End stage renal disease (ESRD) occurs when chronic kidney disease worsens to the point at which kidney function is less than 10 % of normal. The kidneys fail to function at a level needed for day-to-day life. Kidneys main function is to remove wastes and excess of water from the body, which gets accumulated in renal failure leading to toxicity. The treatment includes kidney transplant or dialysis with dietary management.

ESRD always follows a chronic kidney disease; the most common cause is diabetes and high blood pressure. Other causes are –

1. Diseases affecting arteries reaching or leaving the kidneys.
2. Congenital abnormalities of kidneys
3. Polycystic kidney disease
4. Too much abuse of pain medications or other drugs
5. Toxic chemicals
6. Autoimmune disorders like systemic lupus erythematosus (SLE), scleroderma
7. Injury
8. Glomerulonephritis
9. Kidney stones and secondary infections
10. Reflux nephropathy
11. Various other kidney diseases

Symptoms include –

1. General ill feeling and fatigue
2. Pruritis (itching) and dry skin
3. Weight loss without effort
4. Headache
5. Loss of appetite
6. Nausea and vomiting
7. Swelling
8. Bone pains
9. Bad breath
10. Abnormally dark skin
11. Changes in nails
12. Bleeding easily – bruises, nosebleed, blood in stool
13. Impotence
14. Restless leg syndrome
15. Sleeplessness
16. Excessive thirst
17. Frequent hiccups
18. Amenorrhea
19. Drowsy and confused state
20. Cannot concentrate or think clearly
21. Numbness in different parts of the body
22. Cramps or twitching of muscles.
23. Abnormal health and lung sounds
24. Diminished or no urine production

ESRD leads to buildup of waste products and fluid in the body, which affects most body systems and functions, including, blood pressure control, red blood cell production, electrolyte balance, vitamin D and calcium levels and thus bone health. Hence the patient on dialysis needs to undergo various tests often to manage the condition -

1. Sodium
2. Potassium
3. Phosphorus
4. Calcium
5. Magnesium
6. Albumin
7. Cholesterol
8. Electrolyte
9. Complete blood count (CBC)
10. Erythropoietin
11. Parathyroid hormone (PTH)
12. Bone density test

Treatment and management -

Management and treatment of ESRD includes kidney transplant or dialysis and dietary management, it is essential for the patient to know and understand everything about the treatment especially about dialysis and its types.

Why dialysis – dialysis helps to remove and maintain waste products, fluid and the electrolyte balance in the body. A special diet is important as dialysis alone does not effectively remove all the waste products. And dietary management also helps minimize the amount of waste build up and to maintain the fluid, electrolyte and mineral balance in the body between the dialysis.

One needs to do lots of changes in their diet –

ESRD patients need high protein, low sodium, potassium and phosphorus diet and a restricted fluid intake. Lets consider each in little details -

Fluid –

Urine out put drops during kidney failure. Most dialysis patients urinate very little or not at all, and therefore fluid restriction between treatments is very important. Without urination, fluid will build up in the body and cause excess fluid in the heart, lungs, and ankles.

Your nutritionist will calculate the daily required amount of fluid on the basis of –
• The amount of urine output in 24 hours
• The amount of weight gain between the dialysis treatment
• Amount of fluid retention
• Levels of dietary sodium
• Whether you are suffering from congestive heart failure.

Tips –
• Avoid or minimize eating food with too much of water like – soups, jell-o, popsicles, ice creams, grapes, melons, palm fruit, coconut water, lettuce, tomatoes and celery.
• Use smaller glasses.
• Take sips of water
• Minimize sodium intake. Avoid salty food
• Freeze juices in an ice tray and suck them to minimize thirst (do count these ice cubes in your daily fluid intake)
• Avoid getting too hot, going out in sun.

Sodium balance –

As said above ESRD patient need to avoid high sodium diet. Hypertension in ESRD is mostly due to positive sodium balance and volume expansion (accumulation of too much of fluid in the body). ESRD patients on dialysis can effectively treat or control hypertension without antihypertensive drugs just by having a low sodium diet (2 g/day). Also low sodium diet will make you feel less thirsty and thus help avoid gulping extra fluids.

Tips –
• Avoid – canned, processed food, processed smoked meat.
• Avoid food with salt topping viz – chips, nuts etc.
• Read labels carefully – select one that reads – low sodium, no salt added, sodium free, unsalted.
• Avoid foods that list salt near the beginning of the ingredient list.
• Choose food which contains salt less than 100 mg per serving.
• Remove salt shaker from the table.
• Cook food without salt instead use herbs for flavoring.
• Avoid preserved foods – ketchups, sauces, pickles, popadums
• Do not use salt substitutes, they contain potassium. And potassium is also restricted in kidney disease.

Potassium balance –

Normally a high potassium diet is recommended to control hypertension and thus minimize the risk of stroke and heart failure, but in case of ESRD, they cannot tolerate high potassium diet as they cannot excrete potassium from their body. High potassium levels in blood will lead to life threatening hyperkalemia induced arrhythmia.

