Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Nov 1.
Published in final edited form as: Curr Opin Nephrol Hypertens. 2024 Aug 6;33(6):593–602. doi: 10.1097/MNH.0000000000001015

Plant-based diets for kidney disease prevention and treatment

Hyunju Kim 1,2, Casey M Rebholz 3,4,5
PMCID: PMC11419939  NIHMSID: NIHMS2013409  PMID: 39115418

Abstract

Purpose of review:

Plant-based diets are associated with a lower risk of hypertension, diabetes, cardiovascular disease, and mortality. Using the most recent evidence, we critically appraised the role of plant-based diets in primary and secondary prevention of CKD with a focus on key nutritional factors (dietary acid load, phosphorus, potassium, sodium, and fiber).

Recent findings:

In healthy individuals, observational studies found that greater intake of plant protein and higher adherence to plant-based diets (overall, healthful, and provegetarian) was associated with a lower risk of CKD. In those with CKD, plant-based diets were associated a lower risk of mortality, improved kidney function, and favorable metabolic profiles (fibroblast growth factor-23, uremic toxins, insulin sensitivity, inflammatory biomarkers). Only few studies reported nutrient content of plant-based diets. These studies found that plant-based diets had lower dietary acid load, lower or no significant difference in phosphorus and sodium, and higher potassium, and fiber. One study reported that vegetarian diets were associated with severe vitamin D deficiency compared to non-vegetarian diets.

Summary:

Plant-based diets provide several benefits for prevention and management of CKD, with little risk for individuals with CKD. Incorporation of vitamin D rich foods in plant-based diets may be helpful.

Keywords: plant-based diets, incident CKD, CKD progression, mortality, nutrient intake

Introduction

There has been growing interest in whether plant-based diets can prevent the onset of chronic kidney disease (CKD) and delay progression to end-stage kidney disease (ESKD) or prevent adverse outcomes. Following a plant-based diet is associated with lower risk of hypertension and diabetes, strong risk factors of CKD (1–3). Plant-based diets may also play a role in managing CKD, as these diets were inversely associated with cardiovascular disease (CVD) risk and all-cause mortality (4–6).

Current guidelines

The 2020 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines concluded that evidence is not sufficient to recommend plant or animal protein intake based on their effects on nutritional status, calcium or phosphorous levels, or lipid profile in individuals with CKD (7). In the 2024 Kidney Disease: Improving Global Outcomes (KDIGO) guideline, those with CKD are recommended to adopt a diet higher in plant foods compared to animal-derived foods, and there was an emphasis on considering phosphorus, potassium, sodium, and protein intake (8). Plant-based diets have nutritional characteristics (higher intake of fruits, vegetables, and fiber, and lower dietary acid load and sodium) that may be beneficial or concerning in the context of CKD (Figure 1). A concern for adopting plant-based diets is nutritional adequacy, and risk of hyperkalemia and hyperphosphatemia due to higher potassium and phosphorus content (9–11). The KDOQI guidelines specifically suggest 1) reducing dietary acid load, 2) modifying dietary phosphorus intake to maintain serum phosphate levels in the normal range, 3) adjusting potassium intake to maintain serum potassium in the normal range, and 4) limiting sodium intake to <2.3g/d (for KDIGO, limiting sodium intake to <2.0 g/d) (7,8). We will critically appraise plant-based diets with a focus on these key nutritional factors (dietary acid load, phosphorus, potassium, sodium, and fiber) using the most recent evidence base.

Figure 1.

Figure 1.

Open in a new tab

Potential benefits and concerns of plant-based diets for prevention and management of chronic kidney disease

Definition of plant-based diets

Despite the widespread use of ‘plant-based diets,’ there is an ambiguity in this term. Plant-based diets are predominant in plant foods and low in animal products. Plant-based diets do not necessarily restrict animal products (12,13). Therefore, plant-based diets are broader than vegetarian diets, which are defined based on exclusion of animal products. For example, vegan diets exclude all animal products; lacto-ovo-vegetarian diets exclude meat and fish, and pescetarian diets exclude fish. Several dietary patterns considered to be healthy are rich in plant foods [e.g., Dietary Approaches to Stop Hypertension (DASH) diet and Mediterranean diet]. The potential role of these plant-rich dietary patterns for the primary and secondary prevention of CKD have been reviewed in prior studies (10,14–16). Therefore, this review will focus on studies of plant-based diets or vegetarian diets and CKD outcomes.

Recent findings

Plant-based diets and risk of CKD

In the last 5 years, seven observational studies have investigated the association between plant-based diets and CKD in healthy individuals (Table 1) (17–23). These studies focused on the plant protein intake (17–19), vegetarians compared to non-vegetarians (20,21), plant-based dietary index defined a priori (22), or plant-based diets identified using a data-driven approach (23).

Table 1.

