In the US, quince is available in the fall. You can find it at farmer’s markets, large supermarkets and specialty and ethnic stores. Turkey is the world’s largest quince producer/exporter.

Nutritionally, a medium quince has around 75 calories and 14 grams of carbohydrate. With only 181 mg potassium, 16 mg phosphorus and 4 mg sodium, quince is a great fruit choice for a kidney diet.

Treat yourself to a new taste experience! Look for the raw fruit to cook or shop for quince paste or jelly.

Here’s an easy recipe for Baked Quince: 

Portions:  8           

Serving size:  1/2 quince

Ingredients

• 4 medium quinces
• 1 cup sugar
• 3 cups water
• 2-1/2 tablespoons unsalted butter

Preparation

1. Preheat oven to 350° F.
2. Peel the fruit, cut in half and remove seeds. Place in a baking dish.
3. Pour sugar over quince halves and dot each piece with butter.
4. Add water and bake for 1 hour.
5. Serve each quince half with a spoonful of whipped topping.

Nutrients

152 calories, 0 protein, 30 g carbohydrate, 4 g fat, 10 mg cholesterol, 5 mg sodium, 93 mg potassium, 9 mg phosphorus, 9 mg calcium, 0.8 g fiber

Visit DaVita.com to discover more kidney-friendly fruit recipes. Some of  my favorites include:

• Apples Baked in Cider
• Blueberry Peach Crisp
• Creamy Grape Salad
• Peach Cobbler
• Traverse City Cherry Crisp
• Zingy Spiced Pears

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

Phosphorus Challenge

‘Got milk substitute?’ and ‘Which products are best?’ are most likely the questions most people following a kidney diet are asking.

DaVita dietitian Chien-Wei Kung, RD researched milk substitutes and published her results in the March 2010 Journal of Renal Nutrition. Milk replacement products include nondairy creamers, soy milk, rice milk and almond milk. Many of these products are lower in the minerals of concern for a kidney diet, but there are a lot of variations between brands. Some substitutes have added calcium and phosphorus and some have phosphate containing food additives. Other products have potassium levels similar to milk. Beware of Hemp milk which tends to be quite high in potassium.

As Kung mentions in her article, manufacturers reformulate their products often, so it’s a challenge to keep updated on which milk substitutes are best for a kidney diet. Here are a few of the products that are lowest in potassium, sodium, phosphorus and calcium.

Soy milk- Hain Celestial WestSoy® plain and vanilla, Edensoy® light original

Rice milk- Hain Celestial Rice Dream® original, Pacific Foods, Pacific® plain rice, Trader Joe’s rice drink, organic, original, unsweetened, Whole Foods market 365 organic rice milk, unsweetened

Almond milk- Pacific Foods Pacific® organic, almond original unsweetened and vanilla, Blue Diamond Almond Breeze® original and vanilla

Nondairy creamers- Rich’s Coffee Rich®, Bay Valley Foods Mocha Mix® original, Nestle Coffeemate®

Many recipes in the DaVita.com recipe collection use milk substitutes instead of milk to help lower potassium and phosphorus content. Here are some of my favorites:

Make Ahead Pancake Batter

Chicken and Rice Casserole

Creamy Pasta Primavera

Zucchini Casserole

White Gravy for Casseroles or Pot Pies

Home-style Vanilla Ice Cream

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

Phosphorus Challenge

Some good hot cereal choices include cream of wheat, Malt-o-Meal, grits, and even oatmeal a few times a week. (Stick with the cook and serve cereals instead of the higher sodium instant ones.) Many diet guides place oatmeal in the limit or avoid list because it does contain more phosphorus than the other hot cereals listed.

For ready-to-eat cereals look on the Nutrition Facts label and select the brands lowest in sodium and phosphorus. Lower sodium choices help with blood pressure control. Many cereals give the % Daily Value for phosphorus rather than milligrams. Try to go with those containing 10% DV or less. In general, cereals with added nuts or whole grain tend to have higher amounts of phosphorus.

Our thinking on limiting whole grains is going through a shift currently. You see, in some foods that are naturally high in phosphorus, the phosphorus is bound as phytate and we do not break it down to release all the phosphorus during digestion. So a food naturally high in phosphorus may only contribute 40% to 60% of that phosphorus to the be absorbed into the bloodstream.

