Guiding CKD Care Through Updated Dietary Guidelines, With Tim Pflederer, MD

In response to the recently released federal Dietary Guidelines for Americans, 2025–2030, nephrologists should ensure patients with impaired kidney function, chronic kidney disease (CKD), or end-stage kidney disease (ESKD) are following individualized, treatment-informed diets.1

The US Department of Health & Human Services (HHS) released the updated guidelines on January 7, 2026, emphasizing high-quality protein, healthy fats, fruits, vegetables, and whole grains while discouraging highly processed foods and refined carbohydrates.1

“I think the direction of [the guidelines] is right and good for kidney disease, but at the same time, there are nuanced messages that our patients need to hear related to those guidelines,” Tim Pflederer, MD, shared in an interview with HCPLive.

Patients with renal impairment have reduced glomerular filtration rate (GFR), which limits the kidney’s ability to excrete potassium, phosphorus, and nitrogenous waste from protein metabolism. Excess protein, particularly from animal sources, can increase renal solute load, stimulate hyperfiltration in residual nephrons, and accelerate CKD progression, as Pflederer highlighted in a previous discussion with our team.2

Consequently, intake of high-potassium foods and protein must be carefully managed, with attention to laboratory monitoring, CKD stage, and dialysis schedules.2,3,4

While the guidelines encourage more whole vegetables and fruits, clinicians should encourage their patients with kidney disease to carefully select options. Many common fruits and vegetables are high in potassium, Pflederer explained, including bananas, oranges, potatoes, tomatoes, avocados, and dried fruits.3,4

Hyperkalemia occurs when serum potassium rises above safe physiologic levels, which can trigger cardiac arrhythmias and sudden death. In patients with advanced CKD or ESKD, impaired renal excretion makes them particularly vulnerable. Patients on dialysis rely on the treatment to remove extra potassium, so dietary intake must be carefully adjusted based on the timing of treatments between sessions.3,4

“If they're having difficulty with potassium, they should talk to their physician to make certain that the foods that they're eating that are whole, fresh fruits and vegetables, particularly, are not high in potassium,” said Pflederer.

Clinicians can offer options with regulated levels of potassium, including apples, berries, grapes, white rice, white bread, and fresh white meat. Additionally, cooking methods such as boiling or leaching may reduce potassium content, which may help patients manage intake more safely.3,4

The guidelines also encourage avoidance of processed foods, which Pflederer acknowledges can benefit kidney health. Many processed products contain phosphorus additives, which are almost completely absorbed and can accumulate quickly in patients with reduced kidney function, increasing the risk of mineral imbalances and long-term complications.5

In patients with CKD, impaired kidney function reduces phosphate excretion, which can trigger increases in fibroblast growth factor 23 (FGF23) and parathyroid hormone (PTH). Over time, this can weaken bones and cause calcium to deposit in blood vessels and organs, increasing the risk of heart attack, stroke, and other complications.6

“Eliminating processed foods will at the same time be overall good for their health, and eliminate and reduce the phosphorus burden that is difficult for people with kidney disease to handle,” said Pflederer.

Editor’s Note: Pflederer reports no relevant disclosures.

References

1. Fact Sheet: Trump Administration Resets U.S. Nutrition Policy, Puts Real Food Back at the Center of Health. HHS.gov. Published January 7, 2026. https://www.hhs.gov/press-room/fact-sheet-historic-reset-federal-nutrition-policy.html

2. Ko GJ, Kalantar-Zadeh K. How important is dietary management in chronic kidney disease progression? A role for low protein diets. The Korean Journal of Internal Medicine. 2021;36(4):795-806. doi:https://doi.org/10.3904/kjim.2021.197

3. ‌Potassium and Chronic Kidney Disease - DaVita | DaVita. DaVita. Published June 20, 2025. https://davita.com/diet-nutrition/articles/potassium-and-chronic-kidney-disease/

4. Six Steps to Controlling High Potassium. National Kidney Foundation. Published August 12, 2024. https://www.kidney.org/news-stories/six-steps-to-controlling-high-potassium‌

5. ‌National Kidney Foundation. Phosphorus and Your CKD Diet. National Kidney Foundation. Published June 26, 2025. https://www.kidney.org/kidney-topics/phosphorus-and-your-ckd-diet

6. Russo D, Battaglia Y. Clinical Significance of FGF-23 in Patients with CKD. International Journal of Nephrology. 2011;2011:e364890. doi:https://doi.org/10.4061/2011/364890