The Vegetarian Diet and Chronic Kidney Disease

By DaVita^® renal dietitian Chhaya Patel, MA, RD, CSR

What is a vegetarian?

A vegetarian is a person who follows a specific diet and has specific food choices which include plant foods. Vegetarians do not consume meat, but depending on what type of vegetarian they are, they may eat other products from animal sources.

Most vegetarians fall into one of the following categories:

• Lacto-vegetarians: Consumes dairy products and plant foods, but excludes eggs.
• Lacto-ovo vegetarians: Consumes eggs, dairy products and plant foods.
• Pesco-vegetarians: Eats fish in addition to eating plant foods, dairy products and eggs.
• Vegan: Consumes only plant foods and no animal products.

If you’re a vegetarian, you don’t have to start eating meat because you have chronic kidney disease (CKD) or have started dialysis. To combine your vegetarian lifestyle with a kidney diet, you’ll need to devise a meal plan to fit your nutritional needs. Here are some things your dietitian may help with for your new diet:

• Monitor your calorie intake so you’re getting enough calories.
• Include vegetarian sources of protein and calorie supplements when needed.
• Increase your phosphate binders that may be needed for meals and snacks.
• Suggest a lower potassium dialysate for those on dialysis to control potassium levels.
• Adjust your diet as needed for acceptable urea clearances.
• Provide resources, recipes and renal education materials specific to your needs.

Food for a vegetarian, kidney-friendly diet

Vegetarian diets can meet the higher protein needs of a dialysis patient..

Protein-enriched foods for vegetarians on a kidney diet may include:

• Meat analogs (meat substitutes such as soy burgers, tofu, hot dogs and deli slices)
• Soy products (tofu, tempeh)
• Beans and lentils
• Nuts and nut butters
• Eggs and egg substitutes
• Dairy products
• Grains

The protein and nutrient content can vary for tofu products, soymilks and meat analogs. Check product labels for the specific nutrient content per serving (such as protein, sodium, potassium, phosphorus, etc.). Powder and liquid protein supplements may be an option for patients with who are unable to meet their protein needs by food alone.

Benefits of being on a vegetarian diet with kidney disease

Plant protein sources have been shown to:

• Decrease protein in the urine (proteinuria)
• Slow the decline of glomerular filtration rate (GFR) and kidney blood flow
• Result in less kidney tissue damage when compared to animal proteins
• Reduce kidney cyst growth
• Improve lipid (blood fat) profile of the blood

Modifying the source of protein rather than restricting the amount of protein may be effective. Plant sources alone can provide high quality protein and adequate amounts of essential amino acids, if a variety of plant foods are consumed daily and energy needs are met.

Vegetarian diets may help slow down the progression of kidney disease without compromising nutritional needs. High protein consumption has long been shown to potentially have harmful effects on the kidney in those with pre-existing kidney disease.

Iron, calcium, zinc, vitamin D and B12 should not be a concern for vegetarians on dialysis. The renal vitamin that is prescribed for hemodialysis patients should contain vitamin B12 and zinc. All dialysis patients are regularly evaluated and prescribed calcium, vitamin D and intravenous (IV) iron by their doctors if and when they need it.

Pitfalls of being on a vegetarian diet with kidney disease

While people in the earlier stages of kidney disease are generally told to limit protein intake, dialysis patients require more protein because of protein loss during dialysis and increased body needs. It is more difficult for vegetarian dialysis patients to consume enough protein and keep potassium and phosphorus controlled without using a protein supplement—this is especially true for those who are vegans, because no eggs or milk products are consumed.

Foods that cannot be eaten on a vegetarian, kidney-friendly diet

Vegetarians will need to limit certain foods with high amounts of sodium, phosphorus and potassium based on their kidney function and lab report, just like other chronic kidney disease patients.

Sodium restriction for vegetarians with kidney disease

Sodium in some vegetarian foods can be high. The foods high in sodium are usually processed, commercially-produced plant proteins. To reduce sodium intake, the use of high-sodium foods such as meat analogs, salted nuts, miso, frozen entrees, marinated tofu products, savory snacks and meals in a cup should be limited.

Phosphate restriction for vegetarians with kidney disease

Legumes, nuts and seeds will need to be limited for people with CKD, if high potassium and phosphorus levels become an issue. Consumption of a vegetarian diet may require an increase in the number of phosphate binders for patients in end stage renal disease (ESRD) or on dialysis.

Potassium restriction for vegetarians with kidney disease

Fruits and vegetables are the primary source of potassium and may need to be limited for vegetarians with CKD. Selecting the lowest potassium fruits and vegetables over higher potassium choices can help keep potassium levels down. Other foods high in potassium that vegetarians may use are soybeans, textured vegetable protein (TVP), soy nuts, soy flour, natto (soybean paste) and wasabi. Potassium amounts will need to be modified and levels monitored carefully by your renal dietitian.

Protein restriction for vegetarians with kidney disease

The quality of vegan protein sources is a concern for dietitians working with vegetarian patients. Renal dietitians recommend an acceptable soy-based product for vegetarian dialysis patients. Meat analogs are a significant source of protein. Look at nutrition labels for sodium content. In addition, the quality of protein is determined not only by the source of the protein, but also by the mixture of vegetable protein sources throughout the day. This means a meal plan for a vegetarian dialysis patient only needs to include foods from all the vegetarian food groups to meet recommended protein needs.

Beans and nuts are considered too high in potassium and phosphorus to be incorporated into a kidney diet. But with careful dietary planning with your dietitian, certain ones can be included in the vegetarian meal plan.

Menu items for a vegetarian, kidney-friendly diet

DaVita.com features delicious recipes for those that are vegetarian. Visit DaVita.com/Recipes and go to the Browse Tags section. Click on “All tags” and then “Vegetarian,” you will see a list of all the vegetarian recipes on the website. Here is a sample of kidney-friendly vegetarian recipes:

Breakfast

• Breakfast Burrito
• Festive Egg Scramble
• Maple Pancakes

Lunch

• Eggplant Casserole
• Individual Frittatas
• Pasta Primavera

Snack

• "An Apple a Day" Muffin
• Honey-Maple Trail Mix
• Soft Pretzels

Dinner

• Armando's Chiles Rellenos
• Pierogi with Sweet Cabbage and Mushroom Filling
• Vegetable Casserole Delite

Dessert

• Dessert Cups with Fresh Fruit
• Strawberry Sorbet
• Warm Bread Pudding