Category: Nephrology · Kidney nutrition
How Does the Sweetener INS 968 (Erythritol) Affect the Kidneys? How It Is Cleared, How Much Is Reasonable at Each CKD Stage and on Dialysis, and the Heart Signal to Know
AI Overview / Quick Answer (BLUF)
INS 968 is erythritol, which does not raise blood sugar. About 78% leaves unchanged in urine within 24 hours. No direct kidney toxicity is known, but levels linger as kidney function falls, and studies link it to platelet activation, so keep amounts small, especially in late-stage CKD.
how the body handles erythritol (E 968) per the EFSA 2023 re-evaluation ·
blood levels in CKD and dialysis · the platelet and heart signal · reasonable amounts by kidney stage · other sweeteners.
General background on chronic kidney disease from MedlinePlus and eating with kidney disease from NIDDK ·
When to seek care ·
How the kidneys clear it ·
Heart signal ·
Amounts by CKD stage ·
FAQ
A Question From a Kidney Patient Group: How Much Does the Sweetener INS 968 Affect the Kidneys?
A member of a kidney patient group asked: “How does the sweetener INS 968 affect the kidneys, and how much?” The code is common on sugar-substitute labels, sugar-free coffee and tea, keto snacks, and powdered stevia or monk fruit sachets.
The short answer: based on current data, the kidneys are not directly harmed by this sweetener, but they are its main exit route. The less the kidneys filter, the longer it stays in the blood.
The more important recent question is about platelets and the heart, where people with kidney disease already carry high risk.
Seek Care Promptly (Red Flags)
- Chest pain or pressure, facial droop, one-sided weakness, slurred speech, or one red, swollen, painful leg — possible heart attack, stroke, or clot. Call emergency services.
- Diarrhea or vomiting so heavy you cannot eat or drink, or dizziness on standing — people with kidney disease dehydrate quickly and risk acute kidney injury.
- Very little urine or none for more than 12 hours (if you are not yet on dialysis).
- On dialysis: rapid weight gain between sessions, swelling, breathlessness, or being unable to lie flat — possible fluid overload. Contact your dialysis unit now.
- Irregular heartbeat, marked muscle weakness, or tingling around the mouth — possible high potassium, which needs an urgent blood test.
- If you have diabetes: sweating, palpitations, confusion, or drowsiness — possible very low or very high blood sugar, especially after changing diet or medicines on your own.
These symptoms are not always caused by a sweetener, but they are signs that people with kidney disease should not wait out, and medicines or supplements should not be adjusted on your own while waiting to be seen.
1. What INS 968 Is and How It Differs From Sugar
INS 968 (E968 in Europe) is the food-additive code for erythritol, a sugar alcohol found in small amounts in fruit and fermented foods.
The erythritol used in food is made industrially by yeast fermentation and purification (EFSA 2023),
so “natural” should not be read as safe at any dose.
How to read the label
Labels may say erythritol, INS 968, or E968. Many products sold as powdered or sachet “stevia” or “monk fruit” use erythritol as the main bulk,
because pure stevia and monk fruit extracts are so intensely sweet that they need a filler to be spoonable. Always check the first ingredients.
It does not raise blood sugar: this part is true
In volunteers given 1 g of erythritol per kg of body weight (Bornet 1996), blood glucose and insulin did not change over 3 hours.
Erythritol contains no nitrogen, so it does not add urea (BUN). That does not mean it places no load on the kidneys, because the kidneys remain its main exit route.
2. How the Body Handles Erythritol, and Where the Kidneys Come In
Direct answer: erythritol is almost fully absorbed in the small intestine, is not metabolized, and is filtered by the kidneys into urine unchanged. The kidneys are its exit route, not an organ it directly damages.
Rapid absorption, unchanged urinary excretion
In Bornet 1996, blood levels peaked at 90 minutes and then fell slowly; 30% was excreted in urine in the first 3 hours and 78% in 24 hours.
Less than 20% remained unabsorbed and reached the colon. A safety review (Munro 1998) found that at high doses about 90% leaves in urine.
EFSA 2023 adds that a small fraction is converted to a compound called erythronate.
All figures come from people with normal kidney function. The same excretion study has not been done in people with kidney disease.
Filtered, then partly reabsorbed
Renal clearance of erythritol is about half that of creatinine (Bornet 1996), meaning the kidney filters it and the tubules reabsorb part of it.
