Should Patients Eat During Hemodialysis Treatments?
Helene Christner
Monica Riley
Should
patients on hemodialysis be allowed or encouraged to eat during a
dialysis treatment? As with any debate, there are always at least two
opposing views and this argument is one that continues to have
clinicians on the “pro” and also on the “con” sides.
One point made by the pro-side is that many of our patients have
diabetes. Consistency with diet, exercise, and insulin regime is
important to maintaining control of blood glucose levels. Regularly
missing or skipping meals is not encouraged for anyone trying to
maintain a healthy lifestyle and, in particular, it is not a good
practice for the population with diabetes. Skipping meals can disrupt
the balance of insulin control and can lead to life-threatening
hypoglycemic complications.
In general, those supporting eating during hemodialysis advocate for
allowing patients to consume small meals or snacks during their
treatments in order to improve their overall nutritional status.
Improving or at least maintaining the nutritional status of patients on
hemodialysis is just one of the many challenges faced by health care
teams; and, by improving the nutritional status of our patients, we
will undoubtedly increase the odds for positive outcomes.
Because treatments last 3 to 4 hours, patients on hemodialysis are
often receiving a treatment through a meal period on treatment days.
Treatments are routinely scheduled for 3 days per week, potentially
resulting in 156 lost meals per year. This would mean that patients on
hemodialysis are missing or are prevented from eating one meal on more
than 40% of the days in a given year on dialysis. If patients are not
allowed to eat during dialysis, they are at jeopardy for missing meals;
this equates to a lost opportunity to improve their nutritional
outcomes. Even the Centers for Disease Control (CDC) suggests it is
appropriate for patients to eat food brought from home to be consumed
while the patients are undergoing dialysis treatment (CDC, 2001).
Those advocating for meals during dialysis see this meal and treatment
time as a good opportunity to supplement and improve the patients’
dietary intake by allowing patients to eat during their treatments.
Both sides seem to agree that treatment time is a fortuitous time to
discuss and review dietary intake, lab results, and general teaching.
Because of the potential distractions, however, those arguing against
eating during treatment do not see this time as appropriate for
consuming any foods. There is evidence that food intake should be
limited an hour or more before all hemodialysis treatments to avoid
medical problems during dialysis.
If a patient’s blood glucose drops during hemodialysis, those against
eating during dialysis can argue that glucose testing is easily
attainable while the patient is on dialysis. The dialysate electrolyte
concentration is a dextrose based solution of 200 mg/dl, but despite
this, some patients will experience hypoglycemia. If blood sugars do
decline, juice is available in most units and may be effective in
reversing the low blood sugar levels. Since treatments are routinely
scheduled, patients can be encouraged to adjust meal times around
dialysis treatments. In units that do not allow eating during
treatment, patients usually bring in juice, a high protein/caloric
nutrition drink (or other supplements), and snack meals for after
treatment.
Nurses who do not support eating during dialysis have some very
persuasive arguments for their position. One point often made concerns
the issue of postprandial hypotension. When food is consumed, blood is
shunted to the gastrointestinal track to aid digestion. Blood flow in
the splanchnic and hepatic circulation is elevated. This shunting of
blood reduces systemic circulating blood volume that may result in a
decrease in systemic blood pressure (Kinnel, 2005). Patients who eat
during dialysis have often reported experiencing nausea and vomiting,
or some may have episodes of diarrhea. These types of complaints may
lead patients to request to discontinue their treatments prematurely.
When treatment duration is shortened, adequate solute clearances,
dialysis adequacy, and outcomes are affected.
A serious blood pressure drop can occur when the shunting of blood to
aid digestion is coupled with the treatment’s fluid removal goal. In
response to hypovolemia, the body may respond with an increased heart
rate and vasoconstriction to improve venous return. Cramping may occur,
and, if vomiting occurs, it may increase the risk of aspiration. Drops
in systemic blood pressure may jeopardize the efficacy and/or duration
of the dialysis treatment as well as adequate organ and tissue
perfusion.
A point that may be made by individuals on the con-side is that eating
during dialysis may lead to less-than- desired Kt/V results. They
hypothesize that, when blood is shunted to the digestive organs and
away from the systemic large vessels, clearances are affected. This
implies that the circulating blood in the digestive organs reduces the
amount of available blood to be circulated through the dialyzer, and
therefore diminishes clearances.
Yet another point for not allowing food consumption during hemodiaysis
focuses on the question of liability. Nonsupporters contend that when
patients are allowed to consume food during their dialysis treatments,
there is the possibility for litigation to occur. This now becomes a
question of safety. Hypotension is the number one complication that
occurs with hemodialysis, and allowing situations that may induce or
exacerbate a known risk factor creates a potential for liability. This
particular issue has been raised in website chat rooms, such as
AllNurses.com (2003) and AllExperts.com (2005). The suggestion is that
physicians and nurses may be liable if they permit patients to actively
engage in a behavior that we know has the potential of causing harm.
Bringing food into the unit may require preparation, for example,
heated by microwave or arranged for the patient’s convenience. This
assistance takes time away from the dialysis staff during an already
busy schedule to stop and “play waiter or waitress.” Nurses employed in
units that do not permit food to be eaten during the dialysis treatment
time have pointed out the burden of potential trash that staff has to
clean up related to drink spills, food wrappers, and emesis.
Conclusion
The
question of whether patients should eat during or just before a
hemodialysis treatment is one with many facets and warrants more
research. Patients who miss meals regularly may jeopardize their
nutritional health status. Allowing eating during hemodialysis may pose
immediate safety and infection control concerns as well as long-term
treatment outcomes. The legal implications indicate that facilities
need to establish policies for their patients concerning food intake
during hemodialysis. Research studies have not directly answered the
questions related to patients eating during hemodialysis except the
risk of hypotension and related physiological responses. Until that
occurs, facilities will need to develop policies, inform patients of
the risks and rationales, and ensure that those policies are being
followed.
References
AllExperts.com.
(2005). Eating on dialysis. Retrieved February 1, 2008, from
http://en.allexperts.com/q/Nephrology-975/Eating-dialysis.htm
AllNurses.com. (2003). Eating on dialysis. Retrieved February 1, 2008,
from
http://allnurses.com/forums/f48/eating-dialysis-33787.html#post411278
Centers for Disease Control and Prevention (CDC). (2001).
Recommendations for preventing transmission of infections amongst
chronic hemodialysis patients. Morbidity and Mortality Weekly Report,
50(RR-5), 1-43. Retrieved February 1, 2008, from
http://www.cdc.gov/MMWR/ PDF/rr/rr5005.pdf
Kinnel, K. (2005). Should patients eat during hemodialysis treatments? Nephrology Nursing Journal, 32(5), 513-515, 568.
The Controversies in Nephrology Nursing
department focuses on exploring ethical and clinical issues within the
nephrology clinic practice in a point/counterpoint format. Address
correspondence to: Christy Price Rabetoy, Department Editor, through
the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ
08071-0056; (856) 256-2320; or by emailing her at
christycpr@comcast.net. You may also log onto this column at
www.nephrologynursingjournal.net (clink on Department link) and email
your comments to the Editor (see Discussion Area). The opinions and
assertions contained herein are the private views of the contributors
and do not necessarily reflect the views of the American Nephrology
Nurses' Association.
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