How Much Protein Does A Dialysis Patient Need?

Before starting dialysis, you may have been told to restrict your protein intake. This is to avoid putting too much stress on the kidneys and further progressing your kidney failure. However, once you start on dialysis your protein needs change.

At first this may be a difficult transition, especially if you have been following a low protein diet for a while. There are many factors that determine how much protein you need. This blog will breakdown all you need to know about protein as a dialysis patient.

What Is Protein And Why Is It Important?

Protein is one of the main macronutrients in your diet (besides carbohydrates and fat). Your body needs macronutrients in greater quantities in comparison to vitamins and minerals, which are called micronutrients. 

Because your body does not store protein as it does with carbohydrates and fat, it is important to get enough from your diet.

Protein is made up of long chains or building blocks called amino acids. Some amino acids are made by the body, but others are not. We refer to these as essential amino acids because they need to be supplied by your diet.

There are over 10,000 types of protein in the body which can be found in every one of your cells (1). Protein has many important functions including:

• Forming the building blocks of your muscles, tissues, bones, skin, hair, and nails.
• Building and repairing tissue and making new cells.
• Providing an energy source for your body.
• Oxygenating your blood. Red blood cells contain a protein (hemoglobin) which carries oxygen throughout the body.
• Making enzymes which help you properly digest your food.
• Playing an important role in hormone regulation.
• Helping to make antibodies that fight off illnesses and infection, heal wounds, and keep you well.

Why Do Dialysis Patients Need More Protein?

Since dialysis helps to remove the build-up of protein waste products in your blood, you no longer need to follow a low protein diet.

In fact, your protein needs tend to be higher than the general public due to some of the stressors associated with dialysis (refer below to factors that affect albumin) and the fact that you do lose a little bit of protein every dialysis treatment.

If you are on hemodialysis you can lose an average of 6 to 12 g of amino acids per treatment (2, 3).

Protein losses are higher on peritoneal dialysis since you are doing dialysis on more of a daily basis (~5 to 15 g/day).

In addition, you may lose more protein than others depending on the type of peritoneal membrane you have (e.g., high transporter). Protein losses also increase with episodes of peritonitis which is a peritoneal dialysis related infection (2).

Eating enough protein to meet your needs is important to avoid what we call Protein Energy Wasting (PEW). This is a condition usually caused by a combination of factors including poor/inadequate nutrition, nutrient deficiencies, muscle wasting, inflammation, and inadequate dialysis.

Labs: How To Check Your Protein Status

There are different blood tests that we look at to get an idea of your overall protein status. These main tests include albumin, BUN (blood urea nitrogen), and nPNA.

Albumin

Albumin is a major protein in your body which is made by the liver. The amount of protein you eat affects this production. Once synthesized, albumin rapidly enters the bloodstream where it carries hormones, vitamins, enzymes, and other substances throughout your body.

Albumin also helps keep your fluid from leaking out of your blood vessels into your tissues, preventing edema.

Albumin is a measurement of your protein status over the past ~three weeks. A normal range for albumin is considered to be between 3.5 to 5.5g/dL.

Ideally, we like to see your albumin level at 4.0g/dL or higher. However, this can often be difficult to achieve due to your blood albumin levels being affected by many things – not just how much protein you are eating.

What Makes Your Albumin Low?

Low albumin levels have long been a nutritional marker for increased hospitalization rates and mortality in dialysis patients.

How much protein you are eating does impact your albumin levels, but there are also many other factors that can potentially make your albumin levels too low. Some of these include:

• High protein losses in your urine and in the dialysate.
• Chronic inflammation is very common among dialysis patients and can lower your albumin levels. Causes of inflammation include oxidative stress associated with the dialysis process, gut dysbiosis, retention of uremic toxins, diseases such as lupus and diabetes mellitus, in addition to advanced age.
• Infections, illness, wounds. In all these situations your body uses your protein to help fight infection and help you heal.
• Cancer and liver disease can impact your albumin levels.
• Having edema or too much fluid accumulated in your body (fluid overload) can dilute the albumin in your blood. When your albumin is low, this makes it even more difficult to remove this extra fluid through dialysis.

