No daily fluid intake recommendation applies to all people with diabetic kidney disease. “Optimal water intake should be individualized, based on clinical assessment and risk factors rather than a universally recommended amount,” says Abbal Koirala, MBBS, assistant professor of medicine at Johns Hopkins University in Baltimore. “Both too much or too little water intake can be harmful, and the ideal range depends on a person’s stage of CKD, other medical problems they may have, such as heart failure, and their risk of fluid overload or low blood sodium, also known as hyponatremia.”
Boonphiphop Boonpheng, MD, assistant professor of medicine at University Hospitals of Ohio, suggests considering additional factors when determining ideal fluid intake:
- A person’s metabolism
- Transient losses (the small but constant loss of water through the skin and when exhaling)
- The impact of fever, sweating or exercise, especially in those who live in hot or humid climates
- Diarrhea
Dr. Boonpheng highlights other considerations that can make water recommendations in CKD and complex diabetes. “In cases of advanced kidney disease or for people on dialysis, you may need to limit your water intake to avoid low blood sodium levels,” says Boonpheng. “However, if you have a history of kidney stones, a higher fluid intake helps prevent recurrence. Aim for about 70 to 85 ounces (about 2 to 2.5 liters) of fluids per day, spaced throughout the day, and try sipping water after dinner. If your blood sugar is poorly controlled — above 180 mg/dL — your kidneys excrete excess sugar in urine, resulting in additional water loss. You may need to drink more to keep up.”
Hydration considerations can be even more complicated for people with advanced kidney disease. “People with stage 4 or 5 chronic kidney disease are often advised to limit their fluid intake to less than 1.5 liters per day to avoid hyponatremia, but a healthcare professional should adjust this based on hot climates or increased insensible losses,” says Dr. Koirala. If you’re not low-sodium, Koirala recommends drinking water if you’re thirsty.
Fluid Options for People with CKD and Diabetes
- Ice
- Soups
- Stews
- Protein drinks
- Dairy and non-dairy milk
- Frozen fruit
While these options offer some variety, extra caution may be necessary for some people who adhere to restricted fluid intake. “In most cases, people with CKD and type 2 diabetes do not need to closely monitor foods with high water content,” says Boonpheng. “The exception is when there are other electrolyte problems, such as low blood sodium. In these cases, it may be helpful to track total fluid intake, including soups, fruits, and other water-rich foods.”
Koirala recommends that people with advanced chronic kidney disease track their intake of foods with a high water content. “These may contribute to fluid retention in advanced CKD, leading to hyponatremia,” he says. He also suggests watching fruit and vegetable intake because of their potentially high potassium content, which may increase the risk of high potassium levels in people with advanced chronic kidney disease. Many people with advanced chronic kidney disease must limit their potassium intake.
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