Is Beetroot Good for Dialysis Patients?

Beetroot holds real promise for people on dialysis, largely because it is packed with inorganic nitrate that the body converts into nitric oxide, a molecule the dialysis process itself aggressively strips from the blood. Early clinical evidence suggests beetroot juice can replenish that lost nitrate, improve blood vessel function, and deliver antioxidant compounds that combat the oxidative stress common in kidney failure. The catch is that beetroot also carries oxalate and, depending on a person’s specific situation, could worsen dangerous blood pressure drops during treatment sessions.

Why Dialysis Creates a Nitric Oxide Problem

Nitric oxide keeps blood vessels relaxed, regulates blood pressure, and protects the cardiovascular system. People on hemodialysis already face elevated cardiovascular risk, and the dialysis machine makes it worse by physically pulling nitrate and nitrite out of the bloodstream. One study measured what happens during a standard session: blood exiting the dialysis unit contained roughly 57 percent less nitrite and 84 percent less nitrate than blood going in. After four to five hours of treatment, the new steady-state levels of both molecules stayed well below where they started.¹ Separate research in both adults with end-stage kidney disease and those with acute kidney injury confirmed the pattern: hemodialysis consistently drives down circulating nitrate and a downstream signaling molecule called cGMP, suggesting that the procedure impairs the body’s ability to both make and use nitric oxide.²

This chronic depletion is not a minor biochemical footnote. The researchers who documented it suggested that persistent low nitrate and nitrite probably reduces nitric oxide availability in the body and may partly explain why dialysis patients die of cardiovascular causes at such high rates.¹ So anything that safely restores those levels between sessions could, in theory, be protective.

How Beetroot Juice Fills That Gap

Beetroot is one of the richest dietary sources of inorganic nitrate, and after you swallow it, bacteria in the mouth convert the nitrate to nitrite, which the body then turns into nitric oxide. A randomized crossover trial directly tested this in adults on chronic hemodialysis. After patients drank active beetroot juice, plasma levels of both nitrate and nitrite rose significantly. Importantly, the juice did not raise blood pressure or plasma potassium, and no adverse events were reported in any participant.³ Healthy volunteers drinking the same juice showed a similar rise in nitrate and nitrite, though the increase was less dramatic, likely because their baseline levels were not depleted by dialysis.

This is encouraging because it shows that the body’s nitrate pathway still works in dialysis patients. The machinery is intact; it just runs low on fuel. Beetroot juice, at least in a single dose, appears to refuel it without triggering the electrolyte spikes or blood pressure problems that nephrologists worry about.

Effects on Blood Vessels

Beyond simply restoring nitrate numbers, beetroot juice appears to improve how blood vessels actually function. A pilot study in patients with chronic kidney disease found that drinking beetroot juice significantly lowered both peripheral blood pressure and the renal resistive index, a measure of how stiff and resistant the kidney’s blood vessels are. The researchers attributed the effect to nitric oxide released after the nitrate was absorbed.⁴

A separate study in midlife and older adults with renal dysfunction went further, measuring flow-mediated dilation of the brachial artery, a standard test of endothelial function. After beetroot juice supplementation, that measure improved by about 28 percent, while a placebo group saw no change. Lab work on the participants’ blood serum told a complementary story: cells exposed to the post-supplementation serum produced more nitric oxide and showed roughly 25 percent lower oxidative stress bioactivity.⁵ Interestingly, preliminary data from that trial hinted that women saw larger improvements in endothelial function than men, though the numbers were small and need confirmation.

These vascular improvements matter because stiff, poorly functioning blood vessels are a leading cause of the cardiovascular events that dominate dialysis patient mortality. If beetroot juice can measurably loosen those vessels and reduce oxidative damage, the downstream clinical benefits could be substantial, though no long-term outcome trials have been completed yet.

The Oxalate Concern

Beetroot is not just nitrate. It is also a well-known source of oxalate, a compound that can crystallize in the kidneys and other tissues. The American Journal of Kidney Diseases lists beets alongside spinach, rhubarb, chocolate, and black tea as foods whose high oxalate content can cause oxalosis, a condition where oxalate crystals deposit in tissues and worsen kidney damage.⁶

For dialysis patients, the concern is somewhat different from the general population. Healthy kidneys filter and excrete oxalate, but kidneys that have largely or completely stopped working cannot. Oxalate accumulates in the blood, and while dialysis removes some of it, the clearance is incomplete. Adding a concentrated oxalate source like daily beetroot juice could push the balance in the wrong direction, particularly for patients who already have elevated oxalate levels or a history of calcium oxalate kidney stones.

