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Eating well on peritoneal dialysis Information for patients This leaflet is for patients on peritoneal dialysis and their friends and relatives. It explains the reasons why you should eat well and gives dietary advice and tips. Why you may need to alter your diet When your kidneys are not working properly, your body’s waste products build up in your blood. Many of these are harmful (e.g. urea, potassium). Peritoneal dialysis (PD) removes waste products from your blood, to stop the levels of waste products from getting too high. Even when you are on PD there may still be some potential complications, which are avoidable by combining your dialysis treatment with an appropriate diet. Changes to your diet can help to: − Control blood pressure − Maintain a healthy weight − Keep your heart and blood vessels healthy − Keep your bones healthy − Prevent a build up of harmful waste products Diet and fluid advice is individual to each person and depends on many other things, such as other medical conditions, blood results and eating patterns. Your dietitian will advise you on which parts of this advice are most relevant to you. 1 Protein Protein is an essential part of your diet to help build and repair body tissue. During PD, some protein is lost from the body. To counteract this loss, it is important to have plenty of protein in your diet. Examples of high protein foods include: − Animal proteins; red meat, poultry, white fish, tuna, salmon, cottage cheese and eggs (see phosphate section). − Vegetable proteins; pulses e.g. beans/lentils, soya products, Quorn, tofu. Try to include a good-sized portion of a food high in protein at two meals every day. Your dietitian can advise you about the amounts of these foods you require. Potassium You may have previously been advised to follow a low potassium diet, as it is common for potassium levels in the blood to rise when your kidneys are failing. High levels of potassium in the blood can cause an abnormal heart rhythm. PD is very good at removing potassium from the blood, so once PD is established, a low potassium diet is usually no longer needed. Occasionally, the level of potassium in the blood can fall too low. This can be corrected by increasing the potassium in your diet by eating more of foods such as dried apricots, raisins, jacket potatoes, orange juice and bananas. Normal potassium level is around 3.6 - 5.3mmol/l. 2 Phosphate Phosphate is found in a wide variety of foods and is normally removed from the body by the kidneys. When kidney function is worsening, phosphate levels in the blood can become too high. Ideally your phosphate level should be kept between 1.1-1.7mmol/l. If you have high phosphate levels in your blood, this may cause: − Itchy skin and itchy eyes − Weakened/ brittle bones and aching joints − Life-threatening damage to your heart and blood vessels If your phosphate level is high, you can reduce it by avoiding / limiting foods high in phosphate, such as dairy foods. Limit dairy foods to no more than: Milk 1/3 -1/2 pint milk per day Yoghurt Include within milk allowance Cheese 50g (2oz) hard cheese per week Eggs 5 per week (no limit on egg whites) Other foods to avoid include: − Offal meats − Chocolate − Tinned fish with bones, e.g. pilchards, sardines − Prawns − Malted milk drinks − Cola drinks − Nuts − Foods containing lots of baking powder e.g. scones. 3 Phosphate additives Phosphates are often used as a preservative or as an ingredient in processed foods and can contribute significantly to your total phosphate intake. Check the labels of foods to look for any of the following and try to avoid them: − − − − − − − Phosphoric acid Dicalcium phosphate Monocalcium phosphate Pyrophosphates Hexametaphosphate Polyphosphates Sodium phosphate. Choosing fresh, unprocessed food will avoid this problem. Phosphate binders In addition to diet changes, you may also be prescribed some tablets known as phosphate binders. These tablets should be taken when you eat. They work by binding to phosphate in your food and reducing the amount of phosphate your body can digest and absorb from it. The most commonly prescribed phosphate binders are shown below: − Calcichew (calcium carbonate) to be taken before food − Phosex (calcium acetate) to be taken with food − Renagel (sevelamer hydrochloride) to be taken with food − Fosrenol (lanthanum carbonate) to be taken after food If you need more advice about lowering your phosphate level, your dietitian can give you more detailed advice. Salt We should all be trying to reduce our intake of salt and salty food, but it is particularly important for those having dialysis treatment. A diet high in salt can lead to fluid retention and high blood pressure. Salty foods also make you thirsty so is unhelpful if you are trying to control your fluid intake. To avoid eating too much salt, follow these tips: − Do not add salt at the table. − Use only a very small amount of salt in cooking, or none at all. Try to flavour your food with herbs and spices instead of salt. − Cut down on salty processed foods e.g.: Bacon, tinned meat like corned beef, ham, sausages & other processed meat products Smoked or salted fish Anything tinned in brine, like tuna Baked beans Meat and vegetable extract (Bovril, Marmite) Salted nuts, salted biscuits or crackers, crisps Soups - tinned or packet Stock cubes and gravy mixes Pickle / chutney Cheese Many ready-prepared foods If you need more advice about lowering your salt intake, your dietitian can give you more advice about alternative flavourings and using food labels. 