Recent studies of plant-based diets and incident or prevalent chronic kidney disease (CKD) in healthy individuals, and key nutritional characteristics (dietary acid load, phosphorus, potassium, sodium, fiber) of plant-based diets

Author, year Study Design (duration of follow-up) Country Sample size Types of plant-based diets Comparison diet Outcome Results Dietary acid load Phosphorus Potassium Sodium Fiber
Heo, 2023 (UK Biobank)(17■■) Prospective cohort study (9.9 yr) UK 117,809 adults Daily plant protein intake in g/kg/day quartiles; continuous 1 g/kg/day Incident CKD defined using ICD-10 codes as the primary outcome; two consecutive measurements of eGFR < 60 mL/min/1.73m2 or UACR >30mg/g over a 90 day period as the secondary outcome Highest vs. lowest quartiles of plant protein - HR 0.82 [95% CI, 0.73–0.93]. Per 0.1g/kg/day of plant protein was associated with HR 0.96 [95% CI, 0.93–0.99). Results consistent in secondary outcome Not reported Not reported Not reported Not reported Not reported
Bernier-Jean, 2021 (Longitudinal Study of Aging Women cohort)(19) Prospective cohort study (max 10 yr) Australia 1374 elderly women (>30% had eGFR < 60 mL/min/1.73m2) Plant protein intake, animal protein intake Continuous per 10g higher Yearly decline in eGFR Per 10g higher intake of plant protein was associated with slower eGFR decline - beta, 0.12 [95% CI, 0.01–0.23). Intake of animal protein was not significantly associated with eGFR decline Not reported Not reported Not reported Not reported Not reported
Alvirdizadeh, 2020 (Tehran Lipid and Glucose Study)(18) Prospective cohort study (6.1 yr) Iran 1,639 adults Plant protein intake, animal protein intake, total protein intake Tertiles Incident CKD defined as eGFR <60 mL/min/1.73m2 Highest vs. lowest tertile of plant protein OR - 0.29 [95% CI, 0.15–0.55]. No sigificant association between total protein and animal protein intake and incident CKD. Not reported Not reported Not reported Not reported Not reported (Only reported according to tertiles of total protein intake)
Kim, 2019 [Atherosclerosis Risk in Communities (ARIC) Study] (22■■) Prospective cohort study (24 yr) USA 14,686 adults with eGFR > 60 mL/min/1.73m2 Overall plant-based diet index (PDI), provegetarian diet, healthy plant-based diet index (hPDI), unhealthy plant-based diet index (uPDI) Quintiles (PDI, provegetarian; hPDI, uPDI) Incident CKD: 1) eGFR <60 mL/min/1.73m2 with ≥25% decline, 2) kidney-disease related hospitalizations, or 3) end-stage kidney disease Highest vs. lowest quintiles of hPDI - HR, 0.86 [95% CI, 0.78–0.96]. Highest vs. lowest quintiles of provegetarian diet - HR, 0.90 [95% CI, 0.82–0.99]. Highest vs. lowest quintiles of uPDI - HR, 1.11 [95% CI, 1.01–1.21]. Greater adherence to PDI and hPDI was associated with slower eGFR decline PRAL and NEAP lower for those in the highest vs. lowest quintiles of PDI, provegetarian diet, hPDI. Higher dietary phosphorus intake for those in the highest vs. lowest tertile of hPDI. Lower dietary phosphorus intake for those in the highest vs. lowest quintile of uPDI. Not different for PDI and provegetarian diet Higher dietary potassium intake for those in the highest vs. lowest quintiles of PDI, provegetarian, and hPDI. Lower potassium intake for those in the highest vs. lowest quintiles of uPDI No clear trend for PDI, hPDI. Higher sodium intake for those in the highest vs. lowest quintiles of provegetarian diet. Lower sodium intake for those in the highest vs. lowest quintiles of uPDI. Higher fiber intake for those in the highest vs. lowest quintiles of PDI, provegetarian, and hPDI. Lower fiber intake for those in the highest vs. lowest quintiles of uPDI
Xu, 2020 (None) (21) Cross-sectional study (none) China 538 adults (269 vegetarians and 269 age- and sex-matched non-vegetarians) Vegetarians (vegans and lacto-ovo-vegetarians) Non-vegetarian omnivores Blood urea nitrogen (BUN), serum creatinine, uric acid, eGFR Compared to omnivores, vegetarians had lower BUN, serum creatinine, and uric acid, but higher eGFR. Dietary fiber was inversely associated with BUN, serum creatinine, and UA levels, and positively associated with eGFR Not reported Lower dietary phosphorus intake among vegetarians (and vegans, lacto-ovo-vegetarians) vs. omnivores Lower dietary potassium intake among vegetarians (and lacto-ovo-vegetarians) vs. omnivores. Higher dietary potassium intake among vegans vs. omnivores. Lower sodium intake among vegetarians (and vegans, lacto-ovo-vegetarians) vs. omnivores Higher fiber intake among vegetarians (and vegans, lacto-ovo-vegetarians) vs. omnivores
Liu, 2019 (None) (20) Cross-sectional study (none) Taiwan 55,113 Vegetarians, lacto-ovo-vegetarians Omnivorous diet Prevalent CKD (defined as eGFR <60 mL/min/1.73m2 or proteinuria) Compared to omivores, vegans had OR 0.87 [95%CI, 0.77–0.99], and lacto-ovo-vegetarians had OR 0.84 [95% CI, 0.78–0.90]. Not reported Not reported Not reported Not reported Not reported
Ding, 2023 (China National Diabetic Chronic Complications Study) (23) Cross-sectional study (none) China 1522 adults with diabetes Dietary patterns identified using factor analysis1 [1. Chinese traditional diets; 2. healthy diets; 3. plant-based diets Quartiles (Chinese traditional diets healthy diets; and plant-based diets) Renal impairment: eGFR < 60 mL/min/1.73m2 and albumin-to-creatinine ratio (≥3 mg/mmol) Highest vs. lowest quartiles of the plant-based diets - OR, 0.72 [95% CI: 0.52, 0.98]. Chinese traditional diets and healthy diets not significantly associated with renal impairment. Not reported Not reported Not reported Not reported Not reported
Open in a new tab
1

Chinese traditional diets were high in refined grains, red meat, poultry, soybean, vegetables. Healthy diets were high in vegetables, dairy, eggs, and fruits. Plant-based diets were high in soybean, potatoes, and whole grains.

CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; OR, odds ratio; UACR, urine albumin-creatinine ratio; yr, years

In the UK Biobank consisting of British adults without CKD (n=117,809), those in the highest vs. lowest quartile of plant protein intake had a 18% lower risk of incident CKD, after adjusting for sociodemographic characteristics, health behaviors, comorbidities, and use of medications (17■■). Further, per 0.1g/kg/d higher plant protein intake was associated with a 4% lower risk of incident CKD (17). The Tehran Lipid and Glucose Study (n=1,639) and Longitudinal Study of Aging Women (n=1,374) found similar results (18,19). In the Longitudinal Study of Aging Women, elderly women who consumed 10g higher intake of plant protein had slower estimated glomerular filtration rate (eGFR) decline (19). These last two studies reported no significant association between animal protein intake and incident CKD or eGFR decline (18,19).

Two cross-sectional studies in China (21) and Taiwan (20) compared the prevalence of CKD among vegetarians (vegans, lacto-ovo-vegetarians) and omnivores. In the study of Chinese adults, participants were considered vegetarians if they followed a vegetarian diet in the past year (21). Then, responses on a 24-hour dietary recall were used to classify individuals as vegans, lacto-ovo-vegetarians, and omnivores. The study in China found that 269 vegetarians had better kidney function than age- and sex-matched 269 non-vegetarians. Several studies which recruited patients at Taipei Tzu Chi Hospital from 2005 to 2016 reported prevalence of CKD by lacto-ovo-vegetarians, vegans, and omnivores (20,24,25). In their largest study (n=55,113), food frequency questionnaire (FFQ) responses were used to classify individuals to different diet groups (20). Compared to omnivores, Taiwanese adults who were vegan or lacto-ovo-vegetarian had 13% and 16% lower odds of CKD (20).

A large prospective study of middle-aged US adults (n=14,686, Atherosclerosis Risk in Communities Study, ARIC) examined the associations between four different types of plant-based diet indices [overall plant-based diet index (PDI), provegetarian diet, healthy plant-based diet index (hPDI), and unhealthy plant-based diet index (uPDI)] and incident CKD and eGFR decline (22■■). Individuals with greater adherence to PDI, provegetarian diet, and hPDI had relatively lower intake of animal products and higher intake of plant foods, and particularly healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, tea and coffee) for hPDI. Highest vs. lowest adherence to hPDI and provegetarian diet was associated with 14% and 10% lower risk of incident CKD, respectively. Further, highest vs. lowest adherence to PDI and hPDI was associated with slower eGFR decline.

One study of 1522 adults with diabetes in China used factor analysis to derive dietary patterns (23). One of the dietary patterns, was considered as a ‘plant-based diet’ given higher intake of soybean, potatoes, and whole grains (23). Those in the highest vs. lowest quartiles of this plant-based diet had 28% lower odds of prevalent CKD. Two other dietary patterns, ‘Chinese traditional diets’ (high in refined grains, red meat, poultry, soybean, vegetables) and ‘healthy diets’ (high in vegetables, dairy, eggs, fruits) were not significantly associated with prevalent CKD.

Of these studies, only two studies reported nutrient intake (21,22). In Chinese adults, vegetarians (vegans and lacto-ovo-vegetarians combined) had lower intake of dietary phosphorus, potassium, sodium, and higher intake of fiber, compared to omnivores (21). Intake of dietary phosphorus was higher for vegans compared to omnivores (21). In the ARIC study, dietary acid load was lower for those with highest vs. lowest quintiles of PDI, provegetarian diet, and hPDI (22). Dietary phosphorus, potassium, and fiber was higher for those in the highest quintiles of hPDI (22). Phosphorus content is higher in plant foods than animal products, but phosphorus in plant foods has lower bioavailability (26). The study of vegetarians in China and the ARIC study in the US found that vegetarians and those with greater adherence PDI, provegetarian diet, and hPDI had higher dietary fiber intake (21,22). Dietary fiber intake can promote gut motility, reduce postprandial glucose response, lower pro-inflammatory uremic toxins derived from the gut, and improve cardiovascular risk factors (lower low-density lipoprotein cholesterol and blood pressure) (27–29). These results suggest that plant-based diets have nutrient profiles that may be beneficial for kidney health, but highlight the need for future studies to report nutrient intakes.

Plant-based diets in individuals with CKD

Randomized controlled trials

Of the studies published since 2019, only one randomized controlled trial examined the effect of a holistic diet on kidney function (30). The CARDIVEG study (randomized, open, cross-over trial) compared the 3-month effects of a lacto-ovo-vegetarian diet and a Mediterranean diet on kidney function in 118 individuals with low-to-moderate cardiovascular risk profile (Table 2) (30■■). In this intervention, participants were provided a detailed 1-week menu plan to follow while on the lacto-ovo-vegetarian and Mediterranean diets. Both diets were hypocaloric (31). The lacto-ovo-vegetarian diets included eggs and dairy products, but not meat, fish, and seafood, whereas the Mediterranean diets did not restrict the intake of animal products. In terms of dietary intake, lacto-ovo-vegetarian diets had higher intake of plant protein (nuts and legumes), dairy products, eggs, and dietary fiber, but had similar intake of fruits, vegetables, cereals, and olive oil compared to those who followed the Mediterranean diets. Compared to the baseline, lacto-ovo-vegetarian diets reduced creatinine, blood urea nitrogen (BUN), and BUN/creatinine ratio, and increased eGFR at follow-up, after adjusting for changes in weight, blood pressure, LDL cholesterol, and fasting glucose (30). No significant change was observed for the Mediterranean diet period.

