Renal - What can I eat on Peritoneal Dialysis?

An introduction to your diet

Peritoneal dialysis

Healthy kidneys control the amount of water and other substances in the body. These substances come from what you eat and drink. What isn’t used is removed from the body by healthy kidneys as urine.

When your kidneys stop working, waste products and fluid build- up in your blood, which can make you feel unwell.

Peritoneal dialysis (PD) is a treatment to filter blood and remove fluid and waste products using your own body’s peritoneal membrane.

Why is diet important?

Eating well helps you to keep healthy and feel well. You should try to eat regular meals and include a variety of foods.

Following a special diet, in combination with dialysis, will help your body control levels of waste products and harmful substances.

Diet and fluid restrictions are individual and depend on:

• Your current dialysis prescription
• Other medical conditions you may have
• Your eating pattern
• Your blood results (e.g. urea, potassium and phosphate)

Your dietitian will see you individually to advise you on the diet you need to follow. However, as a general rule your diet on PD should be:

1. High in protein
2. Balanced in energy
3. Low in salt
4. Fluid balanced
5. Balanced in potassium
6. Low in phosphate
7. High in fibre

Star fruit has been found to contain toxins that are harmful to renal patients – it should be completely avoided.

1.    Protein

Protein is needed for growth and repair of all body tissues. During dialysis you lose some protein, so it is important to make sure you are eating enough.

Eating 2 good sources of protein every day can prevent muscle wasting and help maintain your strength.

If you have been restricting protein in your diet before starting PD, it is a good idea to relax this now.

Good sources of protein include:

Meat - Beef, pork, lamb, chicken and turkey.

Vegetarian and/or vegan meat alternatives - Tofu, tempeh, seitan, Quorn®, textured vegetable protein.

Fish - Cod, haddock, tuna, plaice, salmon.

Pulses - Beans (including baked beans), peas, lentils, dhal, chickpeas.

Eggs - Please note that eggs are high in phosphate, so try not to eat more than 4 per week.

Cheese - Soft cheese and cottage cheese. Keep cheddar and other hard cheeses to 3-4 oz (100g) per week.
Try to include 2 servings of these high protein foods daily. e.g beans on toast for lunch and fish pie for tea.

2.    Energy (calories)

It is important that your diet provides you with enough energy to fuel your brain and allow you to do all the things you wish to in the day.

Good sources of energy include starchy foods (also known as complex carbohydrates) i.e. bread, pasta, chapatti, rice, noodles, potatoes, oats and breakfast cereals.

Choosing high fibre versions of these foods helps:

• Bowel function
• Feed good bacteria in the gut
• Keep blood sugars stable if you are diabetic

So try granary bread, brown rice, wholemeal pasta, high fibre breakfast cereal, chapatti made with wholemeal flour.

If you are eating well, you may find that your weight increases whilst on PD. This is because some of the glucose (sugar) in the dialysis fluid is absorbed by your body, whilst the fluid is in your abdomen, providing extra calories. In the long term this can lead to an increase in body weight.

Talk to your dietitian for more advice on this. This sugary fluid can also affect your blood sugars if you are diabetic.

If you had a poor appetite before starting dialysis you may and this improves once you start PD. Dialysis helps to remove the toxins in your blood that build up in people with reduced kidney function.

Remember to contact your dietitian if you have a poor appetite, as there are several ways in which we can help.

3.    Salt (sodium chloride)

Although sodium is essential for various body functions, too much can be harmful. If your kidneys aren’t working properly your body cannot balance sodium and water very well.

Eating too much sodium can lead to:

• High blood pressure
• Thirst
• Puffy hands face and feet (oedema)
• Fluid in the lungs making it hard to breathe
• Extra work for your heart
• Needing to use higher strength PD solution to remove excess fluid

Foods to limit 

• Avoid adding salt at the table - if you are not used to this, it can take some time of your taste buds to adjust, but they will
• Smoked meat/fish products i.e. bacon, ham, smoked salmon
• Tinned fish in brine
• Ready meals and takeaways with high salt or MDSG content
• Packet soups and sauces, instant noodles

Foods to choose 

• Use herbs, spices, lemon juice, pepper and marinades to help flavour foods
• Fresh meat and vegetables
• Tinned fish in oil or spring water
• Choose lower salt ready meals - i.e less than 1.5g salt per 100g or less than 0.6g sodium per 100g
• Homemade soup, supermarket fresh soup (found in fridge section), tinned soup an soup in a tetra pack
• Avoid salt substitutes like 'lo salt', 'so low' and other salt alternatives (they are high in potassium)

4.    Fluid balance

Why do I need to monitor what I drink?

When you first start dialysis, you may still be passing water (urine), but it is quite common for urine output to decrease. When this happens, you will need to reduce the amount of fluid that you drink to stop fluid building up around your heart and lungs.

Some signs and symptoms of fluid overload:

• Sudden weight gain
• Swollen ankles, legs, tummy and/or face
• Shortness of breath
• Increased blood pressure

Too little fluid can cause:

• Sudden weight loss
• Low blood pressure
• Feeling dizzy or weak
• Feeling faint when standing
• Leg cramps

The amount you can drink will depend on the amount of urine you make and the amount of fluid you take off on dialysis - called ultrafiltration, or U.

A more detailed leaflet called ‘Controlling your fluid intake’ offers practical tips in ways to manage your fluid restriction. Please ask your dietitian for a copy.

