How to Keep Protein Up and
Phosphorous Down While on Dialysis

Note: Phosphorous gets its name changed to phosphates after it enters the bloodstream. In this article, I’ll call it phosphorous when it’s in food. I’ll call it phosphate when it’s in your blood.

As if counting carbs wasn’t enough… When my wife Nicole went on dialysis she had to start tracking micro-nutrients like phosphorous. Most people simply urinate excess phosphates out of their blood. But since Nicole’s kidneys weren’t working well enough, this wasn’t happening anymore.

The National Kidney Foundation warns that too much phosphate build-up between dialysis treatments causes calcium to be extracted from the bones. Kidney Health Australia also says that high phosphate levels can lead to dangerous calcium deposits in blood vessels, lungs, eyes, and heart. According to WiseGeek, these calcium deposits typically build up in the shoulders, causing “profound discomfort.”

In other words: Bones that break easy. Blindness. Heart attack. Stroke. Pain. Suffering. Death. For these reason my wife Nicole limits how much phosphorus-rich foods she eats.

Limiting phosphorous sounds easy, but it isn’t.

The Trouble with Phosphorous

Unfortunately, most phosphorous-rich foods are also protein-rich. It’s hard to reduce the phosphorous without reducing the protein.

“You need protein in your diet,” explains The National Institute of Health, “to help your body repair cells and make new ones.”

Protein levels are measured in the blood as serum albumin. In a study of 12,000 dialysis patients “…low serum albumin… was most highly associated with death probability.” In other words, not getting enough protein, while on dialysis, might be more risky than getting too much phosphorous.

To further complicate the situation: Dialysis patients need even more protein than they would if they were not receiving dialysis. According to an article in the Clinical Journal of the American Society of Nephrology, dialysis treatment removes protein from the blood. It also says that dialysis hinders the body’s ability to make new protein molecules.

Which Protein-Rich Foods Are Lowest in Phosphorous?

So dialysis patients need extra protein. They also need less phosphorous. Can you consume enough protein without overdosing on phosphorous? That’s a riddle Nicole and I are trying to solve.

We estimate that Nicole needs about 70g of protein a day (at least). That’s about 12 ounces of a protein-rich foods. To pull this off Nicole avoids protein foods which contain more than 100mg of phosphorous per ounce (30g). Our guidebook is the Nutrient Value of Some Common Foods from Health Canada.

Legumes and Soy Products

We don’t even give legumes a chance. Nicole is on a low-carbohydrate diet for type-1 diabetes. In order to get 30g of protein from a bowl of lentil soup, she’d end up consuming 64g of carbohydrates. The carb count in legumes is too high to safely manage with injected insulin. (See the “Law of Small Numbers” chapter in Dr. Bernstein’s Diabetes Solution.)

Regardless of the carb-count, most legumes are simply too high in phosphorous. 83g of adzuki beans contain 6g of protein and 140mg of phosphorous.

Soy products also “contain high levels of aluminum, which is toxic to the nervous system and the kidneys” (according to the The Weston A. Price Foundation). So even though low-carb soy products do exist; we’ve decided to avoid them.

Nuts and Seeds

Protein-rich nuts and seeds appear to be too high in phosphorous. 52ml of almonds contains 6g of protein and 128mg of phosphorus. The same servings size contains 262mg of potassium. Potassium also builds up to toxic levels in dialysis patients. We don’t see how a dialysis patient could safely eat nuts or seeds to meet their protein needs.

Nuts and seeds are also too high in carbohydrates for someone following low-carbohydrate type-1 diabetic diet. One 60ml servings of cashews, for example, contains 11g of sugar.  As Dr. Bersteins says in his article So What’s Low Carb?:

Although a few nuts may contain little carbohydrate, the catch is in the word “few.” Very few of us can eat only a few nuts. In fact, I only have two patients who can count out a preplanned number of nuts, eat them, and then stop. So unless you have unusual will power, beware.

Also, too many nuts and seeds can irritate the gastrointestinal tract and aggravate autoimmune conditions. Dr. Datis Karrazian explains in his autoimmune diet plan that “even just a small snack or a bite of these foods can trigger an immune reaction, inflammation, and an autoimmune flare-up.”

Eggs

Eggs have a moderate level of phosphorous, comparable to red meat or poultry. One egg contains about 90mg of phosphorous. So they can be consumed liberally to meet one’s protein needs.

Egg whites, however, are very low in phosphorous (about 4mg per egg) and high in protein. Hence they offer a way to make some serious cutbacks in phosphorus without limiting protein. A DaVita study substituted meat with 8 ounces of eggs whites for six weeks with a group of hemodialysis patients. 92% of the patients’  phosphate levels decreased.

Dairy

Most milk products – such as milk and cheese — are pretty much out of the question. One glass of milk contains 235mg of phosphorus (plus 366mg of potassium).

The exception is cottage cheese and paneer. These two cheeses have had most of the whey removed. The whey contains the bulk of the phosphorous and almost all of the potassium.

