Living well as a patient on PD
Managing fluids and diet

Managing fluids and diet

Fluid weight is the liquid part of your body. Body weight may change daily depending on what you eat and drink.

Managing fluids

It is important to keep fluids in balance. Your healthy kidneys were able to balance the amount of fluid in your body. PD will help remove some extra fluid but you need to pay attention to the amount of fluids taken in and removed from your body. Your weight and how you feel also depend on your fluid balance.

Your total weight = body weight plus fluid weight

 
 

What should you do each day to balance your fluids?

  • Weigh yourself
  • Check your blood pressure and write it down
  • Use the correct strength of dialysis solutions
  • Look for signs of swelling and puffiness in your body
  • Notice how you feel, i.e. shortness of breath
  • Pay attention to the types of food you eat and the amount you rink
  • There are times when your fluids may need to be restricted

 

How do you know if you have too much fluid?

Too much fluid means “fluid overload,” which can strain your heart.

Symptoms of fluid overload:

  • Shortness of breath
  • Increase in weight
  • Increase in blood pressure
  • Swelling

 

What can you do if you have too much fluid?

  • Follow the advice of your healthcare team
  • Pay attention to your weight, breathing, blood pressure, and swelling
  • Reduce fluid intake
  • Reduce your salt intake
  • Your healthcare team may also use a stronger PD solution
  • Call your healthcare provider if you are unsure

How do you know if you have too little fluid?

When you have too little fluid it is called “dehydration”.

Symptoms of dehydration:

  • Tiredness
  • Weakness
  • Dizziness
  • Lower blood pressure

 

What can you do if you have too little fluid?

Follow the advice of your healthcare team.

Some options may be:

  • Drink some liquids
  • Use a lower strength solution
  • Do not skip any exchanges

 

Managing your diet

PD gives you the opportunity to choose from a wide variety of foods.

Your dietitian will work with you on your diet plan. Tips are available for helping you maintain a more normal diet with fewer limitations.

Renal dieticians provide information about nutrition for people with kidney disease in the following section.

 

Kidney diet cornerstones: Fluid

Adapted from the original by Christine Nash, MSc(C), RD, CDE*
Antonia Zettas, RD, CDE*

 

Fluid and your kidneys

One of the kidneys’ major functions is to maintain the fluid balance in your body. When your kidneys are not working well, they are not able to remove water as effectively. If you take in more fluids than your body is able to get rid of, this can lead to a buildup of excess fluid, or “edema.” Excess fluid can be dangerous, as it puts a great strain on your heart.1

For patients on dialysis, it can be challenging to know what amount of fluid is right for their individual needs. Too much or too little fluid can result in a fluid imbalance; this is not only uncomfortable, but may also put your health at risk. It is very important that you know how to recognize if you are not in a healthy balance. Your registered dietitian will work with you to determine your fluid needs.

 

Possible signs and symptoms of fluid imbalance:*

Overhydration (too much fluid)

  • High blood pressure
  • Swelling (edema)
  • Cramping
  • Shortness of breath
  • Sudden increase in weight

Dehydration (too little fluid)

  • Low blood pressure
  • Feeling dizzy, weak, faint, or lightheaded
  • Cramping
  • Dry mouth
  • Vomiting, diarrhea

*Your healthcare team monitors your fluid status on a regular basis. Knowing the signs and symptoms of having too much or too little fluid in your body enables you to work with your team to come up with a plan that keeps you as healthy as possible.

 

Fluid balance and types of dialysis

Your dialysis treatment plays a significant role in how much fluid you can include in your diet. If you are on a home dialysis therapy such as peritoneal dialysis or home hemodialysis, you may not have the same fluid restrictions as someone who is receiving in-center hemodialysis.

In peritoneal dialysis, fluid is removed daily. Patients may also continue to have urine output, which provides additional removal of water from the body.
In home hemodialysis, treatment hours can be extended or more frequent.1 These therapies often allow patients more flexibility with the amount of fluid they can include each day.

In-center hemodialysis implies that most patients receive dialysis three times a week for four hours per treatment. This means fluid builds up between treatments and as a result, patients must be careful with how much liquid they consume.1

 

How to manage your fluid

Managing your fluid can be challenging when you are on dialysis but it is possible. There are steps you can take to minimize fluid buildup and control your thirst.

1) Know your limit (and stay within it)
Rule of thumb when setting daily fluid targets is to aim for four cups plus the amount equal to how much urine you are making. If you have a larger body mass, your registered dietitian may calculate your fluid allowance based on 5% of your weight.

2) You are what you eat (and drink)
Next to dialysis, food and fluid play the greatest role in keeping your water gains to a minimum.

