PATIENT EDUCATION
Feature Editor: Stacey Phillips, MS, RD
Tips for Dialysis Patients With Fluid
Restrictions
Melanie Wong, BS,* Parianna Ghebleh, BS,† and Stacey Phillips, MS, RD‡
T HERE ARE MANY components to the renal diet
that are important when educating end-stage renal
disease (ESRD) patients requiring hemodialysis. Intake
of the correct amount of fluids on a daily basis is crucial
to stabilizing your kidney patient and reducing potential
symptoms associated with fluid overload including
shortness of breath, headaches, abdominal bloating,
hypertension, heart failure, and edema.1,2 Limiting fluid
consumption is a complex part of the renal diet as there
are many factors that play into patient acceptance of this
restriction. Recommended weight gain between dialysis
sessions is individualized and fluctuations above ideal are
often indicators of noncompliance with fluid and diet
nutritional goals.3 Long-term research has demonstrated
that greater and undesired fluid gain between dialysis
sessions with ESRD patients increases risk of all-cause
and cardiovascular death.4
In 2010, Smith et al used semi-structured focus
groups to gain a better understanding of patient
perspective on self-care and adherence to fluid restric-
tions in 19 hemodialysis patients. Based on their re-
sponses to a series of questions, knowledge, self-
assessment, psychological factors, and social, physical,
and environmental conditions were identified as po-
tential barriers to patient compliance. Within the
participant group, individuals identified lack of moti-
vation to adhere to difficult fluid restrictions as a sig-
nificant psychological challenge often resulting in
noncompliance. In addition, social environment and
peers were highly influential in the individual’s deci-
sion to maintain their fluid allowance. To improve
*Dietetic Intern, Western Michigan University, Kalamazoo, Michigan.
†Dietetic Intern, Michigan State University, East Lansing, Michigan.
‡Clinical Dietitian-Nutrition Services, Mercy Health Saint Mary’s, Grand
Rapids, Michigan.
Financial Disclosure: The authors declare that they have no relevant financial
interests.
Intended Audience: Chronic kidney disease patients, hemodialysis patients.
Address correspondence to Stacey Phillips, MS, RD, Clinical Dietitian-
Nutrition Services, Mercy Health Saint Mary’s, 200 Jefferson Ave, Grand
Rapids, MI 49525. E-mail: staceycphillips@yahoo.com
Ó 2017 by the National Kidney Foundation, Inc. All rights reserved.
1051-2276/$36.00
http://dx.doi.org/10.1053/j.jrn.2017.06.001
Journal of Renal Nutrition, Vol 27, No 5 (September), 2017: pp e35-e38
fluid compliance within the dialysis population, re-
searchers summarized that specific interventions
should be targeted toward the individual barrier for
each patient.5
A more recent study in 2015 by Palmer et al also
examined patient thoughts on the renal diet and fluid
restrictions. The study design included a systematic
review of 46 qualitative studies and encompassed
816 adult chronic kidney disease patients. Similar to
previous findings, patient relationships, adjusting to
change, avoiding temptation, and optimizing health
and personal empowerment were influential areas on
diet compliance. Researchers concluded most individ-
uals felt the renal diet and fluid restrictions were a
substantial burden. The most effective education stra-
tegies for participants were individualized and moti-
vated patient compliance for personal reasons such
as reducing the impact of kidney disease on their
quality of life.6
Personalized fluid consumption goals and education
techniques can improve patient compliance with dietary
restrictions. The National Kidney Foundation recog-
nizes 5 methods to encourage dialysis patients to adhere
to a fluid restriction. Tracking fluids, providing specific
individualized fluid goals, managing thirst, limiting
excessive sodium intake, and adjusting dialysis regimens
to meet patient needs can all be used to support these
individuals.2 Beto et al note that a single educational
strategy is ineffective for all patients. Use of technology,
understanding meal patterns, addressing food coping
methods, involving support persons and sticking with
single, attainable goals are also necessary considerations
when emphasizing nutritional goals to improve fluid
restriction compliance.7 This handout was created to
provide an education tool for practitioners that
addresses many of these goals and should be used with
ESRD patients needing more detailed information on
a fluid restriction.
References
1. Diet – Chronic kidney disease. https://medlineplus.gov/ency/article/
002442.htm. Accessed April 28, 2017.
2. Fluid overload in a dialysis patient. https://www.kidney.org/atoz/
content/fluid-overload-dialysis-patient. Accessed April 27, 2017.
e35
e36
3. Fluid restrictions and kidney disease. https://www.nutritioncaresystems.
com/fluid-restrictions-and-kidney-disease/. Accessed April 28, 2017.
4. Kalantar-Zadeh K, Regidor D, Kovesdy C, et al. Fluid retention is
associated with cardiovascular mortality in patients undergoing long-term
hemodialysis. Circulation. 2009;119:671-679.
5. Smith K, Coston M, Glock K, et al. Patient perspectives on fluid manage-
ment in chronic hemodialysis. J Ren Nutr. 2010;20:334-341.
6. Palmer S, Hanson C, Craig J, et al. Dietary and fluid restrictions in CKD:
a thematic synthesis of patient view from qualitative studies. Am J Kidney Dis.
2015;65:559-573.
7. Beto J, Schury K, Bansal V. Strategies to promote adherence to nutri-
tional advice in patients with chronic kidney disease: a narrative review and
commentary. Int J Nephrol Renovasc Dis. 2016;9:21-33.
 e37

