Physical activity and exercise programs for kidney patients: an Italian survey of nephrology centres.

BACKGROUND: Data on exercise activities in place, and on the interest for developing them in Nephrology Services in Italy is limited. To address this gap, we carried out this cross-sectional study to investigate the status of physical activity and exercise programs available in Italian Nephrology Centres. Additionally, research priorities on this topic were examined. METHODS: We developed a 14-item electronic survey, which consisted of multiple-choice questions covering exercise training programs, physical assessment, barriers to exercise practice and to exercise programs, exercise and physical activity counselling practices, perceived exercise benefits, literature evidence, and research priorities. Data on the characteristics of the centres were also collected. RESULTS: Sixty-two responses from Italian nephrology centres were collected. Ninety-three percent of the respondents were aware of the scientific evidence supporting the benefits of regular exercise programs for chronic kidney disease (CKD) patients. Additionally, in 75% of centres the nephrologists believed that physical activity counselling should be performed by the nephrologists. However, only 26% of centres provided exercise programs, mainly for dialysis patients, and 63% never or infrequently assessed physical activity in the context of patient management. Eighty-nine percent of centres reported barriers to implementing exercise programs, including lack of funding, institutional disinterest, patient refusal, and negative attitudes of the healthcare personnel. Forty-six research priorities related to exercise in CKD patients were suggested, with the majority focusing on impact of exercise programs and physical activity on cardiovascular, nutritional, and psychosocial outcomes. CONCLUSION: This survey highlights the limited availability of exercise programs and physical activity evaluation in clinical practice in Italian Nephrology Centres. However, the survey also revealed a strong interest for counselling CKD patients on physical activity and implementing exercise prescriptions and interventions.

Increased Creatine Kinase May Predict A Worse COVID-19 Outcome.

Early reports from Asia suggested that increased serum levels of the muscular enzyme creatine-(phospho)-kinase (CK/CPK) could be associated with a more severe prognosis in COVID-19. The aim of this single-center retrospective cohort study of 331 consecutive COVID-19 patients who were hospitalized during Italy's "first wave" was to verify this relationship, and to evaluate the role of possible confounding factors (age, body mass index, gender, and comorbidities). We subdivided our cohort in two groups, based on "severe" (n = 99) or "mild" (n = 232) outcomes. "Severe" disease is defined here as death and/or mechanical invasive ventilation, in contrast to "mild" patients, who were discharged alive with no need for invasive ventilation; this latter group could also include those patients who were treated with non-invasive ventilation. The CK levels at admission were higher in those subjects who later experienced more severe outcomes (median, 126; range, 10-1672 U/L, versus median, 82; range, 12-1499 U/L, p = 0.01), and hyperCKemia >200 U/L was associated with a worse prognosis. Regression analysis confirmed that increased CK acted as an independent predictor for a "severe" outcome. HyperCKemia was generally transient, returning to normal during hospitalization in the majority of both "severe" and "mild" patients. Although the direct infection of voluntary muscle is unproven, transient muscular dysfunction is common during the course of COVID-19. The influence of this novel coronavirus on voluntary muscle really needs to be clarified.

Citrate high volume on-line hemodiafiltration modulates serum Interleukin-6 and Klotho levels: the multicenter randomized controlled study "Hephaestus".

