Dialysis from the sharp end of the needle

Beware hidden salt

By Anna Bennett

We hear it again and again - too much salt is bad for you. DSEN has a category of posts on CKD & Salt and Nancy Spaeth recently wrote a detailed comment about salt and the importance of sodium control.  That is the salt that we can see, the salt that we have control over - not putting the salt shaker on the table, cooking without salt.  BUT in today's over processed/fast food environment you may be ingesting salt without even realizing just how much. Moderating sodium in your diet means limiting yourself to about 1500 mg of salt per day.

photo by Craig Jackson

Salt has many names: Some of the sodium ingredients used in food processing include: salt, sodium, monosodium glutamate (MSG), baking powder, baking soda, disodium phosphate, sodium benzoate, sodium hydroxide, sodium nitrite, sodium propionate and sodium sulfite. All of these affect your body's fluid volume, your thirst level and your body's ability to be efficiently dialyzed - you won't be able to pull off enough fluid during a conventional incenter run if you have too much salt on board - too much sodium would make it mathematically impossible for a 3.5 hour 3x a week dialysis schedule to balance the fluid between your blood, your cells and your interstitium.  Your body would have to have fluid removed from its blood compartment faster than it could transfer fluid in from the interstitium. This fluid deficit in the blood compartment is what causes cramping and you won't even finish dialysis at your dry weight. Hours later your cells and interstitium would release their fluid surplus into your blood stream leaving you chronically fluid overloaded. It's a vicious cycle that can start to wind down once salt is brought under control. For more on the body's three fluid spaces see Bill's post Dr. Agar on fluid and solute removal.

Salt is a preservative, and in general the convenient, shelf stable food that you buy pre-made or pre-mixed from the grocery store has too much salt in it.  And I'm not even writing about processed meat - pretty much anything packed in plastic from your deli aisle - turkey slices, Bologna, hot dogs - these meats are treated with sodium and other preservatives to last longer on the shelf. When you are making yourself that Oscar Meyer shaved turkey sandwich (2oz = 460 mg salt) on Wonder Bread (2slices = 260mg), you are adding significantly to your salt consumption.  It may be a quick meal now, but it is shaving time off your life span - you're "saving time", so that you can die earlier. That doesn't make much sense.

Here is how salt can sneak up on you (from Hidden Sodium in food)

• Twizzlers Black Licorice Twists - four strands have 200 milligrams; four strands of Twizzlers Strawberry Licorice have 115 mg.
• Raisin-bran cereals - Kellogg’s has 350 mg per cup; Post, 300 mg; Total, 230 mg.
• Jell-O Instant Pudding & Pie Filling Mix - the chocolate flavor contains 420 mg per serving; lemon, 310 mg; chocolate fudge, 380 mg.
• Prego Heart Smart Traditional Italian Sauce - this has an American Heart Association logo on the label which means saturated fat and cholesterol are restricted, but not that it’s low in sodium. This sauce has 430 mg per half-cup.
• Aunt Jemima Original Pancake and Waffle Mix - prepared as directed, the pancakes have about 200 mg of sodium each.

More Salt Resources:

Top Ten ways to limit your salt intake

World Salt Awareness Week

Hidden Sodium in Supermarket Meats

DaVita sodium and chronic kidney disease

If you're on dialysis, moderate your salt intake. It makes dialysis less of a burden and health impact aside, eating fresh, home made food tastes much better.

World Salt Awareness Week is February 2nd - 8th

By Bill Peckham

World Action on Salt and Health (WASH) is holding its 2nd annual World Salt Awareness Week on February 2nd. This year the focus is salt eaten outside the home. That's a helpful focus - there is no reason people can't salt food to taste rather than having it over salted back in the kitchen. There are a lot of people who have not yet gotten the message, WASH has a lot of education work still to do.

No, really. People with CKD (actually everyone) should not eat a lot of salt

By Bill Peckham

RenalWEB links to an interesting announcement from the American Society of Nutrition Salt reduction may offer cardioprotective effects beyond blood pressure reduction. There is a lot of research that tells us controlling salt is an important part of living with CKD. This research from the American Society of Nutrition that "salt reduction may offer cardioprotective effects beyond blood pressure reduction" is not specific for people with CKD it is a recommendation for everyone.