Phosphorus containing food additives are 90 to 100% absorbed into the bloodstream. Several ways to lower phosphorus is to avoid foods containing phosphate additives, prepare more meals at home with fresh ingredients, and limit fast foods and processed foods on restaurant menus.  A recent review of chicken products found that many frozen chicken products contain 28%  to 100% more phosphorus than fresh, unenhanced chicken.

The reason for starting to pay attention to phosphorus as early as stage 3 chronic kidney disease is that there are already changes going on in the bones and in kidney regulation of phosphorus and parathyroid hormone (PTH). Research indicates there may be a benefit to keep bones healthier and even slow progression when phosphorus is limited to 800 to 1000 mg/day.

So the next time you go shopping for cereal (or other foods as well), look for the amount of phosphorus on the label. It is not required , so if available the food manufacturer has added it voluntarily. In addition, look at the ingredient list and avoid products that have ‘phos’ food additives.

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

Phosphorus Challenge

Can too much of a water soluble vitamin really be bad for your kidneys? I first ran across an article “B Vitamins Harm Kidneys” in the June issue of Nutrition Action Healthletter (http://www.cspinet.org/). According to the article about a Canadian research study, 238 diabetics with early stage chronic kidney disease (CKD) took a high dose folic acid, vitamin B-6, vitamin B-12 pill or a placebo. After three years the study revealed a greater decrease in kidney function and heart attack or stroke in the participants receiving the B vitamin.

I read another article on the same research study in the June issue of Nephrology News and Issues http://www.nephronline.com/ titled “High vitamin B doses may accelerate kidney damage”. The original research was published in the Journal of the American Medical Association (JAMA), April 2010. One of the Diabetic Intervention with Vitamins to Improve Nephropathy (DIVINe) study goals was to determine if the high doses of B vitamins decreased levels of the amino acid metabolite, homocysteine. High homocysteine is linked to a greater risk of heart disease and stroke, even in the normal population. Results were a decrease in homocysteine levels with B-vitamin therapy, but unexpectedly, an increase in stroke and cardiovascular events. However, the number of patients who required dialysis during the three year study period was equal–ten from the vitamin group and ten from the placebo group.

Yet another article on this research study, “B-Vitamin Therapy Linked to Increased Risk in Small Diabetic Nephropathy Trial, but Results Controversial” was published in the May 2010 issue of Nephrology Times www.nephrologytimes.com. Experts questioned several aspects of the study: a small number or participants, borderline significant results, and the fact that larger studies have not shown the harmful effects from even higher doses of B vitamins. One study cited, Homocysteinemia and End-Stage Renal Disease (HOST) had over 2000 participants with advanced kidney disease and did not show evidence that even higher doses of the B vitamins are harmful. One question that was brought up—Is there something about having diabetes and CKD that causes harmful effects in this group? or did study participants who had cardiovascular events have a reduction in kidney function due to the cardiovascular event rather than harm from the vitamins? More analysis of the study data may help provide answers.

In the mean time, what’s safe for you if you have diabetes and CKD? It’s known that changing from a regular healthy diet to a kidney diet may cause lower intake of folic acid, vitamin B-6 and vitamin B-12. In addition, when CKD patients start dialysis there is a loss of B-vitamins from the blood during dialysis.  Deficiency of any of these B vitamins can cause anemia, as well as nerve and skin abnormalities. The chart below compares two of the above mentioned research study B-vitamin levels with a typical renal vitamin and a regular multivitamin.

From a dietitian point of view, try to eat a healthy diet and get your vitamins from food sources. If you have early stage kidney disease, consider a multivitamin if your diet changes have resulted in a decreased intake of meats, milk, whole grains, nuts, dried beans, fruits and vegetables. If you are in later stage kidney disease or on dialysis, stick with the renal vitamin prescribed by your kidney doctor, since the many dietary restrictions contribute to inadequate B vitamin intake and dialysis causes increased losses. If you are taking a vitamin with very large doses of folic acid, B-6 or B-12, ask your doctor about the benefits versus harm.

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

One of the biggest helpers with learning about and following a kidney diet is a good kidney diet cookbook. Several years ago I posted the National Kidney Foundation kidney cookbook list for you to use as a guide. 

