Fluid Restriction in CKD: When it’s critical and how much is too much

In many situations, there is a need for fluid restriction in CKD (chronic kidney disease). Whether it’s ckd stage 3, dialysis patients, or anywhere before or in between, a fluid restriction may become critical when caring for kidney health. 

But how much fluid does that mean? What happens if you drink too much? Is there a risk for dehydration? Let’s dive into all of that and more when it comes to fluid restrictions for kidney disease.

Fluid Restriction in CKD: When it's critical and how much is too much. Blog by Jen Hernandez, Renal Dietitian of Plant-Powered Kidneys

What is a fluid restriction?

A fluid restriction is a medically-directed order in which a person needs to limit liquid or fluid intake to prevent complications from fluid collection in the body.

What are the symptoms of having too much fluid with kidney disease?

Symptoms of too much fluid can vary quite significantly. In many cases, symptoms won’t be noticed as our body tries to adapt to the situation and care for us.

Some symptoms you may notice when it comes to having too much fluid can include:

  • Swelling at the feet, ankles, hands, even face
  • Rapid weight gain
  • Headache
  • Cramping
  • Bloating
  • Abdominal pain or discomfort
  • Shortness of breath
  • High blood pressure

It’s important that you talk with your doctor about your fluid guidelines and if you need to be on a fluid restriction.

What counts as a fluid in a fluid restriction?

Both foods and beverages will count in a fluid restriction. Any type of fluid will be counted. The most common fluids include:

  • Water (flat, filtered, tap, carbonated, flavored, etc)
  • Coffee
  • Tea
  • Milk
  • Juice
  • Alcohol
  • Soft drinks

Besides beverages, any foods that include liquid will also need to be included in a fluid restriction. Examples include:

  • Soup
  • Stew
  • Yogurt
  • Ice cream
  • Gelatin
  • Sauces
  • Watery fruits and vegetables such as watermelon, cucumber, strawberries, cantaloupe, peaches and more

Examples of fluid amounts in different food items

Food item (serving size)Volume of water (mL)
1 can soda (12 oz)332
Gelatin (1 cup)200
Popsicle45
Ice cream/sherbet (1 cup)127
Yogurt (1 cup)182
Peaches, canned (1 cup)218
Grapes (1 cup)120
Watermelon (1 cup)140
Apple (1 medium)171
Examples of fluid amounts in different food items. Information in the table has been obtained from the USDA food database.

Even foods can count towards a fluid restriction. This is where portions are important with your renal diet and fluid restriction or other guidelines.

For more information on different types of foods and beverages for a renal diet, check out our renal diet grocery list.

Do I need to be on a fluid restriction with kidney disease?

Kidney disease is a chronic illness with many stages and causes. Each person will have their own diet and fluid needs. Your primary doctor or kidney specialist will be able to help you understand if you need to be on any fluid restriction.

What about stage 3 kidney disease water intake?

Stage 3 is considered early stage CKD and in general does not start with restricting fluids. A bigger focus when it comes to fluid management with early stages of CKD starts with a focus on sodium restriction.

Stages 1 and 2 of chronic kidney disease are also not generally requiring a fluid restriction. Most often, fluids are encouraged to be consumed according to thirst.

And stage 5 kidney disease water intake?

Stage 5 is considered to be a glomerular filtration rate (GFR) of below 15. Stage 5 is also the period at which a person qualifies for dialysis and kidney transplantation.

With stage 5 kidney disease, water intake is often restricted. However, as with all parts of a renal diet, water intake for stage 5 will be calculated based on the individual – not just due to a certain stage of kidney disease.

What happens if I drink too much water when I have kidney disease?

If you have a fluid restriction advised by your doctor and healthcare team, too much fluid can be extremely hard on your body.

Too much water can cause sodium levels to drop below the normal range and cause hyponatremia. This can lead to severe health problems. Other electrolytes, such as potassium, may also come out of range and cause further severe health complications.

Heart failure is one of the leading causes of death in chronic kidney disease, in part related to efforts of fluid balance.

What’s the recommended fluid intake for dialysis patients?

