Renal - What can I eat on haemodialysis?

An introduction to your diet

Healthy kidneys normally control the level of substances and water in the body, which come from what we eat and drink.

When your kidneys stop working and don’t work as well as they used to, waste products and fluid build-up in your blood, which can make you feel unwell.

Haemodialysis is a treatment used to remove waste products and fluid from the blood using an artificial machine.

Why have I been given this diet information?

You have been given this diet sheet because you have started, or about to start on haemodialysis. Healthy kidneys help control the level of substances and fluid in the body. Haemodialysis is a treatment that helps to remove some of these from your blood using an artifical machine, however they build up in your blood between haemodialysis sessions.

What you eat and drink is important in helping to keep the amount of substances and fluid in the body safe between your hemodialysis sessions. Dialysis also increases the amount of energy and protein you need to eat.

Why is diet important?

Dietary and fluid restrictions are individual and depend on your remaining kidney function, your current dialysis prescription, other medical conditions you may have, your eating pattern and your blood results (i.e. urea, potassium and phosphate). Your dietitian will advise you on what diet to follow.

Having a healthy balanced diet will help you feel well on hemodialysis. You should eat regular meals which include a variety of foods; however, some diet and fluid restrictions may be necessary.

Your diet on haemodialysis should be:

1. High in protein
2. Balanced in energy
3. Low in salt
4. Fluid balanced
5. Low-moderate in potassium and phosphate

1.    Protein

Protein is needed for growth and repair of all body tissues. People can lose muscle and protein stores because of the dialysis process. It is important to include 2 good sources of protein in your diet daily to prevent muscle wastage, and to help maintain your strength.

If you have previously been restricting the amount of protein in your diet prior to starting hemodialysis, it is possible to relax this restriction now.

Try to include 2 servings of protein foods each day.

Good sources of dietary protein include:

Meat - beef, pork, lamb, chicken and turkey (If possible, choose lean cuts of meat and unsalted)

Fish - cod, haddock, tuna, plaice (If possible, choose unsalted and unsmoked fish)

Eggs – please note that eggs are high in phosphate, so try not to eat more than 4 per week. If you are a vegetarian, good source of protein includes pulses i.e. lentils, dhal, chickpeas.

Milk – up to ½ pint (300ml) per day remember to count as part of your fluid restriction

Cheese – Cheddar and other hard cheeses up to 3-4 oz per week Try to include 2 servings of protein foods each day.

If possible, try to include more plant-based foods in the diet or consider implementing some switches throughout the week.
Some plant-based protein sources.

Include

• Legumes and beans: Such as beans, lentils and peas
• Tofu And Tempeh
• Quinoa and whole grains

Sources of protein to limit or avoid

• Processed, packaged meats such as precooked chicken, ham, beef and pork. These foods often contain a phosphate additive, causing rises in the blood
• Salted and cured meats
• Canned meats

2.    Energy

It is important to gain sufficient energy/calories as well as protein in your diet to ensure you obtain good nourishment. Foods which are good sources of energy include starchy foods, i.e. bread, pasta, chapattis, potatoes, rice or noodles.

These can be included as part of a healthy diet with each meal. (Potatoes, sweet potatoes and yams are high in potassium and may need to be limited).

If you have previously had a poor appetite before starting dialysis, many people find that their food intake can improve once they begin having regular dialysis sessions. Dialysis helps to remove toxins/ breakdown products in your blood which can build up in people with reduced kidney function.

Remember to contact your dietitian if you have a poor appetite.

3.    Salt

Your body cannot get rid of salt when your kidneys are not working properly. This may lead to fluid retention and oedema. Oedema is a fluid that can accumulate underneath your skin, and it can show as a puffy appearance on your skin surface. A high salt diet can contribute to high blood pressure and breathlessness. Eating less salt can help control high blood pressure and help you to keep to a fluid allowance.