Here’s a link to the latest version: http://www.kidney.org/professionals/CRN/cookbooks.cfm. I also want to tell you about some of the recipe books for dialysis and chronic kidney patients that I have in my collection.

At the top of my list is my own renal cookbook called “Cooking for David: A Culinary Dialysis Cookbook”. I spent over 3 years working with my co-author and friend Dorothy Gordon, developing recipes and gathering information to help people understand and follow the dialysis diet. Dorothy and I developed over 160 recipes modified in sodium, potassium and phosphorus and all were approved by David, Dorothy’s husband who was on dialysis. Our goal was to make kidney-friendly recipes the whole family could enjoy.

Some of the cookbook features include:

• pre-planned menus
• a meal planning guide
• the kidney diet food pyramid
• explanation of the kidney diet prescription
• nutrient analysis for protein, carbohydrate, fat, cholesterol, sodium, potassium, phosphorus and fiber
• renal and renal diabetic food choices for each recipe
• food lists for high and low sodium, potassium and phosphorus foods

My favorite recipes include Tortilla Rollups, Strawberry Pudding, Busy Day Frittata, Meat Loaf with BBQ Sauce Glaze, Fish Stew, Chicken Chow Mein and Deviled Green Beans.

For more information and weekly recipes with helpful hints visit www.CulinaryKidneyCooks.com. The book is also available on www.Amazon.com, where you can read reviews from people who have purchased the book.

Earlier this year I attended the National Kidney Foundation Spring Clinical meeting in Orlando. One of the sessions featured renal dietitian Joan Brookhyser Hogan, RD and Chef Duane Sunwald and a newly published book, “The Vegetarian Diet for Kidney Disease: Preserving Kidney Function with Plant-Based Eating”. This book offers 38 vegetarian recipes plus information on meal planning, supplements, vegetarian diet benefits and several food composition tables for vegetarian food products. You can find this book on www.Amazon.com.

Another book in my library is a collection of recipes by DaVita dietitian Nina Kolbe titled “Kidney Health Gourmet: Diet Guide and Kidney Friendly Recipes for People Not on Dialysis”. This is a smaller recipe book aimed at people with chronic kidney disease. It features information about kidney diet components, food lists and 58 recipes from Nina’s collection. To find out more wisit www.kidneyhealth1@aol.com or order from www.Amazon.com.

The largest collection of kidney-friendly recipes is the DaVita.com recipe collection featuring over 600 recipes for chronic kidney disease and dialysis. Start by trying some of the recipes, then rate and review to share your experience with others. You can even save the ones you like by adding to the ‘My foods/recipes/meals’ component in DaVita Diet Helper online meal planner for kidney diets.

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

Pineapple fits a low potassium diet plan with 125 mg potassium for 1/2 cup frozen or canned (chunks or crushed), 2 rings or 3/4 cup fresh. Pineapples are very low sodium and phosphorus, high in vitamin C and contributes 1 gram of fiber per serving. It’s also fat-free, less than 1 gram of protein and 13 to 26 grams of carbohydrate depending on presence of added juice or syrup. Pineapple juice has 160 mg potassium for a four ounce serving. Your dietitian may advise you to have the fruit or the juice but not both at the same time if you are limiting potassium.

Suggestions for planning pineapple in your kidney diet include:

• Eat it fresh or straight from the container—it’s good enough to eat without any additions! To peel and cut a fresh pineapple you can view step by step pictures at http://www.howtocutapineapple.com/
• Make a pineapple upside-down cake or pineapple pie
• Add crushed pineapple to cream cheese as a spread or cheese ball
• Make a fruit salad with pineapple, grapes, strawberries and watermelon
• Skewer pineapple with shrimp for the barbecue
• Create a pineapple salsa to serve with your favorite fish or chicken entree
• Broil pineapple rings for a quick dessert
• Make sweet and sour pork or chicken and canned pineapple chunks

Try one of the above suggestions or check out these kidney-friendly pineapple recipes created by DaVita Dietitians for DaVita.com.

