Your Diet

Last updated: Jun-08-2006

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Why Diet?

The purpose of the diet is not to make life harder on us but to keep the electrolytes (chemicals) in the blood within the range, because the kidneys can no longer do that. If your labs are fine that means that whatever you eat is good for you. Never start a diet on your own and never assume that you should follow or wonder about somebody else's diet. Every patient is different, every kidney disease is different, and every kidney failure phase is different.

This page is not going to tell you what your diet should be but how to find out what it should be.

While your neph can tell you what's not good for you, a renal dietitian can tell you what is good for you and give you tasty recipes that can make your life easier even with your food restrictions.
You begin with the dietitian guidelines and adhere to them religiously. Then every month you get feedback from your labs, which lets your dietitian modify your diet.
Remember that the important thing is not what's on your plate but what accumulates in your blood between treatments, therefore patients that make urine are less restricted than others.

Never say that you cheat on your diet. The keyword is moderation. If you love to eat and eat a lot you have a problem, but if you can enjoy small portions you will be able to eat a variety of foods that are considered a no-no by your dietitian.
Remember that the diet given to you is just guidelines.
All diet guidelines should be linked directly to quantities.
A statement like "tomato is a no-no" is meaningless. Three slices of tomato in a sandwich will not kill you.
I can assure you that one tablespoon per day of any edible food will not cause you any harm.
(Of course I don't mean one tablespoon from each and every forbidden food).

You can control many of the chemicals in your system by your diet, meds, and supplements.
Here is a short list:
Sodium, Potassium, Phosphorus, Calcium, Iron, Magnesium, vitamins, protein, sugar, bi-carbonate, lipids (cholesterol and triglyceride).

If you read the labels, most packaged foods give you the amount of sodium, ignoring other chemicals. The amount is given per serving, but sometimes the serving size is ridiculously small, so estimate how much you really eat.
For more info you can call the 800 number (or send email) and ask the manufacture - they always answered me.
Cereal packages give more information. Potassium is usually stated, phosphorus and magnesium are given as percentage of their RDA (Recommended Daily Allowance). RDA is 1000 mg for phosphorus, 1000 mg for calcium, and 400 mg for magnesium.

Once you have good labs, and you understand the correlation between your diet and your labs, you may make some decisions for yourself.
It is essential to any involved patient to have a food value book or access to food database.

Here is a book:
Bowes & Church - Food Values of Portions Commonly Used, 18th edition.

Important: In a database, no value for a nutrient does not mean it is zero, but if percentage is calculated it may appear as zero.

Nutrients

Sodium

Na is the chemistry symbol of sodium (Natrium).
Sodium can be found in almost all foods and especially in canned and processed food.
Sodium causes fluid retention that leads to either or both high BP and edema.
You should also reduce your sodium intake if you cannot control your thirst.
Sodium is not dangerous by itself, as is potassium.
Don't use sodium substitutes - they may contain potassium.
However, don't be scared by sodium or potassium compounds used as preservatives in soft drinks - their amount is negligible.
Is it sodium or salt? What you eat is salt but nutrition data, as well as blood test, gives the amount of sodium. Salt is composed of approximately 40% sodium and 60% chloride.
Note that saline contains 9 grams of salt per 1-liter bag, which is about the concentration of sodium in the blood, therefore giving saline doesn't increase your sodium.

Potassium

K is the chemistry symbol of potassium (Kalium).
Potassium can be found in almost every food. Both high and low potassium levels in the blood are dangerous and may cause immediate cardiac arrest. I don't know of any symptom that gives an early warning. Some say that they feel palpitation and irregular heart bit. (And if you see bright light and angels flying among white clouds, that's a sure sign.......).

HD patients should watch their potassium carefully; those who make urine are usually less restricted. PD patient, as well as pre-dialysis and transplant patients that take diuretics, may need potassium supplements.

Instead of remembering how much potassium is in every food it is easier to remember what foods are:
Low (up to 150 mg)
Medium (150 to 300)
High (above 300)

Note that these categories relate to common serving sizes. If you eat a lot of low K you are in the high, and if you eat a little of high K you are in the low.
Many veggies are in the low to medium category.
Many fruits are in medium to high, except apples and pineapples that are low.
Dried fruits and all kind of nuts are in the high.
Avocado, bananas, cantaloupes, beans, and potatoes are in the high.
Most animal meat and dairy food are in the medium to high.
Food cooked in water losses some potassium to the water.
Canned fruits contain less potassium than fresh ones, just avoid the syrup.

Special treatment for potatoes.
You have probably heard about soaking potatoes in boiling water (leaching). This removes potassium and puts the potatoes in the low to medium category. The longer you soak and boil (replacing the water each time) the more potassium is eliminated.
Since sodium is eliminated too, add some salt to the water, just to keep the taste.
But why not letting someone else do that for you?
Potatoes are also sold pre-cooked. I use frozen hash brown and mashed potato flakes.
The amount of potassium is about half of a regular potato. About 80-100 mg per oz.
We prepare the hash brown cubes with onion and olive oil in the oven. 3-4 oz (100 gram) is a nice portion.

