10-04-2025 06:19 AM

DASH Diet for ESKD Patients: Benefits & Meal Ideas

What is the DASH Diet and How Can It Help ESKD Patients?

DASH diet stands for Dietary Approaches to Stop Hypertension. It was first created to lower blood pressure. The diet is low in sodium and high in fiber, fruits, vegetables, whole grains, low-fat dairy, and protein. As the diet is low in sodium, it lowers blood pressure, reducing kidney strain and lowering the risk of chronic kidney disease (CKD).

ESKD refers to End-Stage Kidney Disease, in which the kidneys can no longer function adequately. It is the last stage of CKD in which the kidneys require dialysis or transplant for the patient's survival. The DASH diet aligns with ESKD patients because it restricts sodium intake while promoting a diet rich in fruits, vegetables, whole grains, and lean protein.

People with ESKD require dietary modifications. They must carefully monitor their protein and fluid intake and limit their sodium, potassium, and phosphorus intake.

Nutrients Beneficial for ESKD Patients:

These nutrients are beneficial for ESKD patients

Protein: Choose high-quality protein sources such as lean meat, fish, eggs, and poultry. This will produce less waste for removal during dialysis.

Salt: Limit salt intake and check food labels to avoid excess salt in a food.

Potassium: Limit high-potassium foods and choose foods that are low in potassium, such as grapes, pineapple, lettuce, green beans, and cucumbers.

Phosphorus: In ESKD, avoid high-phosphorus foods such as nuts, peanut butter, seeds, lentils, beans, sardines, and organ meats.

Vitamins and Minerals: Take calcium, vitamin C, and vitamin D to support healthy bones and tissues, as your dietitian recommends.

Fluid Intake: Limit and track liquid intake, as excess liquid can cause weight gain, swelling, and other complications.

However, besides its benefits, the DASH diet has some potential challenges for ESKD patients. Although the DASH diet is lower in sodium, but high in potassium, this may be challenging for people with ESKD. In ESKD, it is essential to maintain the balance of electrolytes, especially sodium and potassium, to maintain proper kidney health.

Scientific Evidence: How the DASH Diet Reduces Cardiovascular Risk in ESKD

The DASH diet significantly reduces CVD risk in end-stage kidney disease patients. Hypertension and high LDL cholesterol are two major risk factors for heart disease and stroke. Potassium, calcium, and magnesium can be found in large amounts in foods that are part of the DASH diet. The DASH diet comprises fruits, vegetables, and whole grains. It also includes fish, chicken, nuts, beans, and fat-free or low-fat dairy items. The diet limits foods that are high in salt.. It also limits added sugar and saturated fat, such as in fatty meats and full-fat dairy products. However, people with ESKD are also required to manage potassium and phosphorus levels.

A study published by Elsevier in the Journal of Kidney International, "The Dietary Approaches to Stop Hypertension (DASH) diet in chronic kidney disease: should we embrace it?" highlighted the benefits of the DASH diet in lowering blood pressure and CVD risk. For people with chronic kidney disease, the DASH diet may reduce the risk of CKD progression. Hypertension is also a risk factor for chronic kidney disease (CKD) and its progression.

Thus, the research concluded that the Dietary Approaches to Stop Hypertension (DASH) plan lowers the risk of heart disease and blood pressure and is also beneficial in preserving kidney health.

Another ARIC study was conducted over twenty years in a group of over 15,000 middle-aged people. Researchers reviewed records from that study. The National Heart, Lung, and Blood Institute (NHLBI) began the ARIC Study as a statistical study in four U.S. towns. The ARIC study's goals were to describe the steps of heart failure, find genetic and environmental reasons, and follow long-term trends in the population.

People who followed the DASH diet, eating fewer "good" foods like fruits, veggies, and nuts and more red meat and salt with the highest DASH score, were 16% more likely to get kidney disease than those with lower DASH scores. Similarly, people who consumed excess processed and red meat had a 22% higher risk of developing chronic kidney disease.

