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MNT for Hemodialysis

Hemodialysis

Wilma is a 67-year-old woman who was recently diagnosed with end stage renal disease (ESRD). Wilma also has type 2 diabetes and essential hypertension. She was recently admitted to a skilled nursing facility for therapy following a hospital stay where she started dialysis and recovered from sepsis related to pneumonia.

Cassandra, the facility registered dietitian nutritionist (RDN), met with Wilma and completed a comprehensive nutrition assessment. Wilma doesn’t show signs of malnutrition, but Cassandra knows that she is at risk for protein energy wasting because of the inflammatory process, increased protein needs, and catabolic illness that accompany ESRD.1 Her BMI is 27. Wilma’s serum levels of potassium and phosphorus are currently normal and most of her blood glucose levels are around 150 mg/dL, kept at this level by Januvia®. Cassandra learns that Wilma has a good appetite and that she has been a healthy eater since she was diagnosed with diabetes, focusing on lean sources of protein, vegetables, fruits, low-fat dairy foods and whole grains. Wilma says she has been researching renal diets online and has made significant changes to what she eats as a result, cutting out a lot of her favorite foods and increasing her intake of animal protein while in the hospital.

Wilma’s source of information on diets for kidney disease is outdated. In the past, the diet recommended for dialysis patients was high in protein of high biological value, low in phosphorus (limiting dairy foods, meats, and legumes) and low in potassium (limiting many fruits and vegetables). But recommendations for MNT for all stages of chronic kidney disease, including ESRD, were updated in 2020 by the National Kidney Foundation and the Academy of Nutrition and Dietetics.2 Cassandra uses these more recent guidelines to educate Wilma on an appropriate diet to support hemodialysis and help maximize her nutritional status.

Cassandra suggests that rather than severely restricting potassium and phosphorus in her diet, Wilma should adjust her potassium and phosphorus intake if her serum levels (drawn routinely at the dialysis center) are elevated.2 She encourages Wilma to eat natural sources of phosphorus (high protein foods, dairy products, nuts, seeds, dried beans and peas and whole grains) rather than those with inorganic phosphorus like processed meat and cheese, cola and flavored waters, fast foods, and packaged and convenience foods.3

After estimating her protein needs at 1.0-1.2 g/kg body weight2, Cassandra tells Wilma that she should enjoy protein from both plant and animal sources1,2 and discusses appropriate portion sizes of those foods. Together Cassandra and Wilma come up with a plan for her that will allow Wilma to consume enough protein to help prevent malnutrition, provide moderate levels of phosphorus and potassium, and maximize her enjoyment of food at the facility once she is discharged.

For more information about nutrition and chronic kidney disease, consider our program on Nutrition Care for Patients with Kidney Disease, available for purchase at beckydorner.com/product/nutrition-care-for-older-patients-with-kidney-disease.

References

  1. Cooke J, Shanaman EC. Nutrition management of the adult patient on in-center hemodialysis. In: Gonyea JE, Phillips SC, eds. Clinical Guide to Nutrition Care in Kidney Disease. Third Edition.Chicago IL: The Academy of Nutrition and Dietetics; 2023:65-78.
  2. Ikizler TA, Burrowes JD, Byham-Gray LD, et al; KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107. https://www.ajkd.org/article/S0272-6386(20)30726-5/fulltext.
  3. Majorowicz RR. Mineral and bone disorders and kidney disease. In: Gonyea JE, Phillips SC, eds. Clinical Guide to Nutrition Care in Kidney Disease. Third Edition.Chicago IL: The Academy of Nutrition and Dietetics; 2023:65-78.

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