Table 2.

Recent studies of plant-based diets and progression of chronic kidney disease (CKD), adverse outcomes, or metabolic profiles among those with CKD, and key nutritional characteristics (dietary acid load, phosphorus, potassium, sodium, fiber) of plant-based diets

Author, year Study Design (duration of follow-up) Country Sample size Types of plant-based diets Comparison diet Outcome Results Dietary acid load Phosphorus Potassium Sodium Fiber
Dinu, 2021 (CARDIVEG study) (30■■) Randomized controlled trial (3 month) Italy 107 adults (14% had mild kidney impairment) Lacto-ovo vegetarian diet (n=54) Mediterranean diet (n=53) Creatinine, urea nitrogen levels, blood urea nitrogen (BUN), BUN/creatinine ratio, and eGFR Lacto-ovo-vegetarian diet reduced creatinine (5.3%), urea nitrogen levels (−9%), BUN (−8.7%), and BUN/creatinine ratio (−5.8%) while increasing eGFR (+3.5%) from baseline to follow-up. No significant changes were observed for the Mediterranean diet group Not reported Not reported Not reported Not reported Higher intake of fiber pre- and post- lacto-ovo-vegetarian diet
Amir & Kim, 2024 [Chronic Renal Insufficiency Cohort (CRIC)] (36■■) Prospective cohort study (7 yr for CKD progression; 12 yr for all-cause mortality) USA 2,539 of adults with CKD Overall plant-based diet index (PDI), healthy plant-based diet index (hPDI), and unhealthy plant-based diet index (uPDI) Tertiles; continuous per 10-point higher in PDI, hPDI, and uPDI CKD progression and all-cause mortality All-cause mortality: highest vs. lowest PDI - HR, 0.74 [95% CI, 0.62–0.88]. hPDI - HR, 0.79 [95% CI, 0.66–0.95]. Per 10-point higher of uPDI - HR: 1.11 [95% CI, 1.00–1.23]. CKD progression: per 10-point higher of uPDI - HR, 1.14 [95% CI: 1.03–1.25) PRAL lower for those in the highest vs. lowest tertiles of PDI, hPDI. PRAL higher for those in the highest vs. lowest tertile of uPDI Lower phosphorus intake for those in the highest vs. lowest tertile of PDI and uPDI. Higher dietary phosphorus intake for those in the highest vs. lowest tertile of hPDI Higher potassium intake for those in the highest vs. lowest tertiles of PDI, and hPDI. Lower dietary potssium intake for those in the highest vs. lowest tertiles of uPDI. Serum potassium not different by tertiles of PDI, hPDI, and uPDI Lower sodium intake for those in the highest vs. lowest tertile of PDI, hPDI, and uPDI. Higher fiber intake for those in the highest vs. lowest tertiles of PDI and hPDI. Lower fiber intake for those in the highest vs. lowest tertiles of uPDI
Liu, 2020 (none) (37) Prospective cohort study (45 month) China 884 individuals with peritoneal dialysis The ratio of plant-based protein to total protein Continuous per 10% higher all-cause mortality; cardiovascular disease (CVD) mortality Per 10% higher in plant protein to total protein ratio was associated with HR 0.29 [95% CI, 0.10–0.86) lower risk of all-cause mortality, and HR 0.11 [95% CI, 0.02–0.79] lower risk of CVD mortality Not reported No difference in serum phosphate across tertiles of plant protein to total protein ratio No difference in serum potassium across tertiles of plant protein to total protein ratio Similar serum sodium level across tertiles of plant protein to total protein ratio Great intake of fiber for those in the highest vs. lowest tertile of plant protein to total protein ratio
He, 2021 (38) Prospective cohort study (median:28 month) China 1,119 adults on hemodialysis The proportion of plant protein to total protein Continuous variable per 5% higher; restricted cubic spline terms; categorical variable (<40%, 40-<50%, 50-<60%, 60-<70%, and ≥70%) all-cause mortality; CVD mortality U-shaped association between plant protein and all-cause mortality and CVD mortality. For all-cause mortality: Among those with plant protein intake <45%, 5% higher plant protein was associated with HR 0.83 [95% CI, 0.73–0.96]. Among those with plant protein intake ≥45%, 5% higher plant protein was associated with HR 1.09 [95% CI, 1.02–1.16]. Similar results with CVD mortality Not reported Serum phosphate not different by categories of plant protein intake. Serum potassium not different by categories of plant protein intake. Not reported Greater intake of fiber for those with greater intake of plant protein.
Moloudpour, 2024 (Ravansar noncommunicable diseases cohort study) (39) Cross-sectional study (none) Iran 9,746 (11% had eGFR <60 mL/min/1.73m2) Overall plant-based diet index (PDI) Quartiles Prevalent CKD (eGFR <60 mL/min/1.73m2) Highest vs. lowest quartile of PDI - OR, 0.61 [95% CI, 0.48–0.78] Not reported Not reported Higher potassium for those in the highest. vs. lowest quartiles of PDI Lower sodium intake for those in the highest vs. lowest quartiles of PDI Greater fiber intake for those in the highest vs. lowest quartiles of PDI
Yoshioka, 2023 (none) (40) Cross-sectional study (none) Japan 107 individuals with CKD who are not on dialysis Isocaloric substitution model (% of energy from plant protein vs. % of energy from animal protein) Animal protein Fibroblast growth factor-23 (FGF23), phosphate, 1,25 dihydroxy vitamin D, parathyroid hormone levels Replacing 3% of the energy from animal protein with plant protein was associated with lower serum FGF23 level (beta=−0.101). Not reported Animal or plant protein intake was not associated with serum phosphate level. Replacing 3% energy from animal protein with plant protein was not associated with serum phosphate, but associated with a lower FGF23 level Not reported Not reported Not reported
McFarlane, 2022 (none) (41) Cross-sectional study (none) Australia 68 adults with CKD Overall plant-based diet index (PDI), healthy plant-based diet index (hPDI), and unhealthy plant-based diet index (uPDI) Continuous (per 1 unit higher) Uremic toxin hPDI associated with lower levels of serum uremic toxin (p-cresyl sulfate). No significant association with PDI, uPDI and uremic toxins. Not reported Not reported Not reported Not reported Not reported in the context of PDI, hPDI, and uPDI
Chen, 2021 (none) (43) Cross-sectional study (none) Taiwan 95 individuals on dialysis Vegetarians Omnivores Serum urea nitrogen, creatinine, phosphate, vitamin D, status, normalized protein catabolic rate Vegetarian diet was significantly associated with severe vitamin D deficiency, after adjusting for important confounders. No other associations were tested in multivariable logistic regression models Not reported Serum phosphate was lower in vegetarians vs. omnivores Not reported Not reported Not reported
Gonzalez-Ortiz, 2020 (none) (42) Cross-sectional study (none) Sweden 418 men free from diabetes with eGFR <60 mL/min/1.73m2, and not receiving kidney-specific dietetic advice Overall plant-based diet index Quintiles Insulin sensitivity, glucose disposal rate, inflammation (C-reactive protein and interleukin-6) Highest vs. lowest quintiles of PDI was associated with higher insulin sensitivity, glucose disposal rate, and lower levels of inflammation (CRP, IL-6). Not reported Not reported Higher potassium for those in the highest. vs. lowest quintiles of PDI Not reported Greater fiber intake for those in the highest vs. lowest quintiles of PDI
Open in a new tab

CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio; OR, odds ratio; UACR, urine albumin-creatinine ratio; yr, years

Besides the CARDIVEG trial, several trials tested the effects of fruits and vegetables or oral bicarbonate on renal injury, kidney function, and metabolic profile (systolic blood pressure, weight) (32–35). These trials found that intake of fruits and vegetables in individuals with CKD did not increase eGFR, but improved metabolic acidosis, and had additional benefits (lowered systolic blood pressure, weight, and UACR) (32–34). Though these studies did not specifically test the effect of dietary patterns on kidney function, they suggest that plant-based diets may be safe and beneficial for those with CKD.

Observational studies

Three prospective observational studies examined the associations between plant-based diets and hard clinical end points (CKD progression, all-cause mortality, CVD mortality) (36–38). In the Chronic Renal Insufficiency Cohort (CRIC) study of 2,539 adults with eGFR 20–70 mL/min/1.73m2, greater adherence to a priori defined plant-based diets (overall and healthful versions) were associated with 21 to 26% lower risk of all-cause mortality over a median follow-up of 12 years (36■■). Per 10-point higher in an unhealthful version of plant-based diets was associated with a 11% higher risk of CKD progression over a median follow-up of 7 years. This study reported that dietary acid load, sodium, and potassium content was lower for those in the highest vs. lowest tertiles of PDI and hPDI, and opposite trends were observed for phosphorus and fiber. In contrast, dietary acid load and phosphorus was higher for those in the highest vs. lowest tertiles of uPDI, whereas potassium and fiber content was lower. Importantly, serum potassium level was not significantly different across tertiles of PDI, hPDI, and uPDI, suggesting that hyperkalemia was not evident for those with greater adherence to plant-based diets. Based on the results from the CRIC Study, plant-based diets (overall and healthful versions) had favorable nutrient composition, but quality of plant-based diets should be taken into consideration when following a plant-based diet among those with CKD.

A second prospective cohort study of 884 Chinese adults who had peritoneal dialysis found that per 10% higher in plant protein to total protein ratio was associated with 71%, and 89% lower odds of all-cause mortality and CVD mortality, respectively (37). Similarly, a third prospective study of 1,119 Chinese adults on hemodialysis reported that greater intake of plant protein was associated with a lower risk of all-cause and CVD mortality, but only among those with <45% energy from plant protein (38). The study of hemodialysis patients noted a U-shaped association: among those with ≥45% energy from plant protein, greater intake of plant protein was associated with an elevated risk (38). These two studies reported valuable information on blood levels of phosphorus, potassium, and sodium (only in peritoneal dialysis patients), and found that serum phosphorus, potassium, and sodium were not significantly different across categories of plant protein intake. However, dietary fiber intake was higher for those with greater intake of plant protein intake.

