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Protein Intake Management for
Hemodialysis Patients
Teaching Module
Polly Peru
DFM 655
December 4, 2014
San Francisco State University
Dr. George
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Lesson Plan/Overview:
One in nine American adults is currently suffering from chronic kidney disease. Chronic
kidney disease is the eighth leading cause of death in America and 485,000 Americans have
advanced to end stage renal disease (ESRD), for which there is no cure (Kidneyfund.org, 2012).
Treatments are limited to hemodialysis, peritoneal dialysis and kidney transplantation (Snyder,
2011, p. 18). The kidneys perform many vital functions in the body which include: filtering
toxins out of the body, regulating blood pressure, maintaining acid-base balance, and stimulate
the bone marrow to make red blood cells by producing the hormone erythropoietin.
Healthy kidneys function as a filtration system, cleaning wastes and extra fluids from our
bodies. An individual diagnosed with stage five chronic kidney disease (CKD) has end stage
renal disease (ESRD) with a glomerular filtration rate (GFR) of 15 ml/min or less and requires
dialysis treatment or kidney transplant because the kidneys have lost their ability to function
effectively, causing toxins build up in the blood (http://www.davita.com). Hemodialysis therapy
is not a cure for individuals with end stage renal disease (ESRD).
Nutrition is a crucial component for the survival of all living organisms. A properly
balanced diet can aid in supporting optimal health, growth, and repair of the body. The nutrients
provided by food are important and they can dramatically affect all functions of the body.
Maintaining the proper balance of nutrients, electrolytes, and other chemicals is complex,
multifaceted, and somewhat difficult for the overall population. For individuals suffering from
chronic kidney disease and relying on renal replacement therapy three to four times a week to
sustain their lives, maintaining nutrient balance can prove to be frustrating, complicated and
nearly impossible.
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Nutrition for hemodialysis patients is very important in decreasing complications and
improving the quality life for patients. The renal diet for patients with chronic kidney disease and
on dialysis is crucial in the process of treatment and outcome. The renal diet can be very
challenging as it requires strict adherence to the restriction of sodium, potassium, phosphorus,
fluid and the increase of high-quality protein (Stark, 2011, p 93). One of the major challenges
that hemodialysis patients face is meeting their individualized protein recommendations. Dialysis
treatments remove protein waste and some amino acids from the blood resulting in higher needs
of high quality protein. The Kidney Disease Outcomes Quality Initiative Clinical Practices
Guidelines for nutrition of hemodialysis patient’s recommends the following energy and protein
needs:

