While dialysis is a life sustaining therapy, it can also be a discouraging process. It’s normal to have fears about the dialysis process itself, how it will impact your life and family, and wonder what your future may hold. Everyone has different circumstances surrounding their need to start on dialysis. Wherever you may be, it is important for you to know that it is possible to live a healthy life on dialysis. Figuring out what your values and goals are, knowing your options, and making healthier choices will help you get there. The following Top 10 Nutrition Tips were designed as a guide to help get you started.
1. Eating To Support Healthy Blood Pressure
You may be wondering if controlling blood pressure is still important once you start dialysis. The answer is..…absolutely! Having high blood pressure can increase your risk for stroke, heart attack, cardiovascular disease, and congestive heart failure (1). However, achieving better blood pressure control is the key to lowering the risk of these complications and experiencing more comfortable dialysis treatments. Beyond just taking your blood pressure medications, here are 3 Keys to promoting a healthy blood pressure:
Ditch the salt and watch your fluid intake
A low sodium diet will help improve blood pressure control in addition to the amount of fluid your body retains (edema), making it easier to achieve your “dry weight”. Aim for less than 2000 mg of sodium a day (~650mg/meal). You can easily go over your daily goal just by eating a can of soup. Start reading food labels and look for “low sodium” or unsalted on the label. A low sodium food is less than 140 mg per serving (2).
Achieving a healthy body weight
Your blood pressure often rises as your weight increases. Losing those extra pounds (excess fat) can often have a positive effect on your blood pressure. This can mean making simple diet and lifestyle changes that will better support a healthier blood pressure. Achieving your “dry weight” and avoiding a buildup of too much fluid in the body will also help. Refer to Tip #5: Drinking To Support Healthy Fluid Gains.
Regular exercise can help improve high blood pressure as well as reduce the risk of developing low blood pressure during dialysis treatment (3). This doesn’t mean you have to start running marathons. Starting slow with short walks, chair yoga exercises, stretching, Tai Chi, etc., can have a great impact on your overall health. Ask your doctor what is safe for you to do. There are many free online classes available to help you get started.
2. Maintaining Good Blood Sugar Control
Why is it important?
Having poorly controlled diabetes is one of the major causes of kidney failure. Over time, high blood sugar levels can cause damage to the very small blood vessels in your body which not only affects your kidneys, but also your heart, vision, nerves, and feet (4).
What are some of the causes of abnormal blood sugar levels?
High blood sugar can be caused by eating too many carbohydrates (especially refined carbs like white bread, pasta, white rice, breakfast cereals, pastries, added sugars), stress, illness or infection, lack of exercise, and/or not taking the right amount of medication to control your blood sugars. People with diabetes starting on PD (peritoneal dialysis) often will see a rise in their blood sugar levels since they are using a sugar-based solution to perform dialysis.
It is also important to note that when you initially start on dialysis you may be more at risk for developing low blood sugars due to changes in insulin sensitivity and insulin clearance by the kidneys (5). Other causes of low blood sugar are not eating enough (poor appetite), certain medications, infections, and digestive problems.
3 Key Recommended Diet Tips
A common complaint is, “but, I’m tired of checking my blood sugar!” While I know it’s not fun, keeping track of your blood sugars and following up regularly with your diabetes or primary care doctor is still very important! Here are 3 key recommended diet tips:
Eat more fiber, whole vs. refined grains (Refer to Tip #9: Fiber & Gut Health).
Reduce added sugars in your diet: soda, sugary juices/drinks, candy, pastries, sugary cereals, cookies, creamers, salad dressings, BBQ sauce, etc. Look at the nutrition facts label for added sugars per serving. The American Heart Association recommends limiting daily added sugar to 25g/day for women and 36g/day for men. The average American consumes well over 70g (17 teaspoons)of sugar a day!
Balance your meals with healthy protein, vegetables, and a little healthy fat. What is a healthy fat? Two examples would be extra virgin olive oil and avocado oil. You can also sparingly use unsalted grass fed butter and unrefined virgin coconut oil. Too much of any kind of fat is not healthy and adds a lot of extra calories. We’ll talk all about healthy protein in Tip #6.
3. Potassium Balance
Why is potassium so important?
Potassium is a very important mineral and electrolyte in the body that helps your nerves, muscles, and heart work properly. It also helps move nutrients into your cells and carries waste out. Healthy kidneys strictly regulate how much potassium is in the body in order to maintain safe levels. Once your kidneys fail, potassium can build up in your blood from the foods that you eat – sometimes to dangerous levels causing an irregular heartbeat or cardiac arrest. This is why it’s so important to keep your potassium lab results in a safe range (3.5-5.5 mg/dL).
