Nutrition and Dietetics

Image courtesy of Peter Quife - The Lighter Side of Dialysis

What is the recommended diet and nutrition practices of an ESRD or Chronic Kidney Disease(CKD) Stage V patient? Let me attempt to show here what the National Kidney and Transplant Institute(NKTI) nutritionist/dietician discussed with us while confined in hospital. But first let me tell you about the diet I followed before all these have happened.

I was overweight the past fifteen years. Tried to keep myself active but still overweight. Dieting was on and off, so I’d get a little leaner but then I’d gain all of it back again. Starting September of last year, I started a conscious effort to cut down on food intake. Weight loss was very slow, but still, I could feel my clothes were getting a little more comfortable. By December, some people have begun to notice and comment that I have lost some weight. But It was also in December when I started to feel the symptoms I described in an earlier entry. Some of the weight loss I attributed to fruits. These past months, I have been having fruit for breakfast and substituting fruit instead of snacks. I also exerted a conscious effort on cutting down on sodas and fruit juices. I still had them but only on occasion. Alcohol was not an issue because I only take a beer or two about once every two moths on the average. Instead, I had fresh coconut juice or unsweetened iced tea when I felt I wanted something other than water. Of course you couldn’t follow this diet all the time. There is the occasional binging. Overall, even before September, my food intake wasn’t far from what an ordinary Filipino my age would consume.    

All these changed when I was confined. The hospital food was bland, unpalatable and not enough. But I had to eat what came from the hospital kitchen and nothing more, the nurse said, and no fruits or fruit juices . The next day in hospital, I got a visit from a nutritionist/dietician. With handouts, she discussed with me what I can eat and what I cannot eat. They have studied the results of my laboratory work and they have designed a diet plan for me. They called it the Uremic, Diabetic, Low Potassium, Low Uric Acid Diet. So at first glance you can deduce that this is a low sodium, low sugar, low potassium and low purine diet. She tried to explain the reasons and importance of why I have to follow the diet. And here is an attempt to relay them to you. Remember, these are for persons who are on dialysis or who have some impairment in kidney function. Remember too that I am an amateur and not a trained allied medical practitioner. This is just what I have learned from the time of this condition three weeks ago. 

1. Sodium - Causes water retention in the body. A uremic could not pass out the toxins in the body via urine. When one is in dialysis, excess body fluids are removed during the dialysis treatment and somehow, natural urine production is decreased. Regular dialysis leads to reduction or even cessation of urine output in patients. Therefore a low-sodium diet is indicated. The more sodium you consume in between dialysis sessions, the more fluid is retained. The more fluid in the body, the more ultrafiltration is required during hemodialysis and the more strain you impose in your circulatory system and more postdialysis symptoms of dizziness and hypotension.  
2. Sugar - Although my fasting blood sugar numbers were not that bad, we’d like to keep it that way. Therefore, intake of sugary food is also controlled. Although I can still have the occasional slice of cake and ice cream, glucose intake in general must not go over the recommended daily allowance indicated for dialysis patients.
3. Purines - Foods rich in purine should be avoided. Uric acid is filtered out during dialysis, but as I have discussed in an earlier post any significant change in uric acid levels, either up or down, will cause arthritic pain. You do not want your urate levels to be seesawing up and down by consuming purine rich food then taking them out during dialysis. Otherwise, you get unbearable joint pains. 
4. Potassium - Because you have impaired kidney function, potassium is not processed efficiently and passed out in urination. It stays in your bloodstream, saturating it. As I mentioned,  I went on a more fruit diet the past few months. It’s fruit, for God’s sakes, who could go wrong? But as I learned later, all of that was and that I had screaming Potassium levels in my blood. That has been corrected now and therefore, the need to maintain it. So I have a listing of fruits that I can and cannot eat. All fruits have potassium but some of them have minimal content, like pineapple, grapes, apples, berries, peaches, pears, strawberries, mandarine oranges. High potassium fruits that are contraindicated are avocado, banana, oranges, mango, dried fruits. There is also a similar listing of allowed and avoid vegetables.
5. Water and fluids - Water or fluid intake is also reduced for ESRD patients. As a rule I follow the no more than a liter of fluids a day intake. Again, even if you still have urine output, you do not want to accumulate extra fluid in your body. Otherwise there will be intradialysis swelling in your extremities and face. And it can become uncomfortable during or postdialysis.

Food intake quantity is also measured. As I said in an earlier post, you do not want to stray far away from your dry weight. There are considerable consequences. Therefore, we measure intake and are given a recommended daily caloric allowance. Protein is consciously monitored. You do not want a diet too high or too low in protein, even as dialysis patients have a higher protein allowance than nondialysis counterparts. As a rule, not more than three matchbox sized protein(fish, poultry, meat) at every meal. Of course you have to factor in other protein sources like vegetables, and adjust accordingly.

Because I have strictly followed this diet, I have considerable weight loss. They have adjusted my dry weight twice already, once after performing a BCM(Body Composition Monitor) to determine what your lean weight is as opposed to what your weight is with excess fluid. But up to now, three weeks into hemodialysis, I am still registering a weight lower than my assigned dry weight whenever I go to dialysis. I am guessing, they will have to do another BCM and adjust my dry weight accordingly soon until I plateau into my ideal weight. And I have never experienced any uncomfortable postdialysis dizziness, hypotension or muscle cramping. 

So most of my food now is home-cooked and contains no salt. Alternative flavoring by using nonsodium spices. But the good thing is that my taste buds have adapted to this new standard. I still have appetite, and I feel good. Cravings are seldom and other food do not appeal to me anymore. I mean even when there is regular food on the table, be it at home or in restaurants, I can restrain myself and avoid being tempted even for just a taste or a bite. It wasn’t difficult, I guess if you have some self discipline to start with, you adapt easily.

The hospital have perfected the art of cooking these restricted diets and the food that comes from their kitchen is more tasteful that what I get at home. So during dialysis days, I look forward to getting take out food to eat during the session from the hospital kitchen. I just specify, uremic/diabetic/low potassium, and they box up a balanced meal complete with dessert. I get a treat during dialysis days. The important thing is, even with this condition, I have improved confidence, self esteem and attitude. I feel great.