Sodium
High sodium (salt) intake can make you feel thirsty and lead to increased fluid intake. Sodium also causes your body to hold on to extra water. Both can result in excess fluid buildup. Speak to your registered dietitian to learn how you can reduce sodium in your diet.

Fluid
Everything that is liquid at room temperature is considered a fluid and must be counted towards your daily allowance.

Common fluids

  • Water
  • Juices/fruit drinks
  • Tea/Coffee
  • Alcohol
  • Ice cream/sherbet
  • Soup
  • Ice
  • Pop
  • Milk
  • Nutritional supplements
  • Popsicles
  • Jello

Hidden fluid
You may also take in more fluid than you think. Hidden fluid can be found in all foods, which contain water; some have more than others. While you do not count this as part of your daily fluid allowance, you may need to limit the portion size of foods with higher water content.

 

Question: Which food has the greatest amount of hidden fluid?

  1. Green peas
  2. Celery
  3. Watermelon

Answer: 2) Celery. It contains 95% fluid. Watermelon contains 91% fluid and peas contain 79% fluid. 2

3) Tips for controlling fluid intake

Plan ahead

  • Measure how much liquid your favorite cups hold to help plan your fluid for the day.
  • Avoid drinking simply out of habit; save your fluid for when it is important to you.
  • Spread your fluid intake throughout the day.

Track your fluid

  • Keep a daily fluid diary. Measure and mark down each time you have a fluid. Remember: small portions such as ice cubes add up quickly.

Be strategic

  • Take your medication with soft foods such as applesauce. Save your fluid for liquids you enjoy. Important: Check with your healthcare team to learn which pills you can have with your meals.
  • Replace liquids with frozen fruit when possible.
  • Choose foods that are liquid at room temperature less often.

 

Did you know?

For every cup of liquid you drink beyond your daily fluid target, you will see ½ pound of weight gain. 1

4) Tips for controlling thirst

  • Limit salt, spicy food, caffeine and alcohol.
  • Add lemon or mint to cold water.
  • Replace water with plain or flavored ice cubes. It lasts longer and the options are endless.
  • Drink slowly and take small sips to make your fluid last longer.
  • Fruit including grapes and berries taste great frozen and help relieve thirst.
  • Use candy (hard or sour), gum or mints to increase saliva in your mouth. Speak to your dietitian for options that are right for you.
  • Ask your pharmacist about using breath spray or strips.

5) Other strategies

  • Dry mouth?
    Brush your teeth and rinse out your mouth with water or non-alcoholic mouthwash.
  • High blood sugar?
    This could make you feel thirstier. If you have diabetes, it is important to keep your blood sugar under control.
  • Dry air in your home?
    Use a humidifier to add moisture.
  • Hot summer day?
    Stay indoors when possible or spray cold mist on your face and body to keep cool

How much fluid can I have?
The amount of fluid you can include each day will be different for everyone. Your dialysis treatment, urine output and other factors such as medications, body size and physical activity will be considered. Your registered dietitian will work with you to determine your fluid needs.

 


References:

  1. Canadian Association of Nephrology Dietitians. Essential guide for renal dietitians; 3rd edition, 2010.
  2. Canadian Nutrient File 2016.

*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Nephrology Dietitians (CAND).

Kidney diet cornerstones: Protein

Adapted from the original by Christine Nash, MSc(C), RD, CDE*
Antonia Zettas, RD, CDE*

 

What is it?

Protein is a macronutrient important for your everyday health. It is composed of building blocks called amino acids and can be found in every cell of our bodies. There are 20 amino acids that link together in different forms to carry out specific body functions including the building, maintenance and repair of tissues.1

Protein, your kidneys and dialysis
When our body breaks down protein, a waste product is created called urea. Healthy kidneys act as a filter to remove urea, fluid and other waste products from the body through urine. When you are on dialysis, your kidneys are no longer able to filter out enough fluid and waste.2 You must rely on your treatment to keep your waste and fluids balanced.

Patients on dialysis require more protein in their diet. This is because a certain amount of protein is removed during the treatment process. The type of dialysis you are receiving can affect how much protein you should include each day. In peritoneal dialysis, protein is removed on a daily basis. In home hemodialysis, treatment hours can be extended or more frequent, causing additional protein losses. This means patients on home dialysis therapies may require more protein than those who are receiving in-center hemodialysis 3 times per week.3

 

Protein and your diet

Eating enough protein can be challenging. Lack of appetite, altered taste, low energy (fatigue) and financial issues are just some of the barriers that prevent patients from meeting their daily needs. Over time, this can lead to protein malnutrition, resulting in loss of muscle mass and decreased strength. It may also make it difficult to fight infections. Try these strategies to help you meet your goals:

  • Spread protein throughout the day
  • Eat the protein sources on your plate first
  • Choose protein options you enjoy
  • Add small pieces of protein to your soups, salad or pasta
  • Buy inexpensive protein sources such as eggs, canned fish, ricotta or cottage cheese
  • Purchase protein items on sale and freeze for future meals

 

Quick tip

Adding a nutritional supplement can be beneficial when you are unable to meet your protein needs through dietary sources. There are many options on the market including nutrition drinks, protein powders and gels. Speak with your registered dietitian about which ones fit with your kidney diet.