Most of the clinical trials on beetroot juice in kidney disease have used commercially prepared, nitrate-standardized juices where oxalate content is relatively low compared to eating whole roasted beets. Still, anyone considering regular beetroot supplementation on dialysis should discuss oxalate with their care team, especially if they also consume other high-oxalate foods or take vitamin C supplements, which the body also metabolizes into oxalate.⁶

Potassium and the Fear of “Forbidden Foods”

Potassium restriction is one of the most anxiety-inducing parts of the dialysis diet. Many patients are told to avoid fruits and vegetables, and beetroot often lands on the “high-potassium” warning lists that get handed out in renal clinics. This fear shapes real behavior: qualitative research with people on maintenance hemodialysis in the UK found that patients described testing out foods and experimenting with what they could tolerate, despite worrying that eating too much potassium could kill them.⁷

The beetroot juice trials in dialysis patients provide some reassurance on this front. In the randomized crossover study described earlier, active beetroot juice did not affect plasma potassium levels in any of the hemodialysis participants.³ That does not mean potassium is irrelevant. A single dose of concentrated beetroot juice contains considerably less potassium than, say, a large serving of roasted beets eaten as a side dish. The form and amount matter. Concentrated juice designed to deliver nitrate can be formulated to keep potassium relatively low, whereas eating whole beets daily could pile on potassium that the body cannot excrete between sessions.

The broader point is that blanket “avoid all high-potassium vegetables” advice may be too blunt. Potassium tolerance varies by individual, by how much residual kidney function someone retains, and by dialysis adequacy. A nephrologist or renal dietitian can help figure out whether a controlled dose of beetroot juice fits within a specific patient’s potassium budget.

Intradialytic Hypotension and the Timing Question

One of the most common complications during a dialysis session is a sudden, uncomfortable drop in blood pressure, called intradialytic hypotension. Research has linked this problem to nitric oxide: patients who experienced severe drops in blood pressure during dialysis had plasma nitrate concentrations more than three times higher than patients whose pressure stayed stable. Higher pre-dialysis nitrate levels correlated with bigger blood pressure drops during treatment.⁸

This creates a paradox. Between dialysis sessions, boosting nitric oxide through dietary nitrate seems beneficial for blood vessel health and long-term cardiovascular protection. But walking into a dialysis session with nitrate levels artificially elevated by a recent glass of beetroot juice could make intradialytic hypotension worse. No trial has directly tested whether pre-session beetroot juice increases hypotensive episodes, but the physiological logic is concerning enough that timing deserves careful thought.

The safest approach, based on what we currently know, would be to consume beetroot juice after dialysis rather than before. Post-session, nitrate and nitrite levels are at their lowest, so replenishing them makes biological sense and avoids walking into the next session with a nitric oxide surplus that could destabilize blood pressure during fluid removal. Some researchers have explicitly suggested post-dialysis timing for this reason, though formal guidelines do not yet exist.

Betalains and Oxidative Stress

The nitrate story dominates the research on beetroot and kidney disease, but it is not the only one. Beetroot gets its deep red-purple color from betalain pigments, which are potent antioxidants. A narrative review in Nutrition Reviews highlighted beetroot as a source of several bioactive compounds, including nitrate, betaine, and betalain, and noted beneficial effects in chronic kidney disease such as blood pressure reduction, anti-inflammatory action, and scavenging of reactive oxygen species in preclinical studies.⁹ Separate analysis of beetroot’s bioactive profile confirmed that betalain pigments show potent antioxidant and anti-inflammatory activity that may help counteract the oxidative stress typical of end-stage kidney disease.¹⁰

Dialysis patients live under constant oxidative assault. The dialysis membrane itself, the repeated cycles of fluid removal and refilling, and the uremic toxins that accumulate between sessions all generate reactive oxygen species. Chronic inflammation and oxidative stress contribute to the accelerated atherosclerosis seen in this population. Betalains are not unique to beetroot (prickly pear and some other foods contain them), but beetroot is one of the most concentrated and accessible sources. Whether the amount of betalain in a standard serving of beetroot juice is enough to meaningfully shift oxidative markers in dialysis patients has not been directly tested in a clinical trial, though the laboratory and preclinical data are consistently encouraging.