The NIH also shared the findings of its research. It shows that the DASH diet can lower blood pressure in people with cardiometabolic health and CKD in East Asia, the long-term effects are not well-known. There is also evidence that the DASH diet reduces the risk of type 2 diabetes and metabolic syndrome. Other researches also show that the DASH diet and its components may lower the risk of CKD. However, recommending the DASH diet to people who already have CKD is controversial because it is against the current dietary pattern for CKD, especially for people with advanced stages of CKD.

Key Nutrients in the DASH Diet for ESKD Management

Essential nutrients such as potassium, calcium, magnesium, fibre, and moderate protein are most important for managing End-Stage Kidney Disease (ESKD) within safe thresholds. Sodium, phosphorus, and saturated fat should be strictly limited. The DASH diet focuses on a high intake of fruits, vegetables, whole grains, low-fat dairy, and lean protein sources like fish and poultry, making it suitable for ESKD. Food substitutions, such as using cauliflower instead of potatoes, can help maintain these safe thresholds.

Essential considerations for ESKD patients on the DASH diet:

Limit sodium: Limit sodium intake to control blood pressure.
Controlling phosphorus: Monitor phosphorus intake, as high levels can lead to bone problems.
Individualised approach: Consult with a dietitian about changes in the DASH diet according to individual requirement and kidney health.

Breakdown of key nutrients in the DASH diet for ESKD:

Below are some essential key nutrients in the DASH diet for ESKD.

Potassium: Potassium is an essential mineral, and the body requires it for proper functioning. However, excess potassium is dangerous for people with ESKD, so it's important to choose fruits and vegetables that are low in potassium.
Calcium: Maintaining bone health is essential, but high amounts of calcium can cause phosphorus problems, so healthcare providers must carefully monitor it.
Magnesium: Magnesium is essential for maintaining blood pressure. However, moderate intake of magnesium is key to support kidney health.
Fibre: Fiber is necessary to maintain gut health and also control blood sugar. However, it is essential to choose fibre sources carefully to avoid excessive potassium.
Moderate protein: People with ESKD need to limit their protein intake. However, ensuring sufficient protein intake from high quality sources is essential.

Foods to Consume in DASH diet for ESRD:

For people with End-Stage Renal Disease (ESRD), the DASH diet focuses on various fruits, vegetables, whole grains, low-fat dairy products, fish, poultry, beans, nuts, and seeds, while limiting sodium, potassium, phosphorus, and added sugars. It is recommended to consult a dietitian or healthcare provider for personalized dietary guidance.

Fruits: Berries, apples, pears, grapes (in moderation), pineapple, cherries
Vegetables: Broccoli, cauliflower, carrots, green beans, celery, cucumbers, zucchini, lettuce, spinach (in moderation)
Whole grains: Brown rice, quinoa, whole wheat bread, whole grain pasta
Low-fat dairy: Skim milk, low-fat yogurt, low-fat cheese
Protein sources: Lean chicken, turkey, fish (salmon, cod), tofu, egg whites
Healthy fats: Avocados, nuts (in moderation) and olive oil
Recommended supplements: Healthcare professionals may recommend some supplements for people with end-stage kidney disease (ESKD), including folate, niacin, vitamin B6, cobalamin, biotin, and vitamin D. Always consult a dietitian before choosing any supplement depending on the requirements and health status.

Foods to Limit in DASH diet for ESRD

These foods are included in the DASH diet but should be restricted in ESRD.

High-potassium foods: Foods including bananas, avocados, potatoes, tomatoes, cantaloupe, spinach, sweet potatoes, black-eyed peas, dried beans, cooked greens
High-phosphorus foods include red meat, organ meats, full-fat dairy, processed meats, Milk, cheese, and other dairy products, protein-rich foods, fast food, canned foods, colas, bottled ice tea, and other drinks with phosphate additives. Other foods such as chocolate, bran cereals, oatmeal, and egg yolks are also high in phosphorus and should be restricted in ESKD.
High-sodium foods: Processed foods, salted snacks, canned soups
Sugary drinks: Soda, fruit juice concentrates

Sample Meal-Plan of DASH Diet

Below is a 3-day sample meal plan for the DASH diet: balanced meals with low sodium and potassium nutrients that benefit kidney health and are considered the best diet for ESKD patients.

