Lesley L. McPhatter, MS, RD, CSR

Question: I am a new hemodialysis patient. I love to eat ice-cream. My doctor tells me I have to count ice-cream as part of my fluid intake. Is this true and why? Any food that is liquid at room temperature is counted as part of your total daily fluid allowance including ice, Jell-O, sauces or gravies, popsicles and ice cream. As a dialysis patient, you produce less urine. Some dialysis patients don’t produce any urine. Without urination or limited urination, fluid will accumulate in the body and cause excess fluid in the heart, lungs and ankles. Your healthcare team will guide you to the fluid restriction that is right for you. The typical fluid restriction is between 1000 cc (32 oz.) and 1500 cc (40 oz) and varies with your urine output.

Question: I read a lot about dialysis patients needing good sources of protein. What are good sources of protein?
Some amino acids (building blocks of protein) are lost during dialysis, therefore dialysis patients are advised to eat more protein compared to people who are not on dialysis. A high protein diet allows dialysis patients to maintain good health and avoid becoming malnourished. Dialysis patients are usually advised to try to have some protein with each meal everyday. Processed meats usually contain high amounts of sodium, fat and phosphorus, so try to choose fresh meats such as lean cuts of chuck roast, lean ground beef, t-bone or sirloin or flank steaks, chicken, turkey, fresh pork, fish and shellfish. Eggs also contain high quality protein. Dairy products contain protein but also potassium and phosphorus. Your dietitian will help you determine how many dairy products you can use each day.

Question: What about phosphorus? If it’s so important to keep an eye on, why don’t all food products carry the phosphorus content on the labels?
Phosphorus is important in the development of healthy bones. It is found in many foods we eat. People with normal kidney function are able to rid the body of excess phosphorus in the urine. However, people with limited kidney function, cannot get rid of the extra phosphorus. Therefore, the phosphorus can build up in the blood, cause imbalances with calcium and parathyroid (PTH) hormone levels leading to weakening of your bones.

And you are right! The phosphorus level of many foods is not always placed on food labels. When it is printed on the label, it is usually represented by a number called the Percent Daily Value. The Percent Daily Value (%DV) tells you how much nutrients a product contains and how it can fit into your meal plan. The %DV for phosphorus is based on 800 mg per day. If a food contains 20% DV for phosphorus, it contains 160 mg phosphorus and should be limited in the diet. Additive phosphorus is a real problem in processed foods, dark sodas and enhanced meats. Look for food additives such as phosphoric acid on food levels. Additive phosphorus is absorbed at 100 percent whereas phosphorus that occurs naturally in foods such as fresh meats is only absorbed at about 60 percent. Look for and avoid additive phosphorus on food labels.

Kidney disease patients should choose foods low in phosphorus.

High Phosphorus              Foods Low Phosphorus Foods
Dark colas                          Cream Cheese
Beer                                   White or Yellow Cake
Milk, Yogurt                       White rice
Cream soup                        Apples, Berries, Grapes, Plums
Chicken liver                       French, Italian or White Bread
Organ meat                         Green Beans, Cabbage, Carrots

Question: Can anything be done to help dry mouth?
Most hemodialysis patients do experience xerostomia, also known as dry mouth. The condition can be caused by fluid restriction, medications such as blood pressure pills and allergy medications. Many patients just find the condition uncomfortable, but it can lead to bad breath, difficulty speaking and a hard time swallowing.

Here are some tips to help prevent dry mouth:
• Follow a low sodium diet
• If you are diabetic, make sure blood sugar is well controlled. High sugar levels increase thirst
• Avoid caffeinated drinks, acidic/spicy foods, tobacco and alcohol
• Stay cool and use a mister or spritzer when out on a hot day
• Use sugarless gum, sugarless candy or frozen grapes in small amounts
Things to do for the freshest mouth:
• Brush your teeth twice a day
• Floss daily
• Clean your dentures. Remove any food particles
• Visit your dentist for regular check-ups

Question: I’ve never had an exercise program. I’m tired all the time. Is it really important I start exercising now? Isn’t it just going to make me more tired?
Exhaustion at the initiation of dialysis can be related to anemia (low red blood cell count and/or low iron levels), uremia (excessive toxins in your body) and malnutrition due to poor intake prior to starting dialysis due to not feeling well. It is important to check with your doctor before beginning any exercise program. Your physician will be able to recommend an exercise program suited for your condition. Many dialysis units now offer exercise during treatment so be sure to ask at your facility. Patients who have never been on an exercise program are advised to start out slowly.

There are many benefits to exercise. Exercise actually gives you more energy, conditions your heart, helps with weight loss and strengthens muscles. Exercise allows the body to become accustom to physical activity, therefore you are less tired. Almost any physical activity or exercise will be good for you but a good fitness plan includes the following:
• Cardiovascular exercise: Walking, cycling or stationary bike, elliptical or stair stepper machines, or yoga.
• Strengthening Exercise: This helps you become stronger or maintain your strength. Hand or leg weights are common forms or resistance exercise but elastic bands are also helpful.
• Flexibility Exercise: This will help prevent your joints from becoming stiff and painful. Examples: Stretching and yoga

Many physical therapists will advise patients to write down what they are doing. Keeping a log of your physical activity or exercise is a useful tool to monitor your progress as well as being a valuable tool for your doctor.

Remember, there is no magic solution to feeling better on dialysis. Eating a balanced diet, following your fluid, sodium and other dietary restrictions, along with maintaining an exercise program can help you stay healthy and fit. A balanced diet and exercise helps your body function efficiently and provides you with energy to go about an active day. Remember to ask your healthcare team anytime you have questions as you learn about the changes with your diet, medications and treatment regime and options with hemodialysis.

Lesley L. McPhatter, MS, RD, CSR, is a registered dietitian with 18 years experience with the Lynchburg Dialysis Facility (now part of the University of VA Renal Services). She’s a diet educator with all stages of CKD patients including early stages, transplant, peritoneal and hemodialysis.

This article originally appeared in the September 2008 issue of aakpRENALIFE.

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