Dialysis Diet Differences: Hemodialysis and Peritoneal Dialysis 

By DaVita® Dietitian Christine Swafford, MS, RD, CSR, LD 

Whether you’re on hemodialysis (in-center traditional, in-center nocturnal or home) or peritoneal dialysis, your kidney-friendly eating plan is tailored to your needs. Your current body weight, age and other underlying conditions and lab results also play a role in what type of dialysis diet is prescribed for you.

Similarities and differences

Although many components of a dialysis diet (also called a kidney diet) are the same for people on hemodialysis and peritoneal dialysis (PD), there are also differences. To some extent, your diet guidelines are determined by the kind of dialysis you choose.

Calories

Hemodialysis and PD each require adequate calories for your body to function and not become malnourished. People who are able to maintain a healthy body weight enjoy better quality of life and survival rates than those who are underweight.

But there is a difference between these treatment types: some of the calories for PD patients come from the dialysate solution, the cleansing fluid placed in the abdomen that pulls waste out of the blood. It contains dextrose, a form of sugar, providing calories and decreasing the need for as many calories from food. That’s why PD patients may eat fewer carbohydrates than hemodialysis patients do, yet have the same overall calorie intake.

People with diabetes should be especially mindful of the added sugars and consider this for their overall treatment plan. Use of higher concentrations of dextrose — 2.5% (yellow bags), or especially 4.25% (red bags) — will result in larger amounts of carbohydrate absorption and may make blood sugar levels harder to control. Your healthcare team can help you manage this issue more effectively.

Protein

Protein needs are higher in people undergoing dialysis. This may be for several reasons.

• Hemodialysis patients can lose 10-12 grams of amino acids, the building blocks of protein, per treatment.
• PD patients may lose 5-15 grams of protein per treatment.
• Infection, inflammation, sores, anemia, some thyroid issues, metabolic acidosis (common with diabetes) and other medical conditions call for a higher protein intake.
• People who perform daily treatment are able to consume more protein in their diet.

Protein lost during dialysis can be replaced by eating high-quality meat, poultry, fish and eggs. You may require three or more servings each day to meet your protein needs, depending on your kidney diet prescription. In some cases a protein supplement may be included to help meet the increased protein requirements.

Sodium

Hemodialysis and PD patients should limit their sodium intake to 2,000 mg or less daily. The normal healthy American's diet probably already has more than 2,000 mg, so you should avoid adding salt to food. Because you’re unable to get rid of sodium on your own, large amounts can lead to increased thirst, swelling, shortness of breath, high blood pressure and heart failure. High amounts of sodium are found in pre-packaged, processed, frozen, canned, restaurant and fast foods. A dietitian can help you identify hidden sources of sodium, and determine lower-sodium substitutions.

Potassium

High potassium levels are more common in people on hemodialysis. For people in this category, the recommendation is usually 2,000 mg each day. Some people may safely consume more depending on whether they still make urine, how frequently they dialyze and other individual needs.

Potassium removal is more efficient on PD because the treatment occurs daily, so PD patients can eat more potassium-rich foods than hemodialysis patients can. A typical daily goal for PD patients is 3,000-4,000 mg of potassium. Some PD patients may need to add extra high-potassium foods or potassium supplements if their levels are too low.

People on short daily HHD may have less restriction on potassium because they dialyze almost every day, or five to six times per week.

Phosphorus

Excess phosphorus is excreted by heathly kidneys. Phosphorus is found in dark colas, milk, cheese, processed meats, fish, poultry, chocolate, whole grains and nuts. When the kidneys fail, phosphorus builds up in the blood, which can cause severe bone and heart problems, tissue calcification and itching. That’s why the recommended amount is 800-1,000 mg per day.

Most dialysis patients take phosphate binders with their meals. These medications bind up the phosphorus so it can be excreted in the stool instead of being absorbed.

Calcium

No matter which dialysis treatment you’re on, intake of calcium should be no more than 2,000 mg daily, including the calcium from your prescribed calcium-based phosphate binders and other medications. If your calcium or vitamin D level is low, calcium is pulled out of the bones causing them to become weak and brittle. Calcium can also bind with excess phosphorus, depositing in the soft tissue, such as your heart, arteries, skin or lungs. This leads to serious health issues. Do not take calcium supplements without first speaking with your healthcare team.

Fluid balance

Hemodialysis patients may feel the negative effects of fluid imbalance more than PD patients or those on short daily HHD. While this does not mean PD and HHD patients can drink unlimited amounts, their fluid allowance is usually more generous than for those on in-center hemodialysis. However, if PD patients consume too much fluid, they may have to use more concentrated glucose in the dialysis solution to remove it.

High fluid intake can cause swelling, increased blood pressure and shortness of breath. If you try to remove too much during dialysis, your blood pressure may drop and cause you to feel nauseous, dizzy and weak. Muscle cramps are common in people who take in too much fluid, because the body often doesn’t tolerate large fluid removals during a three-to-four hour dialysis treatment. Too much fluid may require longer dialysis treatment times and sometimes more frequent dialysis.

People on dialysis who don’t make urine are recommended to consume less than 4 cups (32 ounces) of fluid each day. This includes fluid-based food, such as soup, ice pops, gelatin, gravy and ice. If you still urinate, the general rule is you may consume 4 cups plus the equivalent amount of urine you make daily. For example, if you urinate 1 1/2 cups, then you may consume 5 1/2 cups of fluid daily. But each patient must speak with a physician or dietitian for specific information.

Fiber 

Whether you’re on hemodialysis or PD, it’s recommended that you consume 20-25 grams of fiber per day. By consuming a diet rich in kidney-friendly fruits and vegetables along with some lower-phosphorus grain products, you should be able to meet your fiber needs.

Foods containing fiber can help protect your heart, blood vessels and colon. When you have chronic kidney disease (CKD), you are susceptible to heart disease, which is the leading cause of death in dialysis patients. High-fiber diets help lower cholesterol levels, which can reduce your risk for a heart attack or other cardiovascular events.

Many patients on dialysis, especially those on PD, complain of gastrointestinal (GI) symptoms, such as constipation or diarrhea. These may be a side effect of various medications. Fiber can help to reduce symptoms. It also can help with weight control and regulate blood sugar levels. Your dietitian can help you find ways to gradually include fiber into your diet.

Summary 

There are some differences between the hemodialysis and PD diets. But once you determine the modality that’s right for your lifestyle, you will be educated on how to adjust your diet to meet your individual needs. Your healthcare team will help you along the way.