Challenges of the DASH Diet for ESKD Patients: Sodium, Potassium, and More

End-stage kidney Disease (ESKD) patients find it challenging to follow the DASH diet because the recommended foods are high in potassium and phosphorus. This can cause dangerous hyperkalemia (high potassium levels in the blood) and hyperphosphatemia (high phosphorus levels in the blood) because damaged kidneys cannot filter potassium as they should. Some modifications are required to perfectly align with the principles of the DASH diet for ESKD.

Key challenges related to the DASH diet for ESKD patients:

High potassium content: Fruits and vegetables are naturally high in potassium, and the DASH diet emphasises eating them. However, people with ESKD who can't filter their potassium are at a high risk for hyperkalemia.
Balancing sodium restriction: Limiting sodium is essential for ESKD patients to control their blood pressure. However, following a strict low-sodium DASH diet can be challenging because they must avoid processed foods and monitor the sodium intake in their meals.
Dietary modifications required: To control their potassium levels, people with ESKD should choose fruits and vegetables that are low in potassium or cook them to remove extra potassium.
Potential nutrient deficiencies: Restricting food items low in sodium and potassium levels leads to a lack of nutrient deficiencies that may be challenging for ESKD patients.
Diet Complexity: Following the DASH diet on ESKD is challenging because it requires close monitoring and frequent adjustments based on individual needs and laboratory values. Since each ESKD patient's dietary requirements differ, the DASH diet should be customised based on individual medical evaluations.

How to Address Challenges related to the DASH diet for ESKD Patients:

These are some ways to address challenges

The DASH diet recommends limiting sodium to up to 2,300 mg per day, with an optimal goal of lowering blood pressure and restricting sodium to 1500 mg. Although this is beneficial for the general population, ESKD patients usually need to limit their sodium intake further to prevent fluid retention. However, extreme sodium restriction can be harmful and may lead to hypotension.
The DASH diet includes fruits and vegetables that are rich in potassium. However, ESKD patients have reduced kidney ability to filter potassium, which increases the potassium level, resulting in hyperkalemia. Hyperkalemia can lead to abnormal cardiac rhythms. Therefore, people with ESKD need to limit their potassium intake.
The DASH diet involves dairy products that are rich in calcium. However, excessive phosphorus may result in bone disorders in ESKD patients. Thus, limiting dairy intake and using phosphate binders to manage phosphorus intake is necessary for ESKD patients.
The DASH diet focuses on lean proteins; however, the protein requirements of ESKD patients vary. Some people need to restrict their protein intake to lower the stress on the kidneys. In contrast, people on dialysis must increase protein intake to compensate for losses. People with ESKD must consult a dietitian for personalized meal plans and adjust their nutrient challenges.
In the DASH diet, fruits and vegetables with high water content may contribute to fluid overload in ESKD patients. They must limit and closely monitor their fluid intake to avoid fluid retention, such as edema or potential dehydration.

Modifying the DASH Diet for ESKD Patients: A Practical Guide

The DASH diet is beneficial for treating people with high blood pressure, heart disease, and kidney disease. Research shows that it also slows the progression of heart and kidney disease. Before starting a new diet, patients should consult with a dietitian if they have chronic kidney disease or end-stage kidney disease. Kidney disease, especially ESKD, requires special restrictions. For dialysis patients, the DASH diet is not recommended because they require special dietary needs that should be discussed with a registered dietitian.

Why are modifications required in the DASH diet for ESKD patients?

In ESKD, the kidneys cannot filter blood, and people with ESKD find it challenging to manage their fluid balance. Thus, modifications become necessary to deal with ESKD. Dialysis patients also require more protein to manage their loss during treatment. However, with modifications, people still need to manage their fluids and minerals like potassium and phosphorus to maintain a healthy balance.

Diet Modifications for Non-Dialysis (Pre-Dialysis) CKD Patients

While the standard DASH diet is not ideal for dialysis patients, tailored versions (with strict potassium/phosphorus limits) may be used under supervision.

