Health Advice

Dietary and Nutrition Management for Dialysis

Hands holding a paper cut out of a kidney

Article by: Consultant Dietitian Charity Chin


What is Dialysis?

Dietary and nutrition management for dialysis is essential for individuals undergoing treatment due to kidney failure. When kidneys fail, they no longer effectively filter blood, leading to the accumulation of wastes and toxins. Dialysis serves as a substitute for kidney function, eliminating concentrated molecules, waste products, and excess fluid from the bloodstream through diffusion and ultra-filtration mechanisms.

Who Needs Dialysis?

Usually people who have kidney failure, or end-stage renal disease (ESRD) may need dialysis. Patients begin dialysis when their blood contains a higher-than-normal range of electrolytes and waste products with the glomerular filtration rate (GFR) reaching approximately less than 15mL/min.

Types of Diabetes

There are two types of dialysis: hemodialysis (HD) and peritoneal dialysis (PD). Both perform normal kidney functions, filtering waste and excess fluid from the blood.

Hemodialysis (HD) is a machine that removes blood from the body by filtering it through a dialyzer (artificial kidney) and returns the cleaned blood to the body. This process usually will take about 3–5-hours, three times a week, that may take place in a hospital or dialysis centre. Some individuals may also do hemodialysis at home. At home treatment may need four to seven times per week for fewer hours each session. Some may choose to do it at night while they sleep.

Peritoneal dialysis (PD) is a tiny blood vessel inside the abdominal lining (peritoneum) that filters blood through the aid of dialysis solution. This solution is a type of cleansing liquid that contains water, salt, and other additives. PD takes place at home which allows one to go about their usual activities while the dialysis solution inside the peritoneal cavity absorbs the extra waste and fluids from the body. The process can take 60-90 minutes, up to four times a day, and sleep with the solution in the stomach all night. Some may prefer to do PD at night during their sleep.

Dietary and Nutrition Management for Dialysis

According to the 2020 update KDOQI Clinical Practice Guideline for Nutrition in Chronic Kidney Disease recommended Medical Nutrition Therapy (MNT), energy, and protein to be included to enhance patient care. MNT recommendation is to optimize the nutritional care by tailoring it to the individuals’ needs, nutritional status, and comorbid conditions to prevent and/or to minimize the complications and eventually to reduce the risk of unfavorable results.

The three main areas covered in MNT include macronutrients, micronutrients, and electrolytes. In adults with CKD on dialysis, it is important that the patient’s diet maintains serum phosphorus and potassium in the normal range. Dietary protein prescription of 1.0g/kg to 1.2g/kg body weight to maintain a stable nutritional status in recommended (Ikizler,2020) with at least 50% of the dietary protein as high biological value such as eggs, poultry, fish, meats, peas, soy and dairy products which provide a complete, essential amino acid profile. Sodium evidence has shown is more consistent that limiting the intake to less than 2.3g/day may reduce blood pressure and improve control in patients.

Hemodialysis patients are at risk of lipid metabolism; therefore, it is recommended that calories from fat to be less than 30% and less than 10% from saturated fat. Daily cholesterol intake should also be less than 300mg and achieve a daily fiber intake of 20-25g. Study has also shown that patients who follow an exercise regimen compared to those who do not exercise have a decrease in mortality. Routine supplementation of vitamin A and E in dialysis patients is also not recommended due to the potential for vitamin toxicity. If necessary, use caution and monitor for toxicity.

