Nutrition for People on In-center Hemodialysis

• The main goal of the diet is to help the patient have good nutrition while keeping the build-up of wastes between treatments to a minimum.
• The in-center HD diet is based on the following food groups:
     • Meat and meat substitutes
       (beef, pork, chicken, eggs, fish, cheese, peanut butter, tofu, and vegetarian meat products)
    • Dairy (including milk, ice cream, yogurt, and pudding)
     • Bread and starches
     • Vegetables and fruits
     • Fats (includes butter and oils) ,„ Calorie boosters (hard candy or jelly beans)
     • Miscellaneous (spices and condiments)

Proteins
• All foods contain large or small amounts of protein.
• Types:
     • High biological value (HBV) or animal protein
       (meat, fish, poultry, eggs, tofu, soy milk, and dairy products)
     • Low biological value (LBV) or plant protein
       (breads, grains, vegetables, dried beans and peas, and fruits)

In the body, proteins:
• Aid growth and maintain body tissues
• Provide energy
• Keep fluid balance in the body
• Form parts of enzyme, hormones, and growth factor
• Form parts of antibodies
• People on Hemodialysis should eat 1.2 grams per kilogram (kg) of body weight per day; half of this should be animal protein.

• After protein is eaten, nitrogenous wastes, such as urea and creatinine, are left over.
• Creatinine is a normal by product of muscle metabolism that healthy kidneys remove.
• Like BUN, high creatinine levels may suggest poor dialysis, but low levels alone don't mean the patient is getting adequate dialysis. Low creatinine levels may occur in patients with poor muscle mass.

Calories
• Calories in food provide energy to run the body
• People on dialysis must eat enough calories to meet their energy needs - or they become malnourished; they will burn protein for fuel
• It is vital to note loss of lean body mass and not mistake it for fluid removal from treatment.
• Signs that a patient has lost body weight, even if postdialysis weight is unchanged, include: fluid buildup in the ankles and fingers, shortness of breath, or the patient saying he or she can't lay flat in bed.

Malnutrition
• Studies have found that many hemodialysis patients are malnourished
• Patients whose serum albumin (protein) levels are less than 4.0 g/dL are more likely to die
• The risk of death also rises as cholesterol levels fall, because low cholesterol also indicates poor nutrition.

Other factors that raise the chances of malnutrition in people on dialysis:
• Metabolic acidosis (a shift of the body's acid-base balance toward acid)
• Illnesses besides kidney failure
• Too many diet limits
• Loss of nutrients during dialysis
• Not enough dialysis
• Hospitalization and surgeries
• Chronic inflammation and infection

Treatment of malnutrition:
• The first step is to try to get the patient to eat more
• If this does not work, oral supplements (nutritional drinks, protein powders, and bars)
• If supplements don't work, tube feedings are a next step
• If tube feedings fails, intradialytic parenteral nutrition (IDPN) or total parenteral nutrition (TPN) - intravenous feeding of a special solution that may have carbohydrates, protein, fat, sugars, and amino acids - may be used.

How You Can help Your Patients Achieve Better Nutrition Status
• At each treatment, ask your patients how they are eating Tell the dietitian and nurse about any changes in appetite, taste, Gl problems (feeling full after very little food, constipation, diarrhea, bloating and heartburn, nausea or vomiting), or trouble keeping blood sugar levels in control.
• Tell the dietitian and social worker if a patient is missing meals due to dialysis treatment times or can't afford to buy food.
• Tell the dietitian and nurse when a patient consistently arrives below dry weight Any unplanned weight loss or low energy level may mean there are nutrition concerns
• For diabetic patients, tell the dietitian if a patient tells you that he/she is having trouble eating or keeping blood sugar under control.
• Encourage patients to follow their fluid and sodium limits. Tell the nurse or dietitian is a patient gains a lot of fluid between treatments.
• Encourage patients to eat as much as they can, but follow the prescribed meal plan.
• Remind patients to take their binders with meals and/or snacks and other drugs and nutritional supplements as prescribed.
• Encourage patients to come for their treatments and stay for the whole time. Tell the nurse and the dietitian if a patient is having problems with treatments that may affect adequacy, like not getting the prescribed blood flow or problems with needle sticks.
• Get involved with patient education.                      |

FLUIDS
• Once the kidneys fail, they make little or no urine. So almost all of the excess fluid patients eat or drink must be removed by dialysis.
• Less obvious forms of fluid loss: breathing, stool, perspiration, etc. use up about 600 mL of fluid each day.
• Fluid limit (most often for in-center HD patients) is the volume of the patient's urine output plus 1 liter (4 cups) per day.
•  Part of the predialysis assessment is figuring out how much water to remove at each treatment.
• Ideally, each treatment will remove the amount of fluid the patient gained between treatments.
• Dry weight is the postdialysis weight at which all or most excess fluid has been removed.
• People at their true dry weight should feel well, have no excess fluid or trouble breathing, and need few, if
any, blood pressure pills.
• If a treatment removes too much fluid, or removes it too quickly, the patient will have hypotension (low blood pressure) painful muscle cramps, dizziness, nausea and vomiting, and may pass out. The patient feel "washed out" and ill for a few hours after the treatment.
• If not enough fluid is removed by a treatment, the patient must try to be even stricter with fluid intake - a discouraging task!
• In the long term, fluid overload can cause congestive heart failure (CHF; the heart cannot pump out all the blood it receives).
• Signs include edema and shortness of breath.


