Plant-Based Diet for ESKD: A Kidney-Friendly Approach

1. Introduction to Plant-Based Diets and ESKD 

End Stage Kidney Disease (ESKD) is the last stage of chronic kidney disease (CKD stage 5) in which the kidneys decline to function and remain only 10-15% of their normal capacity. Kidneys are essential organs responsible for filtering blood and performing many vital functions. In ESKD, the kidney filtration rate lowers and cannot filter blood and remove excess fluid from the body, leading to electrolyte imbalances. For survival, the dialysis or kidney transplant becomes necessary in ESKD. 

Plant-based foods are entirely based on fruits, vegetables, whole grains, nuts, seeds, legumes, beans, herbs, and spices. In ESKD, a plant-based diet is directly linked to a lower mortality risk and improved kidney functions. The diet also shows a favourable metabolic profile in ESKD, with enhanced insulin sensitivity, inflammatory biomarkers, and uremic toxins.

Importance of Individualised Meal Planning:

Individualised meal planning is necessary for ESKD because it considers each individual's preferences, unique dietary requirements, health conditions, and goals. This meal-planning strategy, in collaboration with dietitians, ensures that people receive proper nutrition while considering the complications of ESKD. It leads to improved health outcomes with increased adherence to the diet plan for a specific condition such as ESKD.

History of Plant-Based Diets in Nephrology

In ancient times, practitioners used a plant-based diet to treat kidney diseases such as CKD in nephrology because it was environmentally friendly and ideal for reducing protein intake. The NIH also highlighted that vegan and vegetarian diets have become a popular choice to manage advanced kidney disease. The American Journal of Kidney Disease also highlighted the beneficial effects of a plant-based diet in kidney diseases. It also highlighted that a plant-based diet high in fiber prevents the CKD incidence and progression with improved metabolic acidosis, hyperphosphatemia, hypertension, uremic toxins, and patient satisfaction.

Common Misconception:

Besides the beneficial effects of a plant-based diet, there is a common misconception that all plant-based foods are high in potassium. However, this is not always true because some foods, such as potatoes, bananas, leafy greens, and other vegetables, are high in potassium. In a kidney-friendly diet, it's best to avoid high-potassium foods; however, you can enjoy asparagus, broccoli, cauliflower, and cucumber as low-potassium substitutes.

2. Benefits of Plant-Based Diets for ESKD 

Compared to other diets high in meat and fat, a plant-based diet shows many benefits.

• Reduced acid load: A plant-based diet is low in protein and usually alkaline. It reduces the acid load, lowers the stress on the kidneys, and slows the progression of kidney disease. 
• Lowers creatinine: Due to lower animal protein intake, the high fiber in a plant-based diet is beneficial in managing waste removal. A plant-based diet also lowers creatinine production but does not reverse the functioning of kidneys in ESKD. The diet also contains phytates that bind with phosphorus and lower its absorption in the body. Thus, it is beneficial in managing the high phosphorus levels in CKD patients.
• Improves blood pressure: Plant-based diets are naturally lower in sodium, saturated fat, and cholesterol and higher in fibre and potassium from fruits and vegetables, which can help regulate blood pressure levels. The diet is also beneficial for patients with End-Stage Renal Disease (ESRD) in lowering their blood pressure. Plant-based diets also contain compounds like polyphenols that support cardiovascular health and reduce inflammation, which contributes to high blood pressure in ESRD patients. 

A 2023 meta-analysis also highlighted the role of plant-based diets in preventing and mitigating chronic kidney disease. It concluded that meat can be substituted with plant-based foods, and high legume intake. The plant-based diet ensures the nutritional value and palatability for kidney-disease patients. Specialised nutritional planning is essential to increasing diet adherence and maximising the diversity and nutritional value of the meals consumed. Additionally, consultation with registered dietitians is recommended for custom dietary advice.

Thus, a plant-based diet has a significantly lower carbon footprint than traditional renal diets. It relies less on animal products, which require more resources to produce and contribute to greenhouse gas emissions. 