For people with CKD controlling salt is even more important. This year World Kidney Day on March 12th is being held in collaboration with World Hypertension Day on May 12. The reason for this collaboration is that the vast majority of people with early stages of CKD will die prematurely before they progress to needing renal replacement. This is due in large part to poor cardiovascular health. Everyone with CKD, without exception, needs to protect their cardiovascular health. Controlling salt intake is an important tactic in this fight. The sponsors of World Hypertension day, the World Hypertension League (I hope they all wear jump suits with rank designation patches) have compiled a lot of research into how everyone, including everyone with CKD, can protect their cardiovascular health.

The paper relevant to salt A Dash of Salt and Tone: Recent trials providing new insights into the diet-blood pressure healthlink, makes it clear that control of salt intake is an important part of a healthy diet and  "individuals typically considered to be at the highest risk for hypertension and cardiovascular events, the elderly and African-Americans, had the greatest reduction in blood pressure with these dietary alterations." Simple "dietary interventions consisting of reduced salt intake and increased use of fresh fruits, vegetables and low-fat dairy products" go a long way to a healthy heart. It's a great idea for a partnership and the people running the World Kidney Day effort should be applauded for this year's focus on cardiovascular health.

So it was with great dismay that while wandering cyberspace I came across this recipe in the Kidney Support Network's Xmas 2008 newsletter (pdf link). Per serving: Sodium (mg) 1530; Potassium (mg) 945; Phosphorus (mg) 370. 1530mg of Sodium per serving! I think the World Hypertension League would judge Devilled Sausages & Creamy Garlic Mash unfit for human consumption (to the Pressuremobile team!).

That's just ridiculous. I wrote to the Kidney Support Network:

I was looking through your newsletter - I would like to know more about your organization. For instance some details about the hemodialysis van that is available, I think that would be a great thing to make available here in the NW United States.

But I was SHOCKED and ALARMED by the recipe included in your December newsletter: Xmas Edition 2008 1530 mg of salt per a serving!?! That would be dangerous for people without kidney problems; for people with kidney problems it is without any doubt contraindicated. Salt causes thirst.

Eating one serving of Deviled Sausages & Creamy Garlic Mash would create a thirst that could only be satiated by drinking far too much fluid. People on dialysis must not eat this dish.

Hypertension is a leading cause of stage 5 chronic kidney disease. A diet high in salt can exacerbate hypertension. One serving of Deviled Sausages & Creamy Garlic Mash would very nearly use up a person's day allotment of sodium.

See the abstract Low sodium diet for dialysis patients: myth or reality?, talk to your own Dr. Agar to the south or believe the Rigby, Scribner, Ahmad's paper from 2001  Interdialytic fluid weight gain is mainly caused by sodium intake which makes the rather obvious point again that sodium intake drives thirst

For the sake of your community's health you must redact the recipe from the newsletter at once. And I would suggest rather than getting your recipes from Nestle Australia you should instead ask for permission to take recipes from "Cooking Without a Grain of Salt" available on Amazon.com

Reading it now, after sleeping on it, I would have written it differently but the reply I received makes it clear that it wasn't a mistake. That they do, in fact, think of Devilled Sausages & Creamy Garlic Mash as food for humans:

I hear and understand your concerns about the salt content in the recipe, however it  wasn’t just from Nestle for the general public as I think you have assumed, it was from a site specifically for kidney patients and was checked by dietitians who are our contacts here locally (here in Australia) prior to publishing it. From memory the recipe came from an American site DaVita, as we had to seek their permission to publish, but I will look into it further.

One of the unfortunate issues with diets for kidney patients is that they are all different – and there are very few recipes suitable for everyone. Some people have the fluid restrictions you speak of and others do not, some have to watch protein intake and I have heard of others who are put on high protein diets. It is extremely difficult for generalizations and what we encourage is everyone to do is to educate themselves on what they are able to consume based on their illness and treatment and monitor their health appropriately.

Okay it is true that some small number of people who are on dialysis and still have urine output do not have to strictly control their fluid, most are those who's CKD is due to PKD. I had some fluid output for the first four years of dialysis but that is a poor reason to hang your argument on because the relative numbers are small. The recipe is not healthy and it is particularly unhealthy for people with no renal function who the organization is dedicated to serve. Come on. 945mg of Potassium!

