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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