Helpful Hints for Patients About Thirst and Fluid
• Avoid salty or sugary foods that make you thirsty.
• Ask your doctor or pharmacist if any of your drugs have thirst or dry mouth as a side effects. If so, ask your doctor if there is a substitute that doesn't have this problem.
• Know your fluids (all foods that are liquid at room temperature - like popsicles and ice cream - are fluids).
• Use small cups or glasses instead of large ones.
• Know how much fluid your favorite glass holds. Use small cup size, such as an S ounce cup.
•  Quench thirst with hard candies, (Use sugar-free candies if you have diabetes).
• Brush your teeth or rinse your mouth with mouthwash.
• Rinse your mouth with cold water or cold mouthwash, then spit it out.
•  Suck on frozen grapes or ice cubes.
• Use lemon wedges to help stimulate saliva.
• Make your own popsicles out of a low potassium juice (e.g., grape)
• Ask the wait staff not to refill your glass when you eat out. Ask for a cup of ice and a bit of fluid and take small sips (limit to 1 cup).
• Take pills with pudding or applesauce instead of fluid.
• Measure your fluids. Fill a quart jug of water each morning with your daily fluid limit. Use water from this jug all day. If you drink other fluid, pour that amount out of the jug.

Sodium
• Is found naturally in foods and is the major part of table salt.
• 1/2 teaspoon of salt == has more than 1 gram or 1000 mg of sodium.
• Dialysis patients should not use table salt or most salt substitutes (which have potassium), or eat most foods that are processed with added salt.
• Sodium causes thirst and plays a role in high blood pressure and fluid weight gain.
• Sodium that is retained in the body attracts fluid, which causes swelling.
• Unhealthy kidneys cannot remove excess sodium. Patients must reduce their intake of both sodium and fluids if they develop edema in the face, hands, or feet; if their blood pressure rises; or if they gain weight rapidly.
• Patients who limit sodium in their diet are usually less thirsty - this makes it easier to control their fluid intake.
•  Recommended sodium limit for in-center Hemodialysis is most often 2-4 grams (87-174mEq) per day.
•  This level can be reached by avoiding table and cooking salt, canned foods, packaged "helper" foods,
pickled foods, and preserved meats, such as cold cuts, sausages, and hot dogs.
• Encourage patients to read labels and try no-salt-added herbs and spices (e.g.' basil, lemon pepper, and Mrs.Dash),

Potassium
• A well dialyzed patient should be able maintain a normal range of serum potassium (3.5 - 5.5 mEq) with a diet that includes 2-3 grams (51-77 mEq) of potassium or 1 mEq/gm of protein.
i Patients can leam to limit the obvious high-potassium foods - espresso/cappuccino, avocados, mangos, bananas, orange juice, dried fruit, cantaloupe, dried peas and beans, tomato sauce, and potatoes.
i Patients should also leam proper portion sizes.

Facts About Potassium that Patients Need to Know
« Potassium overload can cause sudden death. » Symptoms ofhyperkalemia include muscle weakness,
abnormal heart rhythms, and cardiac arrest. » Most salt substitutes have potassium-it Hyperkalemia may occur most often after a weekend -
the longest period between in-center HD treatments.

Hemodialysis Care Team

PATIENT:
• Leam about kidney failure and its treatment
• Have input into the care plan, then follow it (diet and fluid limits, drugs, dialysis)
• Tell the care team about symptoms or problems.
• Know his or her rights and responsibilities.

NEPHROLOGIST:
• Licensed physician who specializes in kidney disease
• He/she establishes the plan of care with the other care team members, prescribes the patient's treatment and medications, orders blood tests, and makes changes as needed based on a patient assessment

NURSE:
• Works to coordinate each patient's care with the other members of the care team
• Responsible for implementing the plan of care, designing and implementing the patient education plan, assessing each patient before and after dialysis treatment, providing direct patient care during a treatment, and training other staff.
• A nurse may also be the manager of the center

SOCIAL WORKER:
• Help patients and family members adjust to dialysis and rebuild their lives.
• Counsels patient and family members to help with the emotional and financial issues that are part of dialysis
• Addresses healthcare coverage, rehabilitation, patient resources, and community services.

DIALYSIS TECHNICIAN:
• Patient care technicians - provide care for patient on dialysis, working under a registered nurse
• Biomedieal equipment technicians — maintain and repair the equipment
• Reuse technicians — reprocess dialyzers

RENAL DIETIAN:
• Incorporate patient's nutritional needs, dietary restrictions, and food preferences into a meal plan that will maintain health and that the person can follow and enjoy.
• Teaches the patient, family members, and other caregivers how to best meet nutrition needs.