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<h2><span style="color: #00826a;"><strong>Diet for Chronic Kidney Disease Patients Undergoing Hemodialysis</strong></span></h2>
<p>Hemodialysis does not fully replace 100% of kidney function. Normal kidneys work 168 hours per week. The efficiency of the dialysis machine per minute is equal to or greater than that of normal kidney function. However, when considering the total hours, the dialysis machine only helps remove waste from the blood for 8-10 hours per week, which is equivalent to 6-7% of the normal kidney working hours. The remaining approximately 150 hours are periods when waste still accumulates in the body. After hemodialysis, there are still many wastes remaining in the body, and the levels of essential amino acids necessary for patients undergoing hemodialysis remain low. Additionally, long-term hemodialysis may cause other adverse effects such as protein imbalance. Therefore, patients should not assume that after hemodialysis, they can eat anything freely.</p>
<p>Proper dietary control and intake are very beneficial for chronic kidney disease patients. In patients with mild disease, proper diet according to scientific principles may help slow kidney deterioration. In patients with advanced kidney failure, proper diet helps reduce the production and accumulation of waste in the body, alleviating symptoms such as nausea and vomiting. For chronic kidney disease patients receiving hemodialysis, proper diet helps reduce serum urea-nitrogen levels without causing protein malnutrition and helps lower blood phosphate levels. Special attention should be given to energy, protein, fat, minerals, and vitamins.</p>
<h2><span style="color: #00826a;"><strong>Daily Energy Requirements</strong></span></h2>
<p>For chronic kidney disease patients under 60 years old, energy intake should be 35 kilocalories per day. For patients over 60 years old, energy intake should be 30-35 kilocalories per day.</p>
<h2><span style="color: #00826a;"><strong>Recommended Protein Intake</strong></span></h2>
<p>Chronic kidney disease patients undergoing hemodialysis should consume food with the specified energy value and a protein proportion of 1 gram per body weight. However, they should avoid high-protein foods such as egg yolks, fresh milk, various nuts, and butter because these contain high phosphate and cholesterol levels, which are unsuitable for chronic kidney disease patients.</p>
<p>Patients who can eat normally do not need to take essential amino acid supplements such as Ketosteril or Amiyu because if they consume the recommended amount of protein, they will get enough amino acids. However, if they cannot eat enough protein, taking amino acid supplements can help prevent malnutrition by reducing protein intake by half (about 40 grams of protein per day) combined with essential amino acid supplements of about 7-10 grams per day (as prescribed by a doctor) for the following reasons:</p>
<ol>
<li>The levels of essential amino acids in the blood and cells of chronic kidney disease patients undergoing hemodialysis are lower than normal, impairing the body&#8217;s protein synthesis efficiency.</li>
<li>During hemodialysis, some essential amino acids are lost in the dialysate. If not enough essential amino acids are consumed, patients will develop protein imbalance. Egg whites or fish should be chosen as protein sources because they contain fewer harmful contaminants such as uric acid, phosphate, saturated fatty acids (precursors of cholesterol), and other organic acids compared to other protein sources. Avoid animal offal.</li>
<li>During hemodialysis, contact between the dialyzer membrane and certain blood cells stimulates the release of substances that increase protein breakdown in the body, causing negative protein balance. However, excessive protein intake may cause adverse effects such as:</li>
</ol>
<p>3.1 Increased nitrogen accumulation in the body, especially in the form of urea on non-dialysis days, causing rapid increases in blood urea-nitrogen levels.</p>
<p>3.2 Increased phosphate accumulation in the body, leading to high blood phosphate levels, which raise parathyroid hormone levels, stimulating calcium removal from bones and causing bone disease.</p>
<h2><span style="color: #00826a;"><strong>Recommended Fat Intake</strong></span></h2>
<p>Avoid foods high in animal fat or coconut milk because they contain high saturated fatty acids. Consuming these foods increases blood cholesterol levels, which is harmful to general blood vessels, coronary arteries, and cerebral vessels. Avoid foods such as pork leg, pork belly, roasted duck, fried chicken, Peking duck, curries with coconut milk, lard, egg yolks, fresh milk, and butter.</p>
