N13 — Nutrition at the Chair

When: every weigh-in, snacks and meal trays, diet questions, and the monthly lab review.

Do this

1. Weigh accurately before and after every treatment. Repeatedly finishing below target may reflect tissue loss, fluid change, or a measurement/target issue. Report the trend and assess appetite, function, and volume; it is not proof of tissue loss [11].
2. Ask weekly: appetite? eating on dialysis days? nausea, trouble chewing or swallowing, mouth pain? groceries? Document it for the dietitian [9].
3. Eating on treatment — stable patients only: a small, protein-focused snack early in the run (timing per your unit protocol), upright and fully awake, away from lines and access [5].
4. Patients whose BP drops on treatment: eat before arrival or after treatment — not on the machine [4]. See N5: Intradialytic Hypotension: Chair-Side Response.
5. Reinforce the dietitian’s plan: protein at every meal; less salt to control thirst; avoid foods with “PHOS” in the ingredient list; don’t cut out fruits and vegetables without the dietitian [9].
6. Fish oil (product per your unit protocol): confirm it is on the medication list and ask how many capsules a day. Dose by the EPA + DHA on the label — about 2.4 g/day is the PISCES dose [6].

Call the nephrologist (and tell the dietitian) when

• Unintentional weight loss of 5% over 3 months or 10% over 6 months, or the post-weight keeps landing below target [11].
• Albumin falls below 3.5 g/dL or drops noticeably from the patient’s usual — think infection or inflammation first, intake second [3].
• Eating poorly for more than 2 weeks, trouble swallowing, or mouth pain; or signs of infection (fever, exit-site redness, old-graft tenderness, foot wounds).
• nPCR below 0.8 g/kg/day, or phosphorus, potassium, or BUN suddenly “better” — the patient may have stopped eating [10].
• Symptomatic low BP after eating on the machine [4].
• On fish oil: black stools, needle-site bleeding that won’t stop, new palpitations or an irregular pulse, or a newly found fish or shellfish allergy [12].

Don’t

• Don’t treat a low albumin as only a diet problem [3].
• Don’t feed a patient who is dropping BP, drowsy, or struggling to swallow [4,5].
• Don’t tell patients to eat less protein to control phosphorus — binders and additive avoidance do that, and low protein intake is associated with death on dialysis [9,10].
• Don’t remove fruits and vegetables from the diet without the dietitian.
• Don’t count “fish oil 1,000 mg” as the dose; count EPA plus DHA [6].
• Don’t expect fish oil to raise albumin; it is for cardiovascular protection [7,8].