Chronic kidney disease (CKD) is a progressive condition marked by a gradual loss of kidney function over time. By the time a patient reaches stage 4, the penultimate stage of CKD, the importance of an integrative approach to management cannot be overstated. This approach not only involves careful attention to diet and lifestyle but also the incorporation of conventional medications to manage symptoms and slow progression. In this blog, we will discuss the various aspects of an integrative approach for stage 4 kidney disease.
By Majd Isreb, MD, FACP, FASN, IFMCP
Dietary considerations: Navigating acid Load and potassium
One of the critical aspects of managing stage IV kidney disease is dietary modification. Diet in CKD is nuanced and requires a balance between restricting certain elements while ensuring adequate nutrition. A key concern is the dietary acid load. High acid diets, often rich in animal proteins, can exacerbate kidney burden, hastening the decline in renal function. Therefore, a shift towards a plant-dominant diet, lower in acid load, can be beneficial.
However, this brings us to the conundrum of potassium. Many plant-based foods are rich in potassium, which in the context of CKD can accumulate in the blood and cause hyperkalemia, a potentially life-threatening condition. Thus, patients and caregivers must navigate the tightrope of reducing dietary acid load while managing potassium intake.
It’s crucial to understand that adopting an alkaline, plant-dominant diet to reduce dietary acid load may also influence potassium levels in the bloodstream. Historical research, including a study from the 1950s, indicated that for every 0.1 unit decrease in extracellular pH, plasma potassium concentration could rise by 0.6 mEq/L. Simply put, an increased dietary acid load and higher blood acidity correlate with elevated potassium levels in the blood. In contrast, a lower acid load from an alkaline diet could help manage potassium levels.
Nevertheless, when managing potassium levels remains a challenge, it is essential to carefully choose plant-based foods with lower potassium content. Options such as apples, berries, asparagus, broccoli, cabbage, cauliflower, celery, and corn, for example, can be safely incorporated into the diet. Additionally, employing specific cooking methods can significantly reduce the potassium in foods that typically have high amounts; for instance, leaching vegetables through a process like double boiling can effectively lower their potassium content, making them more suitable for patients with such dietary restrictions.
Join us to end the kidney disease epidemic
Phosphorus: The early bird of dietary restrictions
Phosphorus restriction is another facet of the dietary approach in CKD that needs attention well before stage IV. Phosphate, which is commonly described as phosphorus, is abundant in foods like dairy products, nuts, seeds, whole grains, animal proteins, and processed foods through additives. Higher intake of phosphorus can lead to the activation of the FGF23–Klotho axis. The latter can lead to bone and cardiovascular issues. This makes controlling phosphorus intake vital for all patients with CKD.
An integrative approach involves choosing foods with lower phosphorus bioavailability, such as plant-based sources, since the phosphorus in these foods is less absorbable compared to animal-based sources. Moreover, it’s essential to be vigilant about food labels to avoid phosphorus additives in processed foods.
The antioxidant powerhouse: Supporting glutathione
High levels of oxidative stress and inflammation often accompany Stage IV CKD. Glutathione, a potent antioxidant, is crucial in mitigating these harmful processes. However, in kidney disease, higher oxidative stress can deplete the body’s glutathione.
To bolster glutathione levels, one strategy is to enhance the intake of its precursor amino acids, such as cysteine, glycine, and N-acetyl cysteine. This can be achieved through a balanced diet that includes moderate amounts of sulfur-rich proteins—found in meats like beef, fish, and poultry—and a variety of sulfur-containing vegetables, particularly those from the allium family (such as garlic, onions, leeks, and chives) and cruciferous vegetables like broccoli and kale.
Maintaining this balance is key and can be effectively managed with a predominantly plant-based diet that judiciously includes, rather than entirely excludes animal proteins. This approach ensures adequate provision of essential nutrients while supporting kidney health.
Preventing fibrosis and supporting mitochondria
Renal fibrosis, the final common pathway in CKD leading to end-stage renal disease, is a key therapeutic target. To prevent fibrosis, it’s critical to maintain a balanced diet and manage blood pressure and blood sugar levels. Certain nutrients, such as resveratrol found in grapes and berries, may have antifibrotic properties, while omega-3 fatty acids can help reduce inflammation, contributing to fibrosis.
Energy utilization and mitochondrial support are also crucial. Mitochondrial dysfunction is a contributor to CKD progression. Coenzyme Q10 and L-carnitine are nutrients that support mitochondrial function and may be considered for supplementation. While we often recommend Coenzyme Q10 to these patients, we do not recommend the use of oral L-carnitine. This is because the gut bacteria can metabolize it into TMAO, which is one of the uremic toxins that are associated with poor cardiovascular outcomes. It is, therefore, important to have a healthcare professional guide this supplementation, as CKD affects the metabolism and excretion of various compounds.
Medication and supplement dosing: The fine tuning
Conventional medications play a critical role in the management of stage IV CKD. Angiotensin-converting enzyme inhibitors (ACEis), angiotensin II receptor blockers (ARBs), and sodium-glucose cotransporter 2 (SGLT2) inhibitors are cornerstones in conventional medicine approach to slowing the progression of kidney disease and managing hypertension, a common comorbidity.
However, as kidney function declines, dosing adjustments for medications and supplements are often required to prevent toxicity. It’s important for healthcare providers to regularly review and adjust medication regimens as the disease progresses.
Moreover, some supplements may be contraindicated or require dosing adjustments in CKD. For example, magnesium and certain fat-soluble vitamins can accumulate to harmful levels if not properly monitored. Therefore, an integrative approach to CKD must include a close partnership with a nephrologist to ensure the safe and effective use of medications and supplements.
The bottom line
Managing stage IV CKD requires an integrative approach that melds dietary management, the support of antioxidant systems, conventional pharmacotherapy, and lifestyle changes. This approach addresses the multifaceted challenges of CKD, aiming not only to slow disease progression but also to improve quality of life. With thoughtful dietary choices that balance the reduction of dietary acid load and phosphorus with careful potassium intake, alongside antioxidant support, fibrosis prevention, and energy optimization, patients can tackle CKD from several angles.
It’s imperative for patients and healthcare professionals to work closely together, continually adjusting treatment plans as the disease evolves. Through this collaborative, nuanced approach, the burdens of stage IV CKD can be mitigated, offering patients a semblance of control and hope as they navigate this complex chronic disease.
