5 tsp oil for cooking)

Evening – 2 Threptin biscuit + Puffed rice bhel / air popped unsalted popcorn / boiled corn/ boiled shakarkandi chaat (leached) – 1 small K

Dinner – – 2 Chapati / 1 K rice / 1 K veg Pulao + 40 gm paneer + ½ K dhuli dal + 1 K vegetable preparation (as lunch)

(1.5 tsp oil for cooking)

1500 Kcal Non-Vegetarian Meal Plan

Early Morning – 2 Threptin biscuit + ½ cup Tea (1 tsp sugar)

Breakfast – 2egg whites (boiled / scrambled) + Suji / oats Upma / Poha with vegetables – 1 big K   / 2 Idli + ½ K sambhar + green chutney / 2 toast / 2 stuffed roti with green chutney / 2 small dosa + green chutney +1/2 K sambhar   + Almond milk – 200 ml

(½ tsp oil for cooking + 1 tsp sugar)

Mid-morning –   Fruit – 1 medium Peach/ pear/ apple / Plum / Guava / Papaya (150 gm)/ Fresh Pineapple (100gm) / grapes – 15

Lunch – 2 Chapati / 1 K rice / 1 K veg Pulao + 60 gm fish / chicken prep + 1 ½ K vegetable preparation (Ghia/ tinda/ torai /parwal / bhindi / aloo methi / aloo gobhi / aloo matar (with leached potato) / broccoli/ cabbage

(1.5 tsp oil for cooking)

Evening – Puffed rice bhel / air popped unsalted popcorn / boiled corn/ boiled shakarkandi chaat (leached) – 1 big K + 1/ cup tea (1 tsp sugar)

Dinner – – 2 Chapati / 1 K rice / 1 K veg Pulao + 50 gm grilled tofu + / ½ K dhuli dal + 1 ½ K vegetable preparation (as lunch)

(1.5 tsp oil for cooking)

 Reference:

Nutrition and Hemodialysis. Indian J Nephrol. 2020 Jul; 30(Suppl 1): S55–S66

While millets are nutritious and have several health benefits, there are some limiting factors in their nutrition that need to be taken care of:

Protein Quality: There are 9 essential amino acids and all of them are needed to build proteins, hormones and other important compounds. While millets contain significant amounts of essential amino acids methionine and cysteine, they have limited amounts of essentials amino acid lysine, making the protein in millets less complete.

Antinutrients: Millets also contain certain antinutritional factors such as phytates, polyphenols, tannins and enzyme inhibitors. These compounds reduce protein availability and interfere with the absorption of minerals like iron, zinc, and calcium making them less available for absorption by the human body.

Improving the Protein Quality of millets

Achieving a balanced amino acid profile is crucial for ensuring that your diet provides all the essential amino acids necessary for optimal health. Here are some strategies to balance the amino acid profile of millets.

• Legumes and millets are highly complementary, and when combined, create a powerful nutri-basket with high levels of complete protein (all essential amino acids). Legumes, such as lentils, chickpeas, and beans, are rich in lysine, an amino acid that is relatively lower in millets. Millets are rich in amino acid methionine which legumes are deficient in. It is recommended to add legume to millets in the ratio of 1:3 (legumes: millets) to improve the protein quality of millets. Cooking millet and legumes together also increases the digestibility pf proteins.
• Include a Variety of Millets: Different millets have slightly different amino acid profiles. Incorporating a variety of millets in your diet can help ensure a more diverse range of amino acids. For example, proso millet is relatively higher in lysine compared to other millets, while foxtail millet is higher in methionine.
• Add Nuts and Seeds: Nuts and seeds, such as almonds, sunflower seeds, and chia seeds, can contribute to a more balanced amino acid profile. These foods are rich in various amino acids, including lysine. Sprinkling nuts and seeds on millet-based dishes or incorporating them into snacks can enhance the overall protein quality.
• Include Milk &Milk products: Milk & its products such as curd& paneer are good source of complete proteins. Adding these to millet-based meals can complement the amino acid profile.
• Fermentation –Fermentation involves the action of beneficial microorganisms. It can enhance the protein quality of millets by increasing the content and bioavailability of certain amino acids such as tryptophan, lysine and methionine.
• Germination: Germination involves allowing millet seeds to sprout. Sprouting millets can increase the availability of amino acid like lysine and B vitamins like thiamine & niacin.

While balancing amino acids is essential, most people who consume a varied and well-rounded diet naturally achieve this balance over the course of a day or week.