3. Key Nutrients to Monitor

With careful planning, a vegetarian diet can be safe and beneficial for kidney disease patients. Thus, focusing on managing protein, sodium, potassium, and phosphorus intake is essential.

Potassium: 

Regularly checking your potassium level is the best method to determine your potassium requirements. If your level is high, limit your daily intake of fruits and vegetables to five servings. The safe potassium sources in ESKD include apples and cauliflower instead of consuming high-potassium food such as bananas and spinach. 

A potassium serving size contains:

• 1/2 cup fresh fruit, canned fruit or juice
• 1 cup fresh vegetables
• 1/2 cup cooked vegetables

If the serving sizes do not decrease your serum potassium to the normal range, limit these high-potassium foods:

 

High Potassium Foods Limit 1 per day
Textured vegetable protein	¼ cup
Soy flour	¼ cup
Nuts and Seeds	¼ cup
Dried, cooked beans or lentils, legumes	1 cup
Dried cooked soybeans	½ cup
Tomato products	¼ cup
Potatoes	½ cup
Tropical fruit	½ cup
Melons	½ cup
Dried fruit	¼ cup

 

If you consume beans or textured vegetable protein, substitute different protein sources to prevent high potassium levels. To meet the protein requirements, you can take extra tofu, tempeh, seitan, eggs, meat, fish, or fowl.

Phosphorus 

Concentrated phosphorus can be found in dairy products, dark colas, and processed foods, including vegetarian processed foods. To keep your phosphorus in a healthy range, avoid dark colas and processed foods containing phosphate additives and phytate-rich grains. The other method to lower phosphorus from foods is the soaking method. Soak fruit and vegetables before consumption to reduce the phosphorus levels. However, phytates in plants also reduce phosphorus absorption, but portion control is still critical. Also, limit the following high-phosphorus foods to 1 serving per day in plant-based diets.

 

High Phosphorus Limit 1 per day
Milk	1 cup
Cheese	2 oz
Pudding or custard	8 oz
Yogurt	8 oz
Soy cheese	4 oz
Soy yogurt (non-fortified)	12 oz

You can also substitute up to two cups of soymilk and rice milk for milk each day.  Most commercial nondairy creamers contain phosphate additions, so avoid using processed dairy.

Protein 

Protein is necessary for tissue healing, muscle growth, and infection prevention. In ESKD, you should monitor protein consumption. Always consult a registered dietitian to determine your exact protein requirements for meals. In the pre-dialysis stages of CKD, healthcare providers recommend a protein-restricted diet that aims for a protein intake of up to 0.6-0.8g per kg of body weight per day. You can manage the protein balance in the pre-dialysis stage of CKD with lentils and tofu.

The recommended amount of protein for dialysis patients in ESKD increases, usually ranges from 1.2 -- 1.3 g/kg/day. The foods below can be included in a carefully planned diet in ESKD. 

 

Quality protein	Serving Size = 7 g protein
Egg	1
Veggie type burger	½ to 1
Seitan (Wheat gluten)	1 oz.
Beans, dried cooked	1/3 - 1/2 cup
tofu	¼ - ½ cup
tempeh	¼ cup
Nut butters	2 tablespoons
Meat, Fish, Poultry	1 oz.
Cottage Cheese	¼ cup

Sodium: 

Vegetarian foods are generally healthy, but some foods are high in sodium. Thus, limiting the intake of the following foods in kidney diseases is recommended, especially in CKD. 

• Convenience foods include packaged vegetable broths, canned soups, dried soups, frozen dinners, and miso.
• Cheese made with soy
• Processed dairy cheese 
• Meat substitutes, such as veggie burgers, tofu hot dogs, and various canned or frozen soy items
• Any spices that contain sodium or salt, such as salt, soy sauce, tamarind sauce, or others
• Use herbs and spices as a substitute for salt.
• Carefully consider the food ingredients and labels to find out hidden sodium in the food. 