Even with healthy kidneys, blood levels fall slowly: in Witkowski 2023, healthy volunteers who drank an erythritol-sweetened beverage had raised blood levels for more than 2 days.
When the kidneys decline: longer time in the blood
Because the kidneys are the main exit route, clearance likely falls in step with the filtration rate (eGFR).
There is still no study in people with kidney disease that gave erythritol and measured blood levels over time, so this is inferred from mechanism.
Blood testing in kidney patients supports it: a 2026 study (Li 2026) found erythritol among the metabolites tied to lower kidney function, in both native CKD and kidney transplant recipients.
On dialysis: levels are already high without eating it
The body makes erythritol from glucose (Hootman 2017) and clears it through the kidneys.
In 10 hemodialysis patients (Roboz 1990), pre-dialysis erythritol was above the normal range in every patient, at 25.4–59.0 µmol/L.
A 4-hour session lowered it by about half, yet it stayed more than twice the upper normal limit; Niwa 1993 found a similar pattern.
Eating more simply adds a compound the body already struggles to remove.
3. Does Erythritol Harm the Kidneys?
No direct kidney toxicity found
Animal studies feeding diets with up to 20% erythritol and short human studies found no toxicity to the kidneys or other organs (Munro 1998).
EFSA 2023 set the acceptable daily intake (ADI) at 0.5 g per kg of body weight, based on the dose that starts causing diarrhea in healthy people, because diarrhea can lead to fluid and electrolyte loss.
This value was not designed for people with kidney disease, and EFSA noted that high consumers may exceed it.
Sugar-free drinks and the kidneys: an observational signal
In 3,256 women followed for 11 years (Lin 2011), drinking 2 or more diet sodas a day was linked to 2.02 times the odds of an eGFR decline of 30% or more.
Fewer than 2 a day showed no added risk. The study was observational and the sweeteners of that era were not erythritol, so it only suggests that heavy daily use should not be assumed safe just because it is sugar-free.
4. The Platelet and Heart Signal: Why Kidney Patients Should Know
People with chronic kidney disease have higher cardiovascular risk than the general population, and it rises with CKD stage (KDIGO 2024).
That makes recent erythritol data especially relevant to this group.
Three patient cohorts: high levels tracked with heart attack and stroke
Witkowski 2023 tested blood from 1,157 people undergoing cardiac evaluation, then confirmed the finding in US (2,149) and European (833) cohorts.
People in the top quarter of erythritol levels had 1.80 and 2.21 times the 3-year risk of heart attack, stroke, or death compared with the lowest quarter.
In the lab, erythritol at levels seen in blood made platelets more reactive and sped up clot formation in animals.
Volunteer trial: 30 g raised blood levels more than 1,000-fold
Witkowski 2024 gave healthy volunteers (10 per group) 30 g of erythritol or 30 g of glucose.
In the erythritol group, blood levels rose from 3.75 to 6,480 µmol/L and platelet reactivity increased in every participant; glucose had no such effect.
30 g is about 7–8 teaspoons, close to the amount in one sugar-free drink or dessert, and close to the ADI for a 60 kg adult.
Xylitol shows a similar signal
The same group found that high blood xylitol was linked to 1.57 times the risk of cardiovascular events and also made platelets more reactive (Witkowski 2024 EHJ).
Switching from erythritol to another sugar alcohol does not solve the problem.
The counterpoint: a marker, not necessarily a cause
The body makes more erythritol when blood sugar is high or metabolism is stressed, so blood levels may reflect underlying health more than diet (Mazi 2023).
People with high levels from inherited disorders do not show more clotting, and genetic analyses have not linked sugar alcohols to heart disease (Wölnerhanssen 2025).
The most accurate conclusion: no long-term trial has shown erythritol causes heart events, but kidney patients keep it in the blood longer and carry higher heart risk, so caution is reasonable.
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The score sorts symptoms by urgency only; it does not diagnose any disease.
5. How Much INS 968 Is Reasonable at Each CKD Stage
No clinical guideline sets an erythritol amount for people with kidney disease. This table is this article’s cautious approach, based on the clearance mechanism and blood-level data above.