5 Fluid (liquid) The balance of fluid in your body depends upon your fluid intake (drinks and “wet” foods) and your fluid output (any urine you pass and additional fluid removed by dialysis). It is important to try to keep to your “fluid allowance” to keep your body in fluid balance. If you take in more fluid than is being removed, you will become “overloaded” with fluid. Excessive fluid intake causes a rapid increase in weight, shortness of breath, ankle swelling and high blood pressure. This is harmful to your heart as it then has to work much harder to deal with the extra fluid. Your fluid balance may change over time depending on your urine output and your dialysis regimen. Try to keep your fluid intake to …………………..daily When you drink too much, stronger dialysis bags are needed, to remove more fluid from your body. Stronger bags contain more glucose (sugar), causing additional weight gain and peritoneal membrane damage. It is beneficial to be able to control your fluid intake and stay on “weaker” bags for your dialysis. Managing your fluid intake If you are calculating your intake of fluids remember that many foods have a high fluid content. For example, sauces and gravies, milk puddings, jelly, ice cream and ice lollies may contribute significant amounts of fluid to your overall intake so try to allow for these 'hidden fluids'. 6 Foods to choose Foods in moderation Foods to avoid Protein foods All fresh, unprocessed, lean meat, e.g. beef, chicken, lamb, pork, turkey. White fish (e.g. cod, haddock, plaice, skate, sole), tuna – fresh or tinned in oil or spring water, salmon. Beans, lentils, pulses (if used in place of meat) Dairy foods Milk -1/3-1/2 pint daily, Custard, ice cream, milk puddings, yoghurt (include in milk allowance). Hard cheese – limit to 50g (2oz) week Eggs - up to five a week (but egg whites unlimited). Dairy foods Cream * Cottage cheese, cream cheese e.g. Philadelphia, Margarine*, low-fat spreads, butter*, oils* Cereal foods Corn Flakes, Rice Krispies. Protein foods Bacon, ham, tinned meats, sausages, frankfurters, beefburgers, processed/’formed’ packet meat slices Smoked fish, fish tinned in brine. Veal, liver, kidney, heart, sweetbreads, paté Tinned fish with bones, e.g. pilchards, sardines. Fish roe, kippers, whitebait, Seafood e.g. crab, prawns, scampi. Cereal foods Wholemeal/ white bread, chappatis, pitta bread, cream crackers, crispbreads, pasta, rice, noodles, Branflakes, porridge, Weetabix, Shredded Wheat Plain/ sweet biscuits, cakes*. Fruit & vegetables Chips*, fried or roast potatoes*. Salt-free crisps* (e.g. Salt & Shake crisps with no added salt). Olives in brine. Drinks Beer, cider, lager, sherry, wine, gin, rum, vodka, whisky. Miscellaneous Fruit & vegetables Salt substitutes e.g. Losalt or Selora (contain Boiled/home-made mashed potatoes, jacket about 1/3 sodium of ordinary salt). potatoes, sweet potatoes and yam. Mayonnaise*/ salad cream * Vegetables; fresh or frozen fruits. Reduced salt gravy Drinks Sugar, boiled sweets, honey, syrup, jelly Tea, coffee, herbal teas, squashes, fruit juices, babies, mints. lemonade, mineral or tap water. Miscellaneous Artificial sweeteners, sugar-free boiled sweets, chewing gum or mints, jams or marmalade. All herbs and spices, garlic, pepper, vinegar Low salt stock cubes e.g. Kallo very low salt. * = foods high in fat Dairy foods Cheese spread e.g. Primula / Dairylea Condensed or evaporated milk. Cereal foods All Bran, muesli, cereals containing nuts Biscuits and cakes containing chocolate and nuts. Scones, bread and butter pudding. Drinks Malted milk drinks e.g. Ovaltine, Horlicks, drinking chocolate, cocoa. Coca Cola, milkshakes, Stout e.g. Guinness. Miscellaneous Tinned or packet soups, salt, including sea salt and rock salt, gravy, meat and yeast extracts (e.g. Marmite, Bovril), tomato ketchup, tinned spaghetti & baked beans, Indian snacks (e.g. chevda, gathia, sev), Twiglets, Bombay mix, Salted crisps or other salty savoury snacks, ordinary stock cubes, peanut butter, chocolate spread, gram flour, pizza, quiche, baking powder, nuts, chocolate. It is recommended that all patients with renal disease avoid star fruit as it contains a harmful toxin. Helpful hints − Use a smaller cup. − Take your tablets with your meals wherever possible to save on water. − Use an ice cube in place of a drink (try freezing a little lemon/lime juice in with the ice cube). − Try freezing small pieces of fruit (e.g. grapes, pineapple chunks or berries). − Help to stimulate saliva and stop your mouth feeling dry by sucking a slice of lemon or lime, using sugar free gum/mints or boiled sweets. − Try to take drinks that quench your thirst. Very