Calcium

Vitamins and minerals, such as calcium, can be obtained from various food items. Plant-based dairy with added calcium can be helpful, but balance is essential if phosphate binders are also used. Maintaining normal calcium levels is vital to promoting bone health without disrupting the mineral balance in renal disease. Talk with your doctor or Registered Dietitian before starting any new supplements.

A customised plant-based diet closely monitors potassium, phosphorus, protein, sodium, and calcium levels in ESKD patients to maintain kidney function. It also slows down the progression of kidney disease and enhances the overall quality of life.  

4. Foods to Include and Avoid 

Foods Included in Plant-Based Diet

These are foods included in a plant-based diet and beneficial to consume in a renal diet.

• Consume the right amount of potassium, protein, sodium and phosphorus.
• Select fruits that are low in potassium, such as watermelon, honeydew melon, raspberries, blueberries, cherries, pineapple, olive oil, apples, applesauce, and grapes.
• Low-potassium vegetables include lettuce, green beans, cucumbers, asparagus, carrots, cauliflower rice, peas, zucchini, and radishes.
• Consume various legumes, fruits and vegetables that provide vitamins, minerals, and fiber. 
• Root vegetables are also beneficial and provide a good source of carbohydrates and vitamins. 
• In a plant-based diet, staple foods such as beans, peas, and lentils are healthy options, as they are high in protein, fiber, and minerals, including calcium, iron, and magnesium.
• Seeds, including flax, chia, and pumpkin seeds, are good sources of protein, healthy fats, and vitamins.
• Tofu and tempeh are great meat substitutes and rich in plant-based protein and micronutrients.
• Other plant-based foods such as grains, fortified foods, cereals, plant milks, and nutritional yeast are also healthy options to consume in a plant-based diet. 

Foods To Avoid in Plant-Based Diet in ESKD

People with end-stage kidney disease (ESKD) should limit certain plant-based foods, such as legumes, avocados, potatoes, processed vegan meats, nuts, and seeds, because they are high in potassium or phosphorus.

• ESKD patients should limit legumes, nuts, and seeds because they are high in potassium and phosphorus 
• Tomatoes are also high in potassium, and ESKD patients should avoid eating them.  
• Avocados are a good source of heart-healthy fats, vitamins, and minerals. However, they are high in potassium, so they should be avoided in ESKD.
• Potatoes, nuts, and processed vegan meats are also high in potassium and phosphorus and people should restrict their intake in ESKD.

Managing portion size is essential for end-stage kidney disease (ESKD). Legumes are an excellent source of plant-based protein but contain a high amount of phosphorus. To control protein intake and phosphorus buildup, they limit the serving size of legumes to 1/4 cup of cooked beans. Portion control ensures that patients receive adequate protein intake for energy and muscle maintenance.

Typical Serving Sizes of Plant Protein

The list below highlights the sources of plant protein which can be included in a diet:

 

• ½ cup of cooked beans (6-15 g protein)
• ¼ cup of nuts (8 g protein)
• 2 tablespoons nut butter/spread (8 g protein)
• ½ cup of cooked brown rice/noodles (4-7 g protein)
• 1 slice of whole grain bread (5 g protein)
• 1 unit of a soy-based meat alternative (example, 1 soy-burger patty) (10-20 g protein)
• Protein swap-outs

These are some ideas to swap animal-based sources for plant protein:

Seasonal swaps and variety are great ways to stay with a diet longer. For example, pears in the winter can replace peaches in the summer, allowing patients to eat fresh while maintaining the nutrient content. These substitutions allow people to eat various foods according to the season and make them according to their food preferences without damaging their kidneys.

Low-sodium canned beans and other kidney-friendly products are formulated to ease meal preparation and help people meet daily dietary guidelines. The selection of food products ensures a balanced way of managing ESKD with a plant-based diet.

5. Sample 7-Day Meal Plan 

The Vegetarian Meal Plan for Kidney Disease aims to lower renal stress. It focuses on kidney-friendly fruits, vegetables, and grains to address the dietary requirements of people with renal disease. The meal also focuses on reduced protein, potassium, and phosphorus levels.

Below is a 7-day meal plan focusing on a kidney-friendly plant-based diet.