Dialysis patients are the one most likely to benefit from a fluid restriction. The recommended fluid intake in dialysis can be anywhere from one to three liters of fluid per day, depending on the dialysis modality, residual renal function, and individual fluid needs.

In the United States, every person on dialysis will be seen by a dietitian. Your dialysis dietitian will go over your food and fluid intake and needs to help guide you on if you’re getting enough, too much, or not enough fluid. 

If you have any questions about your fluid restriction on dialysis, speak with your dietitian first.

Examples when more fluid may be helpful

There are certain cases, even with kidney disease, when more fluids are important. Whether it’s more fluids or a fluid restriction in ckd, it’s an important conversation to have with your doctor and healthcare team.

Increasing fluid intake just because you have kidney disease may not be helpful, but there are some cases in which more fluids are important.

Polycystic Kidney Disease

Polycystic Kidney Disease, aka PKD or ADPKD, generally requires more fluids. This is especially important in the earlier stages of diagnosis of PKD. Fluid intake for polycystic kidney disease can be up to 3 liters of fluid per day to help reduce the amount of vasopressin in your body.

Kidney Stones

If you have kidney stones, your doctor may be telling you to drink more fluids to prevent kidney stone formation.

Kidney stones are produced with minerals collected in the kidneys or ureter and create mineral deposits. By drinking more fluids, there is a more continuous flushing of the kidneys and ureter to limit opportunities for these minerals to collect and form stones.

It’s still important to get a goal of fluid intake from your healthcare provider so you have a target amount to aim for that is relevant to your own needs.

Won’t I get dehydrated with a fluid restriction?

If you have a medically necessary fluid restriction, it’s not likely you’ll become dehydrated. This is because your doctor has found that too much fluid is more likely to cause problems with your health.

That being said, it’s still important to get fluids even with a fluid restriction. Your doctor or dietitian can give you a goal value to aim for each day when it comes to how much fluid you can and should have.

To prevent dehydration while on a fluid restriction, it’s important to keep a fluid log so you know how much you are getting. Other things to track with your fluid intake include your blood pressure and weight, which can also give more insight into your fluid balance.

Medications prescribed for fluid restrictions

If you are struggling with your fluid balance, your doctor may prescribe a diuretic to help your body remove excess fluid. These are to only be taken under the prescription from your doctor.

Diuretics help trigger your body to produce more urine so you eliminate more fluids. Examples of common diuretics include: 

  • Thiazides
    • Chlorothiazide
    • Chlorthalidone
    • Hydrochlorothiazide
    • Indapamide
    • Metolazone 
  • Loop diuretics
    • Bumetanide
    • Furosemide
    • Torsemide 
  • Potassium-sparing diuretics
    • Amiloride
    • Triamterene
    • Spironolactone 

Since diuretics help remove fluid from your body, they may also impact your potassium levels. Some diuretics can increase your potassium and some can decrease your potassium. For any concerns regarding your medications, speak with the prescribing physician.

Using a Fluid Restriction Log

If you have to restrict your fluid intake, you may find a log to be helpful. Here are some tips when it comes to successfully tracking your fluid balance.

Keep foods in mind

As mentioned above, many foods have high water content and can make a difference in how much fluid you’re actually consuming. By tracking a food and fluid restriction log, you’ll have a better idea of what you’re taking in. Your doctor will also be able to give you better recommendations if you have a detailed log to provide.

Weigh yourself regularly

It’s very important to track your weight when it comes to monitoring your fluid balance. Our body is made up of up to 60% water, but that can change significantly if your body cannot balance fluids on its own.

Some scales can even give you an estimate of your water percentage along with your weight. While the accuracy may not be 100%, it can be a great tool to track the trends (rather than the exact numbers).

Check your blood pressure 

Since your fluid balance can also impact your blood pressure, it can be helpful to track your blood pressure in a consistent manner. Adding your blood pressure to your fluid log, along with your weight, can give your doctor a great picture of how your fluid balance looks day-to-day.

Examples of fluid restriction in CKD

Below are some examples of what a day would look like with different fluid restrictions. 

Again, it’s important to note that you should only limit your fluids if you have been instructed to do so by your doctor. Following a fluid restriction without medical guidance can result in dehydration and electrolyte imbalances, among other complications.

