When to start a renal diet
Renal Diet - what can dialysis patients eat [Free Dialysis Video Training]
hello hello in this class we're going to
be talking about the renal diet and what
should my patient eat and we're talking
about the dialysis patient in dialysis
people that are in dialysis have a real
challenge in terms of choosing what they
can eat and what they should avoid I
always say we shouldn't say do not eat
this do not eat that we always tell the
patient these things are high for
example in potassium and you should
avoid them if you are going to have any
of those type of foods just do a minimum
amount in just once a week so I tend to
tell that the patients that so that they
don't feel that they are not allowed to
do something because you and I know that
when a person is not allowed to do
something most of the time they would
like they will try to do whatever it is
that they're not allowed to so let's go
ahead and start again
this presentation is called the renal
diet what should my patient eat and this
is what we're going to be covering for
today we're going to be talking about
the dialysis patient a little bit on the
modalities nutrition for hemodialysis
patients we're gonna talk about the
waste and fluid buildup and we're gonna
go over water protein calcium phosphorus
potassium and vitamins so all of these
topics were included in the nutrition
presentation that all students had here
in the classroom but this is going to be
like a summary where we're gonna pick up
all of the topics and put them together
for a better understanding so the goal
is to provide guidance to dialysis and
non dialysis personnel in educating a
renal failure patient on dialysis about
the renal diet and what they can eat so
again we know that dialysis a dialysis
patient is the person that receives
dialysis and they receive dialysis
because they have renal failure the
there are five stages for chronic kidney
disease in the treatment for chronic
kidney disease includes dialysis
medication and diet and diet is the one
that we're going to be focusing today in
dialysis modalities we have different
modalities we have in center
hemodialysis nocturnal in center
hemodialysis peritoneal dialysis and
home hemodialysis but of course the
focus of this course is in center
hemodialysis and in center hemodialysis
the this is the most common type of
hemodialysis offered it's done in an
outpatient center the patient comes to
the clinic three times a week and the
treatments can be between three to five
hours long the staff members perform the
treatment and there are self-care
options available for patients that wish
to they can choose to do something for
do one of the part of the treatments be
it setting up the machine or sticking
themselves or cleaning their chair
anything that will give them a little
bit of empowerment and control over
their illness
so when we talk about the nutrition for
in center hemodialysis we have to
understand that this nutrition could be
different than the nutrition or the diet
that is suggested for the other
modalities so we need to understand this
first remember that the healthy kidneys
work 24/7 they are going to remove the
waste from the blood and when we say
waste I want you to understand that the
waste for us is going to be all of the
minerals all of the vitamins all of the
elements that are in excess that if it
wasn't in excess it wouldn't make any
harm to the patient for example people
that don't have any problems with the
kidneys need potassium need
sodium now people that have chronic
kidney failure they have problems eating
eating foods that are high in potassium
or high in sodium because there's going
to be a buildup because their kidneys
cannot filter those nutrients and that
is when whatever the excess built up in
the body that is the waste that is what
we call the waste so what does waste
mean it is a build up of chemicals
minerals elements vitamins and toxins
mainly acquired through our diet so what
can build up it urea can build up and
urea is a waste too many people tend to
use the term urine and blood to explain
what urea is creatinine is the waste
from the muscles so every time your
muscles move so if I do like this I just
create a creatinine so every time your
muscles move you create creatinine
another thing is potassium sodium
phosphorus and fluids so when any of
these are in excess that is called waste
so the renal diet for in center
hemodialysis patient needs to give them
good nutrition but at the same time
limit the buildup of waste between
treatments patients on peritoneal
dialysis home hemodialysis or North turn
or nocturnal in central dialysis have a
more flexible diet diet can be adjusted
per patient and the level of protein
calories fluid minerals and vitamins can
change based on the need of each patient
the diet helps them feel better between
treatments okay so we also have to
understand that no two patients are the
same patients needs will vary because we
might have a patient that doesn't have
any problems with potassium but here we
probably have a patient that have a
problem with hyperkalemia which would
hi potassium so this is an example of
potassium in this case remember that our
range for potassium is between three