If you feel you have been eating plenty of protein but your albumin levels are still low, then there might be other reasons.

BUN

Another measurement we look at when you are on dialysis is your blood urea nitrogen (BUN) levels. Urea nitrogen is a waste product in your blood that comes from the breakdown of protein from the foods you eat. Normally, urea nitrogen is removed from your blood by your kidneys. However, when your kidney function declines, your BUN levels will increase.

A normal BUN level for someone without CKD is generally considered to be between 6-20 mg/dL (8-23 mg/dL for adults over 60) with normal ranges slightly varying by lab (4).

If you are on dialysis your goal range is higher, usually between 40-100 mg/dL. This range will also vary somewhat depending on the dialysis clinic.

Your BUN level reflects your recent protein intake. If you still make a lot of urine you will have more urea nitrogen losses, making your BUN levels lower. If you are not eating well with poor appetite, this can also make your BUN levels low.

A high BUN level, however, can indicate a high protein intake and/or not receiving enough dialysis to properly filter out your urea nitrogen.

The higher your BUN is, the higher the probability of experiencing uremic symptoms (loss of appetite, fatigue, nausea, abnormal taste, etc). If this is the case, your dialysis prescription may need to be adjusted or you may need to adjust your intake.

nPNA

Your normalized protein nitrogen appearance (nPNA) is also a useful tool to assess your protein status. nPNA provides an estimate of how many grams of protein you are eating per kg of body weight a day.

Most guidelines suggest maintaining a protein intake around 1.0 – 1.2 g/kg/day in dialysis patients. Levels less than 0.8 g/kg/day are often associated with malnutrition (5).

nPNA may not be listed on your monthly lab report, but you can ask your clinic dietitian about it. It’s important to note that nPNA may not be as accurate if you have high urinary losses or are not in a steady nitrogen state (such as taking prednisone, recovering from an illness or when your body has to break down muscle protein to use for energy if you’re not eating enough, etc.).

How Much Protein Should A Dialysis Patient Have Per Day?

Clinical practice guidelines recommend consuming at least 1.0-1.2 grams of protein per kg body weight a day. For those on peritoneal dialysis you may need a little more due to higher losses.

Your protein needs are also higher if you are fighting an infection or have wounds requiring more protein for healing.

So, what does this look like? The chart below gives examples of how many grams of protein you may need a day based on your weight.

Weight	HD/PD: 1.0-1.2g/kg (grams per day)	Higher needs: 1.3-1.4g/kg (grams per day)
45.5 kg (100 lbs)	46-55g	59-64g
56.8 kg (125 lbs)	57-68g	74-80g
68.2 kg (150 lbs)	68-82g	89-96g
79.5 kg (175 lbs)	80-95g	103-111g
90.9 kg (200 lbs)	91-109g	118-127g

In general, 1 oz of protein is equal to 7g. For examples of protein portions, sources, and tips on how to add more protein to your diet download the Protein Tips Handout located under my Resources Tab. Guidelines aside, I believe (based on my experience) that most dialysis patients should aim for at least 1.2g protein/kg of body weight.

More protein is not always better, however. It has been shown that an intake of > 1.4g/kg/day is associated with increased mortality in dialysis patients (6).

What Are The Best Protein Sources?

So far, we have covered why protein is important and about how much of it you need in your diet. But, what foods contain protein and what are the best sources to eat?

High Biological Value Protein

You can get protein from both animal and plant sources. So, which one is better? People definitely have their opinions, but animal sources (meat, fish, poultry, eggs, dairy) are considered to be “high biological value” protein.

High biological value (HBV) protein means that it contains all of the essential amino acids that your body needs and is considered to be a complete source of protein. This type of protein tends to be utilized more efficiently by the body with less waste.

Guidelines recommend that dialysis patients eat at least 50% of their total daily protein needs from high biological sources, with the rest coming from plant sources.

Choosing from a variety of lean and unprocessed meats (Ideally, coming from grass fed animals) is important. Studies have shown a strong link between a diet high in processed red meats and higher incidence of heart disease, stroke, colon and stomach cancer.