<h2><span style="color: #00826a;"><strong>Recommended Mineral Intake</strong></span></h2>
<p>Chronic kidney disease patients undergoing hemodialysis should avoid salty foods such as those containing salt, fish sauce, or soy sauce, and pickled salty foods. Consuming salty foods causes sodium and water retention, leading to rapid weight gain, high blood pressure, and edema. Long-term salty food intake may cause heart enlargement, pulmonary edema, or heart failure.</p>
<h2><span style="color: #00826a;"><strong>Recommended Vitamin and Mineral Intake</strong></span></h2>
<p><strong>Iron supplementation</strong> is recommended to help improve anemia.</p>
<p><strong>Vitamin supplements</strong> containing vitamins B1, B2, B6, B12, folic acid, and vitamin C are recommended because these vitamins are beneficial.</p>
<p><strong>Avoid vitamin A supplementation</strong> because vitamin A levels are already high in chronic kidney disease patients.</p>
<p><strong>Vitamin D supplementation</strong> in the form of 1-alpha-hydroxylated vitamin D, such as 1-hydroxy D or 1,25-dihydroxy D3, is recommended to prevent long-term bone disease. However, vitamin D intake must be closely monitored by a physician because excessive intake can be harmful.</p>
<h2><span style="color: #00826a;"><strong>Recommended Fluid Intake</strong></span></h2>
<p>Chronic kidney disease patients undergoing hemodialysis should limit fluid intake to about 500 milliliters or approximately 2 glasses per day. To monitor fluid overload, patients can weigh themselves every morning. Weight gain should not exceed 0.5 kilograms per day. If weight increases by more than 0.5 kilograms per day, it indicates fluid overload, and fluid intake should be restricted or reduced for that day. Excess fluid in the body can cause swelling in various parts, pulmonary edema, heart failure, or high blood pressure.</p>
<h2><strong><span style="color: #00826a;">Suitable Foods for Chronic Kidney Disease Patients Undergoing Hemodialysis</span></strong></h2>
<ol>
<li>Low-protein diet with 40 grams of protein per day combined with supplementation of 9 essential amino acids, or a high-protein diet with 60-75 grams of protein per day.</li>
<li>Use egg whites and fish as protein sources.</li>
<li>Avoid animal offal.</li>
<li>Avoid animal fats and coconut milk.</li>
<li>Avoid salty foods and limit fluid intake.</li>
<li>Avoid fruits except during dialysis periods.</li>
<li>Avoid foods high in phosphate such as seeds, fresh milk, butter, and egg yolks.</li>
<li>Take vitamin B complex, vitamin C, and folic acid supplements. Take 1-alpha hydroxylated vitamin D as prescribed by a doctor. Avoid vitamin A.</li>
</ol>
<h2><span style="color: #00826a;"><strong>Practical Application in Daily Life</strong></span></h2>
<p>First, calculate the total daily caloric intake based on body weight multiplied by 30-35, depending on age. Protein and carbohydrate provide 4 kilocalories per gram, while fat provides 9 kilocalories per gram. Then calculate the average protein intake allowed per day, approximately 1 gram per body weight. Next, divide the intake into meals, usually 3 main meals. Then calculate the food components according to the food exchange table as follows:</p>
<ol>
<li>One portion of meat group equals</li>
</ol>
<ul>
<li>Cooked meat providing about 5 grams of protein, approximately 1 tablespoon or 15 grams.</li>
<li>One medium-sized chicken egg.</li>
<li>Four medium-sized shrimp, 4 medium-sized meatballs, or 2 large meatballs.</li>
</ul>
<ol start="2">
<li>One portion of rice group provides about 3 grams of protein, including</li>
</ol>
<ul>
<li>20 grams of uncooked rice or about 1 ladle of cooked rice weighing approximately 50 grams (about 12 measuring cups).</li>
<li>Cooked noodles or Kiam Yee 12 measuring cups weighing about 50 grams.</li>
<li>One bundle of rice noodles weighing about 90 grams.</li>
<li>Cooked Kuay Jap noodles 12 measuring cups, 15 grams of bread or 3/5 of a standard slice (1 slice weighs 25 grams).</li>
</ul>
<ol start="3">
<li>Almost protein-free starches that can be eaten without calculating protein include:</li>
</ol>
<ul>
<li>Glass noodles (1 pack 40 grams, cooked yields about 112 measuring cups).</li>
<li>Shanghai noodles (2 large round sheets).</li>
<li>Singaporean Lod Chong, Sarim, mixed desserts, sago, tapioca starch (1 tablespoon = 6 grams).</li>