 

Days	Breakfast	Lunch	Dinner	Snacks
Day-1	Egg white omelette with bell peppers and onions  (Calories: 200, protein: 15g, carbs: 10g, fat: 8g)	Rice with steamed carrots and green beans  (Calories: 350, protein: 8g, carbs: 70g, fat: 2g)	Pasta with cooked zucchini and a low-sodium tomato sauce (Calories: 400, protein: 12g, carbs: 80g, fat: 6g)	White bread with a small amount of jam (Calories: 150, protein: 3g, carbs: 30g, fat: 1g)
Day-2	Cream of rice cereal with a small apple  (Calories: 250, protein: 4g, carbs: 55g, fat: 2g)	Egg salad sandwich on white bread with lettuce and cucumber (Calories: 400, protein: 12g, carbs: 40g, fat: 20g)	Stir-fried tofu with cabbage and bell peppers  (Calories: 350, protein: 20g, carbs: 30g, fat: 15g)	Rice cakes with a small amount of cream cheese  (Calories: 180, protein: 5g, carbs: 30g, fat: 5g)
Day-3	French toast made with egg whites  (Calories: 300, protein: 10g, carbs: 45g, fat: 8g)	Cauliflower and potato curry with white rice  (Calories: 400, protein: 8g, carbs: 70g, fat: 10g)	Vegetarian sushi rolls with cucumber and carrots (Calories: 350, protein: 6g, carbs: 60g, fat: 5g)	Sliced canned peaches in juice (Calories: 100, protein: 1g, carbs: 25g, fat: 0g)
Day-4	Boiled rice with sugar and cinnamon  (Calories: 200, protein: 4g, carbs: 45g, fat: 1g)	Couscous salad with cucumber, bell peppers, and feta cheese (Calories: 350, protein: 10g, carbs: 55g, fat: 8g)	Vegetable stir-fry with tofu and white rice  (Calories: 400, protein: 18g, carbs: 60g, fat: 10g)	White toast with apple butter (Calories: 150, protein: 3g, carbs: 30g, fat: 2g)
Day-5	Pancakes with maple syrup (Calories: 300, protein: 6g, carbs: 55g, fat: 5g)	Macaroni and cheese  (Calories: 450, protein: 15g, carbs: 55g, fat: 20g)	Vegetable stew with carrots and celery  (Calories: 350, protein: 6g, carbs: 70g, fat: 5g)	Pita bread with hummus (Calories: 200, protein: 6g, carbs: 30g, fat: 8g)
Day-6	Bagel with cream cheese alternative (Calories: 350, protein: 10g, carbs: 60g, fat: 5g)	Rice pilaf with peas and carrots (Calories: 300, protein: 6g, carbs: 60g, fat: 5g)	Pasta primavera  (Calories: 400, protein: 10g, carbs: 70g, fat: 10g)	Homemade muffin  (Calories: 200, protein: 4g, carbs: 30g, fat: 8g)
Day-7	Hot oatmeal with cinnamon (Calories: 200, protein: 6g, carbs: 35g, fat: 4g)	Grilled cheese sandwich with low-sodium cheese  (Calories: 350, protein: 12g, carbs: 40g, fat: 18g)	Vegetable lasagna with low-sodium cheese  (Calories: 500, protein: 18g, carbs: 60g, fat: 20g)	Angel food cake  (Calories: 140, Protein: 3g, carbs: 30g, fat: 0g)

Hydration Tips for Kidney Disease Patients:

In the advanced stages of CKD, the amount of fluid is restricted because the kidneys produce little or no urine. Excessive intake of fluid can cause swelling, increased weight, high blood pressure, and oedema. 

What counts in hydration?

Hydration includes drinking all drinks, including tea, coffee, juice, milk, squash, supplement drinks, and liquid consumed while on dialysis. It also counts liquid or melted foods such as soup, gravy, white sauce, cheese sauce, custard, yoghurt, milk puddings, or jelly. To keep track of fluid intake and limit consumption in ESKD, the following measures help restrict intake. 