BACKGROUND: Studies addressing the anti-inflammatory properties of citrate dialysate enrolled patients in both hemodialysis (HD) and hemodiafiltration (HDF), the latter not adjusted for adequate convective exchange. This is a potential source of confounding in that HDF itself has anti-inflammatory effects regardless of the buffer, and optimal clinical outcomes are related to the amount of convection. METHODS: To distinguish the merits of the buffer from those of convection, we performed a 6-month, prospective, randomized, crossover AB-BA study. Comparisons were made during the 3-month study period of on-line HDF with standard dialysate containing three mmol of acetic acid (OL-HDFst) and the 3-month of OL-HDF with dialysate containing one mmol of citric acid (OL-HDFcit). Primary outcome measure of the study was interleukin-6 (IL-6). Klotho, high sensitivity C-reactive protein (hsCRP), fetuin and routine biochemical parameters were also analyzed. RESULTS: We analyzed 47 patients (mean age 64 years, range 27-84 years) enrolled in 10 participating Nephrology Units. Convective volumes were around 25 L/session with 90 percent of sessions > 20 L and ß2-microglobulin reduction rate 76% in both HDFs. Baseline median IL-6 values in OL-HDFst were 5.6 pg/ml (25:75 interquartile range IQR 2.9:10.6) and in OL-HDFcit 6.6 pg/ml (IQR 3.4:11.4 pg/ml). The difference was not statistically significant (p 0.88). IL-6 values were lower during OL-HDFcit than during OL-HDFst, both when analyzed as the median difference of overall IL-6 values (p 0.02) and as the median of pairwise differences between the baseline and the 3-month time points (p 0.03). The overall hsCRP values too, were lower during OL-HDFcit than during OL-HDFst (p 0.01). Klotho levels showed a time effect (p 0.02) and the increase was significant only during OL-HDFcit (p 0.01). CONCLUSIONS: Citrate buffer modulated IL-6, hsCRP and Klotho levels during high volume OL-HDF. These results are not attributable to differences in the dialysis technology that was applied and may suggest a potential biological effect of citrate on CKD-associated inflammatory state. ClinicalTrials.gov identifier NCT02863016.

[Nutritional diet therapy in the management of the patient with Chronic Kidney Disease in advanced phase to delay the beginning and reduce the frequency of dialysis. An option also in the pre-emptive transplant program].

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and / or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty (20) essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Correction: Interaction of healthcare staff's attitude with barriers to physical activity in hemodialysis patients: A quantitative assessment.

[This corrects the article DOI: 10.1371/journal.pone.0196313.].

Nutritional treatment of advanced CKD: twenty consensus statements.

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

Interaction of healthcare staff's attitude with barriers to physical activity in hemodialysis patients: A quantitative assessment.

BACKGROUND AND AIM OF THE STUDY: In hemodialysis patients, sedentarism is a potentially modifiable mortality risk factor. We explored whether healthcare staff's attitude towards exercise interacts with patient-perceived barriers in modifying the level of physical activity in this population. METHODS: In this prospective, cross-sectional, multicenter study we recruited 608 adult patients and 330 members of the healthcare staff in 16 hemodialysis units in Italy. We assessed patient-perceived barriers to, and healthcare staff's attitude towards, exercise by specific questionnaires. We fitted multilevel linear models to analyze the relationships of either barriers or staff's attitude, and their interaction, with a measure of patient self-reported physical activity (the Human Activity Profile-Adjusted Activity Score [HAP-AAS]), adjusting for multiple confounders. We also employed latent class analysis to dichotomize patients into those endorsing or not endorsing barriers. RESULTS: Most barriers were negatively associated with the HAP-AAS (adjusted change attributable to a given barrier ranging between -5.1 ["Feeling too old", 95% Confidence Interval: -9.4 to -0.8] and -15.6 ["Ulcers on legs and feet", 95%CI: -24.8 to -6.5]. We found a significant interaction between staff's attitude and barriers (adjusted P values ranging between 0.03 ["I do not believe that it is physician's or nurse's role providing advice on exercise to patients on dialysis"] and 0.001 ["I do not often ask patients about exercise"]). A beneficial effect of a proactive staff's attitude was evident only in patients not endorsing barriers. CONCLUSIONS: Barriers and non-proactive staff's attitude reduce physical activity in hemodialysis patients. Patients not endorsing barriers benefit the most from a proactive staff's attitude.

Sepsis complicated by brain abscess following ESWL of a caliceal kidney stone: a case report.