Phosphorus

Phosphorus' symbol is P and it is found in many foods, but mostly it goes with protein, both animal and soy (more in dairy food, less in egg whites). Most veggies contain some phosphorus and most fruits don't. All kinds of nuts are high in phosphorus.

High phosphorus may cause calcium loss in the bones. The most distinct symptom is itching.
Low phosphorus is rare in dialysis patients but common after transplant and may cause weakness.

The following table shows average phosphorus content in mg per 1 gram of protein.
Note that this is not 1 gram serving. Animal protein is about 25% of a serving.

phosphate binders bind the phosphorus in the stomach before it reaches the blood stream.
Common phosphate binders are: Tums, Oscal, Phoslo, Renagel. There is a relatively new binder called Fosrenal.
Alucap (or Amphogel) is used in severe cases only and for short period of time. Aluminum is toxic, it accumulates in the bones and brain and may cause dementia.

You should take phosphate binders when you eat, according to the amount of phosphorus you consume.
There are different opinions when to take the binders; I used to take them gradually during the meal. If you forget to take your binders you may take them within 30 minutes or so after the meal. Remember that they work on the food in the stomach.
If you skip a meal don't take your binders.
Carry your phosphate binders with you, take them wherever you eat. If you eat out take more.

Vitamins

Dialysis patients need vitamin and mineral supplements that are removed by dialysis and because of their food restrictions.
However, vitamins A and regular D are not needed. Vitamin A is accumulated in the body and is toxin. Vitamin D is digested by the kidneys therefore dialysis patients need a special form of it called Rocaltrol (or other commercial names).

Many Patients take Nephro-Vite or Nephrocaps, both contain the same vitamins with about 100% RDA in one pill.
The differences are insignificant and should be considered by your neph.
For higher doses, like 1000% RDA, you can take the non-prescription Complex B plus C, which contains the same vitamins.

Note that Nephro-Vite comes in prescription and non-prescription dose, the latter is cheaper.
The difference is 0.8 mg vs. 1 mg of Folic acid (Folate).
However, currently nephrologists prescribe higher dose of Folic acid (up to 5 mg) to reduce the amount of Homocysteine in the blood.
Homocysteine- An amino acid that in high levels may cause heart disease. Individuals with a low intake of vitamins B6, B12, and folic acid tend to have higher homocysteine levels since these nutrients are needed to convert homocysteine into other compounds.
DiaTX is a relatively new multi-vitamin that seems best for renal patients, as it contains higher doses of the above mentioned vitamins (also available with 304 mg iron).

* 0.8 mg for non-prescription.

For more info check these links:

Vitamin info: http://www.daily-vitamins.com/
Nephrocaps: http://www.flemingcompany.com/
DiaTX: http://www.diatx.com/main.php

Iron & EPO

Iron is required for the production of red blood cells. EPO (Erythropoietin, Epogen®) is hormone that makes the bone marrow produce blood cells, but without iron it doesn't work.
Blood count measures the amount of hematocrit (hct) and hemoglobin (hgb). The first is the percentage of solids in the blood and the second is the amount of oxygen carrying substance in the red blood cells.
The ratio between them is about 1:3.
Good hct is above 40%, but for dialysis patient the high limit is 36%, for many reasons.
With hct less than 30% fatigue is common. Once your red blood cells are on the rise you'll have more energy.

EPO is produced by the kidneys and when they fail blood count falls to dangerous low levels.
Many PKD patients still produce EPO, and once they start dialysis and their Bun level goes down they may not need any treatment.
Synthetic EPO is injected sub-Q or given IV through the dialysis tubing.
Dialysis patients suffer from low iron partly because they are restricted in many type of foods.
While Iron pills are commonly used (Ferrous sulfate) they are not very efficient because they are not fully absorbed and may cause stomach upset.
Iron IV is much more effective than pills. The common IV is Dextran (Infed®). Some patients are allergic to it and a test dose should be given before it is administered. It is given during 5 to 10 dialysis treatments.
There is a new kind of iron, called Ferrlicit®. Patients are less (or not at all) allergic to it.

Supplements

If you are not allowed to drink milk then you should know that the common supplements on the market like Ensure or Boost, are not much of a difference.
There is a specific supplement for dialysis patients called Nepro.
This is a shake-like drink in an 8 floz can. Drink it very cold to make it taste better.
Four cans supply a complete daily nutrition with all minerals and vitamins.
Nepro is expensive, if all you need is extra protein there are better choices, see below.