Energy: 35 Kcal/Kg body weight per day

Protein: 1.2 - 1.3 g/Kg body weight per day
Protein energy malnutrition (PEM) in dialysis patients is associated with increased
morbidity and mortality (Ravel, 2013). In contrast, the actual protein intake of hemodialysis or
peritoneal dialysis patients is approximately 0.95-1.0 g/kg/day due to loss of appetite or other
pathophysiological or psychosocial issues, influencing the development of PEM (Kovesdy,
2010). Approximately ten – fifty percent of hemodialysis patients have some degree of PEM
(Gray, Iurrows, Chertow, 2012 pg. 232). Hemodialysis patients require monitoring of their
nutritional status through anthropometric measures, biochemical parameters, diet histories, and
interviews for early detection and prevention of PEM.
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The topic of the lesson plan that I will present will be for adults currently experiencing
hemodialysis, ages 21 and above and will focus on “The Effect of Hemodialysis on Protein
Status”. I spoke with several renal dietitians to identify the main nutritional challenges faced by
hemodialysis patients. All of their answers were basically the same: patients consume too much
sodium, fluid, potassium and not enough protein. They said that it is primarily due to the lack of
knowledge of the renal die; frustration over having to adhere to the strict and limiting renal diet,
or just not caring to comply. A review of scientific based literature and the information that I
collected from the renal dietitians served as the needs assessment tool that lead me to plan a
hemodialysis nutrition education lesson- focused on imparting protein nutrition education to
current hemodialysis patients.
The teaching perspective that I most indentify with and will use in this lesson plan is the
nurturing perspective. Teachers that facilitate the nurturing perspective of teaching believe that
people become motivated and productive learners when the standards for achievement are clear
and accompanied by the balance of academic and emotional support (Pratt, 2006). Being on
hemodialysis and following a renal diet is very challenging and can be a source of anxiety and
depression. I will provide a professional, supportive and non-judgmental learning environment
that focuses on a combination of information dissemination and behavioral change.
Due to the broad range of the participant’s ages and learning and cogitative abilities,
information dissemination will focus on providing clear and evidence based information using
basic nutrition education with an emphasis on protein. My goal is to build an understanding of
the importance of consuming adequate amounts of high quality protein to maintain health while
on dialysis. It is my hope that my lesson will facilitate behavioral change in the form of the
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participants developing the desire and ability to choose high quality protein sources in adequate
amounts to avoid PEM.
The learning theory that will be utilized in this lesson plan is the Health Belief Modelperceived susceptibility and severity, perceived benefits, perceived barriers, self-efficacy, and
cues to action will be incorporated in to the lesson to provide optimal learning. The Health Belief
Model purposes that the cognitive factors influence an individual’s decision to make and
maintain a specific health behavior change (Bauer, Liou, & Sokolik, 2012, pg 18). I will address
personal risk by emphasizing the increased risk of developing PEM from not consuming
adequate amounts of high-quality sources of proteins. I will discuss the impact that PEM can
have on their physiological and physical health and relate that PEM in dialysis patients is
associated with increased morbidity and mortality (Gently) (Ravel, 2013).
When I address the benefits of consuming and maintaining protein status I will relate that
compliance with the renal diet will keep those on various transplantation lists eligible for
transplant; or make those hoping to be placed on a list eligible; and that their overall health will
benefit and they will feel better and not be so weakened by their dialysis treatments. To help the
participants deal with the perceived barriers and to encourage cues to action of indentifying and
consuming high-quality protein sources I will discuss and provide an educational tri-fold
brochure with sources of high-quality protein and ideas for quick and easy on the go sources
along with three samples of protein bars for each participant . To promote self-efficacy I will
