Eating well on haemodialysis - information for kidney patients

These are high protein foods. They are essential:

• For strong muscles
• To fight off infections
• For healthy skin and blood

Before starting dialysis, you may have been advised to eat smaller portions of protein foods. Now your body is losing some protein during dialysis. You need to eat extra protein foods to replace what you are losing.

High protein foods and their recommended portions

• Meat, chicken and turkey - palm size portion
• Fish - hand size portion
• Eggs - 2 eggs
• Beans, lentils - half a tin or 6 tablespoons
• Quorn, tofu, tempeh, soya, protein - palm size portion

Try to eat protein foods at two meals every day. Speak to your dietitian if you are struggling to manage these.

Milk, cheese, yoghurt and fortified soya milk are great sources of protein and calcium. They also contain a lot of phosphate.

Phosphate levels in the blood may be high when the kidneys are not working properly; this can increase your risk of heart disease, cause weak bones and itching. Your dietitian will advise if you need to limit these foods to lower phosphate levels in the blood. See phosphate section below for more information.

These foods give us energy.

Try to include one serving at every meal.

Wholegrain varieties are high in fibre. Fibre helps to keep your bowels healthy and prevent constipation. Constipation can prevent your dialysis from working well.

Try to choose these wholegrain foods:

• Wholemeal or granary bread
• Wholegrain cereals such as shredded wheat or Weetabix
• Wholewheat pasta
• Brown rice

You may have been advised to always boil potatoes, yam, cassava and plantain; this reduces the potassium. Your dietitian will advise you if you still need to do this.

Eat at least five portions of a variety of fruit and vegetables per day.

You may have been advised not to eat some fruit and vegetables because your potassium levels in the blood have been high. Your dietitian will advise you if you still need to do this.

Foods high in fat and/or sugar include pastry, fried foods, cakes, biscuits and chocolate.

If your appetite is good and you want to manage your weight and eat to keep your heart healthy, you could:

• Eat smaller portions of high fat/high sugar foods.
• Choose low fat options where possible such as lean meats.
• Choose lower fat dairy foods such as milks, yoghurts and cheeses.
• Use smaller amounts of unsaturated fats and oils such as vegetable oil and olive oil spread.

Fluid mainly comes from liquids you drink.

When most people start dialysis, they are still passing urine. Fluid is removed from the body by dialysis and by passing urine.

Many people find that after a while on dialysis they pass less urine; they begin to rely on dialysis to remove most of the fluid.

If you are drinking more fluid than can be removed, you will become fluid overloaded (oedema). The extra fluid puts a strain on your heart and lungs. It is often difficult to remove extra fluid by dialysis.

Signs you are overloaded are:

• Rapid weight gain
• Swollen ankles
• Feeling breathless
• Higher blood pressure

You will weigh yourself before and after dialysis sessions. The change in weight from the end of one session to the beginning of the next is mainly fluid. Your doctor, dialysis nurse or dietitian can advise you on your ideal maximum weight gain between dialysis sessions.

If you are gaining too much fluid your doctor, dialysis nurse or dietitian may advise you to limit the fluid you drink.

Tips if you need to have less fluid:

• Try to have fewer drinks and spread your fluid throughout the day.
• Use a small cup or glass for drinks.
• If eating sloppy or liquid foods such as such as soup, custard, yoghurt, ice-cream, reduce how much you drink.
• Spicy and salty foods can make you thirsty so try to reduce these foods.
• Try using plastic ice-cubes in drinks to save extra fluid.
• Rinsing your mouth, gargling with mouthwash and brushing your teeth can help freshen your mouth.
• You can quench your thirst with slices of lemon, orange, frozen grapes, pineapple cubes, boiled sweets, sugar free mints and chewing gum.
• If you have a dry mouth, artificial saliva sprays may help such as Glandosane (available on prescription).
• Keep a record of all liquids you are having including all drinks, soups, gravies, jelly, yoghurts, and ice-cream.

Your dietitian can give you more ideas to help.

Eating less salt can help you to feel better. Reducing salt helps your dialysis remove fluid, can improve your blood pressure and make you feel less thirsty.

Most of the salt we eat comes from processed and ready prepared foods.