point five two point five five point
five I'm sorry merely equivalent and
leader so this is a weak what you see in
on on the screen is a week that goes
from Sunday to Saturday and let's
imagine this patient treatments are from
Monday or Monday Wednesday and Friday so
let's look at Sunday first Sunday you
can see how the potassium slowly builds
up until Monday morning Monday mornings
are going to be the most dangerous days
for the patients that come to treatment
Monday Wednesdays and Friday because
it's one the potassium is going to be in
its highest level inside of the
patient's body and we know that
potassium is something that we we have
to be aware of and we have to monitor
closely because potassium can give
symptoms to your patients from one
minute to another the patient can have
arrhythmias cardiac arrest you name it
potassium is going to affect the muscles
directly I'm sorry and the most
important muscle that the potassium is
going to affect is the heart so Monday
in that treatment the potassium is going
to drop and you can see it right there
on the Monday the how the potassium
drops then it starts building up again
and again and again and again Tuesday
until Wednesday its high again on
Wednesday we dialyze the potassium drops
and the next day it starts building up
again again again until Friday Friday
the potassium drops and then we have two
days off which again makes it Monday the
most dangerous thing okay so again
hyperkalemia is too much potassium in
blood and this can cause change in the
heart rhythm weak muscles belly cramps
skip heartbeats
or heart may stop so the in-center
hemodialysis diet is based on the differ
on these different groups they can eat
proteins and that's gonna be in the
protein is going to be included the beef
the pork the chicken the eggs the fish
the cheese peanut butter tofu and
vegetarian meats and in a minute I'm
going to explain about these different
groups dairy milk ice cream yogurt
pudding bread and starches vegetables
and fruit fats like butter and oils
calorie boosters like hard candy or
jelly beans and others like spices and
condiments
so let's start talk about the protein
first all food have some type of protein
the two main types of protein are the
high biological value and the low but
biological value the high biological
value comes from animal or from soy
protein and some of the examples are
meat fish poultry eggs tofu soy milk and
dairy products and then the low
biological value comes from other plant
protein and some of the examples are
bread grains vegetables dry beans peas
and fruits
now for our dialysis patient it is
suggested that they take the high
biological value protein that they eat
the high biological value protein so the
protein helps maintain body body muscle
and tissue dialysis patient need at
least 50% more protein each day than
healthy people so people that have no
problem with the protein I'm sorry with
that kidneys they will they will eat
whatever is the allowed the suggested
amount allowed in a daily basis and
we're gonna talk about that in a minute
but the dialysis patient should double
that should double that because dialysis
patient lose protein
each treatment okay and the way that the
protein is lost during dialysis is not
that the protein goes through the filter
it's more that the protein attaches to
the fibers inside of the filters so the
protein will create blood urea nitrogen
or B UN and creatinine so the more
protein they eat the more B UN or blood
urea nitrogen and creatinine they're
gonna they're gonna have in their system
so healthy kidneys can remove the UN and
creatinine creatinine but failed kidneys
cannot okay so the protein dialysis
dialysis can decrease the B UN and the
Korea and the creatinine there are some
tests done at the dialysis clinic and
these are gonna be the B UN and the
creatinine again so if the B UN is high
that means that we're probably this
patient is having poor dialysis probably
or that the patient is eating too much
waste if the patient has low B UN means
that there there could be a good
dialysis or the patient may have poor
muscle mass and high creatinine means
that there is an inadequate dialysis low
creatinine means that there could be a
good dialysis or that the patient may
have lost muscle mass so an example um
about this so that you can understand it
better if you compare an old lady an 80
year old lady with a younger man a 40
year old man
the older lady may have less creatinine
even though probably both of them are on
dialysis but the older lady is going to
have a lower creatinine than the younger
man a 40 year old man because the older
led lady has less muscle mass and is
probably less active than the other
so the protein helps increase the
albumin and albumin helps the body heal
and fight diseases so if the albumin is
low the morbidity is higher and the
chances that this person or patient can
die are higher okay since dialysis
patients need more protein than healthy
people it is recommended that they eat
high biological value protein and I had
said that before so here is this table
let's just go over it real quick and
here we have diff different ages but I
want us to concentrate on the two rows