Tips for Dialysis Patients with Fluid Restrictions

Managing fluid intake is one of the goals of your renal diet. The kidneys normally filter waste
products and remove excess fluids from your body. If you have end stage renal disease and
require dialysis, you may retain more fluid than normal. Not only can this cause you to feel short
of breath and swollen (edema), but it can also contribute to complications like heart failure and
high blood pressure. Limiting the amount of liquid you drink on a daily basis can be a difficult
challenge but is important to prevent additional fluid accumulation.

Benefits of a Fluid Restriction:

With dialysis, there is a limit to how much fluid can be removed safely. Following your
recommended fluid restriction can help avoid this problem.

Removing large amounts of fluid during dialysis can cause unwanted symptoms of:
• Low blood pressure
• Cramping
• Nausea/vomiting
• Headache
• Dizziness
• Fatigue

What is considered a fluid?

Anything that is liquid at room temperature is considered a fluid. Some examples include the
following:

• Water, juice, milk

• Coffee and tea
• Soups and broths
• Puddings, yogurt, gelatin desserts
• Ice cubes, frozen desserts (ice cream, popsicles, etc.)

Common Fluid Portions

1 small juice glass 1 cup 1 large mug 1 can 1 Big Gulp

6 fluid ounces 8 fluid ounces 10-12 fluid 12 fluid ounces 32 fluid ounces
ounces
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Tips for Dialysis PaƟents with Fluid RestricƟons

Tips: Tracking Fluid Intake and Weight

• Write down your fluid intake in a small notebook
o Include liquids with meals, snacks and medications
• Download an app to your phone that allows you to track fluids
• Use a water bottle that is marked with your daily liquid goal in ounces or milliliters (mL)
• Measure fluid amounts to ensure correct portion sizes
• Talk to your doctor and dietitian about specific weight and fluid restriction goals for you

Tips: Controlling Thirst

• Avoid foods high in salt that cause increased thirst and blood pressure
• Control your sugar intake as too much sugar and high blood sugars increase thirst
• Suck on frozen fruits such as blueberries and grapes—limit to 1/2 cup servings
• Chew gum or suck on hard candy
• Spread out your fluids throughout the day
• If you have a dry mouth, use a spray bottle or swish and spit to moisten your mouth

Freezing juice or water in an ice cube tray and eating like a popsicle can feel
more refreshing than sipping on small amounts of liquid. Be sure to count as
part of your total fluids!
• Standard trays produce 1 ounce ice cubes

How can meeting with a Registered Dietitian help?

If you have trouble limiting fluids ask yourself, “Why am I drinking more fluids than I should?”
There are many aspects of your lifestyle and dialysis with end stage renal disease which impact
the level of care you need. A plan that works for
someone else may not fit with your lifestyle.
Working with someone who can individualize your
nutrition plan and find solutions that work best for
you can help ensure your success. If you are
struggling to follow your daily fluid restriction, ask
to meet with your dietitian for more education and
diet ideas.