# N13 — Nutrition at the Chair

N13 — Nutrition at the Chair FRONT Front · 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 \[[11](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-11)\].
2.  **Ask weekly:** appetite? eating on dialysis days? nausea, trouble chewing or swallowing, mouth pain? groceries? Document it for the dietitian \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-9)\].
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 \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-5)\].
4.  **Patients whose BP drops on treatment:** eat before arrival or after treatment — **not on the machine** \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-4)\]. See [N5: Intradialytic Hypotension: Chair-Side Response](https://urinenephrology.org/mastery/maintenance-hd/nursing/N5-Intradialytic-Hypotension-Response.html).
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 \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-9)\].
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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-6)\].

### 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 \[[11](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-11)\].
- Albumin falls below 3.5 g/dL or drops noticeably from the patient’s usual — **think infection or inflammation first, intake second** \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-3)\].
- 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 \[[10](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-10)\].
- Symptomatic low BP after eating on the machine \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-4)\].
- **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 \[[12](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-12)\].

### Don’t

- Don’t treat a low albumin as only a diet problem \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-3)\].
- Don’t feed a patient who is dropping BP, drowsy, or struggling to swallow \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-4),[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-5)\].
- 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 \[[9](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-9),[10](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-10)\].
- 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 \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-6)\].
- Don’t expect fish oil to raise albumin; it is for cardiovascular protection \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-7),[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-8)\].

N13 — Nutrition at the Chair BACK Back · why, and the evidence

### Why

1.  Protein-energy wasting affects 28% to 54% of dialysis patients across studies \[[1](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-1)\], and malnutrition raises the risk of death about 1.5-fold on hemodialysis \[[2](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-2)\].
2.  Albumin tracks inflammation: blocking IL-6 raised albumin 0.21–0.28 g/dL in 12 weeks with no change in food \[[3](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-3)\].
3.  Eating on the machine is a trade: it caused 13 versus 2 symptomatic low-BP episodes in a small study \[[4](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-4)\], yet experts support it for patients without contraindications \[[5](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-5)\].
4.  In PISCES, fish oil cut serious cardiovascular events from 33.7% to 20.8% of patients over about 2 years, with less serious bleeding (4.8% vs 7.6%); survival did not change \[[6](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-6)\].
5.  Fish oil does not meaningfully raise albumin: 14 pooled trials showed no change (0.00 g/dL) \[[7](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-7)\], and the only trial sized for albumin found +0.1 versus 0.0 g/dL (P = 0.295) \[[8](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html#n13-ref-8)\].

### Go deeper

- Mastery page: [Nutrition and Protein-Energy Wasting on Hemodialysis](https://urinenephrology.org/mastery/maintenance-hd/nutrition-protein-energy-wasting-hd.html)
- Mastery page: [Inflammation and Fish Oil (PISCES) in Hemodialysis](https://urinenephrology.org/mastery/maintenance-hd/inflammation-fish-oil-hd.html)
- [All dialysis nursing reference cards](https://urinenephrology.org/mastery/maintenance-hd/nursing/index.html)

### References

1.  Carrero JJ, et al. Global prevalence of protein-energy wasting in kidney disease: a meta-analysis (ISRNM). *J Ren Nutr.* 2018;28:380-392. [PubMed 30348259](https://pubmed.ncbi.nlm.nih.gov/30348259/)
2.  Rashid I, et al. Malnutrition as a potential predictor of mortality in CKD patients on dialysis: a systematic review and meta-analysis. *Clin Nutr.* 2024;43:1760-1769. [PubMed 38852509](https://pubmed.ncbi.nlm.nih.gov/38852509/)
3.  Chertow GM, et al. IL-6 inhibition with clazakizumab in patients receiving maintenance dialysis: a randomized phase 2b trial. *Nat Med.* 2024;30:2328-2336. [PubMed 38796655](https://pubmed.ncbi.nlm.nih.gov/38796655/)
4.  Sherman RA, et al. Postprandial blood pressure changes during hemodialysis. *Am J Kidney Dis.* 1988;12:37-39. [PubMed 3389352](https://pubmed.ncbi.nlm.nih.gov/3389352/)
5.  Kistler BM, et al. Eating during hemodialysis treatment: a consensus statement from the ISRNM. *J Ren Nutr.* 2018;28:4-12. [PubMed 29249295](https://pubmed.ncbi.nlm.nih.gov/29249295/)
6.  Lok CE, et al. Fish-oil supplementation and cardiovascular events in patients receiving hemodialysis (PISCES). *N Engl J Med.* 2026;394:128-137. [PubMed 41201837](https://pubmed.ncbi.nlm.nih.gov/41201837/)
7.  Liu R, et al. Effects of omega-3 fatty acid intake in patients undergoing dialysis: a systematic review and meta-analysis of RCTs. *J Am Nutr Assoc.* 2022;41:697-712. [PubMed 34635026](https://pubmed.ncbi.nlm.nih.gov/34635026/)
8.  Daud ZA, et al. Effects of protein and omega-3 supplementation, provided during regular dialysis sessions, on nutritional and inflammatory indices in hemodialysis patients. *Vasc Health Risk Manag.* 2012;8:187-195. [PubMed 22536073](https://pubmed.ncbi.nlm.nih.gov/22536073/)
9.  Ikizler TA, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. *Am J Kidney Dis.* 2020;76(3 Suppl 1):S1-S107. [PubMed 32829751](https://pubmed.ncbi.nlm.nih.gov/32829751/)
10. Shinaberger CS, et al. Longitudinal associations between dietary protein intake and survival in hemodialysis patients. *Am J Kidney Dis.* 2006;48:37-49. [PubMed 16797385](https://pubmed.ncbi.nlm.nih.gov/16797385/)
11. Fouque D, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. *Kidney Int.* 2008;73:391-398. [PubMed 18094682](https://pubmed.ncbi.nlm.nih.gov/18094682/)
12. Gencer B, et al. Effect of long-term marine omega-3 fatty acids supplementation on the risk of atrial fibrillation in randomized cardiovascular outcome trials. *Circulation.* 2021;144:1981-1990. [PubMed 34612056](https://pubmed.ncbi.nlm.nih.gov/34612056/)

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.


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[Website version](https://urinenephrology.org/mastery/maintenance-hd/nursing/N13-Nutrition-at-the-Chair.html) · Markdown synchronized October 3, 2026.