• Carrot Pineapple Salad
• Festive Pineapple Cheese Ball
• Grilled Pineapple Chicken
• Orange Pineapple Ambrosia Salad
• Pineapple Cake
• Pineapple Angel Cake
• Pineapple Rum Crème Cake
• Pineapple, Pork and Pepper Pizza
• Pineapple Rice
• Pineapple Salsa

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

PD is performed on a daily basis which means waste and fluids are removed more often compared to three times a week traditional in-center hemodialysis. For this reason some parts of the diet are more liberal.

Protein – Protein is lost in each exchange so a high protein diet is required to keep albumin normal and prevent muscle wasting. This means eating generous potions of meat, poultry, fish, seafood, eggs or egg whites and in some cases adding a protein supplement. Higher phosphorus protein foods such as milk, yogurt, cheese, beans and nuts are limited in the PD diet.

Potassium – daily removal of this mineral helps keep blood levels in the normal range. A liberal potassium diet of 3000 to 4000 mg/day is often prescribed but this may vary based on individual needs, number and frequency of exchanges, use of an automated cycler, remaining kidney function and lab values. Some PD patients must eat high potassium foods or take potassium supplements to keep potassium from dropping too low.

Sodium – Sodium removal is very efficient with PD, so most people are prescribed a 3000 to 4000 mg sodium diet. This level is easy to reach without too many diet changes. However people who eat out frequently and use many processed and convenience foods could easily exceed this limit. Stricter levels may be required if other health conditions are present.

Fluid – Each exchange allows removal of fluids so there is seldom accumulation of excess fluid in the body. PD patients can regulate fluid by adjusting the glucose concentration in the dialysate. Most patients can consume 2-3 liters of fluid a day but this varies with remaining kidney function and type of peritoneal dialysis therapy.

Additional considerations about diet for peritoneal dialysis include phosphorus, calories, vitamins and minerals.

Phosphorus – This mineral is not easily removed by PD so patients must follow a low phosphorus diet and take phosphate binders when they eat. Higher protein diets contain more phosphorus so keeping phosphorus in control can be a challenge.

Calories – The PD solution or dialysate used to remove waste and fluid contains dextrose which provides easily absorbed sugar calories. Some PD patients gain weight because they are getting 400 or more calories a day from the dialysate.

Vitamins – Several vitamins are lost in the dialysate so a daily supplement is recommended. Special renal vitamins provide folic acid, B complex and 60 to 100 mg vitamin C. Vitamin D, both nutritional and activated, may be prescribed based on blood levels of vitamin D and parathyroid hormone levels.

Minerals – PD patients may require iron supplementation, depending on their ferritin and hemoglobin levels. IV iron therapy is often prescribed when needed of oral supplements may be taken if tolerated.

If you would like more information about dialysis at home including peritoneal dialysis and home hemodialysis:

After signing up for the DaVita Phosphorus Challenge, you will receive 11 emails over the next 30 days with educational information about phosphorus and challenges to help you learn. On the last day you will receive a certificate and you will continue to have access to the games, education content and community section of the DaVita Phosphorus Challenge.

Phosphorus is a serious issue for people with chronic kidney disease. Uncontrolled phosphorus levels contribute to bone and heart disease. Early phosphorus control can keep you healthier.

Sign up and take the DaVita Phosphorus Challenge today. I am interested in hearing from you.

Results from a 4-1/2 year study of almost 1300 Chinese people with type 2 diabetes points to the American Diabetes Association targets to answer this question. (Archives of Internal Medicine, 2010:170:155-161). The study researchers reported that meeting the ADA target goals for hemoglobin A1C (HbA1C), blood pressure, cholesterol and triglycerides make a difference in keeping kidneys healthy. In fact, focusing on these targets can reduce risk of diabetic nephropathy by up to 35%.

American Diabetes Association Targets

• HbA1C less than 7%*
• Pre-meal glucose 90 to 130 mg/dL
• After meal glucose no higher than 180 mg/dL
• LDL cholesterol less than 100 mg/dL
• HDL cholesterol above 50 mg/dL for women and 40 mg/dL for men*
• Triglycerides less than 150 mg/dL
• Systolic blood pressure below 130 mm Hg*

*These targets made a significant difference in reducing risk of kidney disease in the research study.

