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. A patient who repeatedly finishes below target is losing tissue — report it before fluid replaces lost flesh [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].