on the last two rows women's ages 19
through 70 Plus and then men's ages
nineteen seventy plus so these are the
dietary allowance for protein
recommended by the CDC the Centers of
Disease Control here in the United
States so for women ages 19 to 70 plus
the grams of protein recommended are 46
grams and for men 19 to 70 plus the
allowed or the yeah the allowed amount
of protein recommended should be 56
grams for a dialysis patient you want to
go ahead and double that because they
lose protein throughout their treatment
now here are some examples of what does
that amount the amount of protein
represent for example here we can we can
see it better chicken bread chicken
breath of about 3.5 ounces it could be
like the palm of our hand it's 30 grams
of protein and let me go back for a
minute if we go by this table if we go
back to the women the allowed amount
recommended is 46 grams if we eat one
chicken breath 3.5 ounces which is a
fairly small is not that big
of a chicken breath there we have 30
more than 50% of our allowed amount
recommended right so this is an
eye-opener because with this you can see
how much protein we really eat during
the day so a tuna tuna can and this is
like a six ounce can that's about 40
grams of protein if you eat it all
egg and we're talking about a large egg
is about six grams of protein milk one
cup about 8 grams tofu half a cup 20
grams of protein soy milk 1 cap 6 to 10
grand
one cup 6 to 10 grams and then peanut
butter 2 tablespoons 8 grams in terms of
calories the dialysis patients need
calorie they need calorie for energy if
they don't they will become malnourished
and malnourished is when the body burns
the protein for fuel that means they
will burn their own muscles no protein
left for other body functions and that
is dangerous so when patients are you
REMIC or that the build up the waste
buildup is really really high they lose
their appetite because things are not
tasting well they're not smelling well
so who wants to eat if you can't smell
things well or they're not tasting well
right there is something that most of
the patients say that is typical and
what they say is that the food tastes
strange and it has like a metallic taste
they can have they can present nausea
and vomit
new patients tend to have more of these
issues and patients that starts to lose
weight so we got to keep an eye on those
new patients new patients they tend to
to stop eating because things are not
smelling or tasting the same so we want
to keep an eye on those patients and ask
them are you eating well what have you
what did you eat yesterday what did you
eat during the weekend stuff like that
so that we can identify if this
is losing appetite or not and then we
can refer this patient to the dietitian
and if the patient needs the means to
buy the food then to the social worker
so when we talk about weight we want to
talk about we want to focus on real
weight it is often confused with fluid
removal okay so signs of real weight
loss is that the patient the fluid
buildup is going to be in the ankles and
in the fingers the patient has got to be
short of breath and the patient is not
going to be able to lay flat in bed so
you got to ask the patient can you lay
flat in bed and if they say no we know
that there is a fluid buildup so how can
we help the patients we're gonna let the
dietitian know if the patient mentions
he's not eating well we're gonna let the
social worker know so that they can also
help patients to receive the meals your
we're gonna let the nurse know if
patients gain a lot of fluid between
dialysis and then the nurse will report
this to the doctor and a care plan
meeting will be scheduled to plan how
are we gonna manage this patient most of
the time we start with a lot of
Education fluid management education
first and then also letting them know
about the importance of completing their
treatments and coming to their
treatments when they are supposed to
come because when they're cleaner it's
gonna be best for them because they're
gonna be able to smell better and taste
the food better
so malnutrition is the high risk of
death the it can be treated that's a
good thing the patient we can try to get
the patient to eat a little more so that
would be step one so if we have a
patient that is malnourished we're gonna
try to get this patient to eat more if
that doesn't work then we are going to
recommend protein drinks powders or bars
that could be used by the diet
patient and these are gonna be these
products that are for the dialysis
patient for example there is one protein
shake that is called net pro so if it's
a dialysis patient they shouldn't be
taking in Shore or glue sir now those
type of things they should be taking the
protein shake that is made for them
because the the rest of the protein
shakes may have different nutrients that
we don't want to give the patient's like
magnesium potassium etc so if that
doesn't work then the doctors start
talking about a feeding tube to the
stomach if that is not working either
then we move on to the I DP n which is
the intraday lytic parenteral nutrition
and this is nutrition that we will give
to the patient through their veins
during dialysis and this nutrition
nutrition includes carbohydrates protein