The KDOQI 2020 guideline recommends individualized nutrition advice from a renal dietitian for CKD stages 3–5 and dialysis, which should be used alongside this table.
| CKD stage | eGFR (mL/min/1.73 m²) | How well the kidneys clear erythritol | Cautious approach | What matters more |
|---|---|---|---|---|
| Stages 1–2 | 60 or higher | Close to normal | Small amounts such as 1–2 teaspoons a day; avoid daily high-dose drinks | Blood pressure, glucose, albuminuria, and weight |
| Stages 3a–3b | 30–59 | Down to about half or less | Small amounts and not every day; skip keto snacks or sugar-free drinks with large doses | Salt, phosphate additives, kidney-adjusted medicine doses |
| Stage 4 | 15–29 | Very slow; lingers longer in the blood | As little as possible or avoid; ask a renal dietitian | Potassium, phosphorus, fluid, planned protein |
| Stage 5, hemodialysis, or peritoneal dialysis | Below 15 or on dialysis | Almost none; pre-dialysis levels already high; a 4-hour session removes about half | Avoid regular use | Weight gain between sessions, potassium, phosphorus |
| Kidney transplant | Depends on graft function | Depends on the graft eGFR | Follow the row for your current eGFR | Immunosuppressants, blood glucose, blood pressure |
One teaspoon of erythritol weighs about 4 g. The table is not a medical standard; follow the advice of your own doctor or renal dietitian.
6. Real-Life Amounts and Common Misunderstandings
The ADI of 0.5 g per kg is not a target for kidney patients
For a 60 kg adult, the EFSA ADI equals 30 g a day, about 7–8 teaspoons — the same amount that raised blood levels more than 1,000-fold in Witkowski 2024.
The ADI was set to prevent diarrhea in people with normal kidneys and does not account for slower clearance in kidney disease, so it should not be used as a target.
Hidden sources that add up
- Powdered stevia or monk fruit sachets that use erythritol as the main bulk
- Keto snacks, sugar-free cakes, cookies, and ice cream, which may hold several teaspoons per serving
- Sugar-free coffee, tea, and café drinks made with substitute syrups
- Sugar-free gum and candy, which often add xylitol or sorbitol
No need to drink extra water to clear erythritol
How fast erythritol leaves depends on the kidney filtration rate, not on how much you drink. There is no need to drink extra water to flush it.
People with CKD stages 1–3 can drink to thirst, while stages 4–5 and dialysis often require a fluid limit set by the doctor. Drinking extra on your own can cause fluid overload, swelling, higher blood pressure, and breathlessness.
Bloating, nausea, diarrhea: it depends on the dose per serving
A randomized trial in 64 adults (Storey 2007) found that 20 g and 35 g of erythritol in a drink did not increase digestive symptoms.
At 50 g, nausea and gut rumbling appeared, while xylitol caused more watery stools at every dose. For kidney patients, diarrhea matters more than for others because fluid and electrolytes are lost quickly.
7. Comparing Sweeteners for People With Kidney Disease
Comparison table of sugar alternatives
| Option | Sweetness and energy | How the body removes it | Notes for kidney patients |
|---|---|---|---|
| Table sugar | Reference; 4 kcal/g | Burned for energy | Raises blood glucose and weight; small amounts within the meal plan |
| Erythritol (INS 968) | 60–70% of sugar; very low energy | Mainly excreted unchanged by the kidneys | Lingers in advanced CKD; platelet signal; use small amounts |
| Xylitol (INS 967) and sorbitol (INS 420) | Similar to or less sweet than sugar; some energy | Partly metabolized by the liver; the rest reaches the colon | More diarrhea; xylitol shows a similar platelet signal |
| Stevia extract (INS 960) | Hundreds of times sweeter; almost no energy | Broken down by gut bacteria, modified by the liver, excreted in urine | Used in milligram amounts, but many powders are mostly erythritol; check the label |
| Monk fruit (mogrosides) | Hundreds of times sweeter; almost no energy | Mostly broken down in the gut | Limited long-term human data; powders are often blended with erythritol |
| Sucralose (INS 955) | Hundreds of times sweeter; almost no energy | Mostly not absorbed; leaves in stool | Limited data in kidney disease; use small amounts |
| Gradually lowering the sweetness you expect | Lowers both sweetness and energy | Adds nothing for the kidneys to clear | Safest long-term option; the palate usually adapts within weeks |
Substance names and INS codes only; no brand names. The World Health Organization advises against using non-sugar sweeteners for long-term weight control (2023).