Plant Based Sources Of Protein

Most plant based protein sources are considered to be incomplete proteins, meaning they lack one or more of the 9 essential amino acids.

But, what really matters is your intake for the entire day. Your body doesn’t need to get all the essential amino acids with every meal. If you get a variety of plant sources in your diet they “complement” each other to provide a full amino acid profile.

Fun fact: there are a few plant based sources that are considered to be a complete protein on their own. Examples include soy (soy milk, tofu, tempeh, edamame, natto), quinoa, buckwheat, pistachios, and Ezekiel bread.

Some cool benefits of plant proteins: they contain high amounts of nutrients, antioxidants, are a great source of fiber (which makes your gut happy), and are naturally low in cholesterol.

Plant based “meat alternatives” usually use soy, wheat gluten, pea or rice protein. Use caution with some of the meat alternatives as they are more processed and can be high in sodium.

So, really the best protein sources come from including a variety of quality plant and animal based sources in your diet. Avoiding those processed meats with added phosphates and sodium is a smart move.

What if you’re on dialysis and are vegetarian or vegan? You can meet your protein needs on a vegetarian or vegan diet, but it does take some skillful planning and most likely adding a plant based protein supplement to better help you meet your needs.

Protein Supplements For Dialysis Patients

Sometimes it’s difficult to meet your higher protein needs with diet alone, especially if your appetite is low. That’s when supplements come in. Supplements make it easier for you to meet your protein/nutrition needs and give you a boost when you are having a hard time eating enough.

There are so many different types of supplements – all varying in quality. Options include protein powders, pre-made protein drinks, concentrated protein “shots”, and protein bars.

Protein Supplement Tips

The following are a few things to consider when looking for a protein supplement:

• Choose the right type of supplement for you based on your preference and tolerance. You will be more consistent in taking it and therefore get more benefit from it.
• Be aware of added artificial sweeteners and sugar alcohols. For some people, they may cause gut issues and symptoms such as bloating, gas, upset stomach, and diarrhea. Artificial sweeteners include: Acesulfame K, Aspartame, Saccharin, Sucralose. Sugar alcohols include: mannitol, sorbitol, xylitol. A good alternative might be products sweetened with Stevia, a natural sugar substitute.
• Be careful of food dyes. Red 40, Yellow 5, and Yellow 6 (the most commonly used food dyes) have long been known to cause allergic reactions in some people, hyperactivity in children, and may contain contaminants that are known cancer-causing substances. While this is somewhat controversial (the FDA has not banned these dyes), if you’re taking your supplement often it might be best to avoid them.
• Remember, along with protein you will also be getting potassium, phosphorus, and sodium. Look at the nutrition facts label for amount of sodium and potassium per serving and watch out for phosphate additives in the ingredient list.
• Since protein supplements contain phosphorus, you will need to take your phosphorus binder with it to help keep that phos in good control.

In general, it is recommended that your supplement contain:

• Sodium: ~250 mg or less
• Potassium: 250 mg or less
• Phosphorus: 150 mg or less. Ideally, with no added phosphates.
• Protein: at least ~15g protein or more.

For a few suggestions of acceptable protein supplements for dialysis patients check out my Resources tab under START HERE!

Protein Recap

So, how much protein does a dialysis patient need? Probably more than you realized. In this blog we covered:

• Why protein is important.
• Why you need more of it.
• How to check your protein status.
• How much you need daily.
• What the best sources are.
• And – if you can’t eat enough – what to look for in a protein supplement.

Another tip may be to try to eat a protein source before and soon after dialysis to help make up for the protein losses during treatment. If you don’t tolerate eating before dialysis, no worries! Just be prepared with a snack or protein supplement on hand so you are ready to fuel yourself if you need it.

Eating a protein source with every meal is also a good goal – not only to help you meet your protein needs, but also better regulate your blood sugar levels.

Choose quality protein sources over processed and don’t be afraid to add some of those plant based proteins into your diet.

I’m sure there’s more, but for now…….I think that’s a protein wrap!