fat sugars and amino acids TPN would be
like the last resource because TPN means
total parenteral nutrition in this case
is that this patient is receiving most
of their nutrition through their veins
during dialysis and outside of that of
dialysis so now let's talk about the
water so the kidneys two main functions
are to remove the waste and the excess
fluid so there are two things that we do
when the patient comes to dialysis we
remove that waste and we also clean them
so it's not true when a patient tells
you well I didn't gain a lot of fluids
so I'm not going to dialysis because I
don't need dialysis that is not true
they still need dialysis because we need
to clean them okay so dialysis also I'm
sorry the kidneys also have other
functions they also create hormones they
create an acid and base
and they also control the blood pressure
so dialysis patient do not urinate or
produce very little so you're gonna have
patients that still create a little bit
of urine and others that don't create
any at all so the fluid builds up in the
body fluid should be removed removed
during dialysis fluid is limited to a
liter per day in most cases fluid is not
only water it could be foods that are
liquid and room temperature like jello
ice cream and popsicles all those are
counted as fluid to soups coffee all
that okay so anyways let's go back to
the limited amount of fluid that they
have here it says one liter and one
liter is 32 ounces so when you present
this to the patient I'd like to tell
them I don't like to tell them a single
number I don't like to tell them one
liter I'd like to tell them well you can
drink for 8 ounces cups for example that
will give us 32 ounces or I I want to
tell them I want them to perceive that
they can drink a lot okay so I like to
tell them okay so listen you can do to 8
ounces cups and then for 4 ounces cups
okay and that also gives me the 32
ounces if I want them to still see more
I would tell them okay this is what
you're gonna do you can do for 4 ounces
cups and ate 2 ounces cup cups and that
kind of gives them the perception of
okay so I can drink
many of these cups throughout my day
okay so the dry weight is established
for each patient the amount of fluid to
remove during dialysis is established at
the beginning and that would be the the
pre weight so the pay
is gonna walk in we're gonna weigh the
patient and then we're going to subtract
the dry weight from that pre weight too
much fluid causes edema high blood
pressure shortness of breath more fluid
buildup will give potential
complications during treatment and these
complications could be hypotension
cramps dizziness passing out or throwing
up and feeling washed out after
treatments so let me step back for a
minute so that you understand this the
fluid buildup will cause hypertension
before dialysis but during dialysis when
we start dialysis because we are gonna
be removing a lot of fluid then it could
cause hypotension okay and cramps and
dissonance and passing out and all that
but I just wanted to point out the
difference between when the patient is
going to have the hypertension and when
the patient may have the hypotension
okay so most serious complications about
fluid buildup can be myocardial stunning
which is when the heart can be that
strongly and then the LVH which is the
left ventricular hypertrophy which is an
enlargement of the left ventricle of the
heart leading cause of death in the
hemodialysis patient so fluid management
will be advice and treatment modality
change can also help so if we have a
patient in in center dialysis and they
cannot seem to manage their fluid after
multiple education and all that then we
probably have to suggest this patient to
do another modality like probably that's
something that is more frequent more
frequent dialysis will help this type of
patient sodium sodium the major part is
the major part of the table salt 1/2
teaspoon of teaspoon of salt contains
one gram or a thousand milligrams of
sodium and this is crazy because the
alpha teaspoon try to find in your house
half a teaspoon that is nothing but it
contains a large amount of sodium so all
foods contain sodium it can it it can't
all be taken out of the diet
hemodialysis patients should not use
table salt salt or their substitutes ok
best if salty food are avoided all
together so when a dialysis patient is
telling you if they tell you I'm using a
salt substitute you have to say no you
cannot use that salt substitute because
the salt substitutes normally are done
with potassium so that means that
they're sprinkling potassium every time
they eat and we already know how
dangerous potassium can be so sodium can
also they could also have these symptoms
thirst high blood pressure and weight
gain sodium in the blood attracts water
and that will make them swell up have
edema failed kidneys are unable to
remove the sodium and patients should
avoid sodium if they already have the
swelling or the edema in the hands face
hands or feet if they already have high
blood pressure and if they gain weight
quickly because due to fluid buildup so
with the sodium less sodium is going to
make them less thirsty and if they are
less thirsty they're not gonna drink as