Protein: A moderate amount of protein (about 0.6 to 0.8 g/kg/day) is recommended. To decrease acid load and phosphorus content, consume more plant-based proteins (such as beans and lentils.
Potassium & Phosphorus: In case of higher values of potassium or phosphorus, consume fruits and vegetables that are low in potassium, like apples, berries, green beans, cabbage, and limit high-phosphorus foods such as dairy and nuts. To lower the potassium content in vegetables, use the leaching method like boiling or soaking before cooking.
Sodium: Limit sodium intake in ESKD (less than 1500 mg/day) to maintain normal blood pressure and fluid balance.
Overall Pattern: Stick to the DASH while focusing on whole, lightly processed foods. However, it is recommended to consult with a dietitian for customised meal plans, food preferences, before any changes in diet to fit your nutrient limits.

Supplements and Adjustments for ESKD Patients on DASH Diet

In ESKD, dietitians usually recommend dietary supplements including vitamins, minerals, and probiotics based on nutritional requirements and kidney health.

Vitamins and Minerals:

Iron and Vitamin B complex: Beneficial in preventing anemia
Vitamin C: Maintains tissue health and prevents infections
Calcium and Vitamin D: Maintain healthy bones
Niacin: May help reduce phosphate levels
Omega-3 fatty acids: Protect the kidneys and reduce inflammation
Probiotics and prebiotics: Beneficial for gut health, which can be affected by CKD

Can the DASH Diet Be Customized for Dialysis Patients?

The standard DASH diet is not ideal for dialysis patients. However, tailored versions (with strict potassium/phosphorus limits) may be used under supervision.

Diet Modifications for Dialysis Patients

The diet of dialysis patients is different because they require more protein due to more nutrient losses. Other nutrients such as salt, fluids, and minerals are also limited for proper fluid balance. Eating the right amount of these nutrients helps patients feel better while on hemodialysis.

Protein: Dialysis patients have higher protein requirements. Protein helps maintain overall health by maintaining blood protein levels within healthy ranges. It also benefits the immune system, muscles, and faster wound healing. As an alternative to red meat, dialysis patients should consume high-protein food, like fish, eggs, lean meat, and chicken, at each meal. Healthcare professionals recommend a dietary protein intake in the range of 1.0–1.2 g/kg/day for patients on peritoneal dialysis and hemodialysis.
Sodium: People on hemodialysis should consume the same recommended amount of salt, not exceeding 2300 milligrams, which is one teaspoon.
When you look at the nutrition facts of packaged foods, you will see that some foods that don't taste salty also contain sodium. Limit foods that are high in salt, like snacks and cold meat. Consuming a limited amount of sodium is beneficial for maintaining blood pressure within normal ranges.
Potassium: The potassium in dialysis is restricted depending on the specific blood values. People who perform frequent hemodialysis at home do not need to limit their potassium intake. If the potassium level in your blood is too high or too low, it can cause heart problems or even death. Thus, frequently checking potassium levels, especially in dialysis, is essential to maintain it within normal ranges. Healthcare providers recommend some medicines, such as potassium binders, to lower the potassium levels in the blood. To help reduce your potassium, your healthcare provider can also change the dialysate for proper maintenance of potassium.
Phosphorus: The phosphorus values in the blood are usually high in ESKD. Hemodialysis can not effectively remove excess potassium from the blood. High phosphorus levels may result in weaker bones, and phosphorus binding with calcium settles into blood vessels and the heart. Thus, depending on the lab values, limiting the consumption of high phosphorus foods is the best way to reduce it. Always check food labels for PHOS additives before consuming packaged food items. Therefore, experts recommend that people consume more plant-based healthy foods instead of processed foods to lower the phosphorus load during dialysis.

Managing Fluid Intake on the DASH Diet for ESKD

Fluid intake in kidney disease varies depending on the stage of CKD. In CKD stages 1 and 2, healthcare professionals recommend individuals to consume about 8-10 glasses of water depending upon individual fluid requirements (e.g., urine output, edema) to keep the hydration of kidneys. In later stages of CKD (stages 3, 4, and 5 without dialysis), individuals should limit their fluid intake.

