By Rita Solomon-Dimmitt, RD, CSR, LDN

Are you confused with safe food choices? Ask to see your renal dietitian! A registered dietitian (RD) is specifically trained in the basics of nutrition as well as the chemistry and psychology of foods (why we choose the foods we love). As you can see from your monthly laboratory reports, you may have become somewhat of a chemist yourself! You need to seek the assistance of the renal RD to help you with your nutrition goals for dialysis.

It is important to ask the right person to help you with your questions about dialysis. There are many specialists in dialysis who work under the guidance of a physician who coordinates the effort:

• Nephrologists are physicians who specialize in kidney disease;

• Registered renal dietitians are specialists in renal nutrition and the impact of foods and medication on your laboratory values;

• Nurses are specialists in assessing your health and response to medications;

• Patient care technicians are trained to care for you during the dialysis procedure;

• Biomedical technicians are specialists in assessing the quality of the dialysis machines and water treatment;

• Social workers are trained to assist you with both community resources and your emotional response to chronic kidney disease (CKD).

No one looks forward to the need for dialysis, and some people delay the initiation of dialysis unaware of the vast improvement in their appetite and relief of symptoms related to uremia or the build up of waste products. You may find hemodialysis allows broader nutrition goals compared to nutrition limits in pre-dialysis. The more liberal nutrition goal for hemodialysis is due to the ability of the artificial kidney to remove waste products on a regular schedule. Peritoneal dialysis certainly requires more protein and perhaps more liberal electrolytes due to the daily removal of waste products. The dialysis setting lends itself to ongoing contact with the registered renal dietitian to assess your nutritional intake and follow-up with monthly laboratory evaluation.

As you begin dialysis, the RD will meet with you and your caregiver to complete a nutritional assessment. The nutritional assessment is used to determine your usual meal patterns and food preferences. They will ask what foods you enjoy and what meal patterns you have – do you miss breakfast or snack all day? They can use that information in conjunction with your diagnoses and physician recommendations to determine the best nutrition goals for you. The goals will be based on your body size and gender, etiology (cause and origin) of your kidney disease and other disease processes and treatment modality.

It is important through proper nutrition to regain strength and stamina that may have declined prior to dialysis. The RD will focus on areas in which you may need enhancement:

• Protein is used to build and repair tissue, maintain adequate protein stores, and fight infection. Your dietitian can recommend protein amounts based on your size and laboratory values. Protein sources to add to your meals are eggs, beef, chicken, fish, peanut butter, soy protein, etc.

• Kilocalories (or calories) are needed to maintain or increase weight. Calories are found in carbohydrates (bread, cereals, vegetables and fruits); fats (margarine, oil, mayonnaise and salad dressing); and protein foods. Your dietitian will help you determine portions to achieve your individual weight goals.

Occasionally, electrolytes that are normally removed by healthy kidneys will need to be limited on hemodialysis or peritoneal dialysis:

• Sodium may need to be limited to assist with the reduction of thirst. Excess sodium and fluid can contribute to swelling of your ankles or face, increased blood pressure and potential for heart damage due to a thickening of the wall of the left ventricle. Sodium sources in foods can be found in table salt, processed meats, canned meats and vegetables. Herbs and spices can help reduce the need for table salt and enhance the flavor of foods.

• Fluids may need to be limited if your urine output declines. You can usually gain as much as 1 kg or 2 pounds of fluid a day safely, depending on your body size. Check with your health care providers to verify the amount of fluid you can tolerate. Fluid sources are found in beverages such as milk, coffee, tea, water and soft drinks as well as foods that are liquid at room temperature such as ice, popsicles, soup, pudding and ice cream. Substitutes for fluid would be to utilize lemon slices, frozen grapes, chewing gum or sugar-free candy to reduce thirst.