Preventing low potassium levels is also important. If you are doing PD (peritoneal dialysis) or more frequent dialysis treatments, you are removing more potassium which can sometimes cause low levels. Your potassium needs are usually higher in comparison to someone who is only receiving dialysis 3 days a week.
What is my daily potassium goal on dialysis?
Your daily potassium goal can range from 2000-3000mg/day depending on your needs. When looking at food labels, a high potassium food is considered to have 200mg or more potassium per serving (usually 1/2 cup). A banana contains approximately 450 mg and 1 avocado about 730 mg of potassium. Examples of lower potassium fruits would be 1/2 cup strawberries (115 mg), or 1 small apple (177 mg). Your grocery list will give you more examples of lower potassium options. Just pay close attention to portion size as eating more than one portion can make a low potassium food into a high potassium food. Aim for 5 servings of fruits/vegetables per day. One serving is considered to be 1/2 cup, 1 small piece of fruit or 1 cup lettuce.
Knowing what your potassium level is, what foods are high in potassium, and eating the right amounts/portions will help you keep your potassium in a safe range. Your dietitian can help guide you through this.
4. Rule Your Phosphorus!
How does phosphorus affect your body?
Phosphorus is one of the most abundant minerals in the body (second to calcium) and has many purposes including building healthy teeth and bones. Phosphorus is found naturally in many of the foods we eat and is also found in the form of additives found in many bottled drinks, processed, and fast foods.
Normally, healthy kidneys remove any extra phosphorus that the body doesn’t need. When your kidneys fail, there is a build up of phosphorus in the blood from the foods that you eat. This signals your body to release calcium out of the bone, which over time causes weak and brittle bones. This also leads to dangerous calcium deposits in your heart, blood vessels, lungs, and soft tissues which puts you more at risk for heart attack or stroke (7). Often you don’t have any symptoms of having a high phosphorus, but sometimes the extra calcium can deposit under your skin causing you to itch.
So, what can you do?
Start reading the ingredients on your food label. Look for ingredients that contain “phos” (phosphate, phosphoric acid). These are phosphorus additives which your body absorbs almost 100%. By avoiding these more processed foods you can eliminate a lot of the phosphorus in your diet.
- Take your “binders” with every meal. If you are just starting on dialysis you may not have been prescribed a medication (“binder”) for your phosphorus yet. Most people on dialysis will eventually need to take phosphorus binders with every meal to help remove some of the phosphorus from the foods that you eat. Taking binders in combination with limiting high phosphorus food sources in your diet (milk, cheese, ice cream, dark colas, cookies, chocolate, pastries, chips, fast foods, etc.) will really help.
- Ensure you’re receiving adequate dialysis. Dialysis does remove some phosphorus from your blood. Ensuring you are getting enough dialysis (Refer to Tip #7) and not skipping or shortening your treatment time. This, in combination with watching your diet and taking your binders with every meal, will help you rule your phosphorus (8)!
5. Drinking To Support Healthy Fluid Gains
One of the main functions of healthy kidneys besides removing toxins/waste products is to balance fluid in your body. Once your kidneys fail, you may notice a decrease in how much you are able to urinate. Your kidneys stop being able to effectively remove extra fluid, causing fluid to build-up in the body (fluid overload). This can have harmful effects on your health(9).
What can happen when you gain too much fluid?
- Swelling (edema) in your hands, wrists, feet, face, ankles, and abdomen.
- Shortness of breath. Sometimes this extra fluid can accumulate in your lungs making it difficult to breathe.
- High blood pressure due to the heart having to pump all the extra fluid in your blood stream.
- Over time an increase in the size of the heart due to the extra workload eventually leading to congestive heart failure.
- Low blood pressure during dialysis treatment. Your body is only able to handle a limited amount of fluid to be removed in a short period of time. Having to remove a lot of fluid in one treatment can cause headaches and uncomfortable cramping. Your fluid removal target is individualized and depends on the person.
What you can do for healthier fluid gains
Eat a low sodium diet! This has a big impact on how much fluid your body retains and how thirsty you are.
Start tracking how much you are drinking. Those large soda and coffee drinks are no longer a good option as you can easily drink your full fluid allowance before lunchtime if you’re not careful. Measure out what an 8 oz cup is and keep track of how many of those cups you are drinking throughout the day. Your daily fluid goal usually ranges from 4 to 6 cups a day (32-48oz) depending on how much urine you are making. Sometimes it’s easier to spread out 8 (4oz) servings throughout the day instead of 4 (8oz) servings.
