If you're undergoing dialysis and experiencing weight loss, it's important to understand the potential causes, associated risks, and how to manage your weight effectively. Maintaining a healthy weight is crucial for individuals with kidney disease, as both being underweight and overweight can increase the risk of complications.
Intentional Weight Loss on Dialysis
If you are considering going on a diet to lose weight, you may wonder how that will work with your dialysis diet. As with most diets, losing weight on a dialysis diet can be challenging and take time to show results. However, losing weight on a dialysis diet is possible with a healthy approach that includes proper nutrition, guidance from a renal dietitian, and regular physical activity.
Before starting any weight-loss plan, consult with your dietitian and doctor. Your dietitian can help you create a meal plan that aligns with both your dialysis diet and your weight-loss goals. Your doctor can recommend suitable exercises. Share your goals with them to receive accurate guidance.
Here are some strategies for healthy weight loss:
- Keep a food journal: Record what you eat, your emotions, and hunger levels.
- Don’t skip meals: This can lead to overeating later.
- Minimize distractions while eating: Turn off the television during mealtime.
- Avoid nibbling while preparing meals.
- Eat slowly.
- Refrain from grocery shopping when you’re hungry.
- Make a list before grocery shopping and stick to it.
- Start exercising slowly: Gradually increase to at least 30 minutes a day.
- Choose an enjoyable activity: Such as bicycling, swimming, or walking.
- Use a pedometer to track your steps: Aim for 10,000 steps a day.
- Take the stairs instead of the elevator.
- Park farther away from store entrances: To get in extra steps when running errands.
- Ask about chair exercises: If you are unable to get up.
- Consider household chores and gardening as exercise.
- Track the calories you burn.
- Try different cooking methods: Use nonstick pans or cooking spray, and grill foods.
- Choose lean cuts of meat: Trim the fat before cooking and remove skin from poultry.
- Buy water-packed canned tuna, chicken, or other meats.
- Buy low-sodium foods: Or rinse them under cool water to remove excess sodium.
- Substitute low-fat mayonnaise and salad dressing for the originals.
- Choose low-calorie nondairy creamer.
- Select angel food cake, graham crackers, low-fat cookies, and vanilla wafers: Instead of cakes, pies, donuts, or high-fat cookies.
- Substitute fresh fruit and vegetables for high-fat snacks: Keep within your potassium allowance.
- Increase fiber intake: Aim for 25 grams per day. Ask your dietitian for tips on high-fiber foods.
- Measure or weigh foods: To get an accurate sense of serving sizes.
- Buy single-serve or smaller packages: If you are tempted to eat more than one serving.
- When eating out, share a meal or take half home.
- Use a meal plan: To determine how many servings from each food group to include each day.
- Reward yourself when you achieve reasonable goals.
Weight loss can be difficult, requiring time and dedication. Some people with chronic kidney disease (CKD) on dialysis have anemia, which causes fatigue, shortness of breath, and dizziness. If you have anemia, ask your doctor when your blood count is high enough to exercise safely. Some dialysis patients feel weak after treatment and lack the motivation to exercise. People on peritoneal dialysis (PD) may have trouble losing weight because they absorb glucose (sugar) from the dialysis solution, potentially adding up to 500 calories per day. The best way to avoid weight gain while on peritoneal dialysis is by using dialysis solutions with the least amount of glucose. People on PD usually have the time and ability to exercise, and this should be a part of your daily routine. Some people find it easier to exercise with an empty abdomen rather than one filled with fluid.
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Reducing food intake usually cuts into the amount of protein eaten. If high-quality protein intake is inadequate while dieting, you may lose muscle mass and your albumin level may drop. Your dietitian can offer guidance to help make sure you eat enough low-fat, high-quality protein. Talk with your dietitian about different meal plans that fit your goals and lifestyle. Your dietitian may also introduce you to frozen meals that cut cooking time but are low in phosphorus and potassium. Be sure to cut out unnecessary calories, such as high-fat and high-sugar foods.
The Significance of Dry Weight in Dialysis
Dry weight is your weight without extra fluid. It's important for dialysis patients to monitor this, as extra fluid can strain your heart and lungs.
