K.B. is sent for an Hd treatment. Over the next 24 hours, K.B.'s nausea subsides, and she is able to eat normally. While you are helping her with her morning care, she confides in you that she doesn't understand her diet. "I just get blood drawn every week and meet with the dialysis dietitian every month—I just eat what she tells me to eat. It's so hard!"
Because K.B. is on HD and has DM, what are her special nutritional needs? Name at least
four specific components of the diet recommended for K.B.
• K.B. will need to be on a diabetic dialysis diet. The diet is adjusted based on the laboratory data
obtained on a weekly or monthly basis to meet the renal requirements. The RN needs to refer any
medical nutrition teaching to a renal dietitian. Because of the complexity of the diabetic dialysis
diet and nutritional needs, make certain K.B. receives a renal registered dietitian (RD) consultation.
• Common adjustments in the diet for a renal patient include restricting protein intake; limiting fluid
intake; restricting phosphorus, sodium, magnesium, and potassium intake; and ensuring adequate
calorie, vitamin, and mineral intake.
• Protein is restricted, based on the degree of renal function impairment (i.e., reduced glomerular
filtration rate). It is a delicate balance between restricting protein intake so that the kidneys are not
overwhelmed and yet preventing protein-calorie malnutrition. The patient receiving HD requires
more protein because dialysis causes some protein loss. Regular BUN and albumin levels are drawn
to monitor whether protein intake is adequate. Poor protein intake is indicated by decreased
albumin levels and might lead to muscle wasting and negative nitrogen balance.
• Fluids are restricted to 600 mL plus the amount equal to the previous day's urine output. Excess
fluid leads to hypertension, cardiac enlargement, tachycardia, shortness of breath, and fluid
collection in the lung bases. If large amounts of fluid are gained between dialysis treatments,
hypertension might occur. A fluid is anything liquid at room temperature such as ice, gelatin, milk,
juice, coffee, tea, soup, popsicles, or ice cream.
• Caloric intake should be 30 to 35 kcal/kg body weight per day to avoid endogenous protein
catabolism. Because she has DM, the renal RD will make renal and carbohydrate modifications to
provide for adequate blood glucose control. To obtain enough calories, the patient might need
to eat sugar-type foods as carbohydrate servings such as jelly beans, hard candies, or gumdrops.
These provide calories but no phosphorus, potassium, or fluid.
• Phosphorus intake is limited to 800 to 1000 mg/day to maintain serum phosphorus between 3.5
and 5.5 mg/dL and to prevent osteodystrophy. Increased phosphorus levels affect bone health.
Dialysis removes limited amounts of phosphorus; drugs that assist with removing phosphorus
might be given. Phosphorus is found in most foods, especially dairy products, meat, chocolate,
whole-wheat products, peanut butter, and colas.
• A high sodium intake increases thirst and leads to edema. Therefore, sodium, intake is usually
limited to 2 to 4 g/day. It is important to teach your patients not to use salt substitutes because
they usually contain potassium chloride instead of sodium chloride.
• Magnesium is excreted by the kidney and accumulates in persons with ESRD. K.B. should be
cautioned about taking additional magnesium. Magnesium is most commonly found in vitamins,
some antacids, and cathartics.
• Potassium intake is usually restricted to 60 to 70 mEq/day. High blood potassium levels can cause
dangerous cardiac dysrhythmias. High-potassium foods include citrus fruits, prunes, dried fruit,
potatoes, nuts, chocolate, milk, legumes, beans, and meat. In addition, seasoning products might
contain high levels of potassium.
• Vitamin and mineral supplementation is needed on a daily basis. Diets that are low in protein are
also low in vitamins and iron; in addition, HD removes water-soluble vitamins from the blood.
Calcium and vitamin D supplements might be needed if the patient's serum calcium levels are low.
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