provide participants with references to obtain science based information and also use verbal
reinforcements when they participate in the class.
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Summary
The need for science based quality hemodialysis nutrition education is evident based on
the high prevalence of chronic kidney disease in the United States. Nutrition plays a key role in
achieving and maintaining optimal health for all humans. For individuals suffering from chronic
kidney disease maintaining the proper balance of nutrients, electrolytes, and other chemicals is
crucial. Given that there is no cure and treatments are limited to hemodialysis, peritoneal dialysis
and kidney transplantation it is imperative that patients have the ability to identify and make
informative nutritional choices that will allow them to avoid unnecessary complications and
maintain their quality of life. A major obstacle to maintaining an individual’s quality life while
on hemodialysis is non-compliance to the renal diet guidelines. Overcoming this obstacle is not
an easy task and requires patience, understanding and a non-judgmental attitude on the part of
the nutrition educator.
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Lesson Plan: Protein Intake Management for Hemodialysis Patients
Duration: 10 minutes
Target Group: Participants are new to hemodialysis treatments or are patients with
consecutively low albumin levels refereed by the clinic’s nephrologist.
Ages 21 & Above
Materials List: 1. PowerPoint presentation
2. Computer
3. Four protein bar samples and evaluation sheets per participant
4. Educational Handout
Overall Goal: To educate hemodialysis patients on the importance of consuming
adequate protein and to provide them with healthy protein options.
Major Concepts:
 Hemodialysis patients need a higher intake of protein to replenish protein lost
during treatments.
 Provide examples of high quality dietary protein and nutritional supplements.
 Phosphate Binders: Remind to take binders with all meals and snacks. All high
quality protein sources are high in Phosphorus.
Icebreaker:
 Have the title slide of the PowerPoint presentation on the screen
 Welcome and thank the participants for being there.
 Ask the participants “Who is new to hemodialysis within the last six months?
 Ask the participants “Who has had the opportunity to meet with their renal
dietitian?
 Ask the participants to name sources of protein.
 Show a slide with pictures of high quality protein sources.
Objectives and Learning Domains; Generalizations and Learning Experiences:
1. Upon completion of this class participants will have the ability to recognize highquality protein options to avoid protein energy malnutrition (PEM).
Domain: Cognitive domain - knowledge
Generalization: Inadequate consumption of high-quality proteins is a risk factor for
protein energy malnutrition.
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Learning Experience: PowerPoint (5 minutes)
Provide examples of high quality protein sources:
Define sources of high quality protein:
Meats:
Contain 7 g protein/1-oz serving or 21 g/3-oz serving:
 Beef (all forms, including ground beef, steaks, and roasts)
 Pork (all forms, including ham, loin, chops, ground pork, bacon, and sausage)
 Poultry (all forms, including chicken, turkey, quail, duck, goose, and Cornish hen)
 Fish (all forms, including finfish, shellfish, shrimp, and canned tuna)
Dairy foods:
Contain 7–8 grams (g) protein/serving:
 1 cup (C) whole, reduced-fat, or skim milk
 1 C buttermilk
 ¾ C yogurt
Cheese:
 ¼ C cottage cheese
 2 tablespoons (Tbsp) grated
Parmesan
 1 ounce (oz) feta
 1 oz other cheeses
Meat alternates:
Contain 6- 7 g protein/serving:
 One egg
 2 Tbsp peanut butter
 ½ C dry beans, peas, and lentils
Soy foods:
 1 C soy milk
 ½ C tofu
 ¼ C tempeh
Other dietary sources of protein:
About 3–5 g/serving, serving sizes vary:
 Breads (white and whole wheat, including buns and rolls)
 Cereals (including oatmeal and flaked cereals)
 Grains (grits, flour, and rice)
Starchy vegetables (green peas, potatoes, winter squash, and corn)
 Popcorn
 Crackers
 Tortilla chips
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
Nuts and seeds
2. Upon completion of this class, the participants will perceive the health benefits and
risks of not consuming their individualized recommended grams of protein per day.
Domain: Affective – Receiving
Generalization: Adequate consumption of high – quality protein for hemodialysis
patients aids in the prevention of protein malnutrition and the
promotion of overall health.
Learning Experience: (5 minutes)