When you have kidney failure, your body depends on dialysis to get rid of the extra fluid and wastes that build up in your body between treatments. When first starting dialysis, finding your dry weight may take a few treatments. Be sure to tell your dialysis care team if you experience cramping, dizziness, or nausea during or after treatment. These symptoms may happen if too much fluid is removed, or if fluid is removed too fast. If you have too much extra fluid in your body, you may need longer or more frequent hemodialysis treatments. There is a limit to how much fluid can safely be removed during each dialysis treatment.
Your dry weight is measured in kilograms. One kilogram is 2.2 pounds. Most hemodialysis patients are advised to limit their weight gain per treatment to no more than 1 kilogram per day (2.2 pounds) between dialysis sessions. 1 kilogram may not sound like a lot. However, when you think of it as almost 4-7 pounds of fluid that needs to be removed, you can start to see how important it is to limit how much fluid you take in between treatments.
You are likely at your dry weight if:
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- Your blood pressure may be within your normal range after dialysis or before your next session.
- You do not experience lightheadedness or cramping between dialysis sessions.
- You do not have swelling in your legs, feet, arms, hands, or around your eyes.
- Your breathing is comfortable and easy.
To maintain dry weight after dialysis:
- Watch your fluid intake. Your healthcare team can tell you what is right for you. Most hemodialysis patients should not drink more than 32 ounces per day. Ask your healthcare team how much fluid is right for you.
- Follow a kidney-friendly diet. Work with your healthcare team to come up with a meal plan that is right for you.
- Avoid salty foods. Salt makes your body hold on to extra fluid. It will also make you thirstier, which makes it harder to control your fluid intake between treatments.
- Keep track of your daily weight. Keeping track of your weight is important between dialysis sessions. If you see sudden weight gain between sessions, you should tell your healthcare provider immediately.
Unintentional Weight Loss: Causes and Concerns
Unintentional weight loss in dialysis patients is a significant concern that requires careful investigation. It can be an early indicator of malnutrition and often precedes a drop in albumin levels. The body breaks itself down to compensate for the lack of energy due to an insufficient diet, a process known as catabolism.
Malnutrition in ESRD patients is multi-factorial. Many of these patients are uremic, dealing with depression or anxiety from their chronic health conditions, food insecure, lacking social support, living in poverty, and struggling to eat balanced meals within the confines of the diet they are supposed to be adhering to.
The causes of unintended weight loss are diverse in pre-dialysis patients, and at the stage of dialysis requirement, a variety of other causes are added. Both stages share a trend towards loss of appetite and nausea, whereby uremic toxins certainly do not represent the only cause. In addition, both stages involve increased catabolism and therefore a higher calorie requirement. In the dialysis stage, protein loss (more in peritoneal dialysis than in hemodialysis) and the sometimes extensive dietary restrictions (low potassium, low phosphate, fluid restriction) are added.
The causes of weight loss were initially categorized under the terms "protein-energy wasting" (PEW), which emphasized protein loss during dialysis, and the malnutrition-inflammation-atherosclerosis (MIA) syndrome, which highlighted chronic inflammation in dialysis patients. However, many other factors contribute to weight loss, which are better described by the term "chronic disease-related malnutrition" (C-DRM). Weight loss is the most significant factor in recognizing malnutrition, as pre-existing obesity (especially type II diabetes mellitus) often makes recognition more difficult.
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The Impact of Long-Term Weight Changes on Mortality
Long-term body weight (BW) change can be a significant prognostic marker for hemodialysis (HD) patients because it may reflect the chronic influence of protein-energy wasting (PEW).
A longitudinal cohort study and post-hoc analysis evaluated participants of a previous randomized controlled trial conducted between 2006 and 2011 who were followed up until 2018. Weight change slopes were generated with repeated measurements every 6 months during the trial for patients having ≥5 BW measurements. Participants were categorized into four groups based on quartiles of weight change slopes; the median weight changes per 6 months were −1.02 kg, −0.25 kg, +0.26 kg, and +0.86 kg for first, second, third, and fourth quartile, respectively. Cox proportional hazard regression was used to evaluate differences in subsequent survival among the four groups.
The study found that a higher rate of weight loss was associated with higher mortality. Compared to patients with a stable or minimal increase in BW, those with a BW loss of 1.0 kg in 6 months had twice the risk of all-cause mortality.
