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  • Review Article
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Quality-oriented diet therapy for chronic kidney disease

Nature Reviews Nephrology volume 22, pages 252–264 (2026)Cite this article

Subjects

Abstract

Traditional dietary advice for people living with chronic kidney disease (CKD) focused predominantly on the quantity of energy and protein provided by the diet as well as restricting the consumption of single micronutrients. However, flaws in the assumptions that underlie this quantity-based approach have led to re-examination of medical nutrition therapy for kidney-related conditions, with a shift towards recommending more varied and liberalized plant-rich diets with a focus on dietary quality. Although clinical practice guidelines for patients with CKD have cautiously acknowledged this shift, less advice is available on how to translate new knowledge into practical and feasible recommendations that describe which foods patients should be advised to eat. In this Review, we provide a framework for the delivery of quality-oriented diet therapy for people with CKD based on the dietary principles of balance, variety and moderation. This approach also requires consideration of the manner in which foods are processed, prepared and integrated into the diet. Successful implementation requires a flexible, individualized approach that involves consideration of both CKD-specific and general dietary factors as well as potential barriers, challenges and behavioural determinants of the patient’s dietary choices and habits.

Key points

  • The traditional kidney diet focused on restricting consumption of high-potassium fruit and vegetables, dairy products, whole grains, legumes, seeds and nuts to reduce the risks of hyperkalaemia and hyperphosphataemia as well as promoting high intake of animal-based protein foods to reduce the risk of protein-energy wasting.

  • Quality-oriented diet therapy promotes dietary balance, variety and moderation to ensure nutritional adequacy and prevent health problems such as dysglycaemia, constipation and dyslipidaemia.

  • To achieve a high-quality diet, patients with chronic kidney disease (CKD) should be encouraged to consume a variety of foods within each food group, including whole fruits and vegetables, legumes seed and nuts, lean meat, fish and seafood, grains and dairy products

  • Meal planning and choosing the right cooking methods can help patients with CKD to achieve a healthy and varied diet; patients should be advised to substitute ultra-processed foods, particularly those with high levels of sodium, potassium and phosphorus-additives, with suitable alternatives, ideally minimally processed foods that are prepared from scratch and integrated into the diet as balanced meals with appropriate portion sizes.

  • Advice to limit or avoid otherwise healthy foods to address persistent hyperkalaemia, hyperphosphataemia and/or protein-energy wasting that does not respond to other dietary or non-dietary treatments should be paired with advice to consume alternatives to maintain dietary balance whenever possible.

  • Quality-oriented diet therapy should be flexible and tailored to the patient, taking into consideration their current diet and the behavioural determinants of their dietary choices and habits.

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Fig. 1: Core principles of a healthy, quality-oriented kidney diet.
Fig. 2: Sample food suggestions for patients with chronic kidney disease.
Fig. 3: Practical steps to help clinicians to plan and implement healthy quality-oriented diets with their patients.

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Acknowledgements

G.B.P., A.S. and C.M.A. contributed to this paper on behalf of the European Renal Nutrition Working Group, which is an official body of the European Renal Association. J.J.C. receives support from the Swedish Research Council (2023-01807), the Swedish Heart and Lung Foundation (20230371), Region Stockholm (ALF Medicine, FoUI-986028), the Martin Rind and Westman Foundations. D.E.S. receives research support from the Nevada Agricultural Experiment Station in the College of Agriculture, Biotechnology & Natural Resources at the University of Nevada, Reno. L.C. receives a research grant from the Brazilian National Council for Scientific and Technological Development (CNPq). A.B. receives research support from Purdue AgSEED, Showalter Research Trust, and KidneyCure.