Five cross-sectional studies investigated associations between plant-based diets and other outcomes [prevalent CKD (39), biomarkers involved in bone and mineral metabolism (40), uremic toxins (41), insulin sensitivity (42), inflammatory biomarkers (42), and vitamin D status (43)]. Generally, these studies found that a greater adherence to a plant-based diet (overall or healthful versions) was associated with lower odds of prevalent CKD, lower levels of serum uremic toxins and inflammation (C-reactive protein and interleukin-6), and higher insulin sensitivity, and glucose disposal rate (39,41,42). In 107 Japanese adults with CKD who were not on dialysis, serum fibroblast growth factor-23 was lower when 3% of animal protein from total energy intake was replaced with 3% of plant protein from total energy intake (40). Serum phosphate was not significantly different by animal or plant protein intake (40). However, in 95 Taiwanese adults on dialysis, vegetarian diet was significantly associated with vitamin D deficiency, and vegetarians had lower total energy intake, protein, fat, and vitamin D compared to non-vegetarians (43). It is important to note that milk sold in Taiwan is not fortified with vitamin D (43). The findings in Taiwan suggests that vegetarians on dialysis would benefit from education on incorporation of vitamin D rich foods to their diets.

Conclusions

Based on the recent evidence, we found that plant-based diets are dietary patterns that may provide several benefits for primary and secondary prevention of CKD, with little risk for individuals with CKD. Individuals following a plant-based diet had lower intake of dietary acid load, lower or no significant difference in phosphorus and sodium, and higher potassium and fiber. Importantly, serum phosphate levels did not differ for vegetarians vs. non-vegetarians, or individuals whose diets were high in plant protein intake. Additionally, serum potassium levels did not differ for those with higher adherence to overall, healthful, or unhealthful versions of plant-based diets in the CRIC study (36). Further, dietary fiber intake was higher for those following a plant-based diet (except for an unhealthful plant-based diet). In one study, vitamin D deficiency and inadequate dietary intake was a concern, which highlights the importance of nutrition education (43).

However, several gaps in research deserve mention. Most studies did not report nutritional characteristics of plant-based diets or serum potassium or phosphate. Future studies should include this information, considering the ubiquity of highly processed plant foods, and findings that unhealthful plant-based diets were associated with an elevated risk of incident CKD and CKD progression (22,36). We found that sodium content was either similar or lower for those following plant-based diets. In general, it is thought that sodium content is lower in plant-based diets, and thus plant-based diets could have anti-hypertensive effect (44). Nevertheless, processed plant foods may be higher in sodium, or sodium can be added during preparation or at the table. It may be worth collecting 24-hour urinary sodium excretion among those with higher vs. lower adherence to plant-based diets in contemporary settings. In individuals with CKD, only one randomized controlled trial tested the effects of plant-based diets on kidney function (30). A systematic review on vegetarian diets and kidney function found four randomized controlled trials (346 total participants), and two of the four studies had high risk of bias (45). A trial which evaluates the effect of plant-based diets on kidney outcomes in those with CKD is needed to strengthen the evidence.

Though plant-based diets are considered healthful, it is important to recognize barriers to adopting plant-based diets. A survey of 10 European countries (n=7590 responses) found that beliefs that plant-based diets may not provide adequate nutrition, beliefs that humans should eat meat, and low expectation of tastiness of plant foods as major barriers to shifting towards plant food consumption (46). Another survey of nephrology patients (n=844 responses) found that family eating preference, lack of meal planning skills, taste preference for meat, lack of knowledge on what healthy food is, cost of food, and time constraints as barriers to following a plant-based diet (47). These results highlight the importance of considering individual preferences, quality of plant foods, ability, time, and access to fresh produce when recommending plant-based diets for primary and secondary prevention of CKD. Adopting and sustaining plant-based diets requires collaboration between patients, nephrologists, and dietitians.

Key Points.

  • Review of the most recent evidence suggests that greater intake of plant protein and higher adherence to plant-based diets is associated with a lower risk of CKD in healthy individuals, and plant-based diets were associated with several benefits (lower risk of mortality, improved kidney function, and favorable metabolic profiles) among those with CKD.

  • There is lack of evidence on nutrient content of plant-based diets, but plant-based diets were lower in dietary acid load, lower or had no significant difference in phosphorus and sodium, and higher in potassium and fiber.

  • Plant-based diets provide useful dietary strategies for prevention and management of CKD, with little risk for individuals with CKD.

Funding:

CMR was supported by a grant from the National Heart, Lung, and Blood Institute (R01 HL153178). HK was supported by a grant from the NHLBI (K01 HL168232). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Financial support and sponsorship:

HK was supported by the National Heart, Lung, and Blood Institute (NHLBI) (K01 HL168232). CMR was supported by a grant from the NHLBI (R01 HL153178).

