Nutritional Assessment in
Hemodialysis
Patient
Haneen Nabeel Molla M.Sc.
Clinical Dietitian
King Khalid University Hospital
Stages of Kidney Disease
 There are five stages of kidney disease.
 It based on the presence of kidney damage and the
glomerular filtration rate (GFR)
 The treatment is based on the stage of kidney
disease.
Stages of Kidney Disease
Stage
Description
Glomerular Filtration Rate
(GFR)*
1
Kidney damage (e.g., protein in
the urine) with normal GFR
90 or above
2
Kidney damage with mild
decrease in GFR
60 to 89
3
Moderate decrease in GFR
30 to 59
4
Severe reduction in GFR
15 to 29
5
Kidney failure
Less than 15
End Stage Renal Disease ( ESRD ) :
 Inability to excrete waste products , maintain fluid
and electrolyte balance and produce hormones.
When is Dialysis Needed?
 Kidneys no longer remove
enough wastes and fluid from
the blood
 When only 10 to 15 percent of
the kidney function left.
When is Dialysis Needed?
 Symptoms such as nausea, vomiting, swelling and
fatigue.
 A high level of wastes in their blood that may be toxic to
their body.
Nutrition and Hemodialysis
 Diet is an important part in hemodialysis patient overall care.
 We will go over some of the important points in the patient
diet which include :
 Getting the right amount of calories and protein
 Staying at a healthy body weight
 Important nutrients in the diet
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Potassium
phosphorus
sodium and fluids
calcium
 Diabetic – Renal Diet
The Goals of the Nutritional
Management in Dialysis
 Prevent nutrients deficiencies
 Control edema and serum electrolytes
 Provide an attractive healthy diet
Anthropometric Measurement
 Weight kg
 High cm
 Body mass index (BMI ): Weight
(Height)2
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Underweight
16.0 to 18.5
Normal (healthy weight)
18.5 to 25
Overweight
25 to 30
Obese Class I (Moderately obese)
30 to 35
Obese Class II (Severely obese)
35 to 40
Obese Class III (Very severely obese)
over 40
Anthropometric Measurement
 adjusted body weight (AIBW) = (Actual weight – IBW)
x 0.32 + IBW women
x 0.38 + IBW men
 Ideal body weight (IBW) : (Height)2 x 22.4 men
x 22.1 women
 % of IBW: Actual Weight x 100
IBW
Getting the Right Amount of
Calories
 To the patients overall health and helps to give them
energy to do their normal activities .
 Calories come from all the foods they eat , and are
important because :
 Give the body energy
 Help to stay at a healthy body weight
 Help the body use protein for building muscles
and tissues.
Getting the Right Amount of
Calories
 Will keep the patients from losing weight.
 The amount of calories recommended will
depend on the individual needs.
Energy
35 kcal/kg of body weight for <60 years;
30 to 35 kcal/kg of body weight for >60 years
Getting the Right Amount of Protein
 In pre-dialysis patients have to be on a low-protein diet.
 During dialysis patients will need diet with more protein.
 It is important for overall health and how well they feel.
 Body needs the right amount of protein for:
 Building muscles
 Repairing tissue
 Fighting infections.
Protein
 Protein is found in 2 types of foods:
Animal sources
Plant sources
poultry , meat , eggs, seafood nuts, seeds , legumes, soy
, milk and cheese
and tofu
Protein
 Some of these protein-rich foods may also contain
lots of phosphorus, which need to be controlled in
their diet.
 Protein : 1.2- 1.3 g/kg of body weight, >50% HBV
protein
Potassium
 Potassium is an important mineral found in food.
 Potassium helps the muscles and heart work properly.
 Healthy kidneys helps to keep the right amount of
potassium in the body.
Potassium
 Too much or too little potassium level in the blood
can be dangerous.
 With hemodialysis, patients need to limit their intake
of high-potassium foods.
Potassium
 Soaking the vegetables after cutting it and cooking it
helps to remove high amount of potassium
 Potassium : 2 to 3 g/day; or 40mg/kg IBW
High-Potassium Fruit
(>200 mg / portion)
The portion size is ½ cup
Apricot, raw (2 medium)
dried (5 halves)
Avocado (¼ whole)
Banana (½ whole)
Cantaloupe
Dates (5 whole)
Dried fruits
Figs, dried
Grapefruit Juice
Honeydew
Kiwi (1 medium)
Mango(1 medium)
Nectarine(1 medium)
Orange(1 medium)
Orange Juice
Papaya (½ whole)
Pomegranate (1 whole)
Pomegranate Juice
Prunes
Prune Juice
Raisins
High-Potassium Vegetables
(>200 mg / portion)
The portion size is ½ cup
Artichoke
Baked Beans
Squash
Beets, fresh then boiled
Black Beans
Broccoli, cooked
Brussels Sprouts
Chinese Cabbage
Carrots, raw
Lentils
Dried Beans and Peas
Legumes
Mushrooms, canned
Okra
Parsnips
Potatoes, white and sweet
Pumpkin
Rutabagas
Spinach, cooked
Tomatoes/Tomato products
Vegetable Juices
Other High Potassium Foods
(>200 mg / portion)
The portion size is ½ cup
Bran/Bran products
Chocolate (1.5-2 ounces)
Granola
Milk, all types (1 cup)
Molasses (1 Tablespoon)
Yogurt
Low-Potassium Fruit
(<200 mg/ portion)
The portion size is ½ cup
Apple (1 medium)
Apple Juice
Applesauce
Blackberries
Blueberries
Cherries
Cranberries
Fruit Cocktail
Grapefruit (½ whole)
Grapes, Grape Juice
Raspberries
Plums (1 whole)
Tangerine (1 whole)
Strawberries
Pears(1 small) canned (½ cup)
Pineapple, Pineapple Juice
Peaches, (1 small) canned (½ cup)
Watermelon(limit to 1 cup)
Low-Potassium Vegetables
(<200 mg/ portion)
The portion size is ½ cup
Asparagus (6 spears)
Beans, green or wax
Cabbage, green and red
Carrots, cooked
Cauliflower
Celery (1 stalk)
Corn, fresh (½ ear) frozen (½ cup)
Cucumber
Eggplant
Mixed Vegetables
Mushrooms, fresh
Watercress
Yellow Squash
Zucchini Squash
Onions
Parsley
Peas, green
Peppers
Radish
Kale
Lettuce
Other Foods Low Potassium
( <200 mg/ portion)
The portion size is ½ cup
Cake: angel, yellow
Coffee: limit to 8 ounces ( 1 cup )
Pies without chocolate or high
potassium fruit
Cookies without nuts or chocolate
Tea: limit to 16 ounces (2 cups )
Rice
Noodles
Pasta
Bread and bread products: (Not
Whole Grains)
Phosphorus
 Phosphorus is a mineral found in different kind of
foods.