Tips –

• Avoid fruits high in potassium – banana, musk melons, cantaloupes, kiwis, honeydew, prunes, nectarines, coconut water, tomatoes, avocado, oranges and orange juice, raisins and dried fruits.
• Have fruits like – peaches, grapes, pears, cherries, apples, berries, pineapple, plums, tangerines and watermelon.
• Avoid vegetables high in potassium – spinach, pumpkin, winter squash, sweet potato, potatoes, asparagus.
• Choose vegetables like – broccoli, cabbage, carrots, cauliflower, celery, cucumber, eggplant (aubergine/brinjal), green and waxed beans, lettuce, onion, peppers, watercress, zucchini and yellow squash.
• Avoid legumes, milk and bran cereal.
• Limit intake of potassium up to 2 gm per day.

Iron –

Patients with ESRD will also need extra iron.

Tip –
• Consume food high in iron levels – lima and kidney beans, beet root, green leafy vegetables (avoid spinach), finger millet, chicken, liver, pork.
• Eat iron fortified cereals
• Take iron supplements as advised by your physician or dietician.

Calcium and phosphorus –

In ESRD phosphorous levels are high as it cannot be excreted from our body. Even in early stages of renal disease, phosphorus levels can become too high. High phosphorus levels will lead to itching, vascular calcifications, secondary hyperparathyroidism and low calcium levels. Thus the calcium deposited in the bones is used up leading to osteoporosis. Hence a phosphate restricted diet is recommended.

Tips –
• Limit intake of dairy foods – milk, yogurt and cheese.
• Can consume dairy products like – margarine, butter, cream cheese, full fat cream, brie cheese, and sherbet as they are low in phosphorus.
• Consult your dietician and take calcium and vitamin D supplement, helps control calcium phosphate levels.
• Avoid caned processed food.

If phosphorus levels are not managed with diet, your physician may prescribe you phosphorus binders.

Weight Management –

ESRD patient’s loose weight without any reason, thus their weight needs to be monitored and managed with proper balanced diet. ESRD patients average calorie intake reduces to lower than 30-35 kcal/kg/day leading to malnutrition. To prevent malnutrition related morbidity and mortality, ESRD patients on dialysis need to undergo a periodic nutrition screening and tests, comparing initials body weight with usual and ideal body weight, dietary reviews, and food diary assessment.

Protein –

You must be confused when I say ESRD patients need high protein, as most known fact is patients with renal diseases should limit their protein intake. True as when protein breaks down in our body urea is formed this cannot be excreted in urine and is toxic when it builds up in the blood stream. This limited protein diet is until patient is put on dialysis. As protein losses are higher in patients undergoing dialysis, they need to consume a high protein diet. Recommended dietary protein in hemodialysis patients is 1.2 g/kg body weight/day and 1.2-1.3 g/kg body weight /day for patients on peritoneal dialysis. If dietary protein – calorie intake is not adequate, patients should take dietary supplements under the guidance of a nutritionist, and if required they should be tube feed or parenteral nutrition should be provided.

Tips –

• Eat high quality protein – fish, pork, eggs, kidney beans, Bengal gram, and soy for every meal.
• Add egg white or egg white powder or protein powder to your diet.

Carbohydrates -

If you are overweight and have diabetes, then you have to limit your carbohydrate intake, however if you are losing weight you need to take high carbohydrate diet. As carbohydrates are good source of energy. Your physician or dietician will recommended the amount of carbs required in your diet.

Tips –

• Include – fruits, vegetables, breads and grains, as they are high in fiber, minerals, vitamins and a good source of energy.
• If you are advised a high calorie diet, consume – hard candies, sugar, honey, jelly, pies, cakes, cookies.
• Avoid desserts made from dairy, chocolate, nuts and bananas.

Fats –

ESRD patients on dialysis are recommended to limit intake of saturated fats and cholesterol as they are at high risk of developing coronary artery disease. They mostly have high triglyceride levels, high LDL (low density lipoproteins) and low HDL (high density lipoproteins). Though you are recommended to eat a high calorie diet, you need to avoid foods that raise your triglycerides and cholesterol levels

Tips –
• Include foods that are high in monounsaturated and polyunsaturated fats and little of saturated fats. Like – sesame seed oil, flaxseeds, olive oil, and cotton seed oil.
• Avoid canola oil, coconut oil, fats, poultry and chicken with skin.

Micronutrients –

ESRDS patients are recommended to have low fat diet and restricted fluid intake. Thus many patients need to take a vitamin supplement as fat soluble (A, D, E and K) vitamins and water soluble vitamins cannot be absorbed adequately form the diet and water soluble vitamins are also lost during dialysis treatment. Mostly these vitamins are given through vein during the dialysis treatment.

To manage all the above nutrients in the right quantity to suit your needs is not an easy task and it cannot be done own your own. DO NOT SELF DIET it can risk your health. This article is for your information and knowledge. Consult a nutritionist who can design a diet fit for your special needs. Always take your family along to understand your dietary needs so they can help you follow your diet. If you follow proper diet and physical activity as recommended by your physician and your nutritionist will help you feel good and lead a relatively healthy life with the ESRD.

Dr Varsha B Patel
www.homeotouch.com