1. Nutritional Assessment in Hemodialysis Patient
Haneen Nabeel Molla  M.Sc.
Clinical Dietitian
King Khalid University Hospital

2. Stages of Kidney Disease
There are five stages of kidney disease.
It based on the presence of kidney damage and the glomerular filtration rate (GFR)
The treatment is based on the stage of kidney disease.

3. Stages of Kidney Disease
Description
Glomerular Filtration Rate (GFR)* 1
Kidney damage (e.g., protein in
the urine) with normal GFR
90 or above 2
Kidney damage with mild
decrease in GFR
60 to 89 3
Moderate decrease in GFR
30 to 59 4
Severe reduction in GFR
15 to 29 5
Kidney failure
Less than 15

4. End Stage Renal Disease ( ESRD ) :
Inability to excrete waste products , maintain fluid and electrolyte balance and produce hormones.

5. When is Dialysis Needed?
Kidneys no longer remove enough wastes and fluid from the blood
When only 10 to 15 percent of the kidney function left.

6. When is Dialysis Needed?
Symptoms such as nausea, vomiting, swelling and fatigue.
A high level of wastes in their blood that may be toxic to their body.

7. Nutrition and Hemodialysis
Diet is an important part in hemodialysis patient overall care.
We will go over some of the important points in the patient diet which include :
Getting the right amount of calories and protein
Staying at a healthy body weight
Important nutrients in the diet
Potassium
phosphorus
sodium and fluids
calcium
Diabetic – Renal Diet

8. The Goals of the Nutritional Management in Dialysis
Prevent nutrients deficiencies
Control edema and serum electrolytes
Provide an attractive healthy diet

9. Anthropometric Measurement
Weight kg
High cm
Body mass index (BMI ): Weight
(Height)2
Underweight to 18.5
Normal (healthy weight) to 25
Overweight to 30
Obese Class I (Moderately obese) to 35
Obese Class II (Severely obese) to 40
Obese Class III (Very severely obese) over 40

10. Anthropometric Measurement
adjusted body weight (AIBW) = (Actual weight – IBW)
x IBW women
x IBW men
Ideal body weight (IBW) : (Height)2 x men
x women
% of IBW: Actual Weight x 100
IBW

11. Getting the Right Amount of Calories
To the patients overall health and helps to give them energy to do their normal activities .
Calories come from all the foods they eat , and are important because :
Give the body energy
Help to stay at a healthy body weight
Help the body use protein for building muscles
and tissues.

12. Getting the Right Amount of Calories
Will keep the patients from losing weight.
The amount of calories recommended will depend on the individual needs.
Energy kcal/kg of body weight for <60 years;
30 to 35 kcal/kg of body weight for >60 years

13. Getting the Right Amount of Protein
In pre-dialysis patients have to be on a low-protein diet.
During dialysis patients will need diet with more protein.
It is important for overall health and how well they feel.
Body needs the right amount of protein for:
Building muscles
Repairing tissue
Fighting infections.

14. Protein Protein is found in 2 types of foods: Animal sources
Plant sources
poultry , meat , eggs, seafood , milk and cheese
nuts, seeds , legumes, soy and tofu

15. Protein
Some of these protein-rich foods may also contain lots of phosphorus, which need to be controlled in their diet.
Protein : g/kg of body weight, >50% HBV protein

16. Potassium Potassium is an important mineral found in food.
Potassium helps the muscles and heart work properly.
Healthy kidneys helps to keep the right amount of potassium in the body.

17. Potassium
Too much or too little potassium level in the blood can be dangerous.
With hemodialysis, patients need to limit their intake of high-potassium foods.

18. Potassium
Soaking the vegetables after cutting it and cooking it helps to remove high amount of potassium
Potassium : 2 to 3 g/day; or 40mg/kg IBW

19. (>200 mg / portion) The portion size is ½ cup
High-Potassium Fruit
(>200 mg / portion) The portion size is ½ cup
Apricot, raw (2 medium) dried (5 halves)
Avocado (¼ whole)
Banana (½ whole)
Cantaloupe
Dates (5 whole)
Dried fruits
Figs, dried
Grapefruit Juice
Honeydew
Kiwi (1 medium)
Mango(1 medium)
Nectarine(1 medium)
Orange(1 medium)
Orange Juice
Papaya (½ whole)
Pomegranate (1 whole)
Pomegranate Juice
Prunes
Prune Juice
Raisins

20. High-Potassium Vegetables
(>200 mg / portion) The portion size is ½ cup
Artichoke
Baked Beans
Squash
Beets, fresh then boiled
Black Beans
Broccoli, cooked
Brussels Sprouts
Chinese Cabbage
Carrots, raw
Lentils
Dried Beans and Peas
Legumes
Mushrooms, canned
Okra
Parsnips
Potatoes, white and sweet
Pumpkin
Rutabagas
Spinach, cooked
Tomatoes/Tomato products
Vegetable Juices

21. Other High Potassium Foods
(>200 mg / portion) The portion size is ½ cup
Bran/Bran products
Chocolate (1.5-2 ounces)
Granola
Milk, all types (1 cup)
Molasses (1 Tablespoon)
Yogurt

22. (<200 mg/ portion) The portion size is ½ cup
Low-Potassium Fruit
(<200 mg/ portion) The portion size is ½ cup
Apple (1 medium) Apple Juice Applesauce Blackberries Blueberries Cherries Cranberries Fruit Cocktail Grapefruit (½ whole)
Grapes, Grape Juice
Raspberries
Plums (1 whole)
Tangerine (1 whole)
Strawberries
Pears(1 small) canned (½ cup)
Pineapple, Pineapple Juice
Peaches, (1 small) canned (½ cup)
Watermelon(limit to 1 cup)