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Author notes

  1. These authors contributed equally: Juan J. Carrero, David E. St-Jules.

Authors and Affiliations

  1. Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden

    Juan J. Carrero

  2. Division of Renal Medicine, Department of Clinical Sciences, Danderyd Hospital, Danderyd, Sweden

    Juan J. Carrero

  3. Department of Nutrition, University of Nevada, Reno, NV, USA

    David E. St-Jules

  4. Department of Nutrition Science, Purdue University, West Lafayette, IN, USA

    Annabel Biruete

  5. Division of Nephrology, Federal University of São Paulo, São Paulo, Brazil

    Lilian Cuppari

  6. Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France

    Giorgina B. Piccoli

  7. British Columbia Renal Agency, Island Health Authority, British Columbia, Victoria, Canada

    Kelly Picard

  8. Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark

    Nikita M. Hansen

  9. Division of Renal Medicine and Baxter Novum. Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

    Alice Sabatino & Carla M. Avesani

  10. Department of Environmental Sciences and Health, University of Nevada, Reno, NV, USA

    Dillon Winkelman

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Contributions

All authors researched data for the article and contributed substantially to discussion of the content. All authors wrote the article. J.J.C., D.E.S. and C.M.A reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Juan J. Carrero.

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Competing interests

J.J.C. participated in the making of the 2024 KDIGO, 2020 KDOQI and 2021 ESPEN clinical guidelines, which contain statements regarding the dietary management of people with chronic and acute kidney disease. He also acknowledges receiving within the last 2 years speaker fees or advisory board fees from Abbott, Fresenius Kabi and Laboratorios Columbia, which commercialize nutritional products for people with kidney disease. A.B. is part of the NextGen Scientists Cohort of the National Dairy Council, and has received honoraria from Ardelyx, Fresenius Medical Care North America, and Dialysis Clinics Inc. L.C. participated in the making of the 2020 KDOQI CKD nutrition guideline. She also acknowledges receiving AstraZeneca, Fresenius Kabi and Abbott Laboratories speaker or advisory board fees. G.B.P. acknowledges receiving within the last 2 years speaker fees and advisory board fees from Fresenius Kabi and travel support by Dr Shar. A.S. participated in the making of the 2021 ESPEN clinical guideline which contains statements regarding the dietary management of people with acute kidney injury. She also acknowledges receiving within the last 2 years speaker fees or advisory board fees from Fresenius Kabi. C.M.A. received speaker honoraria from AstraZeneca, Fresenius Medical Care, Abbott and Baxter Healthcare and received honoraria as advisory board member from Fresenius Kabi. The other authors declare no competing interests.

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Nature Reviews Nephrology thanks Liliana Garneata, Kelly Lambert and the other, anonymous, reviewer for their contribution to the peer review of this work.

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Glossary

Anti-nutrient

Dietary factors that reduce the bioavailability or utilization of nutrients in the body.

Empty calories

Sources of energy that contribute calories with little-to-no nutrients (such as protein powders, alcohol or sugars and fats that are added to food during processing) and thereby lower the nutrient density of the diet (amount of nutrient per kilocalorie).

Food additives

Substances that are primarily added to foods that are produced on an industrial scale for technical purposes, for example, to improve safety, increase the amount of time a food can be stored or modify the sensory properties of food. Food additives are not normally consumed alone as a food and are not normally used as typical ingredients in foods.

Food deserts

Geographical areas that are characterized by having limited access to nutritious food and a predominant availability of unhealthy, mostly ultra-processed foods. Food deserts reflect deliberate, systemic inequalities that are rooted in economic disinvestment and structural exclusion and lead to unequal access to nutritious, affordable and culturally appropriate foods.

Medical nutrition therapy

Tailored dietary behaviour strategies to address dietary problems that contribute to diseases and their complications. These strategies are based on assessment of clinical presentation as well as dietary intakes and their personal, social and behavioural determinants.

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Carrero, J.J., St-Jules, D.E., Biruete, A. et al. Quality-oriented diet therapy for chronic kidney disease. Nat Rev Nephrol 22, 252–264 (2026). https://doi.org/10.1038/s41581-025-01034-0

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