Tips to reduce salt:

• Have more home cooked foods. Cook from scratch where you can.
• Try to reduce processed foods. Sausages, bacon, ham, ready meals, jars of mustard, sauces, pickles, and table sauces are salty.
• When shopping, check food labels. Aim to eat mainly foods which have less than 0.3g salt per 100g or with a green traffic light symbol for salt. If you are choosing ready meals, aim for less than 1.8g per portion.
• Consider having higher salt foods (more than 0.3g salt per serving, or amber or red traffic light) less often and in smaller amounts.
• Free apps such as FoodSwitch or NHS Food Scanner can help.
• Flavour your food with herbs, spices, lemon, garlic, vinegar, dry mustard powder.
• Try to avoid using salt in cooking. Taste food first as you may not need it.
• Try not to add any salt at the table.
• Avoid salt that has ‘low in sodium’ written on the label as these contain potassium. This includes LoSalt, Solo, Saxa So-low.

Your dietitian can give you more help to reduce the salt you eat.

Potassium is a mineral found in many foods. It helps our nerves, muscles and heart to work properly. Our kidneys usually control the level of potassium in the blood. Extra potassium is passed out in the urine.

Dialysis removes potassium but levels can build up between sessions, especially if you start to pass less urine. Your levels of potassium in your blood will be checked regularly.

The target range for potassium in your blood is 3.5 – 5.9mmol/l. A high level of potassium can be dangerous, as it can affect your muscles and heart.

Your dietitian will advise if you need to eat less potassium to keep your blood levels safe.

These are foods and drinks higher in potassium:

• Some fruits such as apricots, avocado, bananas and dried fruit.
• Some vegetables such as mushrooms, parsnips, spinach and tomatoes.
• Potatoes which have not been boiled such as chips and jacket potatoes.
• Snacks such as potato crisps, nuts, chocolate and liquorice.
• Drinks such as coffee, malted milk drinks and fruit juices.
• Alcoholic drinks such as cider and strong ales.
• Soups containing tomatoes and vegetables.
• Salt substitutes such as Losalt, Saxa So low and Solo.

Only limit high potassium foods if you have been advised to.

If you have diabetes, you may have been recommended to eat more fruit, vegetables and nuts. Your dietitian can advise you on appropriate quantities and help you choose lower potassium options.

Phosphate levels in the blood can be high when the kidneys are not working properly; this can increase your risk of heart disease, weaken your bones and cause itching.

Dialysis is poor at removing phosphate from the blood. Your levels of phosphate in your blood will be checked regularly.

The target range for phosphate in your blood is 0.8 – 1.5mmol/l. If your levels are high, eating less phosphate can protect your bones and heart, and help you feel less itchy.

High phosphate food and drinks include:

• Cola drinks and other dark coloured fizzy drinks which contain phosphoric acid.
• Processed foods containing phosphate additives such as ready meals, processed meats and cake mixes. Check the ingredients label for additives with ‘phosphate’ in the name such as diphosphates, triphosphates, sodium phosphate.
• Nuts and chocolate.
• Products with raising agents such as muffins and scones.
• Malted milk drinks, drinking chocolate and cocoa.
• Evaporated and condensed milk.
• Fish with edible bones such as sardines, pilchards and whitebait.
• Shellfish such as fresh crab and scampi.
• Offal products such as liver, liver sausage and pate.

Other high phosphate foods such as dairy products, milk, fish and meat are good sources of protein and other nutrients. Some recommended portion sizes are below.

Your dietitian can guide you on how many portions to have per day or per week. For most people 2 servings per day of dairy foods and up to 6 eggs per week will limit the amount of phosphate you’re eating.

High phosphate foods recommended portions

• Milk - 200ml
• Yoghurt - 1 small pot
• Cheese - 1 small matchbox size portion
• Eggs - 6 per week

If you are already following a low phosphate diet your dietitian will advise if you need to continue. Only limit high phosphate foods if you have been advised to.

To help control phosphate levels, some people may be prescribed tablets called phosphate binders. Your dietitian will advise on the best way to take these to make sure they work well.

Patients Know Best

An easy-to-use online service that allows you to monitor your own blood test results. You can find out more and register to use it at https://patientsknowbest.com/register/

Websites

Information on kidney disease and food written by the kidney dietitians at North Bristol NHS Trust

Education videos on how to eat less salt presented by the kidney dietitians at North Bristol NHS Trust

Kidney Care UK diet and lifestyle information including recipe books to download

Kidney Patient Guide diet information including menus and recipe books to download

Website of the Edinburgh Renal Unit and contains useful dietary information

Webinar on importance of protein for people on haemodialysis

Kidney Care UK practical advice to help you reduce your weekly food shopping bill while maintaining a nutritious and kidney friendly diet