Footnotes

Conflict of interest: none

REFERENCES

  • 1.Satija A, Bhupathiraju SN, Rimm EB, et al. Plant-based dietary patterns and incidence of type 2 diabetes in US men and women: results from three prospective cohort studies. PLoS Med. 2016. Jun 14;13(6):e1002039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Kim H, Rebholz CM, Garcia-Larsen V, et al. Operational differences in plant-based diet indices affect the ability to detect associations with incident hypertension in middle-aged US adults. J Nutr. 2019;150(4):842–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Yokoyama Y, Nishimura K, Barnard ND, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med. 2014. Apr;174(4):577–87. [DOI] [PubMed] [Google Scholar]
  • 4.Satija A, Bhupathiraju SN, Spiegelman D, et al. Healthful and unhealthful plant-based diets and the risk of coronary heart disease in U.S Adults. J Am Coll Cardiol. 2017. Jul 25;70(4):411–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Kim H, Caulfield LE, Garcia-Larsen V, et al. Plant-based diets are associated with a lower risk of incident cardiovascular disease, cardiovascular disease mortality, and all-cause mortality in a general population of middle-aged adults. J Am Heart Assoc. 2019. Aug 20;8(16):e012865. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Gan ZH, Cheong HC, Tu YK, Kuo PH. Association between plant-based dietary patterns and risk of cardiovascular disease: a systematic review and meta-analysis of prospective cohort studies. Nutrients. 2021. Nov 5;13(11):3952. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020. Sep 1;76(3):S1–107. [DOI] [PubMed] [Google Scholar]
  • 8.Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024. Apr;105(4S):S117–314. [DOI] [PubMed] [Google Scholar]
  • 9.Carrero JJ, González-Ortiz A, Avesani CM, et al. Plant-based diets to manage the risks and complications of chronic kidney disease. Nat Rev Nephrol. 2020. Sep;16(9):525–42. [DOI] [PubMed] [Google Scholar]
  • 10.Clegg DJ, Gallant KMH. Plant-Based Diets in CKD. Clin J Am Soc Nephrol. 2018. Dec 26;CJN.08960718. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Zarantonello D, Brunori G. The role of plant-based diets in preventing and mitigating chronic kidney disease: more light than shadows. J Clin Med. 2023. Sep 22;12(19):6137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Satija A, Hu FB. Plant-based diets and cardiovascular health. Trends Cardiovasc Med. 2018. Oct 1;28(7):437–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Kim H, Caulfield LE, Rebholz CM. Healthy plant-based diets are associated with lower risk of all-cause mortality in US adults. J Nutr. 2018. Apr 1;148(4):624–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Bach KE, Kelly JT, Palmer SC, et al. Healthy dietary patterns and incidence of CKD: a meta-analysis of cohort studies. Clin J Am Soc Nephrol. 2019. Oct 7;14(10):1441–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Kelly JT, Palmer SC, Wai SN, et al. Healthy dietary patterns and risk of mortality and ESRD in CKD: a meta-analysis of cohort studies. Clin J Am Soc Nephrol. 2017. Feb 7;12(2):272–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Charkviani M, Thongprayoon C, Tangpanithandee S, et al. Effects of Mediterranean diet, DASH diet, and plant-based diet on outcomes among end stage kidney disease patients: a systematic review and meta-analysis. Clin Pract. 2022. Dec 28;13(1):41–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17■■.Heo GY, Koh HB, Kim HJ, et al. Association of plant protein intake with risk of incident CKD: a UK Biobank study. Am J Kidney Dis. 2023. Dec;82(6):687–697.e1. [DOI] [PubMed] [Google Scholar]; Using data from the UK Biobank, this prospective study with 10 years of follow-up investigated the association between plant protein intake and risk of incident CKD among those without CKD.
  • 18.Alvirdizadeh S, Yuzbashian E, Mirmiran P, et al. A prospective study on total protein, plant protein and animal protein in relation to the risk of incident chronic kidney disease. BMC Nephrol. 2020. Nov 17;21(1):489. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Bernier-Jean A, Prince RL, Lewis JR, et al. Dietary plant and animal protein intake and decline in estimated glomerular filtration rate among elderly women: a 10-year longitudinal cohort study. Nephrol Dial Transplant 2021. Aug 27;36(9):1640–1647 [DOI] [PubMed] [Google Scholar]
  • 20.Liu HW, Tsai WH, Liu JS, Kuo KL. Association of vegetarian diet with chronic kidney disease. Nutrients. 2019. Jan 27;11(2):279. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Xu K, Cui X, Wang B, et al. Healthy adult vegetarians have better renal function than matched omnivores: a cross-sectional study in China. BMC Nephrol. 2020. Jul 11;21(1):268. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22■■.Kim H, Caulfield LE, Garcia-Larsen V, et al. Plant-based diets and incident CKD and kidney function. Clin J Am Soc Nephrol. 2019. Apr 25;14(5):682–91. [DOI] [PMC free article] [PubMed] [Google Scholar]; A prospective study of 23 years which examined the association between different types of plant-based diets and incident CKD and kidney function in healthy individuals in the US
  • 23.Ding Z, Wu X, Liu C, et al. Associations between dietary patterns and renal impairment in individuals with diabetes: a cross-sectional study. J Hum Nutr Diet. 2024. Feb;37(1):193–202. [DOI] [PubMed] [Google Scholar]