Fluid Intake on Dialysis: A person must limit their fluid intake on dialysis. Consult with a nephrologist and renal dietitian regarding the required fluid intake for dialysis. Consuming 32 ounces of fluid daily is usually recommended. If you still urinate, you can have a little more fluid, 32 ounces, and the volume equal to the amount you urinate in 24 hours. For example, if a person urinates 1 cup (8 ounces) daily, he can consume 40 ounces of fluid daily (32 ounces + 8 ounces).

Practical Tips for Implementing DASH Diet

These are some practical tips for implementing the DASH diet in ESKD.

1. Consult with a healthcare provider or dietitian: Depending on your health status, it's important to get personalised renal diet advice. A dietitian can help you with lab results and adjust your diet accordingly.

Meal planning and preparation Tips: Plan meals before time. Consume fresh fruits and vegetables and avoid canned food to limit sodium intake. People on dialysis should keep track of their fluid intake (including liquid foods) and plan meals high in protein to meet their requirements.

Food Substitutions: Substitute high-potassium foods with lower-potassium foods, such as fruits, oranges and bananas. For taste, substitute herbs, spices, lemon juice, and vinegar instead of consuming salt.

2. Cooking Techniques: To lower the potassium level of vegetables, boil the vegetables and throw the water. Wash fruits and vegetables properly to reduce the amount of phosphorus.

Monitor the lab values: Frequent lab checks for minerals such as potassium, phosphorus, and albumin can help adjust them through diet and medicines.

Allow flexibility in a diet: Dietary requirements in a kidney-friendly diet change according to the dialysis schedule, lab results, and overall health. Thus, after consulting with your healthcare team, allow flexibility in dietary patterns.

Lifestyle Synergy: Exercise & Stress Management for ESKD Patients

Kidney disease and other chronic diseases affect both physically and mentally. They directly impact emotional health and burden the kidneys, which increases blood pressure. Thus, it is challenging to follow a diet plan for a longer time. Managing stress is essential for ESKD patients while following a DASH diet. Below are some practical ways to reduce stress.

Deep breathing and meditation involve a few minutes of focused breathing—inhaling through the nose, holding for a moment, and exhaling slowly through the mouth.
Regular exercise reduces stress, improves mood and enhances overall health.
Set time each day for relaxation to train the mind and body to destress.
Talk to a trusted friend, family member, or professional counselor about how you’re feeling to reduce anxiety.
Stay connected with friends, family, and support groups.
Time management and planning for self-care, relaxation, and leisure activities.
Practicing gratitude can improve mood and reduce feelings of anxiety.
Seek Professional Help When Needed

Clinical Studies & Outcomes

The NIH reported that a DASH diet directly links to a lower chance of kidney disease, regardless of demographics, established kidney risk factors, or baseline kidney function. Consuming a healthy diet, such as the DASH diet, is beneficial for preventing kidney disease.

Another observational study published in PubMed, titled "The association of dietary approach to stop hypertension (DASH) diet with hospitalisation risk in patients with COVID-19," shared that adherence to the DASH diet is associated with a lower risk of hospitalisation due to COVID-19. In this study, researchers selected 141 patients who filled out a food questionnaire. The study employed a cross-sectional design in which researchers calculated the DASH score based on eight components of the DASH diet, including fruits, vegetables, legumes and nuts and seeds, whole grains, low-fat dairy, red or processed meats, sweetened beverages, and sodium.

Multiple regression was applied to estimate the OR and 95% CI for hospitalisation due to COVID-19 in each tertile of DASH score. The risk of hospitalisation in the highest tertile of DASH score was 81% lower than the lowest tertile. Researchers found that people who ate more fruits, vegetables, and low-fat dairy items and limited red and processed meat were significantly less likely to stay in the hospital due to COVID-19. Thus, the DASH diet is not only beneficial for lowering blood pressure, but also supports heart health and kidney health.