<li>Cornstarch, arrowroot starch can be eaten freely if calories are not restricted.</li>
</ul>
<ol start="4">
<li>One portion of oils and fats equals 1 teaspoon of vegetable oil, including:</li>
</ol>
<ul>
<li>Vegetable oils such as soybean oil, which is 100% fat and contains no protein.</li>
<li>Thick coconut cream (extracted without water) contains 3% protein, so 1 tablespoon contains 0.65 grams of protein.</li>
</ul>
<ol start="5">
<li>One portion of vegetable group equals vegetables providing 0.5 grams of protein, including:</li>
</ol>
<ul>
<li>Boiled Chinese cabbage 250 grams, lotus stem 170 grams, winter melon 100 grams.</li>
<li>Cucumber 80 grams, bitter melon 70 grams, wood ear mushroom 50 grams, pumpkin 35 grams.</li>
<li>Bok choy and Chinese cabbage 30 grams, kale 25 grams, morning glory 20 grams.</li>
<li>Bean sprouts 12.5 grams.</li>
</ul>
<ol start="6">
<li>One portion of fruit group equals fruits providing 0.5 grams of protein, including:</li>
</ol>
<ul>
<li>500 milliliters canned pineapple juice, 120 milliliters orange juice.</li>
<li>120 grams sapodilla and pear, 100 grams papaya, rose apple, watermelon or 10 bite-sized pieces.</li>
<li>80 grams tangerine, apple, ripe mango.</li>
<li>50 grams guava, longan, banana; 35 grams custard apple; 15 grams durian.</li>
</ul>
<ol start="7">
<li>One portion of fruit group equals</li>
</ol>
<ul>
<li>Fruits providing 0.5 grams of protein, including</li>
<li>500 milliliters canned pineapple juice, 120 milliliters orange juice.</li>
<li>120 grams sapodilla and pear, 100 grams papaya, rose apple, watermelon or 10 bite-sized pieces.</li>
<li>80 grams tangerine, apple, ripe mango.</li>
<li>50 grams guava, longan, banana; 35 grams custard apple; 15 grams durian.</li>
</ul>
<ol start="8">
<li>Condiments include:</li>
</ol>
<ul>
<li>Salt and vinegar contain no protein.</li>
<li>One teaspoon of good quality fish sauce contains 0.3 grams of protein.</li>
<li>One teaspoon of soy sauce contains 0.26 grams of protein.</li>
<li>One teaspoon of oyster sauce contains 0.5 grams of protein.</li>
</ul>
<h2><span style="color: #00826a;"><strong>Example of Food Calculation</strong></span></h2>
<p>A 35-year-old patient weighing 55 kilograms is prescribed 35 x 55 = 1,925 kilocalories and about 60 grams of protein per day, consisting of:</p>
<table>
<tbody>
<tr>
<td width="308">1.      Meat 12 portions</td>
<td width="308">(4-4-4)</td>
</tr>
<tr>
<td width="308">2.      White or sticky rice 7 portions</td>
<td width="308">(3-0-4)</td>
</tr>
<tr>
<td width="308">3.      Wheat-based foods 3 portions</td>
<td width="308">(0-3-0)</td>
</tr>
<tr>
<td width="308">4.      Low-protein vegetables 6 portions</td>
<td width="308">(1-3-2)</td>
</tr>
<tr>
<td width="308">5.      Vegetable oil 6.6 portions (6 1/2 teaspoons)</td>
<td width="308">(2-2-2 1/2)</td>
</tr>
<tr>
<td width="308">6.      Sago or bean starch 60 grams (6 tablespoons)</td>
<td width="308">(30-30-0)</td>
</tr>
<tr>
<td width="308">7.      Sugar 72 grams (6 tablespoons)</td>
<td width="308">(3-3-0)</td>
</tr>
</tbody>
</table>
<p>&nbsp;</p>
<p>Divided into 3 main meals with proportions as indicated in parentheses:</p>
<ul>
<li>Breakfast: Pork or shrimp rice porridge (3 ladles cooked rice, 4 tablespoons cooked meat) and sago pudding (sago and 3 tablespoons sugar)</li>
<li>Lunch: Stir-fried macaroni (60 grams macaroni, 4 tablespoons meat, 35 grams spring onion, 55 grams cherry tomatoes, 35 grams onion, 2 tablespoons vegetable oil) and young coconut custard (starch, beans, and 3 tablespoons sugar)</li>
</ul>
<p>Dinner: Steamed rice 4 ladles, omelet (1 egg, 2 1/2 tablespoons vegetable oil), shrimp curry (30 grams shrimp, 20 grams morning glory, 35 grams pumpkin)</p>
<p>&nbsp;</p>
<p style="text-align: right;">Dialysis Center, Phyathai 2 Hospital, 14th Floor, Building A, Tel. 02-617-2444 ext. 1683, 1684</p>
<div dir="ltr"></div>
<div dir="ltr" style="text-align: right;"><strong>References</strong></div>
<div dir="ltr" style="text-align: right;">
<p>Manual for Chronic Kidney Disease Patients</p>
<div>Undergoing Hemodialysis</div>
<div dir="ltr"></div>
<div></div>
<div><strong>Prepared by</strong></div>
</div>
<div dir="ltr" style="text-align: right;">Department of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Nephrology Unit, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society</div>


Hemodialysis with a dialysis machine does not replace 100% of kidney function. Normal kidneys work 168 hours per week. The efficiency of the dialysis machine is calculated per minute, equivalent to

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