 

Types of protein

Choosing the right type of protein is just as important as eating the right amount of protein each day.

 

Complete protein

“Complete” proteins are animal-based and contain all of the essential amino acids your body is unable to make on its own. They are also easy for your body to absorb and use. Examples of complete proteins include fresh meat, poultry, fish, eggs and dairy.5 It is recommended that at least 50% of your total daily protein intake should come from these sources.4

 

Did you know?

When meats are labeled as “seasoned,” it means they have been injected with sodium, phosphorus and/or potassium and should be avoided if possible.6,7

 

Incomplete protein

“Incomplete” proteins are plant-based and while nutritious, they do not contain all of the essential amino acids. A variety of incomplete proteins must be eaten throughout the day for the body to use them efficiently. These include legumes, nuts, seeds, breads and cereals.8

Some plant-based foods are also higher in potassium and phosphorus and may need to be limited in your diet. Your registered dietitian will work with you to find the right balance.

 

Fast fact

Soy products such as tofu have the similar quality of protein as animal products. Try adding tofu into a vegetable stir-fry for more variety.9

True or false? If you are on dialysis, it is NOT possible to follow a vegetarian diet.

  1. True
  2. False

Answer: 2) False. It is possible to follow a vegetarian diet but you need to work with your registered dietitian to ensure you keep your blood levels safe while meeting your high protein needs for dialysis.

 

Portion size

Once you know how much protein you need, how do you achieve this? The table below can help guide you. It provides examples of approximate serving sizes for common protein sources.10

1 ounce 2 ounces 3 ounces
1 large egg or 2 egg whites 12 medium shrimp 1 pork chop
¼ cup shredded cheese ½ cup ricotta or cottage cheese ½ cup canned tuna
40g roasted chicken breast, sliced 1 medium chicken drumstick cooked fish; size of a checkbook
*2 tbsp peanut butter ½ cup cooked ground beef or poultry cooked beef or poultry; size of a deck of cards
*½ cup cooked beans *⅔ cup Greek yogurt *1 cup regular or firm tofu

*These products are rich in potassium and/or phosphorus for the amount of protein they provide. Your registered dietitian can work with you on how to fit these foods safely into your diet.

 

How much protein can I have?

The amount of protein you can include in your diet will be different for everyone. Your dietary habits and type of dialysis treatment, along with other factors such as your nutritional status, weight, presence of infection and other medical conditions must be considered. Your registered dietitian will work with you to determine your needs and develop a personalized nutrition care plan.

 


References:

  1. Institute of Medicine. Chapter 10: Protein and Amino Acids. https://www.nap.edu/read/10490/chapter/12
  2. The Kidney Foundation of Canada. https://www.kidney.ca/why-kidneys-are-important
  3. National Kidney Foundation, 2016. https://www.kidney.org/nutrition/Dialysis
  4. National Kidney Foundation KDOQI Guidelines. http://www2.kidney.org/professionals/KDOQI/guidelines_nutrition/doqi_nut.html
  5. National Kidney Disease Education Program (NKDEP). NIH Publication No.10-7407. April 2010.
  6. Health Canada. http://www.hc-sc.gc.ca/fn-an/securit/addit/list/index-eng.php
  7. Canadian Food Inspection Agency. http://inspection.gc.ca/food/labelling/food-labelling-for-industry/meat-and-poultry-products/eng/1393979114983/1393979162475?chap=0
  8. Craig and Mangels. Position of the American Dietetic Association: vegetarian diets. J. Am. Diet Assoc. 2009;109(7):1266-82.
  9. Hoffman and Falvo. Protein – which is best? J. Sports Sci. Med. 2004 (3):118-130.
  10. Canadian Nutrient File 2016. https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp

*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Nephrology Dietitians (CAND).

Kidney diet cornerstones: Potassium

Adapted from the original by Christine Nash, MSc(C), RD, CDE*
Antonia Zettas, RD, CDE*

 

What is it?

Potassium is one of the main minerals found in your blood. It is also an electrolyte, which means it carries an “electrical charge.” This charge helps your body carry out many important functions, including muscle contractions and maintaining a normal heart rate, both of which are necessary for a healthy heartbeat. It also plays a key role in metabolism, which converts the nutrients from our food into energy we need for our bodies.