Sample day with 1 L fluid restriction

Breakfast: ½ cup oats cooked with 8oz (1cup) water (240ml) + 8oz black coffee (240mL)

Snack: Whole grain crackers with peanut butter + 8oz of water (240ml)

Lunch: 1 cup kale salad with walnuts and feta 

Snack: Dry roasted edamame + 8oz of water (240ml)

Dinner: Spaghetti Squash with 1 oz Marinara Sauce (30mL) + chickpeas

Total fluids: 990 mL

Sample day with 1.5 L fluid restriction

Breakfast: ½ cup oats cooked with 8oz (1cup) water (240ml) + ½ cup strawberries (60mL) + 8oz black coffee (240mL) 

Snack: Whole grain crackers with peanut butter + 8oz water (240mL)

Lunch: 1 cup kale salad with walnuts, feta and ½ cup of grapes (60 mL) 

Snack: 1 cup almond yogurt (182mL) + ½ cup blueberries (60mL) + 1 glass of water (240ml)

Dinner: Spaghetti squash with 2oz marinara sauce (60mL) + chickpeas 

Dessert: ½ cup ice cream (64mL)

Total fluids: 1,446 mL

Sample day with 2 L fluid restriction

Breakfast: ½ cup oats cooked with 8oz (1cup) water (240ml) +½ cup strawberries (60mL) + 8oz black coffee (240mL) 

Snack: Whole grain crackers with peanut butter + 8oz water (240mL)

Lunch: 1 cup kale salad with walnuts, feta, 1 cup chopped tomatoes (120 mL) and 1 cup of grapes (120 mL) + 8oz water (240mL)

Snack: 1 cup almond yogurt (182mL) + 1 cup blueberries (120mL) + 1 glass of water (240ml)

Dinner: Spaghetti squash with 3oz Marinara Sauce (90mL) + chickpeas

Dessert: ½ cup ice cream (64mL)

Total fluids: 1,956 mL

Tips to following a fluid restriction when you’re thirsty

Following a fluid restriction can be a challenge, but it often comes down to having a list of solutions to prevent yourself from getting too thirsty or overdoing it with your fluids.

Brush your teeth regularly

Good dental hygiene is important for kidney disease for many reasons, including controlling your thirst! The recommendation is to brush twice daily after meals to keep your pearly whites and gums in top shape.

Go suck a lemon

This isn’t an insult- it’s actually a trick! Even if you don’t have lemon on hand, just imagine yourself biting into a big, juicy lemon wedge. Mouth watering yet?

Make flavored ice cubes

Create a tray of flavored ice cubes using fruit like berries, watermelon, cucumber, and yes, lemon! While ice still counts as a part of your fluid restriction, it’s generally giving you about half of what you’d drink if it were just water.

For more ideas, check out my article with tips for following your fluid restriction in the summer.

The main point behind a fluid restriction

The ultimate goal when it comes to a fluid restriction in CKD is to protect the kidneys from being overworked with excess fluid. This, in turn, also helps protect the heart and cardiovascular system from having to push more fluid through the body.

If you are instructed to limit your fluid intake, be sure to get a goal amount of fluid from your doctor or ask to work with a dietitian when it comes to best managing your fluid restriction.

Fluid Restriction in CKD: When it's critical and how much is too much. Blog by Jen Hernandez, Renal Dietitian of Plant-Powered Kidneys

6 thoughts on “Fluid Restriction in CKD: When it’s critical and how much is too much”

  1. Thanks Jen, this was a very insightful article on fluids. As one with Stage 2 CKD and KS it has always been confusing to hear the recommendation to drink more fluids so you make at least 2.5 liters of urine to reduce the risk of KS… Fluid overload has complications.

  2. When I was diagnosed stage four in 2009, my dietitian recommended 3 liters of water including other fluids. However, after my kidney recovered to stage 3 in two years, my nephrologist and dietitian reduced my fluid intake to two and half liters. I am following this since then and I do not have any problem with fluid intake. Thanks for the article which will be beneficial for those who have been suffering from kidney disease.

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