The Oral Bacteria Factor

Something that rarely comes up in patient conversations is that the nitrate pathway depends entirely on bacteria living in your mouth. When you drink beetroot juice, the nitrate itself is inactive. It needs to be reduced to nitrite by specific bacterial species on the tongue and in saliva before the stomach and bloodstream can convert it further into nitric oxide. If those bacteria are disrupted, the whole pathway stalls. This is why antiseptic mouthwashes can actually blunt the blood-pressure-lowering effect of dietary nitrate.

Dialysis patients may be at a disadvantage here. Research on peritoneal dialysis patients has documented significant shifts in the oral microbiome compared to healthy controls, including altered abundances of several bacterial genera.¹¹ Among the genera that decreased was Actinomyces, which plays a role in the oral nitrate-reducing community. Whether these microbiome changes meaningfully impair the conversion of dietary nitrate in dialysis patients has not been directly studied, but it raises an underappreciated possibility: beetroot juice might work less efficiently in some dialysis patients than it does in the general population, simply because their oral bacteria have shifted. Patients who use chlorhexidine mouthwash or take frequent antibiotics may be doubly affected.

Practical Considerations for Choosing a Beetroot Product

Not all beetroot products are equal for dialysis patients, and the distinction matters more here than it does for the general population.

Concentrated juice shots: Products standardized for nitrate content (often around 400 mg of nitrate per 70 mL shot) are what most clinical trials use. They deliver a controlled nitrate dose with relatively low volume, potassium, and oxalate compared to eating whole beets.
Whole beetroot: Eating roasted or boiled beets delivers nitrate plus fiber and other nutrients, but also more oxalate and potassium per serving. Boiling beets and discarding the water can reduce potassium somewhat, a technique renal dietitians often recommend for other vegetables.
Beetroot powder or capsules: These vary enormously in nitrate content and are less well-studied. Without standardization, you may get too little nitrate to be useful or too much oxalate to be safe.
Nitrate-depleted placebo juice: Some beetroot juice products marketed for taste rather than health are processed in ways that strip most of the nitrate. Check the label if the goal is nitric oxide production.

The clinical evidence on safety in hemodialysis patients comes almost exclusively from standardized juice shots, so extrapolating those safety findings to large servings of whole beets or unstandardized supplements requires caution.

Drug Interactions Worth Mentioning

Dialysis patients are typically on multiple medications, and some of those interact with the nitrate pathway. Blood pressure medications are the most obvious concern. If you are taking antihypertensives and adding beetroot juice, the combined effect on blood pressure could be stronger than expected. Research has examined how grapefruit juice, which inhibits certain drug-metabolizing enzymes, enhances the blood-pressure-lowering effects of beetroot juice.¹² For dialysis patients who drink grapefruit juice or take medications that interact with the same enzyme pathways, stacking beetroot juice on top could produce an unpredictable blood pressure response.

Phosphodiesterase-5 inhibitors (medications commonly prescribed for erectile dysfunction or pulmonary hypertension) also work through the nitric oxide pathway, and combining them with concentrated dietary nitrate could amplify hypotensive effects. The interactions are not unique to dialysis patients, but the narrow margin for error in blood pressure management on dialysis makes them more consequential. Any dialysis patient considering regular beetroot juice supplementation should review their medication list with a pharmacist or nephrologist first.

Where the Science Stands

The overall picture is genuinely interesting but still early. The biological rationale for beetroot in dialysis is strong: dialysis strips nitric oxide precursors, beetroot replenishes them, and the vascular benefits are measurable in short-term studies. The safety data from pilot trials is reassuring, with no spikes in potassium or blood pressure in controlled settings. And the antioxidant profile of beetroot adds a secondary layer of plausibility for a population drowning in oxidative stress.

What is missing is the long-term evidence. No trial has followed dialysis patients drinking beetroot juice for months or years to see whether the vascular improvements translate into fewer heart attacks, fewer hospitalizations, or longer survival. The existing studies are small, often involving fewer than 30 participants, and they measure surrogate endpoints like nitrate levels and artery dilation rather than clinical outcomes. This is where nephrologists understandably hesitate. A lot of promising surrogate-endpoint stories in kidney disease have failed to deliver when scaled up. Beetroot juice may ultimately be one of the affordable, low-risk interventions that proves its worth, but it has not crossed that threshold yet. In the meantime, the evidence is strong enough that discussing it with a renal care team is reasonable, and dismissing it as irrelevant would be premature.