People with diabetes who switch from sugar should review medicines and glucose targets with their doctor at the same time.
A step-by-step plan to lower sweetness
Common Beliefs vs. What the Evidence Shows
“INS 968 is natural, so any amount is safe”
Food erythritol is made industrially by fermentation, and safety depends on dose. EFSA set an ADI of 0.5 g per kg per day and found that high consumers may exceed it.
“It has almost no calories, so there is no limit”
Low energy does not mean no other effects. Large single doses cause bloating or nausea, and 30 g raised blood levels more than 1,000-fold with more reactive platelets in volunteers.
“Using it instead of sugar protects the kidneys from diabetes”
It does cut dietary sugar, but no trial shows that switching to erythritol slows kidney decline. What clearly helps is controlling HbA1c and blood pressure and taking kidney-protective medicines as prescribed.
“Drinking lots of water helps the kidneys flush sweeteners out”
Clearance depends on the filtration rate, not water intake, and people with stage 4–5 CKD or on dialysis often need a fluid limit. Drinking extra on your own can cause fluid overload.
“Early-stage CKD can use it freely without thinking about amounts”
No study at any CKD stage has tracked long-term outcomes. By stage 3, clearance is already about halved, and every stage carries higher heart risk than the general population, so small amounts are sensible at every stage.
Frequently Asked Questions (FAQ)
What is INS 968, and how is it different from sugar?
INS 968 (E968) is the food-additive code for erythritol, a sugar alcohol made industrially by yeast fermentation. It is about 60 to 70 percent as sweet as table sugar, provides very little energy, and does not raise blood glucose or insulin. Unlike sugar, which provides 4 kcal per gram, erythritol is mostly not metabolized, and the kidneys are its main exit route.
Does erythritol damage the kidneys?
Based on current data, erythritol has not been shown to be directly toxic to kidney tissue. Animal safety studies and studies in healthy people found no kidney harm, but there is still no study in people with kidney disease that follows long-term outcomes. The real issue is that the kidneys are its main exit route, so levels linger longer as kidney function falls, and recent research links high levels to more reactive platelets.
How much INS 968 is reasonable at each CKD stage?
No clinical guideline sets an amount for people with kidney disease. This article’s cautious approach is: stages 1 to 2, small amounts such as 1 to 2 teaspoons a day; stage 3, small amounts and not every day, avoiding regular high-dose drinks; stages 4 to 5 and dialysis, use as little as possible or avoid, and ask your own doctor or renal dietitian.
Can people on hemodialysis or peritoneal dialysis use erythritol?
Regular use is best avoided. A study of 10 hemodialysis patients found pre-dialysis erythritol above the normal range in every patient, without any reported intake, because the body makes it and failed kidneys cannot clear it. A 4-hour session lowered levels by about half, yet they stayed more than twice the upper normal limit, so adding more from food is not advisable.
Should I drink more water to help my kidneys flush out erythritol?
There is no need to drink extra water to clear erythritol. How fast it leaves depends on the kidney filtration rate, not on how much you drink. People with stage 1 to 3 CKD can drink to thirst, while stages 4 to 5 and dialysis often require a fluid limit set by the doctor. Drinking extra on your own can cause fluid overload, swelling, and breathlessness.
Is erythritol really linked to heart attack and stroke?
There is a signal but no proof of cause. A 2023 study found that people with the highest blood erythritol had 1.80 to 2.21 times the 3-year risk of heart attack, stroke, or death, and a trial in 10 volunteers found that 30 g of erythritol raised blood levels more than 1,000-fold and made platelets more reactive. Critics argue blood levels may simply mark metabolic stress. People with kidney disease already carry high heart risk, so caution is reasonable.
What can I use instead: stevia, monk fruit, or sucralose?
Stevia extract, monk fruit, and sucralose are hundreds of times sweeter than sugar, so they are used in milligram amounts rather than spoonfuls. However, many powdered or sachet products use erythritol as the main bulk, so check the label for INS 968. Xylitol causes diarrhea more easily and shows a similar platelet signal. The best long-term option is to gradually lower the sweetness your palate expects.
I have diabetes and kidney disease. Does switching from sugar to INS 968 help my kidneys?