I never got past the sodium to notice the potassium until writing this post. This recipe is dangerous. If someone has this on the first night of their dialysis weekend and then has leftovers they could easily end up in the hospital or in the ground. Go ahead and keep in mind the varied needs of people with CKD but that should not conflict with offering only healthy menu ideas.

And no, the recipe did not come from DaVita, I will eat this blog if a DaVita dietitian signed off on this salt and fat concoction. It is beyond all belief that DaVita would shill for Maggi's little balls of death or whatever it is the recipe calls for. Google says the only other place the recipe shows up is on Nestle New Zealand. World Kidney Day is coming, let's all try to eat a healthier diet, a diet without a lot of salt. It's a simple way for everyone to live healthier and for people with CKD it is doubly important.

PKD Foundation Webinars: 1/6/09 8PM EST CKD Nutrition

Learn how to eat healthy with PKD in the second in a series of free webinars!

When: Tuesday, January 6 at 8pm ET (7pm/CT, 1am/GMT)
Where: From your home or office computer
How: Register Now!

Renal Dietitian, PKD patient, wife and mother, Kelly Welsh, will help walk you through what foods are good and those to avoid for someone with compromised kidney function. Following the presentation, there will be an opportunity for diet related questions and answers.

Did you miss the first webinar on the “Basics of PKD”?  Click here  to watch Dr. Ronald Perrone, Professor of Medicine, Tufts University School of Medicine and Chair of the PKD Foundation’s Scientific Advisory Committee present this educational, easy-to-understand webinar. 

Dialysis/Kidney friendly menu planning

By Anna Bennett

When I was incenter on dialysis 3x a week - healthy menu planning was an issue.  When I went home on NxStage, I was much less restricted, and the planning became easier.

I started on a renal diet when I was in CKD3 I had many years to adapt to low protein and no salt (see Bill's post on top 10 ways to limit salt intake).   The transition to a dialysis diet was still a big adjustment - I ended up having to supplement my protein (once you start dialysis, the battle is to keep your protein up which is the exact opposite of the pre-dialysis renal diet).  And I counted the days until I could start high dose home hemo.

I have always maintained that the easiest way to transition into a renal diet is to modify what you are already enjoying,  I wrote a post about reworking your recipes to have less protein (while in CKD3 - CKD4).

I also collect cookbooks, and obsessively look on line for recipes.  It is possible to be a "foodie" and be on dialysis.  It just takes some work.  One website that I relied on was food.com.  I would type in some renal friendly ingredients, hit search and it would search its database for possibilities, I would then have to modify recipes to be dialysis friendly when necessary, but all in all it made me feel like I wasn't being forced into a fixed diet and ultimately, it was my choice.

A quick search of Amazon.com showed some CKD5 cook book possibilities as well:

Cooking for David: A Culinary Dialysis Cookbook

The Cleveland Clinic Foundation Creative Cooking for Renal Diets

The Cleveland Clinic Foundation Creative Cooking for Renal Diabetic Diets 

Dialysis Diet, Revised Edition

Since diet affects people with kidney disease in such a major way, I am surprised that there aren't an overwhelming amount of resources.  Bill has some good on line resources (from CKD Links to knowlege and resources)

• Dialysis and CKD Recipes and Nutrition Information
  • USDA Nutrient Data Laboratory
  • Recipes from the Northwest Kidney Centers
  • Culinary Kidney Cooks
    • Recipe of the Week
  • IHD Diet and Recipes Discussion Board
  • Recipes from Davita

And then there is always DaVita's Diet Helper.  If you want dialysis friendly menu planning with little effort, and very little input on your part, this is the service for you. 

After you go through a quick, free online registration, the helper will provide you with a dialysis friendly menu for every day of the year.

(click to enlarge) Here is a sample day's menu.  When you have registered with the website, you simply click on the item, and the recipe and food values pop up for that individual recipe.

Watch the cravings to stay in control of your health

Maria Karalis, the Renal Support Network's go to renal dietitian has an new article up on Kidney Times Why We Crave Comfort Foods? She offers sound advice on how to accommodate food cravings.

To Leach or not to Leach

by Peter Laird, MD

This is Peter from the Idaho potato factory.

