What dietary plan should be recommended for an adult patient with end‑stage renal disease on regular dialysis who also has hypertension and possibly diabetes?

Dietary Plan for End-Stage Renal Disease (ESRD) Patients on Dialysis

For adult ESRD patients on maintenance dialysis with hypertension and diabetes, implement a high-protein (1.2–1.3 g/kg/day), sodium-restricted (<2.3 g/day), phosphorus-controlled diet with individualized potassium management based on serum levels, while ensuring adequate caloric intake of 30–35 kcal/kg/day under registered dietitian supervision. 1

Protein Requirements

Target 1.2–1.3 g/kg body weight per day for metabolically stable dialysis patients, as dialysis removes amino acids and increases protein catabolism 1. This is substantially higher than the 0.8 g/kg/day recommended for earlier CKD stages, reflecting the increased protein losses during dialysis 1.

• For acutely ill dialysis patients, protein needs may increase to 1.5 g/kg/day, but this must be balanced against dialysis adequacy 2
• Use actual body weight for calculations; if the patient is fluid-overloaded, use adjusted body weight to avoid overestimating needs 3

Energy (Caloric) Intake

Prescribe 30–35 kcal/kg body weight per day to prevent protein-energy wasting and maintain nitrogen balance 1, 3, 2. Inadequate caloric intake forces the body to use dietary protein for energy rather than tissue maintenance, negating the benefits of adequate protein intake 3.

Sodium Restriction

Limit sodium intake to less than 2.3 g per day (equivalent to <100 mmol/day) to reduce blood pressure, improve volume control, and limit interdialytic weight gain 1, 4.

• Sodium restriction is the most effective way to limit interdialytic weight gain, as sodium intake drives thirst and subsequent fluid consumption 4
• Extracellular volume expansion from positive sodium balance is the most important contributing factor to hypertension in ESRD patients 4
• Focus on avoiding processed foods with sodium additives rather than restricting whole foods 5

Phosphorus Management

Adjust dietary phosphorus intake to maintain serum phosphate levels in the normal range, prioritizing restriction of inorganic phosphorus additives over naturally occurring phosphorus in whole foods 1, 5.

• Consider the bioavailability of phosphorus sources: additives in processed foods have nearly 100% absorption, while plant-based phosphorus has lower bioavailability (20–40%) compared to animal sources (40–60%) 1
• Monitor serum phosphorus regularly and adjust phosphate binders accordingly 1
• Common pitfall: Overly restrictive phosphorus diets can lead to inadequate protein and calorie intake, worsening nutritional status 6

Potassium Management

Adjust dietary potassium intake based on individual serum potassium levels rather than applying blanket restrictions 1, 7. The goal is to maintain serum potassium within the normal range (typically 3.5–5.0 mmol/L) 1.

• For patients with well-controlled potassium levels on adequate dialysis, severe dietary potassium restriction may be unnecessary and can deprive patients of heart-healthy fruits and vegetables 6, 7
• For patients with recurrent hyperkalemia despite adequate dialysis, implement targeted potassium reduction strategies: educate about high-potassium foods per serving, use boiling methods to leach potassium from vegetables, and avoid hidden sources like low-sodium salt substitutes 8
• Consider newer potassium binders (patiromer, sodium zirconium cyclosilicate) to allow less restrictive diets while managing hyperkalemia 7
• Maintain adequate fiber intake even when restricting potassium, as constipation itself worsens hyperkalemia 8

Calcium Intake

For dialysis patients not taking active vitamin D analogs, prescribe total elemental calcium intake of 800–1,000 mg/day (including dietary calcium, supplements, and calcium-based phosphate binders) to maintain neutral calcium balance 1.

• Adjust calcium intake based on concurrent use of vitamin D analogs and calcimimetics to avoid hypercalcemia or calcium overload 1

Dietary Pattern and Food Choices

Emphasize whole foods low in sodium and phosphorus additives rather than imposing overly restrictive limitations on all food groups 5.

• Prioritize: fresh vegetables (prepared with potassium-reduction techniques if needed), whole grains, lean proteins, and limited amounts of dairy 3, 5
• Avoid: processed foods with phosphorus additives (identified as ingredients containing "phos"), high-sodium packaged foods, and excessive potassium-rich foods only if serum levels are elevated 5, 8
• Critical consideration: Traditional renal diets that severely restrict fruits, vegetables, nuts, legumes, dairy, and whole grains can result in patient frustration, poor adherence, and potentially worse nutritional outcomes 5, 6

Implementation and Monitoring

Refer all ESRD patients to a registered dietitian nutritionist (RDN) for comprehensive nutrition assessment within the first 90 days of starting dialysis, then at least annually or when indicated 1.

• Conduct routine nutrition screening at least biannually to identify those at risk of protein-energy wasting 1
• Monitor nutritional status every 1–3 months including: appetite assessment, dietary intake evaluation, body weight changes, serum albumin, and anthropometric measurements 1, 3
• Assess body composition using multi-frequency bioelectrical impedance (MF-BIA) at least 30 minutes after hemodialysis to allow fluid redistribution 1

Oral Nutritional Supplements (ONS)

For dialysis patients with poor oral intake despite dietary counseling, prescribe oral nutritional supplements as the preferred route 2.

• Give ONS 2–3 hours after usual meals to avoid replacing normal food intake 2
• Renal-specific formulas (higher calorie density, higher protein, reduced electrolytes) should be preferred for patients with electrolyte imbalances, fluid overload, or high protein needs 2
• Standard ONS can be used in patients with well-controlled electrolytes and no fluid restrictions 2
• Intradialytic delivery of ONS improves compliance 2

Special Considerations for Diabetes

For diabetic ESRD patients on dialysis, the same protein target of 1.2–1.3 g/kg/day applies 1. Carbohydrate restriction may not be beneficial in patients with "burnt-out" diabetes (long-standing diabetes with reduced insulin production), and adequate carbohydrate intake may be necessary to meet caloric goals 6.

Critical Pitfalls to Avoid

• Do not implement protein restriction in dialysis patients—they require higher protein intake (1.2–1.3 g/kg/day), not restriction 1
• Do not apply uniform, overly restrictive diets to all dialysis patients without considering individual metabolic control and dialysis adequacy 6
• Do not restrict dietary fat—it provides essential calories and should not be limited in dialysis patients who often struggle to meet energy needs 6
• Do not prohibit eating during hemodialysis treatment—this outdated practice may worsen hypoglycemia and nutritional status 6
• Do not focus solely on dietary restrictions without ensuring adequate protein and calorie intake, as malnutrition is a stronger predictor of mortality than mild electrolyte abnormalities 6