23. Low-Potassium Vegetables
(<200 mg/ portion) The portion size is ½ cup
Asparagus (6 spears)
Beans, green or wax
Cabbage, green and red
Carrots, cooked
Cauliflower
Celery (1 stalk)
Corn, fresh (½ ear) frozen (½ cup)
Cucumber
Eggplant
Mixed Vegetables
Mushrooms, fresh
Watercress
Yellow Squash
Zucchini Squash
Onions
Parsley
Peas, green
Peppers
Radish
Kale
Lettuce

24. Other Foods Low Potassium
( <200 mg/ portion) The portion size is ½ cup
Cake: angel, yellow
Coffee: limit to 8 ounces ( 1 cup )
Pies without chocolate or high potassium fruit
Cookies without nuts or chocolate
Tea: limit to 16 ounces (2 cups )
Rice
Noodles
Pasta
Bread and bread products: (Not Whole Grains)

25. Phosphorus Phosphorus is a mineral found in different kind of foods.
Eating foods high in phosphorus will raise the amount of phosphorus in the blood.
When phosphorus builds up in the blood, calcium is pulled from the bones. Over time, the bones will become weak and break easily.
Dialysis cannot remove all of this phosphorus.

26. Phosphorus
A high level of phosphorus in the blood may also cause calcium phosphorus crystals to build up in the joints, muscles, skin, blood vessels and heart.
These crystals may cause serious problems such as
Bone pain
Damage to the heart and other organs
Poor blood circulation
Skin ulcers.

27. Phosphorus
To keep blood phosphorus at safe levels, patients will need to limit phosphorus-rich foods, and may need to take some medications.
Phosphorus 800 to 1,000 mg/day; or 17mg/kg IBW

28. The portion size is ½ cup
High Phosphorus Food
( >150 mg/portion)
The portion size is ½ cup
Protein
Carp, sardines, beef liver, chicken liver ,organ meats, oysters
Dairy Products:
Milk, Yogurt ,Pudding, Custard, Ice cream and Cream soups

29. High Phosphorus Food Vegetables dried Other foods beans and peas:
bran cereals
brewer’s yeast
nuts
caramels
seeds
Beverages
Ale, Beer
drinks made with milk
chocolate drinks
Cocoa, dark colas
baked beans
black beans
chick peas
kidney beans
lentils
northern beans
split peas
soy beans

30. Sodium
Sodium is a mineral found naturally in foods. It is found in large amounts in table salt and in foods that have added table salt.
Eating too much sodium can make the patient thirsty and cause the body to hold onto more fluid.

31. Sodium The extra sodium can cause: Sodium 1 - 3 g/day
Swelling or puffiness around eyes, hands or feet
Fluid weight gain
Shortness of breath
Rise in blood pressure
More work for their heart
Sodium g/day

32. Sodium Table salt Seasoning salt Garlic salt Onion salt Celery salt
High Sodium Sauces
Salted Snacks
MEATS
PROCESSED FOODS
Table salt
Seasoning salt
Garlic salt
Onion salt
Celery salt
Barbecue
Steak
Soy
Teriyaki
Oyster
Crackers
Potato chips
Corn chips
Pretzels
Tortilla chips
Nuts
Popcorn
Sunflower seeds
Hot Dogs
Cold cuts,
Pastrami
Sausage
Corned beef
Spam
Frozen prepared foods
Commercial mixes
Buttermilk
Cheese
Soups
Tomato products
Vegetable juices
Canned vegetables
Canned raviolis
Chili
Macaroni & Cheese
Spaghetti
Fast foods
Pickles
Olives

33. Fluids
Fluid is any food or beverage that is liquid at room temperature.
Some examples are:
Ice
Beverages like coffee, tea, sodas, juices and water
Frozen desserts such as ice cream, sherbet or Popsicles Gelatin
Gravy and Soups

34. Fluids Signs may noticed with drinking too many fluids
A sudden increase in weight along with swelling
Shortness of breath
A rise in the blood pressure
Fluid : output ml

35. Calcium
Calcium is the mineral that is important for building strong bones.
However, foods that are good sources of calcium are also high in phosphorus.

36. Calcium To prevent loss of calcium from bones
Follow a diet that limits high-phosphorus foods
Take phosphate binders.
In some cases the physician may prescribe a special form of vitamin D to help keep calcium and phosphorus levels in balance and prevent bone disease.

37. Diabetic-Renal Diet in Hemodialysis
Patient on hemodialysis diet will have restrictions in foods containing high amounts of phosphorus, sodium and potassium.
Diabetic patients who are on hemodialysis will be tightly controlled the Carbohydrate intake in order to manage the blood glucose levels.

38. Diabetic-Renal Diet in Hemodialysis
High sugar foods and all carbohydrate containing foods, increase blood glucose levels.
The total amount of carbohydrates the patients eat will be balanced with their medication and activity level.
They could use system called carbohydrate counting to keep their carbohydrate intake balanced.

39. Diabetic-Renal Diet in Hemodialysis
Take low phosphorus and low potassium foods .
Limit milk and dairy intake.
Control blood sugar to help control thirst and fluid gains.
Avoid cooking with salt, salt substitutes, or add salt at the table.

40. Conclusion
Our goal for hemodialysis patients should be a healthy lifestyle that can be maintained in the long run, rather than a short-term "diet”. It's all about making changes that will last a lifetime--changes that are focused on smart, sensible eating.

41. Thank you