• Potassium may need to be limited to protect your heart. A high potassium level can make your muscles weak and potentially cause cardiac arrest and death. Potassium can be found in certain fruits and vegetables such as melons, dried fruit, bananas, oranges, orange juice, avocado, milk, chocolate and salt substitutes. There is a way to lower potassium such as dialyzing (soaking) potatoes and choosing low potassium fruits such as apples, pears and pineapple.

• Phosphorus may need to be limited to protect your bones and cardiovascular system. Phosphorus and calcium deposits in soft tissues, blood vessels or your heart can lead to decreased blood flow and tissue damage or death. Most people on dialysis use a phosphorus binder (medication that keeps you from absorbing phosphorus in foods) you take with each meal and protein snacks. Phosphorus sources found in foods are dairy products such as milk, cheese and ice cream; legumes such as nuts and dried beans; and whole grain products such as whole wheat bread and whole grain cereals. Lower phosphorus alternative foods to choose are white bread, rice, green beans, pretzels and non-dairy creamer.

• If you are diabetic, your glucose levels may tend to drop more easily as you start dialysis. This happens because the kidney is not filtering the blood or insulin as effectively, so more insulin remains in the body. The RD will help you with balancing meals and the physician may change your medication, as well. You can assist with this process by regularly checking your blood glucose levels and taking blood glucose records to dialysis for evaluation if you see extremes in your blood glucose levels. As part of your ongoing diabetes assessment, the laboratory markers may include the glucose and glycohemoglobin or hemoglobin A1C to provide an indication of your typical glucose value over time.

On a monthly basis, the RD will provide you with safer food choices as indicated by your laboratory values. This “snapshot” of your progress will assist you in modifying your intake. You can also improve the comfort of the dialysis process, such as reducing sodium intake and therefore removing fluid to relieve cramping. The dietitian can provide tools to assist you with specific food lists and appropriate substitutes, as well as recipes or seasonings to enhance the flavor of food. The RD can assist you in modifying food types, such as soaking potatoes to reduce potassium, or reducing amounts and in finding acceptable substitutes. For example, it might be possible to eat one hot dog, which is high in sodium, if you use limited amounts and have lower sodium foods the remainder of the day.

Dialysis adequacy is a very important marker that can enhance adequate nutrition. It is more difficult to maintain a good appetite if you are not well dialyzed. The RD works with the dialysis team to monitor your urea reduction ratio (URR) or Kt/V to determine adequacy of dialysis on a monthly basis. These values come from the measurement of pre and post dialysis blood urea nitrogen (BUN) as a marker of adequate clearance. We want you to be well dialyzed and able to eat well. If the URR or Kt/V is not adequate, you may need to have access intervention or increased dialysis time according to the physician’s recommendations.

RDs are interested in your rehabilitation status as well as good nutrition as an indication of your muscle status, strength and stamina. You may be asked intermittently how much you exercise and what you do for exercise as part of your nutritional assessment. Some patients do not specifically exercise, but they garden, walk the dog, rake leaves or mow the lawn. A well-nourished person has the stamina to do more activities with their family and friends. Exercise provides increased ability to go grocery shopping and prepare foods, providing a reciprocal effect.

The renal dietitian should be your ally to assist you in the journey to a better quality and quantity of life. You should not feel as though all foods are “forbidden fruit” and you can learn to have control and make safe choices. The dietitian wants to give you the tools to succeed so you may live long and well on dialysis.

Rita Solomon-Dimmitt, RD, CSR, LDN, has been involved in renal dietetics in an outpatient setting for years. She was involved with the NCDS initiative and has worked with CKD, hemodialysis, peritoneal dialysis, transplant and pediatric patients, and has served as a facility manager and work in operational aspects of a major dialysis provider. Rita currently serves as chair-elect of the Board of Directors of Mid Tennessee NKF.

The information contained herein is intended for educational purposes only. It is not intended and should not be construed as the delivery of medical care. Persons requiring diagnosis or treatment, or those with specific questions, are urged to contact their local health care provider for appropriate care.

This article originally appeared in the January 2006 issue of aakpRENALIFE, Vol. 21, No. 4.

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