sweet or salty drinks will not achieve this as effectively. − Sip your drinks. Use a straw with cold drinks to slow you down. − If you rinse your mouth out with cold water and spit it out rather than swallowing, this can help take the edge off your thirst. Track how much you drink through the day. Start the day with a measuring jug of water equal to your fluid allowance. From this you can make ice cubes and drinks. If you have hot drinks or other liquids not made from water then remove an equal volume from the jug and throw it away. 9 Useful measures to help you add up how much you are drinking: Average Measure Disposable plastic cup 150ml Tea cup 180ml Can 330ml Glass 200ml Mug 200ml Ice cube 20ml Soup bowl 200ml Your home measure 750mls = ¾ litre = about 1⅓ pints 1000mls = 1 litre = about 1¾ pints 1500mls= 1½ litre = about 2½ pints Fibre Constipation can be a common problem for people on PD. It can lead to poor drainage of dialysis fluid. Where possible, try to eat fibre-rich foods to help prevent constipation. Good sources of fibre are: − Wholemeal, granary or high fibre white bread − Shredded Wheat, Weetabix, Branflakes, porridge − Brown rice, wholewheat pasta − Pulses, beans, lentils, dahl − Dried fruit, fresh fruit and vegetables. Aim for 5 portions a day, as long as your potassium level is well controlled. 10 Maintaining a healthy body weight Many people notice that their appetite improves once they start dialysis, and that their body weight starts to rise. For some people, this may be a welcome sign that they are eating better and regaining body weight than had previously been lost. For others, weight gain is unwanted. One of the reasons you may gain flesh weight is the dialysis bags contain glucose (sugar) and this is absorbed in to your body. This provides you with extra calories (energy) that you haven’t had the pleasure of eating! The stronger, higher strength bags contain more glucose, so even more calories are absorbed. If you find you are gaining unwanted weight, you will need to make some changes to your diet to tackle this problem and your dietitian can help you with this. Poor appetite Some people on PD find their appetite is poor. A loss of appetite or feeling of fullness is not uncommon. It is important that you eat sufficient food, especially high protein foods. A poor appetite may lead to a deficiency in important nutrients, resulting in a delay in recovering from infections e.g. peritonitis. If you are worried that you are not eating enough, contact the dietitian for advice on increasing your calorie and protein intake. Your dietitian can advise you about nutritional supplements that can be prescribed by a doctor. 11 Diabetes If you have diabetes, your blood glucose levels may increase when you start dialysis, due to the glucose you will absorb from the bags. You may need to do more regular monitoring for a while and your diabetes treatment may need to alter. If you need help doing this, speak to a member of staff. Vitamins and minerals Some vitamins are lost from the body during dialysis, so you may be advised to take a vitamin supplement prescribed by your doctor. Some vitamins can be harmful to dialysis patients. It is not advisable to take other supplements unless you have checked with your doctor, dietitian or pharmacist. 12 Binders to take Example meal plan Breakfast Fruit Breakfast cereal and milk (from allowance) Bread / toast with butter / margarine / low fat spread / jam / marmalade Egg (from allowance) Tea Mid-morning (if desired) Tea or coffee Main meal _____oz / _____g meat/ poultry OR _____oz / _____g white fish OR _____ tablespoons pulses e.g. beans/lentils/chickpeas Potatoes / rice / pasta Vegetables / salad Fresh / tinned fruit or yoghurt (from allowance) Mid-afternoon (if desired) Tea or soft drink Snack meal Bread Butter / margarine / low fat spread _____oz / _____g lean meat/poultry OR _____oz / _____g tuna OR _____tablespoons cottage cheese OR _____ eggs (from allowance) Salad Fruit 13 Further information National Kidney Federation www.kidney.org.uk The NKF is the National Kidney Patient charity in the United Kingdom. The charity is run by Kidney Patients for Kidney Patients Kidney Research UK www.kidneyresearchuk.org Kidney Research UK is the leading UK charity funding research that focuses on the prevention, treatment and management of kidney disease. The charity also dedicates its work to improving patient care and raising awareness of kidney disease. Kidney Patient Guide www.kidneypatientguide.org.uk This website provides information for renal patients, their partners and families, health care professionals and anyone else who is interested in kidney disease. A variety of cookbooks are available. Ask your dietitian for more details. More information about the Trust can be found at www.royalberkshire.nhs.uk Useful contacts Dietitian Telephone 14 Royal Berkshire NHS Foundation Trust London Road Reading RG1 5AN Telephone 0118 322 5111 www.royalberkshire.nhs.uk This document can be made available in other languages and formats upon request. Department of Renal Medicine/Dietetics, March 2017 Review due: March 2019 15