Foods to avoid/limit

• Avoid salt substitutes i.e. low salt, pansalt, or anything advertised as reduced sodium salt (these are high in potassium)
• Adding salt at the table
• Smoked meat/fish products i.e. bacon ham
• Tinned fish in brine
• Ready meals/take-aways with high salt content and try to avoid adding additional salt to ready meal **
• Packaged soups/sauces

** If you do consume ready meals for convenience, try to include some fresh products/foods with these meals i.e. a small salad or fresh vegetables.

Foods to choose

• Herbs, spices, lemon juice, pepper, marinades to help flavour food
• Fresh meat/fish where possible
• Tinned fish in oil/spring water
• Choose ready meals low in salt/sodium i.e. less than 1.5g salt per 100g or less than 0.6g sodium per 100g

4.    Fluid balanced

Why do I need to monitor what I drink?

When you first start dialysis, you may still be passing urine, but it is quite common for urine output to decrease. This will mean decreasing the amount of fluid that you normally drink to prevent the extra fluid building up around your heart and lungs.

Some signs/symptoms of fluid overload

• Sudden increase in weight
• Swollen ankles, legs, tummy and/or face
• Shortness of breath
• Increased blood pressure

It is common for the medical team to advise on a fluid restriction; it is very important to stick to this restriction. You are usually asked to measure your urine output over 24 hours to see what you typically pass in a day. This will help to determine your fluid restriction on haemodialysis.

You are usually allowed to drink 500ml per day plus the equivalent in volume of your urine output in 24 hrs.

For example, if you usually pass 400ml of urine in 24 hrs, your fluid allowance will be 400ml plus 500ml = 900ml.

Remember

Certain foods items throughout the day will contribute towards your fluid, examples include

• Yogurts
• Jelly
• Ice cream
• Soups
• Sauces and gravy

Controlling your fluid intake is a more detailed leaflet which offers practical tips on ways to manage your fluid restriction. Please ask your dietitian for a copy.

5.    Potassium

The kidneys are responsible for removing excess potassium from the body. Potassium is a mineral that is found in a wide variety of different foods and drinks. Your body needs a certain amount of potassium for functions in the body; it is important to prevent potassium from going too high or too low because it can affect the way your heart beats.

If you have been advised to follow a low potassium diet prior to commencing haemodialysis, please continue to follow this. Once you are established on haemodialysis, your dietitian will review your bloods and can provide further information about continuing on a low potassium diet.

Some tips to keep blood potassium levels in range

• Avoid food items containing a potassium additive, these are commonly found in some fizzy drinks i.e. potassium chloride, potassium citrate and potassium phosphate
• Boil all potatoes and vegetables and then discard the water you use in cooking
• Par-boil potatoes if making chips
• Avoid steamer, microwave or slow cooker if cooking potatoes/ vegetables
• Have no more than 5 portions of fruit and vegetables per day i.e. 2 fruit and 2 vegetables per day
• Avoid dried fruit and nuts
• Avoid large quantities of fresh fruit juice and fruit smoothies
• Avoid potato crisps - choose corn snacks instead
• Avoid mushrooms

Star fruit is toxic to renal patients and should be avoided. More information on potassium can be obtained from a separate leaflet which your dietitian will be able to provide you with if needed.

6.    Phosphate

Phosphate is a mineral which you normally store in your bones with calcium. Your kidneys are responsible for removing excess phosphate from your body. On dialysis, phosphate levels may still go high and can go low on occasion.

High phosphate levels can lead to:

• Itchy skin
• Red eyes
• Calcification of blood vessels which is a long-term consequence of raised phosphate and calcium
• Weak bones

Some tips to keep blood phosphate levels in range

Weekly allowance

• ½ pint (300 mls) milk daily
• 3-4oz hard cheese per week, alternatives such as soft cheese, cottage cheese are encouraged
• 3-4 milky puddings per week (which includes rice pudding, ice- cream, yoghurt, custard)
• Aim for up to 4 eggs per week
• Avoidance of packaged/processed meat/fish products
• Avoid dark cola flavored drinks

Phosphate binders

You may be prescribed a phosphate binder to help control your blood phosphate level. These tablets bind the phosphate from your food, and they need to be taken at mealtimes. Some common binders include Renacet, Sevelamer, Lanthanum.