A recent article in the journal of Food Science shows that the commonly advised method of leaching potatoes is ineffective in removing potassium to safe levels for CKD-5 patients.  The authors did note a significant reduction of potassium levels in potatoes by 50-75% when boiling small slices before eating, whereas the practice of leaching did not remove any significant amount of potassium. 

Bill, I am sure would correctly point out that the usual dietary restrictions on potassium and phosphorus are not needed in the majority of patients on nocturnal, home hemodialysis done on a daily basis.  So, if you wish to eat potatoes, boil them or go to nightly nocturnal hemodialysis. However, you should no longer depend on leaching as a method of removing what can be deadly levels of potassium.

Renal friendly fast food - does it exist?

Maria Karalis, RD, CSR, LD takes us to eat in the fast food world. Putting aside the salad bar there isn't much good to be said about the options at the main burger chains - get  a plain burger at McDonald's? I understand that Maria is trying to find some middle ground and to be realistic because clearly a lot of people eat at these places - including a lot of people on dialysis - but this is not renal healthy food.

It is hard to see how fast food can go with conventional dialysis. Daily nocturnal dialysis makes the phosphorus and potassium less of an issue but the fat and salt is still a problem. The goal should always be to dialyze more and to take more time to eat. Just slow down. You can eat better and enjoy the food more.

Eating during dialysis: Good or bad?

RenalWEB links to a Controversies in Nephrology Nursing article on ANNA: Should Patients Eat During Hemodialysis Treatments? by Helene Christner and Monica Riley. They list the pro and con arguments. I've heard it all before - this has to be the subject of 100s of discussion board and listserv threads.

Sure. Sure. I support the conclusion of the article - we need more research into the actual dialysis treatment but I think we can sort this one out without a double blind study. I think those who put forward the con argument are talking about blanket policies. One size fits all rules that accommodate the lowest common denominator amongst a unit's dialyzors. I think a willingness to adopt blanket policies does not speak well of the unit.

Obviously some dialyzors have no problem eating during treatment. However, I've been to dialysis units across the globe, I know sandwiches are often served. Most dialyzors - if well dialyzed, do not have a problem eating . I know most other countries in the world - the sandwich serving countries - have much better dialysis outcomes. I know that a blanket no food policy is not justified in most cases (if a unit is running all of their patients for less than four hours, a no food policy may be neccessry but it will be the least of their patients problems).

As far as the threat of novel lawsuits? In my experience the threat of a novel lawsuit is the last refuge for a weak argument.

Recipe for those on dialysis, and those diabetic and on dialysis

Tomorrow is the Sunday winter farmer's market near my house; I'll be able to buy all these ingredients for Green Tomatoes with Goat Cheese using this recipe from the Northwest Kidney Centers. Green Tomatoes with Goat Cheese fits well in the diet of people with dialysis and those who also have diabetes. I should be able to whip this up pretty quick - we'll see, last week's Burritos Rapidos took about twice as long as the advertised 15 minutes but I have to admit that I'm just not well organized.

Ingredient green tomatoes	Amount 4 medium
balsamic vinegar	1 tablespoon
oregano leaves, minced	2 teaspoons
goat cheese, crumbled	1 cup
olive oil	4 teaspoons
ground pepper	to taste
toasted French bread	8 slices

Preparation

Cut tomatoes in to ½ inch thick slices. Coat a shallow baking dish with oil. Place tomato slices, in a single, overlapping layer, in the bottom of the dish. Sprinkle tomatoes with vinegar and scatter minced oregano over tomatoes. Top with crumbled goat cheese and drizzle with olive oil. Broil 5-8 inches below a preheated broiler and broil until tomatoes are hot and cheese is just starting to brown, about 7-8 minutes. Place on toasted bread, season with pepper and serve immediately.

Nutritional Content:

Calories 173 Carbohydrates 9 g Protein 7 g Sodium 135 mg Potassium 280 mg Phosphorus 161 mg

Serves Four, Nutritional Content is per Serving.

With nightly extended dialysis I can go back for seconds.

Recipe to accommodate dialysis and/or diabetes

This recipe for an Burritos Rapidos is from the Northwest Kidney Centers. Burritos Rapidos fits well in the diet of people with dialysis and those who also have diabetes. As the name implies you can prepare these in 5 minutes, cook them in 10. In 15 minutes you have a delicious meal.