Protein wastes and amino acids are removed during henodialysis treatments
therefore hemodialysis patients have higher protein intake needs.

Amino acids are the building blocks of protein and need to be replenished
between dialysis treatments for optimal health.

Albumin is used by your renal healthcare team as a biomarker of nutritional
status in patients with chronic kidney disease. Your albumin level will be tested
monthly and it is important that every patient know their albumin status.

Your renal dietitian will calculate the amount of protein in grams per day that
your need to maintain optimal health and avoid protein energy malnutrition.
3. At the conclusion of the PowerPoint presentation students will sample three renal
diet approved nutritional protein bars and rank their satisfaction of each bar using
a evaluation form provided along with the samples.
Domain: Psychomotor – guided practice
Generalization: Exposure to samples of high-quality meat alternatives enables
hemodialysis patients to experience a wider variety of dietary
protein options.
Learning experience: (2 minutes)

A quick reference protein brochure will be provided with examples of highquality meat alternatives.

Three samples of popular nutritional protein bars will be provided to each
participant.
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
Precautions on choosing renal diet approved sources of nutritional protein
supplements (protein bars, powders and beverages) will be provided.

Risks and benefits of consuming prescribed phosphate binders will be provided
and examples will be displayed on a slide during the PowerPoint presentation.

A satisfaction evaluation form will be provided to each participant to rank the
three samples of protein bars. The information gathered from the participants
evaluations will be provided to a hemodialysis unit that will be stocking protein
bars for their patients that need them during and after treatments.
Sample of protein evaluation form.
Please rate the protein bar samples in the order that you preferred them.
1 = I liked it
2 = It was ok!
3 = I did not like it
_______ Luna Lemon Zest
_______Pure Protein Chocolate Peanut Butter
_______Balance Bar Peanut Butter
Summary: To avoid protein malnutrition it is imperative that hemodialysis patients
consume adequate amounts of protein from high-quality sources to
compensate for protein lost during treatments. It is also important that
all meat alternatives and supplements are renal approved and that
prescribed phosphate binders are taken with every meal and snack.
Evaluation: (1-2 minutes)
At the beginning the class ask participants to raise their hands if they have been on
hemodialysis less than six months.
After presenting and discussing high-quality protein sources, meat alternatives, and
protein supplements ask “who has used protein supplements?” and which ones?
Ask participants to try the three samples of protein bars and the rank them in order of
satisfaction on the evaluation form provided.
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Assignment:
Students will be asked to complete the protein bar satisfaction form.
Students will be asked to know: their monthly albumin level.
Students will be asked to consume high – quality protein sources using the brochure
provided to them.
Students will be asked to be mindful to take their phosphate binders.
Evaluation Strategies/Conclusion:
It will be difficult for me to immediately evaluate if the objectives of my lesson were
met. My goal was to provide information to hemodialysis patients on the importance of
consuming high-quality protein sources and the risks of not consuming adequate amounts of
protein. A clinical situation would be a more suitable setting for me to evaluate if the objectives
of my lesson were met since I would be able to monitor biochemical tests that indicate nutritional
status. I should have asked more questions during my presentation to assess the participant’s
knowledge and understanding of the information that I was presenting.
It is my hope and the main objective of my presentation that the various teaching
methods, information and goals that I utilized in my presentation will allow hemodialysis
patients to avoid the risk of developing protein energy malnutrition. It is very important to me to
make hemodialysis patients aware of the importance of protein management since protein energy
malnutrition in dialysis patients is associated with increased morbidity and mortality and this
knowledge can help them maintain their health and quality of life while on dialysis. I also want
to make the renal diet as uncomplicated and appetizing being that most patients find it difficult to
follow due to its many restrictions. The results of the protein bar satisfaction ranking indicated
that the Lemon Luna bar was the overall favored protein bar.
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Oral Self-Evaluation:
1. What was the topic or title of your presentation?
The title of my presentation was Protein Intake Management for Hemodialysis Patients.
2. Describe one thing that you did well in this presentation.
One thing that I did well in my presentation was that I related to the participants that following
the renal diet is very possible and I provided them with a protein source brochure to take to the
grocery store.
3. Describe one thing that you would change about your preparation of this presentation.
I would have provided nutrition education that included Protein, Fat, and Carbohydrate intake
sources for hemodialysis patients.
4. Comment on the content of your presentation: do you feel that you provided your
audience with information that they did not know prior to your presentation?
Explain.
I felt that I provided new information since most of the participants have been on dialysis less
than 6 months. The renal diet is complicated, especially to new patients who have many
adjustments and emotions to deal with.
5. Comment on your eye contact: was it sufficient? Why or why not? If not, how do you
plan to improve your eye contact for your next presentation?
I felt that my eye contact was good, although it could have been better. With more practice I will
develop the ability to make better eye contact and as I become more proficient with the material I
will not have to rely on reading notes and looking at the screen.
6. Comment on your gestures and movement: were they effective? Why or why not? If
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not, how do you plan to improve your gestures and movement for your next
presentation?
I appear very nervous. To overcome being so nervous I plan to continue to do as many public
speaking engagements as I can.
7. Comment on your practice for this presentation: did you practice thoroughly? If you
feel that you did not practice thoroughly, how will you modify your practice for
your next presentation? Be specific.
I did practice for this presentation many times. I knew the material well but I become nervous
when I have to present in front of my peers and instructor. I need to practice not being nervous in
front of my peers, especially my current classmates. Everyone is very supportive and there is no
need for me to be nervous.
8. Please provide an overall assessment of your presentation. Were you satisfied with
your presentation? Why or why not?
I was not pleased with my overall presentation. I was pleased with my PowerPoint, brochure, and
the content of my presentation. I was not pleased that I was so nervous.
SMOG Reading Level:
I used the SMOG reading level procedure to calculate the approximate grade level that
my educational material would be the most suitable for readability. The brochure that I designed
to give to the participants of this lesson plan contained 50 countable words. The conversion table
indicates that this brochure is best suitable for a 10th grade level. My audience consists of
hemodialysis patients that range from age 21 and above. The participants come from all
socioeconomic levels, educational levels and cultures. I wanted to design educational material
that would be suitable for all levels of readers therefore this is an adequate level.
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Reference List
Gray, L.D., Burrowes, J.D., Chertow, G.M. (2014). Nutrition in kidney disease.
Springer, New York: Springer Science + Business Media
Kidney disease and dialysis information - DaVita. http://www.davita.com/
Kidney Fund. (2012). Kidney disease statistics.
Retrived from http://www.kidneyfund.org/about-us/assets/pdfs/akfkidneydiseasestatistics-2012.pdf
Snyder, R. (2013). What you must know about Dialysis: The secrets to surviving and thriving on
dialysis. Garden City Park, New York: Square One Publishers.
Stark S, Snetselaar L, Hall B, Stone RA, Kim S, Piraino B, Sevick M A (2011) Nutritional Intake
in Adult Hemodialysis Patients, Top Clin Nutr, Vol. 26, No. 1, 45–56.
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Wu, W. H. (2013). Changes in the energy and sodium content of main entrées in U. S. chain
restaurants from 2010 to 2011. Journal of the Academy of Nutrition and Dietetics, 209-219.
Bauer,K. Liou. D, Sokolik, C. (2012). Nutrition counseling and education skill development.
Belmont, California: Wadsworth