much fluid if they have more sodium in
their body they are going to be drinking
many much more fluid so the US
guidelines suggest that we take 1,500
milligrams of sodium per day even if we
do not salt we find sodium and other
foods like canned foods packed helper
foods pickled foods preserved meats such
as cold cuts like hams turkey ham
sausages and hot dogs patients should
try no salt herbs and spices like basil
lemon pepper and mrs. dash
so there are some myth that the American
Heart Association has and I will I will
include this the PDF the PDF of this
presentation is going to be below this
video
and you can check it out check out the
PDF of this presentation so that you can
read the seven salty myth busted by the
American Heart Association so now let's
talk about potassium in dialysis patient
the normal should be between 3.5 to 5.5
million high potassium foods are high
potassium foods like examples of high
potassium foods could be avocado mangoes
bananas oranges dry fruits melon dry
peas and beans tomato sauce potatoes
salt substitutes expresso or cappuccino
so the patients we should strongly
advise the dialysis patients to avoid
these types of foods chewing tobacco may
increase the potassium as well orange
juice is very high in potassium and
potatoes is also high as high source of
potassium so we do need potassium for
the nerves muscles water balance and the
use of glucose but too much would be
hyperkalemia and it will cause change in
the rhythm of the heart weak muscles
belly creme skipped heartbeats and the
heart may stop and if we have to
too little like we don't have enough
hypokalemia can cause fatigue weak
muscles changing the heart of the rhythm
and then this the the having it low is
really rare in in center dialysis
patients but we still have to be aware
that it could happen and mainly it could
happen to these to the patients that are
vomiting or having diarrhea they can
lose they can lose potassium through
diarrhea or vomiting so we have to keep
an eye on the under so the patient can
eat and in order to avoid high foods
high input
the patient can eat pasta or rice drink
apple or cranberry use read food labels
many water and many energy water's
vitamins or minerals rinks have lots of
potassium and the meat can be injected
with potassium for more shelf-life so we
have to read the labels we have to read
the label to see if there's any
potassium in that food that we are
buying or them at least the amount
because sometimes we are not going to be
able to buy something that is totally
free of potassium because it's used as a
preservative but we want to see the
amounts we want to see that it's low
amounts ok so potassium is checked every
month at the clinic and with the results
we're able to determine how much
potassium intake the patient can have
and we also can determine what is the
dialysate bath that we're using with
that patient so potassium can build up
in the body the highest after 2 days off
and that would be for a patient that is
Monday Wednesday and Friday that would
be on the morning Monday and for a
patient that is Tuesday Thursday and
Saturday that would be on the Tuesday
morning okay so kajak so late may be
used to lower the potassium kajak cently
is the medication used for that and the
food labeled low salt may have high
potassium content calcium dialysis
patients range from 8.4 to nine point
nine milligrams and deciliters and it
shouldn't be higher than ten point two
the total intake for patients should be
two thousand milligrams per day failed
kidneys cannot keep calcium and
phosphorus in balance therefore patients
could have complications such as
secondary hyperparathyroidism or mineral
bone mineral bone disorder and the
problem with these disorders is that
this is something that is going to be
that we're gonna see it in the long run
this is not something that you will see
it immediately and the risk is that by
the time that we identify it it's
because it has been building up for a
long time so it is very difficult to
treat once we identify it phosphorus in
center dialysis remove phosphorus but
not too much because the phosphorus cell
is bigger than for example the count of
the calcium cells or the potassium cells
so the phosphorus cells is bigger and it
takes a longer time to be able to remove
it from the body so the foods that the
patients should limit our dairy cola
beans whole grains and nuts limit of 800
to a thousand milligrams of day of
phosphorus phosphorus is in most foods
because is the number one preservative
flavor enhancer and additive used in the
United States and the level should stay
between 3.5 and 5.5 hyper phosphate emia
is too much phosphorus and it's linked
to MBD or mineral bone disease and
higher risk of death MBD symptoms could
could could be itching bone and joint
pain muscle weakness and bone fractures
patients may not feel anything until
bone damage has occurred
phosphorus and calcium bond together and
they cause crystal like deposit that can
cause hardening of the arteries and
veins so when calcium and phosphorus
meet this is it's almost like love at
first sight okay and they bond together
and then is very difficult or almost
impossible to separate them again and