Quench your thirst using these tips:
- Squeeze lemon into your water.
- Freeze grapes or berries and suck on one. Having something cold in your mouth can help.
- Brush your teeth and tongue regularly and use non-alcohol mouthwash for dry mouth. Keeping it in the refrigerator can keep it nice and cold.
- Chew sugar free gum and suck on sugar free hard candies.
- Freeze your favorite beverage and sip on it as it melts.
6. The Power of Protein
Before starting dialysis you may have been told you should limit your protein intake in order to put less stress on your kidneys. However, once you start dialysis your protein needs increase. You loose a little bit of protein every time you dialyze, so it’s important to replace those losses.
Why does protein matter?
Every cell in the human body contains protein. You need adequate protein to help build and repair your cells and muscle tissue, to support your immune system to help fight infection and heal wounds, to produce hormones and enzymes for proper digestion, to basically keep you healthy!
So, how do you meet your protein needs?
Your dietitian can help guide you specifically on how much you need each day. The goal is to choose from a variety of different fresh (less processed) protein sources and try to eat a good portion with every meal. Your protein needs can range from 6-10 oz a day depending on your body weight and individual needs.
Look for fresh meats without sodium nitrates and phosphates added on the ingredients list. Try to avoid more processed/high sodium meats like: luncheon meat, ham, salami, corned beef, bacon, sausage, SPAM/canned meats.
There are also high protein grains such as amaranth, buckwheat, kamut, millet and quinoa. These grains, in addition to other plant based proteins like beans and legumes, can not only add extra protein to your diet but also fiber. It is important to note that all protein sources do contain potassium and phosphorus, so portions do matter. Focusing on avoiding the more processed sources will help you make healthier choices. If you’re finding it difficult to meet your protein needs, supplements can be helpful. Your dietitian can help determine what is right for you.
7. Ensure You Are Getting Enough Dialysis
Your doctor and dialysis team routinely check to make sure you are receiving enough dialysis. There are many factors that impact your dialysis “adequacy”. This can include the length of time on dialysis, body size, blood flow rate, type of dialyzer used, and how well your access is functioning (catheter, graft, or fistula if you are on hemodialysis) to name a few. If you are doing PD, how many “exchanges” you do, the strength of dextrose solution used, and the permeability of your peritoneal membrane (the speed of transport of waste products and fluid across the membrane) are all important factors affecting your dialysis. Whether you are doing hemodialysis or peritoneal dialysis (PD), it is important to get enough dialysis to feel your best (10).
Know your Kt/V
This is a formula that measures your dialysis adequacy to determine if your current Rx is removing enough waste products. This is checked monthly for hemodialysis and quarterly for PD. For 3 days a week hemodialysis treatments your Kt/V should equal at least 1.2. For PD or more frequent dialysis your weekly Kt/V should be at least 2.0. Know your numbers! This will be on your monthly lab report.
What you can do:
Come to all your dialysis treatments and stay the whole treatment time. Your dialysis treatments only replace a small part of the normal function of your kidneys. Missing or shortening your treatment time will have serious consequences to your health and your life. Make the time for treatment!
Protect and keep your access clean. It is your lifeline! Your dialysis care team will teach you the steps for good access care.
Be involved in your care. Ask questions. It’s also good to know that if the type of dialysis you are currently doing is not working well for you, you have the option to change to a different modality. Talk to your healthcare team for more information.
8. Antioxidants & Anti-Inflammatory Foods
What are antioxidants and why should you care?
A good question! Antioxidants are synthetic (man-made) or naturally occurring substances made in your body and found in certain foods that offer protection against cell damage caused by free radicals (unstable molecules). When there are more free radicals than antioxidants in your body, this can cause oxidative stress. Being on dialysis already exposes you to more oxidative stress and inflammation. Oxidative stress can increase your risk for certain diseases like cancer and heart disease(11). Eating a diet rich in antioxidants can help protect you from these risks and boost your immunity.
Examples of antioxidants
Vitamins C and E, selenium, and carotenoids (bright yellow, red, and orange pigments in fruits and vegetables) are a few examples of antioxidants.
Here are a few anti-inflammatory foods high in antioxidants that you can include in your diet (vegetable and fruit portions=1/2 cup):
- All berries!
- Green tea
- Pecans, walnuts (1/4 cup)
- Kidney beans (1/2 cup)
- Bell peppers
- Red cabbage
- Leafy greens, kale
Experiment and try cooking apples in with your oatmeal and add some cinnamon. Drink turmeric or green tea. Squeeze lemon into your water. Flavor your dishes with lots of garlic. Add sautéed bell pepper and onion to your egg scramble. Don’t forget the cilantro and shredded red cabbage on your tacos. Have fun with it!