  • 24.Wu CL, Tsai WH, Liu JS, et al. Vegan Diet Is Associated with a Lower Risk of Chronic Kidney Disease in Patients with Hyperuricemia. Nutrients. 2023. Mar 16;15(6):1444. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Hou YC, Huang HF, Tsai WH, et al. Vegetarian Diet Was Associated With a Lower Risk of Chronic Kidney Disease in Diabetic Patients. Front Nutr. 2022;9:843357. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.McCarty MF, DiNicolantonio JJ. Bioavailable dietary phosphate, a mediator of cardiovascular disease, may be decreased with plant-based diets, phosphate binders, niacin, and avoidance of phosphate additives. Nutrition. 2014;30(7–8):739–47. [DOI] [PubMed] [Google Scholar]
  • 27.Lu L, Huang YF, Wang MQ, et al. Dietary fiber intake is associated with chronic kidney disease (CKD) progression and cardiovascular risk, but not protein nutritional status, in adults with CKD. Asia Pac J Clin Nutr. 2017;26(4):598–605. [DOI] [PubMed] [Google Scholar]
  • 28.Xu H, Huang X, Risérus U, et al. Dietary fiber, kidney function, inflammation, and mortality risk. Clin J Am Soc Nephrol. 2014. Dec 5;9(12):2104–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Satija A, Hu FB. Cardiovascular benefits of dietary fiber. Curr Atheroscler Rep. 2012. Dec;14(6):505–14. [DOI] [PubMed] [Google Scholar]
  • 30■■.Dinu M, Colombini B, Pagliai G, et al. Effects of vegetarian versus Mediterranean diet on kidney function: Findings from the CARDIVEG study. Eur J Clin Invest. 2021. Sep;51(9):e13576. [DOI] [PMC free article] [PubMed] [Google Scholar]; A randomized controlled crossover trial which tested the effect of vegetarian and Mediterranean diet on kidney function.
  • 31.Sofi F, Dinu M, Pagliai G, et al. Mediterranean versus vegetarian diet for cardiovascular disease prevention (the CARDIVEG study): study protocol for a randomized controlled trial. Trials. 2016. May 4;17:233. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Goraya N, Simoni J, Jo C, Wesson DE. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int. 2012. Jan 1;81(1):86–93. [DOI] [PubMed] [Google Scholar]
  • 33.Goraya N, Simoni J, Jo CH, Wesson DE. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clin J Am Soc Nephrol. 2013. Mar 7;8(3):371–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Goraya N, Simoni J, Jo CH, Wesson DE. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney International. 2014. Nov 1;86(5):1031–8. [DOI] [PubMed] [Google Scholar]
  • 35.Goraya N, Wesson DE. Dietary interventions to improve outcomes in chronic kidney disease. Curr Opin Nephrol Hypertens. 2015. Nov 1;24(6):505–10. [DOI] [PubMed] [Google Scholar]
  • 36■■.Amir S, Kim H, Hu EA, et al. Adherence to plant-based diets and risk of CKD progression and all-cause mortality: findings from the Chronic Renal Insufficiency Cohort (CRIC) study. Am J Kidney Dis. 2024. May;83(5):624–35. [DOI] [PMC free article] [PubMed] [Google Scholar]; This prospective study with a long follow-up provides important evidence on adherence to different types of plant-based diets and CKD progression and all-cause mortality in individuals with reduced kidney function
  • 37.Liu X, Hu Z, Xu X, et al. The associations of plant-based protein intake with all-cause and cardiovascular mortality in patients on peritoneal dialysis. Nutr Metab Cardiovasc Dis. 2020. Jun 9;30(6):967–76. [DOI] [PubMed] [Google Scholar]
  • 38.He Y, Lu Y, Yang S, et al. Dietary plant protein and mortality among patients receiving maintenance hemodialysis: a cohort study. Am J Kidney Dis. 2021. Nov;78(5):649–657.e1. [DOI] [PubMed] [Google Scholar]
  • 39.Moloudpour B, Jam SA, Darbandi M, et al. Association between plant-based diet and kidney function in adults. J Ren Nutr. 2024. Mar;34(2):125–32. [DOI] [PubMed] [Google Scholar]
  • 40.Yoshioka M, Kosaki K, Matsui M, et al. Association between the intake of plant and animal proteins and the serum fibroblast growth factor-23 level in patients with chronic kidney disease analyzed by the isocaloric substitution model. Endocr J. 2023. Jan 30;70(1):31–42. [DOI] [PubMed] [Google Scholar]
  • 41.McFarlane C, Krishnasamy R, Stanton T, et al. Diet quality and protein-bound uraemic toxins: investigation of novel risk factors and the Role of microbiome in chronic kidney disease. J Ren Nutr. 2022. Sep;32(5):542–51. [DOI] [PubMed] [Google Scholar]
  • 42.González-Ortiz A, Xu H, Avesani CM, et al. Plant-based diets, insulin sensitivity and inflammation in elderly men with chronic kidney disease. J Nephrol. 2020. Oct;33(5):1091–101. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Chen MY, Ou SH, Yen MC, et al. Vegetarian diet in dialysis patients: A significant gap between actual intake and current nutritional recommendations. Medicine (Baltimore). 2021. Feb 12;100(6):e24617. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Joshi S, Ettinger L, Liebman SE. Plant-Based Diets and Hypertension. Am J Lifestyle Med. 2019. Sep 24;14(4):397–405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Świątek Ł, Jeske J, Miedziaszczyk M, Idasiak-Piechocka I. The impact of a vegetarian diet on chronic kidney disease (CKD) progression – a systematic review. BMC Nephrology. 2023. Jun 12;24(1):168. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Perez-Cueto FJA, Rini L, Faber I, et al. How barriers towards plant-based food consumption differ according to dietary lifestyle: Findings from a consumer survey in 10 EU countries. International Journal of Gastronomy and Food Science. 2022. Sep 1;29:100587. [Google Scholar]
  • 47.Betz MV, Nemec KB, Zisman AL. Patient perception of plant based diets for kidney disease. J Ren Nutr. 2023. Mar 1;33(2):243–8. [DOI] [PubMed] [Google Scholar]

RESOURCES