Ingredient	Quantity
Canola or olive oil	1/2 tablespoon
Red bell pepper, diced	1/2 of pepper
Green onions (scallions), sliced thin	4
Eggs, beaten	4
Corn tortillas	4 (6-inch)

Cook Time
10 minutes. Try adding shredded cheese, salsa, cilantro, sauteed mushrooms, and other items for a different flavor.

Preparation

1. Heat oil in a medium frying pan on medium heat.  Add bell pepper and green onion and cook for 5 minutes.
2. Add eggs and scramble about 5 minutes or until done.
3. Place tortillas between two damp paper towels, then place on a plate.  Microwave on medium heat for 3 minutes.
4. Spoon egg mixture into warm tortillas.  Roll up the tortillas and enjoy.

Nutritional Content:

Calories	140
Carbohydrates	14 g
Protein	7 g
Fat	6 g
Sodium	50 mg
Potassium	182 mg
Phosphorus	163 mg

Nutritional Content is per burrito.

Top ten ways to limit salt intake

Apropos of Home Dialysis Central's featured paper on the impact of sodium intake - here are the Top Ten Tips for Shaking the Salt Habit (pdf link) from the Northwest Kidney Centers:

1. Avoid meats that are labeled, “Enhanced.” They are injected with salt water and have up to 10 times the salt of regular chicken, turkey, pork and other meats.
2. Talk with your butcher. Ask them to point out to you meats that are “fresh” and don’t have salt water added. You’ll save money too, since you won’t be paying a premium price for salt water!
3. Avoid meals that just need a microwave to heat them up.
4. Make your own fast frozen meals. Whip up two casseroles; portion one into individual containers and freeze. Then, when you need a quick meal, your microwave can be your best friend!
5. Avoid foods that are labeled, “Instant” or ‘Quick.” Often these foods have salt added to speed up the cooking.
6. Take just a few minutes more and make real oatmeal, or put rice in a rice cooker while you make the rest of the dinner.
7. Avoid lunchmeats and processed meats and cheeses.
8. Use peanut butter, cream cheese with jam, egg salad, rinsed tuna, or sliced leftover meat from last nights dinner.
9. Avoid foods that have 400mg of sodium or more per serving. Try and keep your daily intake to about 2,000mg of sodium.
10. Buy fresh foods and cook them yourself. Try our fast stir-fry recipe (Salt-Free Stir-Fry) in the recipe section. It took just 12 minutes to cook in our test kitchen, and while it was cooking, the rice in a bag finished up.

More on salt's impact on stage 5 CKD

Nephron.com links to an abstract Low sodium diet for dialysis patients: myth or reality? by Chazot, Collonge and Charra. This September 2007 paper again links sodium control to lower fluid gains between dialysis treatments. The authors are from Tassin France, well know for their commitment to extended dialysis. It was here during a 1996 trip that I was provided the best meal to date while dialyzing. Four courses - with wine or beer available. It is my understanding that funding of the kitchen has since been cut back which in turn has impacted dialyzor's willingness to extend their treatments.

Ice chewing goes main stream

When I first started dialysis in the early '90 the Northwest Kidney Centers had ice machines that were older but they made the best chewing ice. They had built in water purifiers and would constitute the ice with just the right amount of air. I craved ice. Eventually the machines wore out and were replaced with machines that made somewhat inferior chewing ice and the habit was broken.

I thought of my ice chewing days when I read Chew This Over: Munchable Ice sells Like Hot Cakes. I thought craving and chewing on ice was just a dialysis-thing I didn't realize I was on the front end of a trend. There is even a website  Icechewing.com. The Wall Street Journal online even produced a video version of the story (I've eaten a lot of Taco Time ice in my day - in Seattle Dick's Drive Ins are another source of great ice)

Renal-ly responsible snacks for the Super Bowl

Davita has some timely guidance in preparation for this weekend's gridiron battle for the Vince Lombardi Trophy. Dialysis diet snacks for Super Bowl® XLII gives some suggestions from the DaVita.com Recipe section: Spicy Crunch and Munch Mix, Raw Veggies and Dip, Festive Pineapple Cheese Ball and Cranberry Dip with Fresh Fruit.

Sounds good or...  you could dialyze daily, overnight 35 to 50 hours a week and then enjoy nachos and a couple beers.