Why Not Meals During Dialysis ?

[kristina]

Kam Kalantar-Zadeh, MD, MPH, PhD
October 16, 2009
Commentary

Why Not Meals During Dialysis? Kam 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.
From the September 2009 Issue of Renal And Urology News »

[cassandra]

Thanx for finding the article Kristina, I agree that our friends in The US of A have suffered long enough now, but considering this report is 7 yrs old and I still here the same arguments, I won't hold my breath waiting for change anytime soon. Any idea why?

[Simon Dog]

Why Not Meals During Dialysis?

Because the staff does not like crumbs on the floor???

[Vt Big Rig]

Why Not Meals During Dialysis?

Because the staff does not like crumbs on the floor???

I'll bet that is closest to the truth..

[talker]

Rules and regulations prevail.
Federal, state and local regulations all have a voice in 'the how and what of it'
--------------------------------------------
(299 pages of rules)
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/downloads/esrdpgmguidance.pdf
-------------------------------------------
http://www.infectioncontroltoday.com/articles/2007/04/infection-control-in-the-dialysis-setting.aspx

Deficient practices should be monitored and corrected internally with a strong and diligent QC process.
All should be responsible for monitoring and correcting poor practice (CMS, state surveyors, management, doctors, staff, staff educators, QA/ QC nurses, patients and families). Simple things like enforcing common infection control practices, providing education, and positive reinforcement while improving outcomes keep the momentum rolling and move clinics closer to their goals.

These infection control practices include the following:
•No food/drink in unit
•Limited family visits
•Handwashing and hand sanitizing
•Double bagging hazard trash
•Disinfection of dialysis equipment and blood spills
•Ensuring equipment is in good working condition and placed in correct storage areas
•Monitoring staff and patient serum status
•Clear designation of clean and dirty areas in the clinic
•Staff education about laundering scrubs at home
•Internal audits with corrective action plans
•Close supervision of new and inexperienced staff
•A strong occupational and post exposure service for staff with a comprehensive facility plan
•Proper barrier and staff PPE Special attention to hemodialysis control panels with regard to blood spills (a high touch area)
•Dressings and antiseptics that are catheter compatible and effective.

[PrimeTimer]

Who would pay for the food, catering, assignment of food based on patient desire/need/restrictions and the lawsuits?

[Simon Dog]

Who would pay for the food, catering, assignment of food based on patient desire/need/restrictions and the lawsuits?

Perhaps the real question was "why can't patients bring their own food"?

[MooseMom]

Exactly right, Simon Dog.

When my mother was on dialysis, she'd often bring her own snacks with her.  Whenever I was in town, I'd bring her a Whataburger.  Other patients would regularly have a family member bring them a meal.

My mom had sisters located all over the southern US, and whenever she'd visit them, she'd of course have to have dialysis sessions arranged.  Each clinic seemed to have their own protocols about eating while on dialysis.  I suspect that it all depends upon how convenient or inconvenient it is for the staff; that's when they drag out the old "but you might choke!" argument.

[Simon Dog]

I do most of my transient visits at FMC clinics, however, the RN at a DaVita clinic I used in WA told me they encourage their patients to bring meals.

One issue is that patients with low BP have have it lowered a bit further when blood rushes to the gastric system to process incoming.

[iolaire]

I've not been told to stop eating at the 4-5 DaVita center's I've visited.  No US centers have provided food or drink so I bring it with me.  Every foreign clinic I've visited has provided a snack and coffee or tea - usually with a ton of sugar in the tea...

[PatDowns]

The purpose of dialysis is to cleanse the blood of toxins and excess fluids.  Eating meals while on the machine defeats that purpose.  Small snack, fine.  Best to eat before, including 2 oz. of good protein and then afterwards.   Hypotension is a valid concern.   A large number of patients, diet non-compliant, come in with way too much fluid to remove over a 4 hour session.  What happens?  BP drops because the body can't handle the rapid fluid removal.  A 10 oz. drink is an additional 300 cc. (over a half pound) of fluid to pull off.  Most clinics, even the ones that say no food or drinks, will say OK to small snacks. 

Personally, I haven't eaten while on the machine in the last dozen years.  And before that, on my first tour of duty on dialysis, I would take in a couple of donuts and a cup of coffee at the most.  When in the hospital, I would wait until after treatment to eat.  Even now, doing nocturnal for 6 hours, I'll eat about an hour before going in and then have a bowl of cereal and a light sandwhich when getting home before hitting the sack.  I enjoy eating and psychologically I don't want to associate it with my dialysis treatment.  Gives me something good to look forward to afterwards.

About the article above, the only thing I agree with the author is his point about what patients usually bring to eat - high phosphorus cheeseburgers and super-sized soft drinks.  Well, sodium-laced fast food fried chicken is pretty standard here in the South as well.

[MooseMom]

NoahVale, you are now PatDowns?

[PatDowns]

NoahVale, you are now PatDowns?

Am I the only one who reads Profile Signatures?

[MooseMom]

NoahVale, you are now PatDowns?

Am I the only one who reads Profile Signatures?

Well, I do, so that makes two of us.  I also recognize your photograph.  It's nice.

[PatDowns]

Well, I do, so that makes two of us.  I also recognize your photograph.  It's nice.

Thank you!

[MooseMom]

I had not realized that the original PatDowns had passed.  I am very sorry to hear this.