 Eating foods high in phosphorus will raise the
amount of phosphorus in the blood.
 When phosphorus builds up in the blood, calcium is
pulled from the bones. Over time, the bones will
become weak and break easily.
 Dialysis cannot remove all of this phosphorus.
Phosphorus
 A high level of phosphorus in the blood may also
cause calcium phosphorus crystals to build up in the
joints, muscles, skin, blood vessels and heart.
 These crystals may cause serious problems such as
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Bone pain
Damage to the heart and other organs
Poor blood circulation
Skin ulcers.
Phosphorus
 To keep blood phosphorus at safe levels, patients
will need to limit phosphorus-rich foods, and may
need to take some medications.
 Phosphorus 800 to 1,000 mg/day; or 17mg/kg IBW
High Phosphorus Food
( >150 mg/portion)
The portion size is ½ cup
Protein
 Carp, sardines, beef liver,
chicken liver ,organ meats,
oysters
Dairy Products:
 Milk, Yogurt ,Pudding,
Custard, Ice cream and Cream
soups
High Phosphorus Food
Vegetables dried
beans and peas:
baked beans
black beans
chick peas
kidney beans
lentils
northern beans
split peas
soy beans
Other foods
bran cereals
brewer’s yeast
nuts
caramels
seeds
Beverages
Ale, Beer
drinks made with milk
chocolate drinks
Cocoa, dark colas
Sodium
 Sodium is a mineral found naturally in foods. It is
found in large amounts in table salt and in foods that
have added table salt.
 Eating too much sodium can make the patient thirsty
and cause the body to hold onto more fluid.
Sodium
 The extra sodium can cause:
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Swelling or puffiness around eyes, hands or feet
Fluid weight gain
Shortness of breath
Rise in blood pressure
More work for their heart
 Sodium 1 - 3 g/day
Sodium
SEASONIN
GS
High
Sodium
Sauces
Salted
Snacks
MEATS
PROCESSED FOODS
Table salt
Seasoning
salt
Garlic salt
Onion salt
Celery salt
Barbecue
Steak
Soy
Teriyaki
Oyster
Crackers
Potato
chips
Corn chips
Pretzels
Tortilla
chips
Nuts
Popcorn
Sunflower
seeds
Hot Dogs
Cold cuts,
Pastrami
Sausage
Corned
beef
Spam
Frozen prepared foods
Commercial mixes
Buttermilk
Cheese
Soups
Tomato products
Vegetable juices
Canned vegetables
Canned raviolis
Chili
Macaroni & Cheese
Spaghetti
Fast foods
Pickles
Olives
Fluids
 Fluid is any food or beverage that is liquid at room
temperature.
 Some examples are:
 Ice
 Beverages like coffee, tea, sodas, juices and water
 Frozen desserts such as ice cream, sherbet or Popsicles
Gelatin
 Gravy and Soups
Fluids
 Signs may noticed with drinking too many fluids
 A sudden increase in weight along with swelling
 Shortness of breath
 A rise in the blood pressure
Fluid : output + 1000 ml
Calcium
 Calcium is the mineral that is important for building
strong bones.
 However, foods that are good sources of calcium are
also high in phosphorus.
Calcium
 To prevent loss of calcium from bones
• Follow a diet that limits high-phosphorus foods
• Take phosphate binders.
 In some cases the physician may prescribe a special
form of vitamin D to help keep calcium and
phosphorus levels in balance and prevent bone
disease.
Diabetic-Renal Diet in Hemodialysis
 Patient on hemodialysis diet will have restrictions in
foods containing high amounts of phosphorus,
sodium and potassium.
 Diabetic patients who are on hemodialysis will be
tightly controlled the Carbohydrate intake in order
to manage the blood glucose levels.
Diabetic-Renal Diet in Hemodialysis
 High sugar foods and all carbohydrate containing
foods, increase blood glucose levels.
 The total amount of carbohydrates the patients eat
will be balanced with their medication and activity
level.
 They could use system called carbohydrate counting
to keep their carbohydrate intake balanced.
Diabetic-Renal Diet in Hemodialysis
 Take low phosphorus and low potassium foods .
 Limit milk and dairy intake.
 Control blood sugar to help control thirst and fluid
gains.
 Avoid cooking with salt, salt substitutes, or add salt
at the table.
Conclusion
 Our goal for hemodialysis patients should be a
healthy lifestyle that can be maintained in the long
run, rather than a short-term "diet”. It's all about
making changes that will last a lifetime--changes that
are focused on smart, sensible eating.
Thank you