the thing is that their cells are not
rounded they create the they create like
a crystal cell and they have like a
shape form okay so that's why they
deposit they can try to come out through
the pores and that's why the patients
are itching too much very much they can
deposit in the organs they can damage
the veins
I had a patience years ago that when a
patient years ago that when he went to
his transplant he was called for a
transplant they opened him and when they
what they saw was that the the artery
and the vein going to the kidneys and
those were the same artery and veins
that they were going to use for the new
kidneys they were calcified okay
so the patients need to know this
information we need to indicate the pay
the patients because when we see the
symptoms when we see all this it's it's
probably a little too late
so since removal of phosphorus from the
food as difficult patients are ordered
phosphate binders they come and form a
pills powder or liquid they are taken
with foods and they bond with
phosphorous and then the phosphorous is
excreted in the stool if they get
constipation a stool softener will be
ordered and modalities like nocturnal
dialysis help with phosphorus control
now very important and this is something
that I always like to mention when the
patient is on a phosphorus binder they
have to take this medication with their
food it's not in the morning and or at
night is with their food so the proper
way to take it is at least or not more
than half an hour before they eat or
they can take it in the middle of their
meal okay or they can take it a maximum
of thirty minutes be after their meal so
let me go back and say that again thirty
minutes before their meal they can take
it in the middle of their meal or thirty
minutes after their meal it has to be
while the food is still in the stomach
if the food is not in the stomach or the
food passes the stomach this is not
going to work so how the foods that are
very very high in phosphorus are the
following
milk ice cream yogurt or pudding and we
have to become investigators these are
questions that we can ask the patients
have you had or have you been eating
this milk ice cream yogurt or pudding
cheese or peanut butter cheese flavor
crackers or snack foods liver organ
meats hot dogs sausages or enhanced meat
can't
Selman with bones or sardines nuts or
seeds almonds pecans sunflowers or
pumpkin seeds dry beans and peas or
baked beans including canned beans and
peas quick breads biscuits corn bread
pancakes or waffles made from mixes bran
muffins bran cereals or granola bars
Pisa lasagna
tackles corn tortilla or fast foods
chocolate caramels or candies containing
chocolate nuts or caramels colas Canty
beer cocoa or other drinks containing
phosphate additives foods or drinks with
hitting stars of phosphorus like because
not all the time the phosphorus is going
to be clear in the label they could come
with these different names so these are
different types of phosphorus additives
phosphate polyphosphate pyrophosphate
phosphoric acid and phytate so these are
some suggestions instead of milk they
can have non-dairy creamers rice milk
and they should be the unenriched rice
milk instead of cheese they can have
cream cheese or sour cream instead of
Cola they can have lemon-lime soda some
brands are Rubio rip root beer I'm sorry
and lemonade and tea and also ginger ale
they can have instead of chocolate candy
they can have jelly beans or hard candy
always aware the patient that some of
these foods still count as fluids and
diabetic and diabetic patients should
also follow diabetic diet
now let's talk about the vitamins and in
terms of vitamins we have water soluble
vitamins and we have fat soluble
vitamins the most important to know
about is for the dialysis patient is the
water soluble vitamins because those are
the ones that they lose mostly in that
case we're talking about biotin Falasca
fullest in vitamin b6 b12 and C niacin
thiamine riboflavin B truth patients
should take 60 to 100 milligrams of
vitamin C one to five milligram of
folate 2 milligrams of vitamin b6 and 3
micrograms of vitamin b12 patients are
ordered special vitamins and they these
can come with the name of Rena bite or
never bite dialysis patients cannot take
vitam over-the-counter vitamins so they
should have their special vitamins
ordered so in conclusion the renal diet
is a very limited diet patients should
be approached with empathy when educated
about what they can or cannot eat as a
health care giver you can help the
dialysis patient determine what they can
eat in order to feel better remember
that we are all part of a team and it is
our responsibility as a team to educate
our patients when we educate our
patients we help improve their quality
of life so I hope this helps you
understand better the renal diet for
dialysis patients and remember that this
is focused on the in-center dialysis
question patient so if you have any
questions please send them to info at
utopia HCC comm and there is no quiz for
this topic because the quiz is going to
be substituted with the presentation
that you guys already did in class
so I hope you liked it and see you soon
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