• One pint: 570ml
• One litre: 1000ml
• One teacup: 150ml
• One mug: 300ml
• One small glass: 180 ml
• One can drink: 330 ml
• 1 tbsp sauce: 15-30ml
• Small bowl porridge: 90ml
• 100g jelly: 85ml
• 100g ice cream: 60ml
• 75g custard: 60ml
• 125g yoghurt: 100ml

 

For example: 

A patient of ESKD with fluid restriction of 750 ml can consume

• 3 cups of 150-ml tea
• 2 half cups (75ml) of water with medicines
• remaining 150ml can be used for milk on cereal or puddings

Tips to Maintain Fluid Restriction in ESKD

• Avoid salt and salty foods because they make you thirsty.
• Take a small cup for drinks that contains only 150ml
• Using a jug, measure the amount of liquid you can consume.
• Distribute your daily hydration intake throughout the day.
• Drinks should be taken between meals, not with meals.
• Consume beverages that will quench your thirst. 
• Drinks should be sipped, not gulped! To slow down, try using a straw for cold beverages.
• Consume drinks with various flavours.
• Try to suck small ice cubes if you are thirsty (count each ice cube as 15ml) 
• Use mouthwash or ice water to rinse your mouth, but avoid swallowing it.
• You do not need to count the water used to cook pasta or rice. Ensure they are drained well before eating.

Grocery List of Plant-Based Diet for ESKD

ESKD patients must make a proper grocery list and prioritise low-potassium and phosphorus foods to lower the kidney burden. Below are low-potassium fruits and vegetables with serving sizes that are kidney-friendly in a plant-based diet.

 

Low-potassium fruits	Serving size
Apple	1 medium
Applesauce	½ cup
Apricots, canned in juice	½ cup (drain liquid first)
Blackberries	½ cup
Blueberries	½ cup
Cherries	½ cup
Cranberries	½ cup
Fruit cocktail	½ cup (drain liquid first)
Grapes or grape juice	½ cup
Grapefruit	½ whole (in certain medications such as statins and immunosuppressants, avoid consuming grapefruit)
Mandarin oranges	½ cup
Peaches	1 small fresh or ½ cup canned
Pears	1 small fresh or ½ cup canned

 

Low-potassium vegetables	Serving size
Alfalfa sprouts	½ cup
Asparagus	6 spears
Beans, green or wax	½ cup
Broccoli (raw or cooked from frozen)	½ cup
Green cabbage	½ cup
Red cabbage	½ cup
Carrots, cooked	½ cup
Cauliflower	½ cup
Celery	1 stalk
Cucumber	½ cup

6. Challenges and Solutions 

Following a plant-based diet, especially in ESKD patients, may be challenging. A plant-based diet poses many risks, including nutritional deficiencies, hyperkalaemia, protein inadequacy, and taste fatigue. Below are some mitigation risks to overcome the challenges and make it suitable for ESKD patients.

• Hyperkalaemia risk: Plant-based diets are generally high in potassium due to their plant sources, which increase the risk of hyperkalaemia and may be fatal for ESKD patients. While plant-based diets are high in potassium, the fibre-rich content of plant sources also helps in potassium excretion. To overcome the risk of high potassium, substitute low-potassium foods in your diet. Another method to lower the potassium content in fruits and vegetables is ‘double boiling.’ Soaking and boiling potatoes effectively reduces the potassium content in potatoes and removes up to 50% of potassium.

• Protein Adequacy: To ensure adequate protein intake in a plant-based diet, prioritise consuming high-quality protein sources such as legumes, nuts, seeds, and whole grains. Also consider incorporating plant-based complete protein sources like tempeh, tofu, or quinoa. You can also combine rice with lentils for complete amino acids.

• Taste fatigue: To overcome the risk of taste fatigue, take breaks, use a palate cleanser, and focus on diverse flavours. To stick with a plant-based diet for longer, you can also consume taste enhancers, such as lemon zest or cinnamon, for flavour without sodium. 