Lifestyle changes add up to the most effective actions you can take. These include:

• A healthy diet with whole grains, fruits, vegetables and low-fat meat, poultry, fish and low-fat or non-fat dairy products.
• Balance your carbohydrate intake to help control blood sugar response to eating.
• Eat fish high in omega 3 fatty acids more often and use healthy fats in food preparation, such as olive oil and canola oil. Avoid trans-fats as much as possible.
• Start moving-exercise 30 to 60 minutes a day helps control glucose and blood pressure better.
• Deal with stress; it’s a natural part of life and will always be there but you can change how you think and react to stressful events.
• Be kind to yourself; take time to relax and acknowledge your efforts at taking care of yourself. Smile more often.
• Engage your family for support and their involvement in lifestyle change toward a healthier family.

Remember the saying “An ounce of prevention is worth a pound of cure”. In the case of diabetes and preventing or delaying kidney disease the ounce is worth more than it’s weight in gold!

A recent article from Nutrition Action, health newsletter by the Center for Science in the Public Interest (CSPI), lists additional health dangers from eating too much salt. These include:

• left ventricular hypertrophy, thickening of the left side of the heart that leads to heart failure
• stiff arteries that contribute to early heart disease
• increased protein in the urine for people who have kidney damage
• osteoporosis linked to increased calcium loss in the urine

All of these are significant if you have kidney disease becaue people with chronic kidney disease (CKD) have much higher rates of both heart and bone disease.

Normal blood pressure is 120/80 or lower and high blood pressure is 140/90. Numbers in-between these ranges indicate pre-hypertension, a sign that a person is developing high blood pressure. Once you are diagnosed with high blood pressure, your treatment goal is to keep blood pressure as close to normal as possible. Following a low sodium diet will help you reach this goal.

On average, American women consume 3000 mg sodium a day and men consume 4000 mg. Studies show that high blood pressure medications are more effective if salt intake is reduced. How much? The new goal is 1500 mg or less sodium a day. Compare this to the old goal of 2400 mg or less and even dietitians start to question how you can achieve this level. The answer? Turn to the restaurants and food manufacturers and demand more accountability for the amount of salt and sodium added to your food. You get 75-80 % of your salt intake from what’s added to food during processing and preparation.

The desire for salt is acquired, and it’s easy to retrain your taste for salt. Pick some of these guidelines to start decreasing your salt intake along with lowering your risk for stroke, heart attack and further kidney damage.

• Read labels and select the lowest sodium foods. Look for ‘No Salt Added’, ‘Low Sodium’, ‘Unsalted’ and ‘Reduced Sodium’ products.
• Minimize the use of condiments, seasonings and flavorings added to food—often an additional 500 mg of sodium is added.
• Experiment with herbs, spices and low sodium seasonings. In addition to salt, your taste buds respond to sweet, bitter, sour and savory (umami). Try lemon, vinegar, fruits, citrus zest and chilies to add flavor to food.
• Expand your cooking skills and eat home prepared meals more often. In addition to giving you control over sodium, you will save money on your food bill.
• If you order take-out or use a higher sodium packaged food, try adding fresh or frozen vegetables or unsalted pasta, couscous or rice to reduce sodium per serving and increase the number of servings.
• Rework your favorite recipes to reduce high sodium ingredients and try new lower sodium recipes to add to your collection.
• Ask for nutrition information for fast food, take out and restaurant meals so you are informed about how much sodium you are getting.

Instead of……………………………………………………. Try this
Ready to eat dry cereals                                                Farina, cream of rice, grits or puffed cereals
Regular canned vegetables                                           Unsalted canned, fresh or frozen vegetables
 Plumped or enhanced meats                                        Fresh meats without injected ingredients                              

Commercially made salad dressings                         Homemade salad dressings
Deli sandwich meats                                                         Fresh cooked chicken or roast beef
Processed cheese                                                               Natural, unprocessed cheese
Salted chips, pretzels                                                        Unsalted chips, pretzels,
Salted crackers                                                                    Low sodium crackers
Tuna canned in salt                                                            Unsalted canned tuna

Kidney diet resources from DaVita.com

Review and rate recipes

Discussion Forums

Monthly Recipe Alerts

DaVita Diet Helper

Coming soon…The DaVita Phosphorus Challenge