Remember to take your phosphate binder before, with or after your meal/snacks as prescribed. It is important to take it as close to mealtimes as possible.

Foods to choose more from

Fruits - Apples, pears, grapes, berries, tinned fruit, peaches.

Vegetables - Carrots, broccoli, runner beans, peas, cabbage, aubergine, bean sprouts, green salad.

Dairy - Dairy products such as cow's milk and cow's milk yoghurt, cheese, creme fraiche, cream, organic rice, oat or almond milk.

Starchy foods - Boiled potatoes which have been par boiled prior to further cooking. Pasta, rice, noodles, bread, whole grains such as quinoa and couscous, porridge oats.

Protein - Chicken, turkey, white fish, eggs (within allowance), tofu, tinned or soaked beans and pulses such as lentils, chickpeas and kidney beans.

Snacks - Corn, rice or maize based crisps, popcorn, boiled or jelly sweets, marshmallows, plain biscuits such as rich tea or digestives, plain cakes.

Drinks - Water, apple juice, cranberry juice, lemon soda (less than 150ml per day), tea, coffee (limit to one per day).

Foods to limit or avoid

Fruits - Bananas, dried fruits, mango, advocado, fresh fruit juice (less than 150ml a day) and smoothie drinks.

Vegetables - Spinach, mushrooms, tomato puree, sundried tomatoes.

Starches - Potatoes such as jacket potatoes, oven, microwave or shop bought chips, hash browns, frozen potato waffles, sweet potatoes, seed bread, any dried cereals containing a high number of dried seeds or nuts such as muesli.

Protein - Processed meats, canned meats, ham and other deli meats.

Snacks - Potato crips, chocolate, nut snacks, dried fruit, cakes or biscuits containing a lot of dried fruit or nuts.

Drinks - Coffee (limit to one per day). Coconut water, tomato juice, vegetable juices, smoothies, beer and cider.

Suggested meal plan

Milk Allowance
½ pint per day for drinks, on cereal, etc.

Breakfast
Fresh fruit juice (small glass) or tinned fruit or fresh fruit
Cereal i.e. cornflakes/rice krispies/Weetabix/fresh porridge oats with milk from allowance and/or toast with butter or margarine and jam or marmalade

Snack Meal
This could be a sandwich or something on toast
Bread/rolls/crackers with butter or margarine with meat e.g. chicken/turkey/beef
OR fish e.g. tuna /tinned salmon
OR eggs from allowance e.g. boiled, poached, scrambled or omelette
OR cheese from allowance
Plus, salad (lettuce, cress, cucumber)
1 x fresh fruit or tinned fruit or jelly

Main Meal
Include a starchy carbohydrate i.e. potatoes/rice/pasta/chapattis/ noodles/bread
Make a roast or pasta-based dish or casserole dish like shepherd’s pie/casserole/curry
Include meat, e.g. chicken/turkey/beef/lamb/pork OR fish, e.g. cod/plaice/haddock/sole OR vegetarian options pulses, e.g. lentils/ baked beans/Quorn/tofu. Plus, salad and/or vegetables
 
Pudding
Chocolate éclair/madeira cake/jam tart/sponge/milky pudding from weekly allowance e.g. custard/rice pudding/ice cream/yoghurt

Supper
Toast/crackers/biscuits and a small drink

If you have diabetes, you will need to limit your intake of sugary foods and drinks.

Contact details

Tel: 0161 206 1994
Email: RenalDietitians@nca.nhs.uk

Useful websites

Greater Manchester Kidney Information Network
https://www.kidneyinfonet.org/kin/gmkin/

Kidney Care UK
https://www.kidneycareuk.org/

Kidney kitchen Uk
https://kidneycareuk.org/get-support/healthy-diet-support/ kidney-kitchen/recipe-index