Dietary management of patients with type 2 diabetes and chronic kidney disease: A comprehensive literature review

Table 1 Summary of macronutrient recommendations

Nutrient	Key recommendations	Evidence and considerations
Protein	General DKD: About 0.8 g/kg/day (non-dialysis); dialysis: 1.0–1.2 g/kg/day; prioritize plant-based proteins (e.g., soy)	High protein intake may increase GFR and renal strain; plant proteins may reduce proteinuria and mortality risk vs red meat
Carbohydrates	Individualized intake; minimize refined sugars; consider “carbohydrate-last” eating pattern	CL eating may reduce postprandial spikes; cultural adaptations (e.g., Mediterranean diet) can improve glycemic control
Fats	Limit saturated fats (< 7%) and trans fats (< 1%); replace with omega-3 fatty acids (fish, flaxseeds) and monounsaturated fats (olive oil, nuts)	Mediterranean/DASH diets could lower CVD risk and improve lipids; cultural models (e.g., Levantine diet) enhance adherence

CL: Carbohydrate last; CVD: Cardiovascular disease; DASH: Dietary approach to stop hypertension; DKD: Diabetic kidney disease; GFR: Glomerular filtration rate.

Table 2 Summary of micronutrient recommendations

Nutrient	Key recommendations	Evidence and considerations
Potassium	Individualized restriction; prioritize natural sources (fruits/vegetables) over additives; limit processed foods with KCl	T2DM + CKD increases hyperkalemia risk (RAAS inhibitors, age); stepwise approach: Address non-dietary causes first, then limit low-nutrient sources (e.g., juices, chips); potassium additives in low sodium foods are highly bioavailable (↑ risk)
Phosphorus	Non-dialysis CKD: About 700 mg/day; hemodialysis: Monitor protein-bound phosphorus (1.2–1.4 g/kg/day ≈ 1450–1600 mg phosphorus)	Hyperphosphatemia drives vascular calcification; animal proteins and additives are major sources; however, strict restrictions risk malnutrition; education improves adherence in hemodialysis (limited evidence in other CKD stages)
Sodium	< 2 g/day (5 g salt); combine with DASH diet for BP control	High intake worsens HTN, CVD, and proteinuria; enhances RAAS-blocker efficacy but may transiently ↓eGFR (protective hyperfiltration reduction?); DASH diet + low sodium may slow CKD progression

BP: Blood pressure; CKD: Chronic kidney disease; CVD: Cardiovascular disease; DASH: Dietary Approach to Stop Hypertension; eGFR: Estimated glomerular filtration rate; HTN: Hypertension; KCl: Potassium chloride; RAAS: Renin-angiotensin-aldosterone system; T2DM: Type 2 diabetes mellitus.

Table 3 Summary of fluid recommendations

Group	Fluid needs	Key notes
CKD stages 1–3	Typically unrestricted	Adequate function; monitor for heart failure
CKD stages 4–5 (non-dialysis)	May need restriction	Depends on urine output and cardiac status
Heart failure (any stage)	Restriction often required	Prevent fluid overload regardless of CKD stage
Hemodialysis	Strict limits	Prevent complications from fluid shifts
Peritoneal dialysis	More liberal intake	Daily dialysis allows flexibility; monitor sodium/sugar intake

CKD: Chronic kidney disease.

Table 4 Summary of dietary patterns

Dietary pattern	Benefits	Challenges	Cultural adaptations
DASH diet	Lowers blood pressure; improves insulin sensitivity and glycemic control	Requires high adherence; limited access to fresh produce in some regions	Use grilled fish, bulgur, and herbs like za’atar/sumac instead of salt; emphasize traditional whole grains
Mediterranean diet	Reduces inflammation; improves kidney function; lowers T2DM/CKD risk	High cost of olive oil/seafood; unfamiliarity with dietary structure	Incorporate tabbouleh, hummus, grilled fish; adjust portion sizes; use local oils and nuts
Plant-based diet	High fiber for glycemic/gut health; reduces kidney protein load and inflammation	Risk of B12/iron deficiency; potential potassium/phosphorus imbalance in CKD	Include ful medames, vegetable stews, lentils/chickpeas; education on balanced inclusion of small meat portions

CKD: Chronic kidney disease; DASH: Dietary approach to stop hypertension; T2DM: Type 2 diabetes mellitus.

Table 5 Summary of recommendations for Ramadan fasting in patients with type 2 diabetes mellitus and chronic kidney disease

Domain	Recommendation
Risk assessment	Perform individualized pre-Ramadan evaluation to understand risk and guide decision-making
Eligibility	Support fasting only for patients with stable CKD (stages 1–3) and well-controlled T2DM
Monitoring and safety	Monitor renal function and hydration status during Ramadan; advise breaking fast if clinical deterioration occurs
Care approach	Implement tailored plans with medication adjustments, hydration strategies, and diet guidance

CKD: Chronic kidney disease; T2DM: Type 2 diabetes mellitus.