Managing Unintentional Weight Loss
Here are several strategies to help patients at risk for malnutrition:
- Educate patients on the importance of compliance to treatment to reduce uremia.
- Work with a dietitian to create a personalized meal plan: This plan should address dietary restrictions while ensuring adequate calorie and nutrient intake.
- Address underlying medical conditions: Manage anemia, depression, and other health issues that can contribute to weight loss.
- Consider nutritional supplements: If dietary intake is insufficient, supplements can help meet nutritional needs.
- Monitor weight regularly: Track weight changes to identify and address weight loss early.
The Link Between Kidney Disease and Body Weight
Kidney disease is associated with both obesity and unintentional weight loss. Obesity may increase the risk of developing CKD and its progression to advanced stages. As many as 1 in 3 cases of kidney disease in the United States are associated with obesity.
Additionally, obesity is associated with the development of several risk factors for kidney disease, such as:
- Type 2 diabetes
- Hypertension (high blood pressure)
- Hyperlipidemia (high cholesterol)
- Coronary heart disease
- Sleep disorders
Diabetes and high blood pressure are the main causes of kidney disease. These two conditions are responsible for up to two-thirds of all cases of CKD. Some research shows weight gain may account for up to 75 percent of the risk of high blood pressure. Having a BMI of 30 or higher is associated with diabetes.
In addition to increasing your risk of developing kidney disease, people with higher body weights and CKD may progress to kidney failure more quickly than people who have healthy BMI scores. In those with a rare type of kidney disease called immunoglobulin A nephropathy, complications such as high blood pressure, proteinuria (protein in the urine), and kidney lesions were more common in those with higher body weights.
If You’re Overweight, Intentional Weight Loss May Reduce Your Risk of Serious Health Complications. A 2021 study found that people who lost an average of 13 percent of their body weight had a lower risk of developing type 2 diabetes, sleep apnea (when your breathing starts and stops when you’re sleeping), high blood pressure, high cholesterol, and asthma. In this study, researchers discovered that losing weight reduces the risk of developing CKD.
A 2020 study found that if you attempt to lose just five pounds at several different times throughout your midlife, you may reduce your risk of death. Researchers in this study found this was true for people even if they had a higher body weight or gained weight over time.
While weight loss can reduce the risk of many health problems, it’s uncertain whether losing weight will help improve outcomes or kidney function for people with CKD. A 2021 review combined the results of 17 different studies involving people with CKD who were overweight and trying to lose weight. Researchers found little or no differences in weight loss, proteinuria, or blood pressure between people trying to lose weight and those who weren’t. More studies are needed to find out if weight loss in people with CKD may help them live longer or prevent heart disease.
Dietary Restrictions and Weight Loss Challenges
If you’re living with kidney disease, you may have to follow a special diet to help balance the levels of electrolytes, minerals, and fluid in your body. Your diet may limit some of the lower-calorie food options that will keep you feeling full while trying to lose weight.
Examples of foods that may need to be limited if you have kidney disease include:
- High-sodium foods - Added table salt, packaged foods, and fast food
- Protein - Meat, beans, and nuts
- High-phosphorus foods - Deli meat, dairy products, oatmeal, beans, and soft drinks
- High-potassium foods - Oranges, bananas, potatoes, dairy products, and whole wheat bread
A high-protein diet has been proposed as a way to increase weight loss while still feeling full. However, if you’re following a low-protein diet to treat kidney disease, you may not be able to eat high-protein foods.
If you’re following a low-phosphorus or low-potassium diet, talk to your doctor and dietitian about which kidney-friendly foods you can add to your grocery list. Some examples of low-potassium vegetables include iceberg lettuce, cabbage, cucumbers, onions, and bell peppers. Low-potassium fruits include apples, berries, and pears.
Wasting Syndrome (Cachexia) in Kidney Failure
Some people with kidney failure can also develop wasting syndrome (called cachexia), which can cause the loss of fat and muscle. Wasting syndrome is caused by more than just a loss of appetite. In people with end-stage renal disease (ESRD), wasting syndrome can be caused by inflammation and differences in metabolism. Additionally, some appetite-suppressing hormones may build up in your body if your kidneys can’t effectively filter them out of your blood.