 

Potassium and your kidneys

The kidneys play an important role in maintaining safe levels of potassium in the blood. When you are on dialysis, your kidneys are no longer able to balance potassium as efficiently. Many different factors can cause potassium levels to become too high or too low. This can be dangerous to your heart.

 

Potassium and your diet

Nutrition is central to managing your blood potassium levels when on dialysis. There are several things you can do with your diet to help keep your blood potassium at a safe level:

1) Food choices
Potassium can be found naturally in most foods, but some contain much higher amounts than others. For example, a ½ cup of sliced kiwi contains 3 times as much potassium as a ½ cup of diced pineapple.1

It is important to remember that everyone’s potassium needs are different. Foods you may be asked to limit or increase in your diet may not be the same as others. Your registered dietitian will work with you to develop an eating plan that is right for you.

2) Portion size
When it comes to potassium, serving size matters. Having a large amount of a low-potassium food can turn it into a high-potassium food. For example, one serving of 10 cherries is a low-potassium option. But if you have two servings (i.e. 20 cherries), the potassium content is the same as a small banana!1 On the other hand, higher potassium foods may fit into your diet if eaten in smaller amounts.

3) Reading labels
When choosing packaged foods, reading labels can help you determine how much potassium they contain. It is important to know that manufacturers are NOT required to report potassium in the Nutrition Facts Table.2 Just because the quantity is not included doesn’t mean the product is potassium-free! Some foods also contain potassium additives, which can contribute a large amount of potassium to your diet.3 Reading the ingredient list can help you identify what is in the product.

4) Food preparation Potassium can be removed during the process of canning fruit and cooking vegetables.4,5 This may allow you to add more variety to your diet. For example, a ½ cup of canned papaya contains 2.5 times less potassium than a ½ cup of fresh papaya.1 Soaking and/or double boiling root vegetables can also remove extra potassium.5,6

 

Quick tip:

Watching your sugar intake? Be sure to drain the syrup or choose canned fruits that are packed in water.

Question: Which method removes the most potassium from root vegetables?

  1. Soaking
  2. Soaking plus double boiling
  3. Double boiling

Answer: 3) Double boiling. It removes up to 70% of the potassium.7

 

How to double-boil potatoes:

Peel and cut potatoes in small cubes, put them in a large pot, and cover them with cold water.
Bring them to a boil. Remove the pot from the stove and drain the water.
Add fresh water to cover the potatoes.
Bring to a boil a second time, reduce heat, and simmer until potatoes are tender.
Drain and discard the water.

 

 

Potassium and your dialysis treatment

Your dialysis treatment also plays a role in how much potassium you can include in your diet. If you are on a home dialysis therapy such as peritoneal dialysis (PD) you may not have the same potassium restrictions as someone who is receiving in-center hemodialysis (ICHD).

In PD, potassium is removed on a daily basis. Many patients also continue to have urine output, which provides additional removal of potassium from the body. Patients are often allowed more flexibility with the amount of potassium-rich foods they can include in their diet.

In ICHD, most patients receive dialysis multiple times a week. This means potassium can build up between dialysis sessions and as a result, patients are often required to limit their potassium intake. 8

How much potassium can I have?

The amount of potassium you can include in your diet will be different for everyone. Your dietary habits and type of dialysis treatment, along with other factors such as medications and urine output must be considered.8 Your registered dietician will work with you to determine your needs and develop a personalized nutrition care plan.

 


References:

  1. Canadian Nutrient File 2016. https://food-nutrition.canada.ca/cnf-fce/index-eng.jsp
  2. http://www.hc-sc.gc.ca/fn-an/label-etiquet/nutrition/index-eng.php
  3. http://www.kidneycommunitykitchen.ca/archives/2735/
  4. Rickman et al. Nutritional comparison of fresh, frozen and canned fruits and vegetables II. Vitamin A and carotenoids, vitamin E, minerals and fiber. Food Agric. 2009;87:1185-1196.
  5. Bethke and Jansky. The effect of boiling and leaching on the content of potassium and other minerals in potatoes. J Food Sci. 2008;75(5):80-85.
  6. Burrows and Ramer. Removal of potassium from tuberous root vegetables by leaching. J Ren Nutr. 2006;16(4):304-311.
  7. Picq et al. Effects of water soaking and/or sodium polystyrene sulfonate addition on potassium content of foods. Int J Food Sci Nutr. 2014;65(6):673–677.
  8. Canadian Association of Nephrology Dietitians. Essential guide for renal dietitians; 3rd edition, 2010.

*Both authors are registered dietitians at the home peritoneal dialysis unit at the Toronto General Hospital (UHN). Christine Nash is the co-chair of the Canadian Association of Renal Dietitians (CAND).