Why Not Meals During Dialysis?
Kamyar Kalantar-Zadeh, MD, MPH, PhD
Overnutrition is a major problem in the general population and a serious risk for metabolic syndrome, cardiovascular disease, and death.
In dialysis patients, however, protein-energy malnutrition and wasting are by far the stronger risk factors for death. Two-thirds of dialysis patients have a serum albumin below 4.0 g/dL, a surrogate of malnutrition and poor outcomes.
Even though correcting malnutrition is difficult, keeping them hungry during hemodialysis (HD) treatment days does not help. Inadequate food intake, especially during HD treatment days, is a common practice among American dialysis patients, whereas in many other countries meals are routinely served during dialysis treatment.
When nephrologists or dialysis centers are asked why meal trays for patients do not exist during dialysis treatments, the nearly universal answers are postprandial hypotension, risk of choking or aspiration, infection control and hygiene issues, fear of fecal-oral transmission of such diseases as hepatitis A, staff burden and distraction, and diabetes and phosphorus control.
Meals are routinely given to dialysis outpatients in most European countries. German dialysis patients eat invariably during their dialysis treatments and have higher serum albumin and greater survival than their American counterparts. In the past, meals during dialysis were routine in the United States as well. Some VA hospitals still provide meal trays during all three dialysis shifts. Most dialysis clinics allow a dietary supplement.
I would argue that in addition to improving nutritional status, providing in-center meals would improve patient compliance and satisfaction, as many patients will be more motivated to attend treatments when they know a meal awaits them. Although eating during dialysis rarely leads to hypotension in Europe, I would even argue that it can be considered as an effective strategy against intradialytic hypertension.
Many patients already bring in their own food, including high phosphorus cheeseburgers and super-sized soft drinks. We can offer them more appropriate food with higher protein content and lower phosphorus-to-protein ratio and potassium content along with phosphorus binders and vitamins with the meals. As we move towards longer dialysis sessions and a bundling system, we need to rethink meals on dialysis, which would probably require only a small fraction of the funds currently used for the expensive medications we give to our dialysis patients.
Dr. Kalantar Zadeh is the Renal & Urology News Medical Director for Nephrology.