When is the best time to work with a dietitian for CKD?

CKD occurs when the kidneys gradually lose function over time. It often develops slowly over years due to uncontrolled diabetes, hypertension, glomerulonephritis, and other kidney-related conditions. Detecting and managing CKD early is crucial for slowing its progression and reducing complications. By working with a dietitian who specializes in CKD, people can make dietary changes to help protect their kidney function and potentially avoid dialysis or a transplant.

Stages of chronic kidney disease

CKD is divided into 5 stages. Your stage of CKD is determined using a blood test called an estimated glomerular filtration rate (eGFR) and urinary albumin creatinine ratio (uACR). For an accurate diagnosis, you need to complete these tests twice, about three months apart.”

Stage 1: eGFR 90 or higher and kidney damage; (e.g. uACR 30 or higher) for 3 months or more

Stage 2: eGFR 60-89 and kidney damage; (e.g. uACR 30 or higher) for 3 months or more

Stage 3a: Mild to moderate loss of kidney function; (eGFR 45-59 for 3 months or more)

Stage 3b:  Moderate to severe loss of kidney function; (eGFR 30-44 for 3 months or more)

Stage 4: Severe loss of kidney function; (eGFR 15-29 for 3 months or more)

Stage 5: Kidney failure; (eGFR less than 15 for 3 months or more) or you are on dialysis

Benefits of Working with a Dietitian in Stage 2 or 3 CKD

Preserve kidney function

Making dietary changes can help preserve kidney function. The National Kidney Foundation, Kidney Disease: Improving Global Outcomes (KDIGO), and the American Society of Nephrology recognize the importance of these adjustments. These changes include, but are not limited to:

sodium restriction

protein modification

phosphorus reduction

potassium management

metabolic acidosis management

blood sugar control (For diabetic CKD patients)

weight management and caloric control

reducing saturated fat and processed foods

improving the gut microbiome

This list of changes may seem overwhelming, but the right support can make them feel almost effortless.

Education and empowerment

Working with an RD who specializes in CKD can help you shift from fear to empowerment. Trying to figure out what to eat on your own can lead to confusion with all the conflicting information—but it doesn’t have to be that way! A dietitian can help you identify opportunities to improve your kidney health and support you in making those changes. With the right guidance, you can take control of your choices and avoid feeling like a victim of the system.

Managing comorbidities

CKD often occurs alongside high blood pressure, heart disease, and anemia. It can also lead to bone disease and inflammation. You can manage these conditions through dietary changes. The sooner you start working with an RD, the earlier you can use diet to intervene.

Detrimental Effects of Waiting Until Stage 4 CKD

Many healthcare providers take a ‘wait and see’ approach instead of encouraging patients to be proactive with dietary and lifestyle changes. Just the other day, I met a lovely lady who, with tears in her eyes, asked me why her doctor hadn’t told her about her kidney disease until her eGFR dropped below 30. She felt sad, angry, and afraid. If her doctor had referred her at stage 2 or 3, she could have learned about kidney-friendly changes and received support to prevent further decline. Now, in stage 4, her situation is more critical. I reassured her that she can still work to preserve her remaining kidney function, but earlier intervention would have made a world of difference.

Unfortunately, this is not a rare occurrence.  Many of my clients did not know of their kidney disease until it was advanced. 

Increased incidence of symptoms

Stage 4 CKD marks a significant decline in kidney function. And it brings complications that are often absent or mild in stages 2 and 3. Symptoms such as fatigue, swelling (edema), shortness of breath, itchy skin, and changes in urination become more noticeable as waste products accumulate in the blood. Metabolic imbalances also worsen, leading to more severe anemia, metabolic acidosis, and higher risks of potassium and phosphorus retention. This can contribute to dangerous heart and bone complications. Cardiovascular disease risk significantly increases due to worsening hypertension, fluid overload, and vascular calcification from phosphate buildup.

More restrictions

Dietary management becomes more restrictive in stage 4 to slow further decline and manage symptoms. Protein intake is often reduced to 0.55 to 0.6 g/kg/day to limit waste buildup. Sodium, phosphorus, and potassium intake require stricter monitoring. Many medications need dosage adjustments or discontinuation due to reduced kidney clearance. Some patients may require phosphate binders or anemia treatments like erythropoiesis-stimulating agents (ESAs). At this stage, discussions about dialysis or a kidney transplant become more pressing, as preparation for advanced treatments can improve outcomes. Addressing CKD early in stages 2 or 3 through dietary and lifestyle changes can help prevent or delay these serious complications.

Why do doctors not refer their patients to RDs more often in earlier stages of CKD?

Time Constraints

Primary Care Providers (PCPs) have a limited amount of time to address the many aspects of your health that they are trying to manage. If a lab value doesn’t flag, or seems inconsequential compared with the other health problems they are trying to help you with, they may not see it as enough of a priority to use their time with you to discuss it.

Outdated protocols

PCPs have to understand a wide range of health conditions, so their awareness of the latest research on every single health condition may not be completely up to date. Since their training involves knowing what medications to prescribe and what treatments to order, they may only be aware of parameters for prescribing a medication or ordering a treatment. Many health care systems today use protocols to determine treatments, and there is usually not a protocol for referring patients to a dietitian for CKD in stage 2 or 3. It can take years for protocols to catch up with current research, especially when it comes to treatments like medical nutrition therapy.

Not knowing who to send their patients to

Simply put, there are just not a lot of dietitians who specialize in CKD, and doctors are not always aware of those of us who do. Add to that the complication of sending a patient outside a large hospital system to see an independent specialist like myself, and it just doesn’t happen without the patient taking the initiative.

What can you do?

1. Be your own advocate.
2. Obtain copies of your lab results every time and keep track of your eGFR and creatinine.  
3. If you notice that your eGFR is trending down or your creatinine is trending up, bring it to the attention of your PCP. 
4. Ask for further testing to confirm a CKD diagnosis if you suspect you have it. You should have blood tests about 3 months apart. You will also need a urinary albumin/creatinine ratio (UAC) to be diagnosed with stage 1 or 2.
5. If your eGFR is less than 89 for 3 months in a row, and you have a UAC >30, reach out to a registered dietitian who specializes in CKD (like me)  to get started on the right track with your kidney health. 

If you’re looking for a structured, step-by-step approach to managing CKD, check out my Kidney Health Clarity Program. In it, I guide you through meal planning, lab monitoring, and personalized kidney-friendly nutrition strategies.

👉Learn more here!

Your kidneys deserve the best care—start taking action today!