5.    Potassium

Potassium is a mineral that is found in most foods.

Your body needs potassium for muscle contractions and nerve signals and for your heart to work properly. Healthy kidneys remove excess potassium from the body. As kidneys fail some people need to restrict potassium in their diet.

Peritoneal dialysis is quite effective at removing potassium and many people on PD can relax their potassium restrictions.

Some people have to make an effort to eat high potassium foods every day to ensure their levels do not get too low.

If you have been advised to follow a low potassium diet prior to starting PD, please continue to follow this until advised otherwise by your doctor or dietitian.

Your potassium levels will be monitored and over time it will become clearer if you need more or less potassium in your diet now that you are on PD.

More information on potassium can be found in separate leaflets which your dietitian will be able to give you if needed.

6.    Phosphorus (phosphate)

Phosphorus is a mineral which is an important component of bones. Kidneys remove excess phosphate from the body. Dialysis isn’t as good as the kidneys at this, so phosphate levels in your blood can go up when you are on dialysis.

High phosphate levels can lead to:

• Itchy skin
• Red eyes
• And in the long term: Calcification of blood vessels

The target range for phosphate in your blood is:     

Some tips to keep blood Phosphate levels in range:

• Avoid highly processed foods where possible
• Avoid cola and other dark coloured fizzy drinks
• As a general rule phosphates from plant foods are less easily absorbed than those from animal sources. So, try swapping meat for vegetable protein foods (see protein section) at some meals

Try to keep to the following allowances:

• Up to ½ pint milk daily (or you could try a plant milk)
• 100g/4oz hard cheese per week
• 3-4 milky puddings per week (e.g. rice pudding, ice cream, yoghurt, custard)
• 4 eggs per week

Phosphate binders

You may be prescribed a phosphate binder to help control your blood phosphate level. These tablets work in your stomach to bind the phosphate in your food, stopping it from being absorbed into your blood. They therefore need to be taken at mealtimes. Some examples are calcium acetate, sevelamer, lanthanum.

7.    Fibre

Constipation is a common problem for people on PD and can lead to poor drainage of dialysis fluid from your abdomen.

In order to prevent constipation your doctor may prescribe regular laxatives. Eating a diet that is high in fibre can also help.

Fruit and vegetables

Fruit and vegetables are great sources of fibre. Try to make sure you are eating your 4 a day if you are on a potassium restriction (5 a day if not).

Whole grain products

Choose the wholemeal/granary version of foods like bread, pasta, rice.

Pulses

Vegetable protein foods like beans and lentils are much higher in fibre than meat, fish and eggs. Try adding some to your meals
e.g. soups, salads, or making lower meat versions of foods like cottage pie and pasta Bolognese using lentils in the sauce/filling.

Highly processed foods

You may have heard in the media about the potential effects of highly processed foods on your health. This is because some of the additives to foods such as processed meats, ready meals*, pies, pasties and some vegetarian meat substitutes, have been linked to poor health.

As renal dietitians, we believe that these foods can still form part of a nutritious diet and can be extremely useful at times when you are struggling to eat, have a poor appetite, find it difficult to prepare meals or have limited cooking facilities.

However, when you are eating well with a good appetite it is worth remembering that these foods can be high in phosphate.

A separate leaflet ‘phosphate additives’ has more information on this - ask your dietitian for a copy.

*Ready meals are also high in salt, and are often low in vitamins, minerals and fibre. If you do consume ready meals for convenience, try to include some fresh/frozen vegetables with these meals e.g. a small salad or boiled vegetables.

Suggested meal plan

This is an idea of some foods that you can eat when you are on PD.

Milk Allowance

½ pint a day in drinks, on cereal etc

Breakfast

• Fresh fruit juice (1 small glass) or tinned fruit/fresh fruit
• Cereal e.g. cornflakes/rice krispies/Weetabix/homemade porridge with milk from allowance
• Wholemeal toast with butter or spread and jam or marmalade, or a boiled egg
• Tea, coffee or water

Light meal (lunch/tea)

This could be a sandwich or something on toast (e.g. beans) or soup

• Bread/roll/crackers/with butter or spread
• Meat or fish or eggs or cheese
• Plus salad
• Fresh or tinned fruit or yoghurt (from allowance)
• Drink of your choice

Main meal (dinner) e.g. roast dinner/pasta dish/casserole/shepherd’s pie/curry

• Potatoes/rice/pasta/chapatti/noodles/bread
• Include meat or fish or vegetable protein
• And salad or vegetables

Pudding

• Chocolate éclair/Madeira cake/jam tart/sponge with custard from allowance or double cream/milky pudding from allowance

Supper

• Toast/crackers/biscuits and a small drink

Remember to take your phosphate binders at mealtimes, as prescribed.

If you require more meal and snack ideas, ask your dietitian.

If you have diabetes, please talk to your dietitian about how to incorporate this advice into your diet for diabetes

As dietitians we are thinking mainly about the nutritional value of foods when writing a diet sheet such as this one. However, there are many other reasons to eat, and a big one is enjoyment and pleasure. Talk to your dietitian about how you can include your favourite foods in your PD diet.

Contact details

Tel: 0161 206 1994 or email renaldietitians@nca.nhs.uk

Useful websites

Greater Manchester Kidney Information Network – www.gmkin.org

Kidney Care – www.kidneycareuk.org