According to the Academy of Nutrition and Dietetics’ Nutrition Care Manual, the daily recommended nutrient intakes for adults on dialysis are as follows:

  • Protein: 1.2g/kg average weight (50% high biological value)
Energy for adults
<60 y/o, 35kcal/kg standard body weight
>60 y/o or obese 30-35kcal/kg
Lower calorie level suggested for older adults with a more sedentary lifestyle and an overall loss in lean body mass.
Higher calorie level suggested for patients who are extremely high activity levels, who are underweight, or who have catabolic stress.
Sodium and Fluids
>1 L fluid output, 2-4g Na and 2L fluid
<1 L fluid output, 2g Na and 1-1.5L fluid
Anuria (without urine output) 2g Na and 1L fluid
Try to limit Na intake to less than 2.3g/day to reduce blood pressure and improve volume control.
High sodium diet can lead to excessive fluid intake.
Fluid intake may need to be restricted. Additional fluid can build up in the body causing harmful health effects such as edema, difficulty breathing, high blood pressure and heart problems.
  • Potassium: 40mg/kg ideal body weight ||  It is important to adjust and maintain serum potassium within normal range
  • Phosphorus: 800-1000mg or <17 mg/kg ideal body weight or standard body weight
    Avoid processed, packaged, and fast foods as they typically contain added phosphorus.
  • Calcium: Adjust calcium intake while considering the concurrent use of vitamin D to avoid hypercalcemia or calcium overload.
  • Magnesium: 0.2-0.3 g

Dietary and Nutrition Management for DialysisPhosphorus Food Choices

  • Grain and baked goods:
    Lower: fresh breads, plain cereals (oatmeal, corn flakes)
    Higher: processed breads and cereal, biscuits, brownies, cakes, muffins, ready-to-eat waffles
  • Protein foods:
    Lower: all-natural chicken, turkey / seafood, lean and fresh beef, pork, whole eggs or egg whites, tofu, beans, hummus (1/4-1/3 cup), unsalted nuts (1/4 cup)
    Higher: processed meats (bacon, ham, hotdogs, chicken nuggets, sausage), breaded/fried meats, organ meats (kidney/liver)
  • Dairy and dairy alternatives:
    Lower: unfortified dairy alternatives (almond/rice beverages), milk or soy beverage (1/2 cup), cottage cheese with no “phos” ingredients (1/2 cup), yogurt (all natural, unsweetened, or plain)
    Higher: non-dairy creamers, processed cheese, fat free cream
  • Vegetables
    Lower: fresh, frozen, or canned without added “phos” ingredients
    Higher: vegetables with sauces added
  • Fruits:
    Lower: fresh, frozen, or canned without added “phos” ingredients
    Higher: fresh, frozen, or canned with added “phos” ingredients
  • Beverages:
    Lower: water, fresh brewed coffee/tea, fresh lemonade
    Higher: most colas, energy and sports drinks, canned/bottled coffees and teas, flavoured water, beers, wines

Dietary and Nutrition Management for DialysisPotassium Food Choices

Most foods have some potassium, but vegetables and fruits are the easiest way to control the diet. Potassium level is a very much concern for patients who are on dialysis. High levels of potassium are one of the most common causes of kidney failure, so one needs to limit their daily intake according to their individual needs. A tip for dietary and nutrition management for dialysis is that consumers should be aware that products labelled “low salt” or “low sodium” may have more potassium since potassium is used as a salt substitute.

Lower = <200mg/servingHigher = 200mg or more/serving

Serving size of food is ½ cup, 1 small fruit, or 1 cup leafy green unless otherwise noted. Potassium levels may change if a food is fresh, cooked, or canned.

  • Vegetables:
    Lower: asparagus, broccoli, bean sprouts, cabbage (red/green), carrots, cauliflower, celery, corn, cucumbers, eggplant, greens (kale, mustard greens, watercress), peppers, lettuce, leeks, mushroom, onions, radish

    Higher: avocado, beets, brussels sprouts, Chinese cabbage/bok choy, potatoes (white, sweet, yams), pumpkin, spinach, tomatoes
  • Fruits:
    Lower: apple, berries, grape, grapefruit (1/2), lemon and limes, pear, watermelon, fruit juice (apple, cranberry, grape, pineapple)