One-fifth a cup of cottage cheese contains 6g of protein and only 64mg of phosphorous. It also has less than 1g of sugar.

More whey is removed when making paneer. Therefore paneer should have even less phosphorous and virtually no sugar. You can make your own paneer at home. You can buy it from a local Indian grocery or Indian restaurant. And you can even purchase it online.

Nicole has been experimenting with fermented cottage cheese and paneer for breakfast. Sometimes dinner, too. She gets the bulk of her calcium needs, however, from homemade stock (made from chicken and beef bones).

Fish

Most fish are very high in phosphorus. The only exceptions seem to be smoked salmon and canned tuna. I assume the canning process removes some of the phosphorous.

Smoked salmon is pricey, so Nicole aims to consume a can or two of tuna each week. One can of tuna has about 6 of the 12 ounces of protein we are aiming for each day.

Many types of fresh or frozen shellfish, however, are low in phosphorus. These include lobster, shrimp, crab, crayfish and oysters. Clams and mussels are too high in phosphorus. Interestingly, all canned shellfish is listed as being quite high in phosphorus.

Limiting fish may be a good idea for kidney failure patients regardless of phosphorous content. “Nearly all fish contain traces of mercury,” says the Physicians Committee for Responsible Medicine. “Many other toxins, including other heavy metals and organochlorine pesticides, find their way into water and aquatic life as well.” Without a properly functioning kidney, it’s very difficult to process pollutants.

We only buy our tuna from sources that ensure its purity like Vital Choice and Raincoast Trading. Even then, it seems wise to somewhat limit how much fish a renal patient consumes.

Nonetheless, many of the benefit of fish can be obtained by consuming fish oil. Fish oil appears to contain only trace amounts of phosphorous. Quality fish oil has also been screened and filtered so that it is only has trace amounts of mercury. Nicole consumes a tablespoon of Carlson Labs Norwegian Fish Oil each day.

Poultry

With the exception of processed deli meats, poultry contains less than 100mg of phosphorous per serving. Nicole is a big fan of chicken and consumes 5 ounces almost every day (10 ounces if you count the bones). Duck, turkey and goose are also fine.

Red Meat

Looking through the guidebook, red meat seems to be a safe bet for keeping phosphorous levels down (if we don’t include deli meats). Red meat is also rich in iron, a nutrient much needed by renal failure patients (and, probably, type-1 diabetics at large).

Nicole’s been experimenting with 5 ounces of organic, grass-fed ground beef three times a week. She’s been a vegetarian for well over a decade, so eating hamburgers (without the bun) is quite a lifestyle change. I make beef for dinner on the evenings following her dialysis treatment. Blood loss during dialysis contributes to iron-deficiency. The iron in beef should help her recuperate.

Organ Meats

In an effort to get Nicole’s iron levels up we started feeding her beef liver — about one ounce a day. We didn’t even think it would be high in phosphorus until a nurse at her dialysis unit mentioned it. Indeed, liver is quite high in phosphorus.

Chicken liver is slightly lower in phosphorus, while providing much more iron. So one could eat half as much chicken liver (than beef). This would cut ones phosphorus intake in half while getting as much iron as they would from beef liver. Unfortunately, they’d also be cutting their protein intake in half.

Nicole has decided to focus on heart and kidney meats instead of liver. They are low in phosphorous and provide as much iron as liver. The whole family certainly finds beef preferable to liver from a taste perspective. Heart is pretty tough, so we puree small amounts into stocks or soups.

I would like to find a source of organic kidneys. I suspect eating kidneys may be good for healing damaged kidneys.

A Typical Day

A typical day right now may involve:

  • Breakfast: 2 raw eggs (blended with sour cream and vegetable juice). Or 1/2 cup of fermented cottage cheese.
  • Lunch: 5 ounces of chicken, turkey or duck. 1 raw egg and 1 ounce of beef heart pureed into chicken stock.
  • Dinner: 5 ounces of beef, lamb, sheep or tuna. 1 raw egg pureed into chicken stock.

So that’s 2-5 ounce of protein for breakfast, 7 ounces for lunch and 6 ounces for dinner – a total of 15-18 ounces a day (roughly 90g of protein). Each serving has less than 100mg of phosphorous. This means she should be consuming less than 1800mg of phosphorous per day.

Three Other Horseman of the Phosphorous Apocalypse

Of course, protein-rich foods are not the only the only way to raise your phosphorus levels. Cocoa (chocolate), carob and colas (soft drinks) are also very high in phosphorus. Since none of these foods are necessary for health they can easily be eliminated.

Protein foods, however, cannot be eliminated from the diet. In fact, many dialysis patients are probably suffering (and even dying) from lack of  protein.  Therefore, the above listed protein-rich foods, which are lower in phosphorus, may prove very helpful.

Thinking outside the CKD matrix,
–John C. A. Manley

P.S. For alternative ideas on dealing with chronic kidney disease check the following articles:

P.P.S. For one-on-on help improving life while on dialysis (or avoiding it altogether) you can book a telephone (or Skype) consult with me.

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