If you have been diagnosed with chronic kidney disease (CKD) and are on dialysis, you should have already heard the terms “fluid management or fluid restriction” and understand what these terms mean. If this has not been explained to you, make sure you reach out to your nephrologist and dietician to get more information. It is very important to understand fluid management and how it pertains to your specific care plan.
What is fluid management?
When you have CKD and are on dialysis your kidneys are no longer able to help excrete water and maintain the normal fluid balance you need to stay healthy. While dialysis helps by removing excess fluid, depending on how often you do dialysis and the type of dialysis you choose, you may need to restrict how much fluid you can have each day to keep your body from becoming overloaded with fluid.
Throughout the day, you take in fluid from a variety of sources, including from the liquids that you drink and the foods you eat, some of which contain a high amount of water and therefore count as liquids including fruits, vegetables, ice cream and Jell-O.
What is fluid overload and why is it bad?
Fluid overload (hypervolemia) is when the body takes on more fluid than it can get rid of. Fluid overload can lead to serious health complications and an increased risk of death. Therefore, it is extremely important to recognize the signs and symptoms of fluid overload and monitor your fluid intake closely with chronic kidney disease.
Signs and symptoms of fluid overload include:
Swelling (edema) which is usually noticed in the hands, feet, ankles and face
Headache pain due to excess fluid in the body
Feeling bloated from excess fluid around the abdominal cavity
High blood pressure (hypertension) resulting from increased fluid in the bloodstream
Shortness of breath (difficulty breathing caused by excess fluid backing up into the lungs)
Increased or decreased heart rate (cardiac issues), caused by the heart having to work harder to pump the excess fluid circulating in the bloodstream
Notify your nephrologist or healthcare team if you experience any of the above signs and symptoms. You may need an additional dialysis session sooner than your next scheduled appointment. Your nephrologist and/or healthcare team can assess this.
Which type of dialysis requires fluid restriction?
While both hemodialysis and peritoneal dialysis will require you to monitor your fluid intake, hemodialysis will require fluid restriction. With hemodialysis, you will likely be dialyzed 3 times per week. Since the kidneys cannot excrete urine appropriately, you will need to restrict your intake of fluids in between dialysis days to ensure you do not wind up in fluid overload. Typically this means limiting fluid to three or four 8-ounce cups of fluid a day, but if you are able to urinate you may be able to have more liquid. Ask your nephrologist and dialysis care team how much fluid you may have each day or alternatively how much weight you can safely gain between dialysis treatments. Over time, you will get a sense of how much liquid you have been adding between dialysis treatments by the amount of weight you have gained, which is why it is important for you to track your weight.
With peritoneal dialysis, you will be dialyzed more frequently so you may not need to restrict your fluid intake. You may actually have to increase your fluid intake with this type of dialysis. You and your dialysis team will monitor labs and fluid intake to determine your needs depending on your dialysis regimen.
Tips and tricks for managing fluid restriction:
Know your daily fluid limits and monitor your intake closely by keeping a daily intake journal or by using the NKF H2Overload App (available for iPad and iPhone). Your dietician or nephrologist will set these limits based on your lab values and/or dialysis treatment.
Suck on sugar-free hard candy to ease dry mouth.
Freeze your daily fluid intake amount in smaller containers and sip on it throughout the day as it melts. This will prevent you from drinking all your daily allowance too early in the day.
Monitor your sodium intake. Too much sodium can make it harder to remove excess fluid from the body even with dialysis.
Try to avoid spicy foods as these can lead to increased thirst.
Stay cool and chew on ice. If you choose to chew on ice, especially during the hotter months, make sure you keep track of how much liquid you freeze. This also needs to be included in your daily fluid intake.
Learn more about the water volumes in various foods from the USDA here.
You can do this!
While fluid restriction can be very challenging, it is extremely important to adhere to, and monitoring your fluid intake can become routine over time. Always reach out to your treatment team and your support team for encouragement to help keep you on track.
If you know someone else with CKD who is on dialysis (maybe someone in your dialysis session), ask them about their experiences and share tips and tricks to help each other stay on track with how much water you consume between dialysis sessions.
“Fluid Overload in a Dialysis Patient.” National Kidney Foundation, 30 Mar. 2018, www.kidney.org/atoz/content/fluid-overload-dialysis-patient.
“CNNT Lead Article - Fluid Management in Hemodialysis: The Ongoing.” National Kidney Foundation, 3 Mar. 2017, www.kidney.org/content/cnnt-lead-article-fluid-management-hemodialysis-ongoing-challenge.
“CNNT CASE REVIEW - Fluid Management: Importance and Interventions.” National Kidney Foundation, 16 July 2018, www.kidney.org/newsletter/cnnt-case-review-fluid-management-importance-and-interventions.
“Choosing a Treatment for Kidney Failure.” National Institute of Diabetes and Digestive and Kidney Diseases, 9 Dec. 2021, https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/choosing-treatment#options.
“Eating Right with Kidney Failure.” National Institute of Diabetes and Digestive and Kidney Diseases, 9 Dec. 2021, www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/eating-right.
“Water, Hydration and Health” Nutr Rev. Barry M. Popkin, Kristen E. D’Anci, and Irwin H. Rosenberg. Included data from the USDA national nutrient database for standard reference, Nutr Rev. 2010 Aug; 68(8): 439–458. doi: 10.1111/j.1753-4887.2010.00304.x