    Higher: bananas, dried fruits (apricots, dates, figs, prunes, raisins – ¼ cup), kiwi, melon (cantaloupe, honeydew), orange (fresh, 1 medium), papaya (1/2 medium), peach, plantain, pomegranate, fruit juice (pomegranate, prune, orange, carrot)
  • Grains:
    Lower: cereal, whole grain and plain (1 cup), oatmeal (1 cup), bread, whole grain, raisin, white (1 slice), pasta (whole grain & white), rice (white/brown)

    Higher: bran cereals, granola
  • Protein foods:
    Lower: peanut butter (1 tbsp), hummus (1/4 cup), tofu (firm, soft, silken), vegetarian patty

    Higher: legumes (black, kidney, pinto, lentils, chickpeas), beef, fish poultry, nuts, soy (soy nuts, tofu – extra firm/lite)
  • Beverages:
    Lower: lemonade, tea

    Higher: coconut water, low-sodium broths and soups (bouillon cube), bottled/instant tea

Dietary and Nutrition Management for DialysisKidney Management

  • High blood potassium levels (hyperkalemia)

    Choose low-potassium fruits and vegetables
    Limit high potassium intake
    Limit meat serving size
    Limit daily dairy intake to ½ cup milk or ½ cup yogurt
    When considering your potassium intake, it’s beneficial to opt for low-potassium juice alternatives, such as apple or grape juice. By selecting these options, you can effectively manage your potassium levels and maintain optimal health.
  • Fluid overload

    Keep track of all fluids
    Fluids encompass a wide range of options, encompassing not only beverages but also other substances. These include liquid at room temperature, as well as items like soap, ice-cream, sorbet, popsicles, and ice. It’s important to recognize that hydration can come from various sources beyond traditional drinks, providing flexibility in meeting your fluid intake goals.
  • Dry mouth

    To maintain optimal health, it’s advisable to reduce sodium/salt intake to less than 2300mg/day. This step is crucial as excessive sodium consumption has been linked to various health concerns. By limiting salt intake, you can effectively manage blood pressure levels and decrease the risk of cardiovascular issues. Additionally, adopting a lower-sodium diet contributes to overall well-being and supports a healthier lifestyle.
    Keep lips and mouth moist by rinsing mouth, brushing teeth, usually spray bottle with water.
  • Nausea/vomiting

    Eat small meals or snacks
    Avoid skipping meals or eating large meals
    Use ginger tea to relieve nausea
  • Constipation

    Avoid fried and high fat foods
    Eat high-fiber food
    Participate in physical activity is able

Conclusion

Patients with CKD/ESRD undergoing dialysis require special dietary considerations. They need to adjust their intake of certain foods. Diet counseling and nutrition education are recommended for prevention and management. It’s crucial to consume the right amounts of protein, calories, fluids, vitamins, and minerals daily to optimize health and reduce mortality. Successful dietary management requires personalized intervention and monitoring. Consultation with your clinician is essential for better care.


References:

  1. Ikizler T, A, Cuppari L: The 2020 Updated KDOQI Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease. Blood Purif 2021; 50:667-671.
  2. Ikizler T, Burrowes JD, Byham-Gray LD, Teta D, Wang AY-M. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. American Journal of Kidney Diseases. 2020 [cited 2022Mar.6]. Available from: https://www.ajkd.org/article/S0272-6386(20)30726-5/fulltext
  3. Dialysis: Types, How It Works, Procedure & Side Effects. Cleveland Clinic. 2021 [cited 2022Mar.6]. Available from: https://my.clevelandclinic.org/health/treatments/14618-dialysis
  4. Byham-Gray L, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. American Dietetic Association; 2004.
  5. De Waal D, Heaslip E, Callas P. Medical Nutrition Therapy for Chronic Kidney Disease Improves Biomarkers and Slows Time to Dialysis. Journal of Renal Nutrition. 2016;26(1):1-.
  6. Phosphorus Content of Foods. Nutrition Care Manual. [cited 2022Mar.6]. Available from: https://www.nutritioncaremanual.org/
  7. Potassium Content of Foods. Nutrition Care Manual. [cited 2022Mar.6]. Available from: https://www.nutritioncaremanual.org/
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