People on ESKD can also track their nutrient intake using an online web platform or mobile applications such as a chronometer. It is beneficial for renal patients to track the intake of critical nutrients, including sodium, potassium, and protein, to maintain it within normal ranges for optimal health.

Additionally, interventions involving peer groups for dietary modification can be more affordable than medical interventions by healthcare providers. Peer groups encourage people to share recipe ideas and encourage renal patients to stick with a plant-based diet for a longer time.

7. Scientific Evidence and Case Studies 

Many scientific studies show the positive effect of a plant-based diet in advanced stages of CKD. "The Role of Plant-Based Diets in Preventing and Mitigating Chronic Kidney Disease: More Light than Shadows," a study in the Journal of Clinical Medicine in 2023, found that a plant-based diet delays dialysis and lessens metabolic problems in ESKD. The main goal of this research was to give an in-depth look at previous research on the effects of plant-based and low-protein-based diets on people with chronic kidney disease.

Plant-based diet linked with reduced mortality:

Many studies indicate that plant-based diets are safe for people with CKD, even when they limit protein intake. This eating habit is associated with a lower risk of mortality in CKD patients, as observed in the healthy population. Plant-based diets should be part of the treatment advice for preventing and caring for people with CKD.

Plant-based diet changes gut bacteria and lowers uremic toxins:

"Plant-Dominant Low-Protein Diet for Conservative Management of Chronic Kidney Disease" was published in 2020. It found that a plant-based diet high in fiber and low in protein may also change the bacteria in the gut. This method can change uremic toxin production, slow CKD development, and lower the risk of heart disease. PLADO is a heart-healthy, safe, flexible, and doable diet that could be the main part of a conservative and preventative approach to managing CKD that goes against the current model that is based on dialysis.

The research titled “Effect of the Gut Microbiome on the reduction of uremic toxins in patients with Chronic Kidney Disease” was also conducted. A network meta-analysis of randomized clinical trials (RCTs) was carried out in this research. Researchers looked at how taking prebiotics, probiotics, and synbiotics affected uremic toxins like indoxyl sulfate (IS), p-cresyl sulfate (pCS), urea, and creatinine levels in CKD patients in stages 3 to 5 according to KDIGO standards. The results concluded that changing the gut microbiota through these methods can reduce certain uremic toxins. However, more research is required to understand how the microbiota changes and alters the makeup of bacteria in the gut.

Plant-based diet with favourable kidney outcome:

Another study, published in the Clinical Journal of the American Society of Nephrology in 2019, titled “Plant-Based Diets and Incident CKD and Kidney Function,” also shows the positive impact of plant-based diets. It concluded that higher adherence to healthy plant-based and vegetarian diets was associated with favorable kidney disease outcomes.

Thus, the 2020 KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines recommended protein restriction, a low-protein diet (0.55-0.6 g/kg/day), or a very-low-protein diet (0.28-0.43 g/kg/day) with keto acid analogues for non-dialysis CKD patients to reduce the risk of kidney disease and improve quality of life. 

 Frequently Asked Questions

Can I eat tomatoes in a plant-based diet?

Yes, you can eat tomatoes on a plant-based diet, but only peeled/ seeded and in a small amount. It is a common fruit (botanically) and a healthy, versatile food source. 

How to get enough iron?

To get adequate iron intake in a plant-based diet, focus on iron-rich foods and pair them with vitamin C to enhance absorption. For example, pair lentils with vitamin C-rich bell pepper to get sufficient iron.

Is almond milk safe?

Yes, almond milk is a safe and often recommended plant-based milk alternative for people on a plant-based diet with End-Stage Kidney Disease (ESKD). It is preferable due to its lower potassium and phosphorus content than cow's milk. However, some almond milk also contains phosphorus additives, so choose =unsweetened, additive-free milk for enhanced benefits in kidney disease.

Can this diet replace phosphate binders?

No, while a plant-based diet can contribute to managing phosphorus levels in chronic kidney disease (CKD) due to the lower bioavailability of phosphorus in plant foods, it cannot completely replace phosphate binders but may reduce its dosage.