Is eating allowed during hemodialysis (hemodialysis) treatment?

Eating During Hemodialysis: Clinical Recommendation

Yes, eating during hemodialysis is allowed and should be encouraged for most patients, particularly those at risk for malnutrition or protein-energy wasting. The restriction of eating during hemodialysis is an outdated practice that may worsen hypoglycemia and nutritional status without proven benefits. 1

Evidence-Based Rationale

Nutritional Imperative for Dialysis Patients

• Hemodialysis patients require 35 kcal/kg body weight/day for those under 60 years and 30-35 kcal/kg/day for those 60 years and older to maintain adequate nutritional status. 2
• Protein requirements are elevated at 1.2-1.3 g/kg body weight/day for metabolically stable dialysis patients to prevent muscle wasting. 3, 4
• Malnutrition prevalence ranges from 28-54% in chronic hemodialysis patients, making aggressive nutritional support critical. 2

Shift in Clinical Practice

Recent data demonstrates a significant evolution in practice patterns:

• In 2011, 28.6% of U.S. hemodialysis clinics prohibited eating during treatment, but this decreased to 22.6% by 2014, reflecting growing recognition that nutritional status takes priority. 5
• The primary reason clinics shifted to allowing eating was increased focus on nutritional status. 5
• International practices are more permissive, with U.S. restriction rates more than double those found in other countries. 5

Addressing Common Concerns

Hypotension Risk:

• While food intake during hemodialysis can cause a drop in systolic and diastolic blood pressure, the timing of meals (1 hour vs. 2 hours into treatment) does not significantly affect blood pressure changes. 6
• The blood pressure drop continues for 1-1.5 hours after eating, suggesting meals should be timed early in the hemodialysis session for better management. 6
• Food intake does not significantly increase nausea or vomiting during hemodialysis. 6

Autonomic Dysfunction Considerations:

• Patients with autonomic dysfunction (indicated by low very low frequency heart rate variability) may have difficulty tolerating fasting during hemodialysis. 7
• This suggests that eating during dialysis may actually be more important for certain vulnerable patients rather than contraindicated. 7

Practical Implementation Algorithm

Step 1: Default Position

• Allow and encourage eating during hemodialysis for all patients unless specific contraindications exist. 1, 5

Step 2: Optimize Timing

• Provide meals early in the hemodialysis session (within the first 1-2 hours) to allow blood pressure stabilization before treatment completion. 6
• Consider intradialytic oral nutritional supplements (ONS) as these are associated with better compliance. 3

Step 3: Monitor High-Risk Patients

• Patients with frequent intradialytic hypotension should be monitored more closely when eating, but this should not automatically preclude food intake. 2
• For patients with severe autonomic dysfunction (low VLF on heart rate variability testing), eating during dialysis may be particularly beneficial to prevent hypoglycemia. 7

Step 4: Nutritional Supplementation Strategy

• Provide small, frequent meals rather than large boluses to minimize hemodynamic effects. 3
• Use hemodialysis-specific formulas for tube feeding if needed, while standard ONS can be used for oral supplementation. 3
• Deliver ONS 2-3 hours after usual meals when given outside of dialysis to avoid nutritional substitution. 3

Critical Pitfalls to Avoid

• Do not impose blanket restrictions on eating during hemodialysis based on outdated concerns about hypotension or aspiration risk without individual assessment. 1
• Do not prioritize fluid restriction over adequate caloric intake, as this may lead to lower protein and calorie consumption when patients actually need higher intake. 1
• Do not use isolated hypotensive episodes as justification to restrict eating; instead, optimize ultrafiltration rates, dialysate sodium concentration, and treatment duration. 2
• Avoid excessive dietary restrictions that may worsen quality of life and nutritional status without proven survival benefits. 1

Special Populations

Malnourished Patients:

• These patients should receive intensive dietary counseling and be strongly encouraged to eat during dialysis. 2
• If oral intake remains inadequate despite counseling, consider oral supplements, tube feedings, or adding amino acids to dialysate. 2

Diabetic Patients:

• Restricting eating during hemodialysis may worsen hemodialysis-induced hypoglycemia, particularly problematic in diabetic patients. 1