|Year : 2018 | Volume
| Issue : 3 | Page : 86-87
Diet in dialysis patients: Is it “EK Chammach Kum or 3 Scoops Zyada??”
Umesh Khanna1, Meera Shah2
1 Director, Lancelot Kidney and GI Center; Nephrologist, Karuna Hospital and Asian Heart Institute, Mumbai, Maharashtra, India
2 Dietician, Karuna Hospital and Asian Heart Institute, Mumbai, Maharashtra, India
|Date of Web Publication||23-Apr-2019|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Khanna U, Shah M. Diet in dialysis patients: Is it “EK Chammach Kum or 3 Scoops Zyada??”. J Renal Nutr Metab 2018;4:86-7
|How to cite this URL:|
Khanna U, Shah M. Diet in dialysis patients: Is it “EK Chammach Kum or 3 Scoops Zyada??”. J Renal Nutr Metab [serial online] 2018 [cited 2019 Sep 18];4:86-7. Available from: http://www.jrnm.in/text.asp?2018/4/3/86/256827
The answer to the above question is both.
Yes!!! Ek chammach kum salt for sure but additional 3 scoops of protein intake will definitely help.
How do you plan a diet for a dialysis patient?
Any dietitian has to be adept in at giving advice which should be not only logical, scientific, culturally correct, financially appropriate but also should be more convincing than.
- The neighboring aunty
- The local dhobi (washerman) who doubles up as a well-wisher and
- The dominating “Atya” or “Bhuva” from Chicago.
As a dietician, you may have tried hard to find the cause of unexplained hyperkalemia yet failed miserably because you lacked the CID skills to unearth the hidden advice given by his vegetable vendor who has advised him “lo salt” is better as it is “low in salt.” Sometimes, you would end up scratching your head as to the reason for fluid overload in your patient whom you have advised an appropriate salt and fluid restriction, and yet you could not wean him off the “quacks or spiritual healers.” Advice of taking three glasses of water in the early morning for his constipation.
Hence, the job cut out for nutritionists and nephrologists is, first, to make the family unlearn all the silly or dangerous advice being dished out by well-wishers, by WhatsApp groups and to revive his brain cells and reboot his old brainwashed computer.
| Chronic Kidney Disease Stage 5 Patient Reaching the Stage of Dialysis-Role of a Dietitian|| |
Is it shifting gear or a paradigm shift in strategy!!!.
Before planning a diet for such a patient, one must understand that as chronic kidney disease (CKD) progresses from stage 3–5 to dialysis, certain changes occur in the patient's clinical feature, biochemical profile, and the metabolic milieu and accordingly, one has to shift gears.
To put it simply, as the glomerular filtration rate (GFR) falls, the urine output drops and after a few months of dialysis, the patient becomes anuric and hence fluid control becomes a permanent necessity. With the drop in GFR and urine output, there is sodium retention, potassium retention, and phosphorus retention leading to a need for tighter control of salt, potassium, and phosphorus.
However, the major change that occurs in dialysis patients is the monster of protein-energy wasting, malnutrition, inflammation, and increase in cardiovascular mortality.
| Shifting Focus of Diet Plan from Chronic Kidney Disease Stage 3 to Dialysis Stage|| |
With progressive worsening of CKD, our focus shifts from not just controlling sugars, blood pressure, and proteins (slowing down the progression of CKD) to preventing malnutrition-inflammation-atherosclerosis syndrome and also preventing hospitalization due to pulmonary edema, hyperkalemia, uncontrolled hypertension, and coronary artery disease.
Hence, when the dietitian plans a diet for a dialysis patient, the following points should be taken into considerations:
- Dietitian has to be not only adept at giving a diet plan but also look for signs of malnutrition
- Dietitian must remember that diet, and dietary modification is a dynamic process in a dialysis patient and assessment of dry weight, protein-energy wasting, and checking laboratory reports form a very important part of a dietician's duty in these patients especially on a monthly basis
- Changes in diet will have to be made based on the socioeconomic and logistic consideration of life in a metro of a middle class, nuclear family struggling with managing a lifelong devastating illness
- Dietitian also has to keep in mind the emotional and psychological issues of a young dialysis patient whose shattered life has taken a 360 turn having to cope with a disease that needs lifelong dialysis. Thus, a dietitian needs tremendous empathy, tact, and expertise in handling such volatile patients who can rebel in their dietary adherence
- Finally, your advice should be in sync with the treating nephrologist and also most importantly the dialysis technician and the dialysis nurse who should also be trained adequately in dietary management.
| Barriers to Improving Health in Spite of Your Advice|| |
- Many patients struggle with the idea of following the high-protein diet instructions because they think that this advice is directly in conflict with the previous dietary advice of low-protein diet
- Restriction of foods can lead to monotony of diet and malnutrition
- Loss of appetite is common in dialysis patients and contribute to undernutrition
- Social factors such as solitude, depression, and inability to cook meals may cause undernutrition
- Restricted intake of foods makes it difficult to provide adequate energy and proteins needs
- Irregular dialysis schedule can pose a problem to follow the prescribed diet.
Protein-energy malnutrition (PEM) is common in patients with CKD undergoing dialysis. PEM is, however, just one aspect of a syndrome known as the malnutrition-inflammation complex syndrome which takes into account the association between chronic inflammation and nutritional status.
Let us identify the metabolic and nutritional issues for malnutrition and PEM and find solutions for the same.
Anorexia in dialysis patients
It is basically because of uremic toxicity, inadequate dialysis, infections due to the temporary jugular catheter or perma cath, too many medications such as phosphate binders and iron tablets and of course autonomic gastroenteropathy.
Few measures to tackle anorexia
- Increasing the frequency of dialysis
- Changing jugular, perma cath to fistula
- Adding prokinetic agent like domperidone
- Reducing the number of medications if possible.
Malnutrition could be also due to dietary restrictions
Either by health-care team or by false belief of “well-wishers.”
The solution to this is to follow the KDOQI guidelines:
- ENERGY: 35 Kcal/kg BW/day
- PROTEIN: 1.2 g/kg IBW/day; >50% should come from hepatitis B virus
- Salt and liquid restriction
- Potassium restriction, if required.
Nutrient losses during dialysis
Due to adherence to hemodialysis membrane, nutrients are lost during dialysis. Since this cannot be corrected, one has to replace it with vitamins and minerals.
Hypercatabolism caused by comorbid illness such as cardiovascular disease, diabetic complications, and infections
- This can be avoided by reducing the incidence of jugular and perma cath
- Preventing hepatitis, pneumonia, and influenza by vaccination
- Promoting fistula first policy in all patients
- Early detection of comorbid conditions such as hypertension, diabetes, and heart disease.
Acidemia with metabolic acidosis can be corrected by sodium bicarbonate.
Thus, the dietician is one of the most important pillars in managing dialysis patients, and judicious nutritional management can improve not only the lifespan but also quality of life of every dialysis patient.