For patients whose dialysis or treatment schedule is not affected, the RNG recommend:
- that they continue to be managed according to appropriate local, national and international nutritional guidelines
- face to face contact should be avoided where possible
- remote review of patients should be considered, unless this may compromise patient care
NICE guidance (2020) states that dialysis units should develop individualised plans for patients so that their dialysis schedule can be reduced safely if that becomes necessary, to enable the on-going operational delivery of dialysis in the unit or at home if there are constraints because of widespread COVID‑19.
Less frequent dialysis will lead to reduced removal of potassium and fluid on a weekly basis, with longer gaps for the build-up of these between dialysis sessions. For patients whose dialysis schedule is reduced, the following guidance should be considered, to minimise risk of potential complications associated with hyperkalaemia and fluid overload.
We acknowledge that this anxious and challenging time for patients is likely to lead many to feelings of being overwhelmed. Furthermore, practical issues with food supply may arise. Patients who are classified as clinically extremely vulnerable are able to access the government’s support offer, ensuring they have access to food, medicines and basic supplies.
Renal dietitians should be careful to assess the patient’s ability to receive dietary advice and focus strongly on prioritisation of crucial dietary guidance, whilst using a pragmatic approach.
All nutritional guidance should be supported with appropriate written or pictorial information in accordance with local policy or guidelines. The Renal Nutrition Group has examples of patient information which can be utilised as required.
The RNG recommends:
- Pre-dialysis serum potassium levels should be managed according to local policy, but in the absence of this suggest that levels should ideally be ≤5.5mmol/l, and no higher than 6.0mmol/l
- The frequency of monitoring for pre-dialysis serum potassium levels should be increased according to local policy
- Non-dietary causes of high serum potassium should be considered and treatment provided according to local policy
- Dietary advice should be provided to those patients with pre-dialysis serum potassium levels ≥5.5mmol/l, aiming to reduce dietary potassium intake to 50-70mmol per day, or no more than 1mmol/kgIBW/day where possible
- Local policies should address the prescription of potassium binders to allow the frequency of dialysis to be reduced, and the potential for their use should be explored on an individual patient basis
- Consider reducing potassium contribution from protein foods by advising patients to reduce their dietary protein intake as detailed below
The RNG recommends:
- Local policies should address the use of fluid restriction to allow the frequency of dialysis to be reduced.
- Inter-dialytic fluid weight gain (IDWG) should be <2.5kg or <5% of dry weight, in accordance with local policy
- Dietary advice should be provided on reducing fluid intake to no more than 500-750ml/d in anuric patients, or 500mls plus daily urine output, in accordance with local policy.
- Individual patient education should include discussing the potential consequences of non-compliance with a fluid restriction.
- Dietary advice should be provided on the importance of reducing dietary salt intake to no more than 5g per day.
- Close communication with the medical and nursing team regarding fluid management targets and fluid allowances
The RNG suggests:
- Consider advising patients to reduce dietary protein intake to 0.8-1g/kg/d, particularly in patients who are complaining of uraemic symptoms. The potential benefits and risks of protein restriction should be considered on an individual basis, dependent on current nutritional status and risk of protein energy wasting.
- Close monitoring of nutritional status, and adjustment of recommendations for dietary protein intake as necessary