For complete nutritional info, and how to order, check this link and select Nepro from the list:
http://www.rosslabs.com/productHandbook/adultNut.asp

Protein

Usually hemodialysis patients, and more so PDers, need protein supplement.
Albumin is the protein storage in the body. If it is too low the immune system and the muscles are compromised. Also low albumin is associated with fluid retention.
Your dietitian should tell you how much protein you need per day, but generally it is about 1 gram per 1 kg of body weight (0.45 gram per lb.)
The problem with protein is that it goes with phosphorus.
A 16 oz steak contains about 100 gram protein and almost the daily allowance of phosphorus.
Here is a comparison of some protein supplements (protein in grams, all others in mg):

Eggs

One egg contains about 7 grams of protein but the yolk contains over 200 mg cholesterol and 80 mg phosphorus.
If you have elevated cholesterol use Eggbeaters instead of eggs.
This product is 99% egg white, no cholesterol and low phosphorus.
You can add egg whites if you like (they are cheaper).
It is a very good substitute for scrambled or fried eggs (but not for sunny side up...).
If cholesterol isn't a problem and your phosphorus is under control then one yolk per day is okay.

Got Milk?

Dairy food is not good for you because of both high potassium and phosphorus.
One cup of milk (8 floz) contains (in mg): K=400, P=250, Ca=300, that's 30 mg phosphorus per Ounce.
Still dietitians usually recommend 4 floz (120cc) of milk per day.
Soy milk contains half the phosphorus but almost the same amount of potassium.
Milk substitues & creamers contain about 15-20 mg phosphorus per ounce (about one half of milk), and they can be diluted with water.
Rice milk, like Rice Dream, isn't much of a milk, it is mostly water and carbs. There are conflicting nutrition data between the manufacturer and the USDA data base.
I used 50-50 mixture of Coffee-Rich and water for my cereals.
For better taste, make it 1/3 of each - Coffee-Rich, water, milk.
Instead of milk you can use low fat ice cream, or sherbet or sorbet (for less phosphorus) to prepare shake, and add whey protein powder to make it healthier, and don't forget to take your phosphate binder with it.

Coke Anyone?

Coke contains very little sodium, traces of potassium, and 3.6 mg phosphorus per Ounce.
That is 44 mg per can.
For comparison, same amount of beer contains twice as much phosphorus, and milk 8 times.
So you can enjoy a can of Coke once in a while, just don't overdo it.
Of course, don't drink it if your phosphorus is close to or above the limit. You have to leave some room for phosphorus that is unavoidable with your protein.

Alcohol

Once in a while a beer or a glass of wine will not do you any harm.
Most red and white wines contain very little phosphorus and 80-100 mg potassium per glass (3.5 floz = 100 cc).
Regular beer contains 45-100 mg phosphorus and 80-100 mg potassium per bottle (12 floz = 360 cc).
Drinks like gin, rum, vodka, whiskey contain traces of potassium and phosphorus, however, if you don't make urine then most of the alcohol stays in your body until your next dialysis. During dialysis alcohol is removed, like other toxins, in a short period of time, so if you come drunk you'll have the mother of all hangovers.
Cheers!

Anti-acid

Calcium based anti-acids are okay if your calcium is not too high. Other anti-acids like Mylanta are based on magnesium or aluminum and are dangerous. Ask your doctor.

How to enjoy food

• Have info of food values
• Understand the relationship between your diet and your labs
• Eat in moderation
• Plan ahead - eat less K and P in one meal so you can eat more in another

I usually ate routine meals but occasionally I ate everything I liked, from potatoes to tomatoes, grapefruits to pizza, ice cream to Coke, all in moderation (I don't like bananas).

• You do dialysis two days in a row because of scheduling reasons
• You have a test or procedure that requires fasting
• You are sick and don't eat at all

Once you can or want to eat it is time to celebrate.
In the fewer meals you can eat and drink what you would normally eat in two days.

Interesting observation:
If you don't eat you can eat anything you want.......

Eating out

Eating out is always tricky. Try not to do it more than once a week and not on weekends.
Restaurants have their own way of cooking. Usually salt and MSG are used generously, but in many places you can ask for low sodium dishes.

If you plan on eating dinner then skip lunch, so you'll be able to enjoy your meal without guilt.
Order rice instead of potatoes, small portions of meat/fish, chicken is preferred, eat half of the salad, avoid soup, drink one glass, no juice and no refills, remember that wine or beer is like any other fluid. Share dessert with somebody.
And take more phosphate binders than usual.

If your mom is cooking for you tell her again and again that everything that is healthy is not good for you, and drinking is good for the kidneys but only when they work. Wish you luck......

Eating on the Machine

If you eat during the treatment, keep the food wrapped and keep your hands clean. In some units eating is prohibited for hygienic reasons. Eating may also lower your blood pressure.
Whatever you eat or drink should follow your regular diet. It is absolutely not true that on the machine you can eat anything you want. Use phosphate binder same as you would at home.
Remember that about half of the potassium that you eat during the treatment stays in your body.
Note that dry food (nuts, dried fruits) contains high concentration of phosphorus and potassium.
Take the leftover with you; the staff doesn't have to clean after you.