Reducing the Levels of Antinutrients

Reducing anti-nutrients in millets can enhance their nutritional profile and improve the bioavailability of minerals. Following methods can help to minimize anti-nutrients in millets:

• Soaking: Soaking millets in water for 12 to 18 hrs can help reduce anti-nutrients. This process is particularly effective for reducing phytates. Rinse and change the water during soaking to enhance the removal of these compounds.
• Fermentation: Fermenting millet-based products, such as batter for dosa or idli, activates endogenous enzymes which degrade antinutritional factors like trypsin inhibitor, phytic acid and tannins and enhance the overall nutritive value of millets
• Germination: Germination activates enzymes that break down anti-nutrients and increase the availability of minerals like calcium and iron. After germination, the millets can be dried and then used for cooking. Germination is particularly effective in reducing tannins &phytates.
• Cooking: Proper cooking methods, such as roasting, boiling or steaming, can also help reduce anti-nutrients. Cooking breaks down certain compounds, making them more digestible and less harmful.

It’s essential to note that millets are already nutritious and have several health benefits. The goal is to enhance their nutritional value further by combining them with other complementary foods or traditional household food processing and preparation methods.

Cause

GERD can be caused by many things such as:

• Eating large meals.
• Certain foods like fried foods, spicy foods, tomatoes and processed tomato-based products citrus fruits, peppermint, garlic, onions, chocolate, coffee, tea, and carbonated beverages.
• Exercising after a meal.
• Lying down, especially after meals.
• Smoking and drinking alcohol.
• Hiatal hernia, which is a bulging of the stomach into the chest, can cause reflux.
• Increased pressure on the abdomen by being overweight or pregnant or even by wearing tight clothes.
• Strain while coughing, bending, or lifting.
• Emotional stress may worsen GERD, especially for people with high levels of anxiety.

Symptoms

GERD is not the same in each person, but the most common symptoms are:

• Heartburn (burning feeling in the chest), that usually happens 30 to 60 minutes after eating; often worse when you are lying down. The discomfort can be intense and is usually mistaken for a heart problem.
• Feeling, like food is coming back up into your mouth, maybe with a bitter taste.
• Sore or hoarse throat.
• GERD can irritate the airways, leading to a persistent cough that may be mistaken for allergies or a respiratory infection.
• Feeling like there is a lump in your throat or as though food sticks in your throat when going down.
• Nausea
• Trouble swallowing
• Frequent burping

Treatment

Diet & lifestyle changes play a crucial role in managing GERD by reducing the frequency and severity of symptoms.

Nutritional advice

• Avoid trigger foods that may make your symptoms worse. Try keeping a food diary to keep track of which foods trigger your symptoms.
• Choose fruits with lower acidity levels, such as bananas, melons, apples, papaya and pears.
• Opt for lean sources of protein, such as skinless poultry, fish. Avoid high-fat meats and processed meats like sausages and bacon.
• Choose whole grains like oatmeal, brown rice, whole wheat bread, and whole grain pasta. Avoid or limit foods made with refined grains.
• Opt for low-fat or fat-free dairy products, such as skim milk, yogurt, and cheese.
• Limit portion sizes.
• Eat several small meals throughout the day.
• Eat Slowly and Mindfully: Chew your food thoroughly and savour each bite. Eating too quickly can lead to swallowing air, which can exacerbate GERD symptoms.
• Cooking Methods: Choose gentle cooking methods like baking, steaming, grilling, or broiling instead of frying.
• Ginger and Aloe Vera: Ginger and aloe vera are known for their soothing properties. Consider incorporating them into your diet, either through ginger tea or by adding aloe vera to smoothies or drinks.
• Chew Gum: Chewing sugar-free gum between meals can stimulate saliva production, which helps neutralize stomach acid.
• Stay Hydrated: Drink plenty of water throughout the day but avoid drinking large amounts just before or after meals, as this can increase stomach pressure.
• Dinner Timing: Have your largest meal earlier in the day and keep dinner portions smaller.
• Meal Spacing: Allow at least 2-3 hours between your last meal or snack and bedtime to give your stomach time to digest food.

Lifestyle changes

• Don’t bend over, lie down or exercise after a meal.
• Sleep on your LEFT side.
• Lose weight if you are overweight.
• Raise the head of your bed 6-8 inches with blocks or a wedge under your mattress.
• Avoid tight-fitting clothing.
• Stop smoking.
• Engage in regular, moderate-intensity exercise. Avoid vigorous exercise immediately after eating.
• Limit or reduce stress in your life. Try breathing exercise, yoga, or meditation techniques.
• Avoid non-steroid and anti-inflammatory drugs (ibuprofen, Aleve), aspirin and pain medications as these can make heartburn worse.

Medication –Antacids can give short-term relief of acid reflux.

Remember that individual triggers and sensitivities can vary, so it may take some experimentation to determine what works best for you. Many individuals can manage their symptoms effectively with diet and lifestyle modifications. If these changes do not provide sufficient relief, consult a doctor.