By Stacy Adams, MPH, RD, CDN

Prior to starting hemodialysis, patients are often taught how to reduce the amount of protein in their diet with the hope that by doing this, the need for dialysis might be delayed. However, once dialysis is initiated, dietitians begin to do the opposite and educate patients on ways to increase their protein intake.

What is protein and what is its role in the body?

Webster’s dictionary defines protein as “fundamental components of all living cells and includes many substances, such as enzymes, hormones and antibodies.” Protein helps with growth and maintenance of body tissue and prevents loss of muscle mass. It plays a role in fighting infection, healing of wounds and it provides a source of energy to the body. Proteins are also involved in the transport of cholesterol and fat-soluble vitamins and they help keep osmotic balance among body fluids.

What are the sources of protein?

High quality sources of protein include such things as chicken, fish, turkey, lean meat, duck, lamb, fresh pork, eggs and limited amounts of milk products. Lower quality sources of protein include grains, fruits and vegetables, which are not as well utilized by the body as are the animal sources listed above, but are still necessary in the diet.

How much protein should patients on dialysis consume?

According to the National Kidney Foundation (NKF), patients receiving hemodialysis should take in approximately 1.2 grams of protein per kilogram of body weight. Of that, 50 percent or more should come from high quality animal sources. This means that a medium-framed adult who is 5 feet 4 inches tall, and weighs roughly 143 pounds (65 kg), should consume 78 grams of protein daily. Of course, each patient is an individual and everybody’s needs are different. Patients that are on peritoneal dialysis or who have received a transplant may have different needs. Your dietitian will work with you to help determine your protein needs.

Why is it especially important for patients on hemodialysis to obtain sufficient amounts of protein from their diet?

Adequate protein intake is essential to maintenance of good health while avoiding malnutrition. Lacking sufficient dietary protein, patients with chronic kidney disease or undergoing dialysis may become weak and may lose their ability to fight infections effectively. Unfortunately, there is an association between malnutrition as indicated by a low albumin level in the blood and the risk of death in hemodialysis and peritoneal dialysis patients. In the blood, albumin acts as a carrier and helps to maintain blood volume and blood pressure. Some investigators believe that this risk may be caused by a loss of amino acids, which are the building blocks of protein, during the actual dialysis treatments. Others point out that when the dose (amount) of dialysis is inadequate, people are still in kidney failure resulting in a loss of appetite and deficient nutrition. 

For these reasons, dialysis patients, especially those with a lower than normal (four grams per 100 ml of blood) albumin level, are counseled to make certain that their dose of dialysis is sufficient and to consume more protein than an average person who is not on dialysis. To stay healthy, nephrologists recommend a minimum of 1.5 to two grams of protein per kilogram of “dry weight”— that is the ideal weight without fluid retention. A good guideline is to eat at least 25 percent of the protein requirement at each meal and use snacks and supplements to meet the total requirement. Dietitians encourage meat, poultry, fish or cheese at every meal, frequent egg dishes, and high protein supplements, like Ensure, at least once a day until the albumin level rises to normal.

What happens if protein needs are not met through diet alone?

Dialysis patients sometimes complain of loss of appetite, particularly on the days of the week that they receive their treatments. This may lead to an inadequate intake of protein in the diet. In an effort to prevent malnutrition, patients are encouraged to speak with their dietitian if this becomes a problem. The insufficient amount of protein eaten may start to be evident in a patient’s appearance, weight or lab values. Specifically, albumin, creatinine and pre and post blood urea nitrogen, the protein indicators, should be assessed monthly to see how patients are doing and to detect any downward trend that may occur.

If a patient cannot meet the recommended intake of protein from food alone and maintain a serum albumin of 3.5 g/dl (greater than four is ideal), dietitians will work with that patient to find alternative methods. Protein powders are one option as are oral supplements in the form of milk-like products or fortified juices. There are supplements designed specifically for the dialysis patient containing only those necessary nutrients, with high amounts of calories and protein and low amounts of potassium and phosphorus. Diabetic specific formulas exist for dialysis patients watching their glucose levels. In certain cases, dietitians or physicians may recommend an appetite stimulant.

Patients who are unable to take oral supplements, and have a poor nutritional status may need to receive Intradialytic Parenteral Nutrition (IDPN). IDPN is a combination of amino acids, dextrose and fat that is given to patients during hemodialysis treatments. This provides nutritional support to patients during their regularly scheduled treatments and helps to meet their protein and calorie needs and improve their nutritional status.

What can I eat?

One of the most popular questions asked by patients is, “What can I eat?” Well, in terms of protein there are many choices. Keep in mind that if you are supposed to be consuming 70 grams of protein per day, that one ounce of meat provides roughly seven grams of protein. Protein portions are usually two to four ounces per serving and patients should try to have some protein with each meal everyday.

When selecting meat, try to avoid those that are processed because they are often higher in sodium than fresh meats. Choose lean cuts of fresh beef such as chuck roast, eye round, lean ground beef, T-bone or sirloin steaks. Avoid sausage, hot dogs, pastrami and corned beef. Choose pork tenderloin, but avoid bacon and ground pork. The phosphorus content can be high in certain types of fish, so try selecting catfish, grouper, cod, shrimp or snapper. In terms of poultry, skinless chicken and turkey are good options and lastly choose eggs (one whole or two egg whites) or try 1/4 cup of the low cholesterol egg substitute.

Finally, for those patients who are vegetarians, adhering to a renal diet can become somewhat tricky. In such cases, protein can be obtained from soy protein, dairy products and protein powders or supplements, if necessary. Speak with your dietitian if you have concerns as to whether you are consuming enough protein in your diet.

Though the renal diet can seem very restrictive at times, there is much to be enjoyed in the way of protein! Bon Appetite! Enjoy.

Stacey Adams, MPH, RD, CDN, is a renal dietitian at the Rogosin Institute in New York City, where she has worked for the past three years. She has been a registered dietitian for five years, during which she earned her master’s degree in Public Health Nutrition.

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 healthcare provider for appropriate care.

This article originally appeared in the May 2004 issue of aakpRENALIFE, Vol. 19, No. 6.

Back