It lowers sugar from food, but no trial shows that switching to erythritol slows kidney decline. What clearly helps the kidneys is controlling HbA1c and blood pressure, cutting salt, and taking kidney-protective medicines as prescribed. A study of 3,256 women also found that drinking 2 or more diet sodas a day was linked to 2.02 times the odds of faster kidney decline, although it was observational and did not study erythritol itself.
Scientific Mechanism: From the Gut, Through the Glomerulus, to the Platelet
Summary by Asst. Prof. Dr. Norawit Raatpiboon:
erythritol is a small four-carbon molecule that crosses the small-intestine wall quickly. Human enzymes barely break it down, so it yields no glucose and does not trigger insulin.
In the blood it is filtered by the glomerulus and partly reabsorbed by the tubules, so its clearance is about half that of creatinine.
As glomeruli are lost in chronic kidney disease, the main exit narrows and post-meal levels likely persist longer. Because the body also makes erythritol from glucose via the pentose phosphate pathway, people on dialysis have high baseline levels even without eating it,
and a hemodialysis session removes about half. On the vascular side, high erythritol makes platelets respond more strongly to stimuli and release factors that promote clotting,
while kidney patients already have stiff arteries and abnormal platelet function. That is why this article recommends using less as kidney function falls, even though erythritol does not directly damage kidney tissue.
E-E-A-T and Academic Citations
Written and reviewed by Asst. Prof. Dr. Norawit Raatpiboon (ผศ.ดร.นรวิชญ์ ราษฎร์พิบูลย์)
from peer-reviewed research and clinical guidelines indexed in PubMed and the EFSA assessment.
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- Munro IC, et al. Erythritol: an interpretive summary of biochemical, metabolic, toxicological and clinical data. Food Chem Toxicol. 1998. PubMed 9862657
- EFSA FAF Panel. Re-evaluation of erythritol (E 968) as a food additive. EFSA J. 2023. PubMed 38125972 · EFSA plain-language summary
- Hootman KC, et al. Erythritol is a pentose-phosphate pathway metabolite and associated with adiposity gain in young adults. Proc Natl Acad Sci U S A. 2017. PubMed 28484010
- Roboz J, et al. Polyol concentrations in serum during hemodialysis. Clin Chem. 1990. PubMed 2253350
- Niwa T, et al. Analysis of polyols in uremic serum by liquid chromatography combined with atmospheric pressure chemical ionization mass spectrometry. J Chromatogr. 1993. PubMed 8458907
- Li Y, et al. Serum metabolites in relation to kidney function in non-transplant and kidney transplant settings. BMC Nephrol. 2026. PubMed 42056966
- Witkowski M, et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med. 2023. PubMed 36849732
- Witkowski M, et al. Ingestion of the non-nutritive sweetener erythritol, but not glucose, enhances platelet reactivity and thrombosis potential in healthy volunteers. Arterioscler Thromb Vasc Biol. 2024. PubMed 39114916
- Witkowski M, et al. Xylitol is prothrombotic and associated with cardiovascular risk. Eur Heart J. 2024. PubMed 38842092
- Mazi TA, et al. Elevated erythritol: a marker of metabolic dysregulation or contributor to the pathogenesis of cardiometabolic disease? Nutrients. 2023. PubMed 37764794
- Wölnerhanssen BK, et al. Sweeteners: erythritol, xylitol and cardiovascular risk-friend or foe? Cardiovasc Res. 2025. PubMed 40444390
- Storey D, et al. Gastrointestinal tolerance of erythritol and xylitol ingested in a liquid. Eur J Clin Nutr. 2007. PubMed 16988647
- Lin J, Curhan GC. Associations of sugar and artificially sweetened soda with albuminuria and kidney function decline in women. Clin J Am Soc Nephrol. 2011. PubMed 20884773
- Ikizler TA, et al. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis. 2020. PubMed 32829751
- KDIGO CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. Kidney Int. 2024. PubMed 38490803
Medical Disclaimer
This article is general education, not a diagnosis, prescription, or individual medical advice.
The right amount of any sweetener for a person with kidney disease depends on CKD stage, blood results, other conditions, and dialysis status; ask your own doctor or renal dietitian.
Do not start or stop medicines on your own. If you have any symptom listed under Seek Care Promptly, go to a hospital or call emergency services.