9. Fiber & Gut Health
The Importance of Gut Health
There has been a lot of talk lately about the importance of gut health and your microbiota – and for good reason! Your gut makes up almost 70% of your immune system. I know it’s weird to think about, but our body is made up of trillions of bacteria, viruses, fungi, and other living microorganisms. Most of these “microbes” hang out in the large intestine and are referred to as your microbiota. These microbes/gut bacteria play a huge role in digestion, metabolism, immune and brain health (12).
Having kidney disease already puts you at risk for poor gut health due to the increase in uremic toxins, inflammation, medication side effects, constipation, and eating a low fiber diet to name a few. Improving the health of your gut can help reduce some of these problems and improve your immune system.
So, what can you do?
The first step would be to decrease the amount of processed foods in your diet which contain additives and preservatives that negatively affect your microbiota. Processed foods are pre-packaged foods with added oils, sugar, salt, and preservatives. These include chips, cookies, pastries, candies, fast foods, many breakfast cereals, frozen prepared meals, cakes, biscuits, and meat products.
- Eat more fiber! Fiber helps in many ways. Insoluble fiber keeps things moving and helps you better digest and transport waste out of your body preventing constipation. Soluble fiber has “prebiotic” powers because they ferment in your gut helping to feed your good bacteria and reduce the bad bacteria. A lot of the high fiber foods (fresh fruits and vegetables) are also high in antioxidants which is a bonus!
Examples of high fiber foods
(1/2 cup portions unless otherwise noted)
Apples (1 small)
Pears (1 small)
Popcorn, air-popped (3 cups)
Quinoa, brown rice
Shredded wheat (1 biscuit)
You may also benefit from taking a daily probiotic to help increase the good bacteria in your gut. There are many different kinds/strains to choose from and not all probiotic supplements are high quality. Renadyl (also targets the removal of uremic toxins) and VSL#3 are a couple of good options. Also, if you are taking antibiotics you should definitely take a probiotic in addition as antibiotics will kill your good bacteria as well as the bad (13). Just make sure to take them a couple hours apart or take a yeast based probiotic (Florastor) which is more resistant to the effects of antibiotics. Talk to your doctor to determine if taking a probiotic is right for you.
10. Mind & Body Wellness
There is no way to sugarcoat it. Dialysis is a life-changing therapy. Dealing with chronic kidney failure can impact all areas of your life, relationships, emotional and physical well-being(14). Dealing with this added stress becomes an important part of your self care in order for you to live your best life. Your disease does not define you. Tap in to your strengths, adapt, learn, and do the things that give you joy, drive your purpose, and strengthen your relationships.
Beyond fueling your body with healthy foods, here are a few suggestions on ways you can improve your overall health and well-being:
Meditation and mindful breathing
It all starts with the mind. Your mind and thoughts can have a powerful effect on your health. You can use your breath as a powerful tool to help you nourish your body and organs with oxygen and relieve stress and tension. There are many free apps that you can download onto your phone to help you get started. Try Calm or The Mindfulness App.
Yoga and Tai Chi
Both yoga and Tai Chi have been shown to build strength, muscle tone, balance, relieve stress and pain, and improve mood and sleep (15). What’s holding you back from trying it? Again, there are many free apps and online websites/videos you can access to get you started. There are also options for chair/wheelchair versions. I recommend the website DoYogaWithMe. They offer a lot of free classes (in addition to paid options). You can also download the apps Simply Yoga, and 5 Minute Yoga. For Tai Chi I recommend the video: Gentle Tai Chi and Qi Gong LEAP Service.
Make time to do the things that give you pleasure
That could mean reading a good book, journaling, gardening, listening to your favorite music, dancing, art, volunteering, etc. Doing things for others and staying productive can be rewarding. Don’t forget to make time for you and the things that make you happy!
I know all of this information is a lot to take in. You don’t realize all that your kidneys do for you until they stop working. Don’t get discouraged! Find what works for you and start making small changes that will enable you to live a healthy life on dialysis. Find a routine and schedule reminders for taking your medications, incorporating exercise, grocery shopping and meal planning. Keep in mind your goals and what’s important to you. Whether it’s to get a transplant, to travel, watch your kids or grandkids grow up or accomplishing a goal you’ve been putting off. These are the things that are going to keep you motivated and drive you forward. Don’t forget to download a copy of the Top 10 Nutrition Tips which includes a Grocery List and Sample Meal Plan.
You got this!