A 47-year old, Caucasian man underwent extracorporeal shock wave lithotripsy (ESWL) of a 14mm calcium stone in the right renal pelvis, without urinary tract obstruction or sepsis. 24 hours after ESWL septic shock occurred and the patient was admitted to the Intensive Care Unit (ICU). Escherichia coli emerged from the blood and urine culture. The patient developed acute renal failure and it was necessary to start a continuous renal replacement therapy (CRRT). Infection was successfully treated, patient recovered renal function and an improvement of general condition occurred. The patient was then discharged but three day later the patient returned to the hospital to seek treatment for left facial hemiparesis and hypotonia of his left arm. The brain computed tomography showed a wide abscesso (55x75mm) in the frontal right parietal region. A neurosurgical intervention was then performed and the culture of the drained material resulted positive for Escherichia coli. The guidelines of European and American Associations of Urology do not suggest a prophylactic antibiotic therapy for pre-ESWL (except in the presence of risk factors). The serious complication that occurred in the described low risk patient raises the question of whether routine culture and/or antibiotic prophylaxis, is appropriate.

[The presence of crystals of sodium polystyrene sulfonate in the colonic wall: innocent bystander or pathogenic factor?]. / La presenza di cristalli di sodio polisterene sulfonato nella parete colica: fattore patogenetico o semplice marker di somministrazione?

Hyperkalemia is a frequent electrolyte disturbance in patients on dialysis or non-dialysis CKD patients, including those using renin-angiotensin system inhibitor drugs. Sodium polystyrene sulfonate (SPS; Kayexalate) is a resin widely used for hyperkalemia treatment. Unfortunately, its use entails some serious unwanted gastrointestinal side effects. We report the case of a 64-year-old male diabetic patient, suffering from ESRD on hemodialysis, who was treated with 30 g of Kayexalate twice a week (long interdialytic interval). This is a quite common case in the clinical practice. The patient experienced an episode of rectal bleeding followed by the diagnosis of non-specific colitis through colonoscopy. Histological examination, showed the presence of crystals of Kayexalate in the colonic mucosa leading to the suspect of iatrogenic intestinal damage caused by Kayexalate administration. Treatment with SPS was stopped. Nevertheless crystals remain evident in the intestinal mucosa in a colonoscopy performed 14 months later due to a new episode of rectal bleeding. Two years after the first episode the patient died because of intestinal infarction. The review of the literature highlights the risk of serious side effects such as necrotizing colitis with perforation both for the drug in sodium phase and in calcium phase. New intestinal potassium-binger agents, apparently without intestinal severe side effects, are under clinical evaluation. This case does not assess if the crystals deposited in the colonic mucosa are inert or have contributed to the final event, but it shows that Kayexalate is a drug with potential harmful effect even when used orally, at very low dosage and without sorbitol. In our opinion, the SPS should be prescribed carefully, especially as chronic administration, and the prescription should be limited to real and pressing requirements.

Physical exercise programs in CKD: lights, shades and perspectives [corrected].

In the general population, moderate exercise is associated with several health benefits including a decreased risk of obesity, coronary heart disease, stroke, certain types of cancer and all-cause mortality. In chronic kidney disease (CKD), physical inability is an independent risk of death. Health benefits of regular exercise in CKD patients include improvements in functional and psychological measures such as aerobic and walking capacity and health-related quality of life. Nonetheless, in CKD patients exercise rehabilitation is not routinely prescribed. Renal patients are heterogeneous across the different stages of CKD so that the assessment of physical capability is mandatory for a correct exercise program prescription. To plan appropriate exercise programs in the CKD setting, targeted professional figures should be actively involved as many psychological or logistic barriers may hamper exercise implementation in these subjects. Different approaches, such as home exercise rehabilitation programs, supervised exercise training or in-hospital gym may theoretically be proposed. However, physical exercise should always be tailored to the individual capacity and comorbidities and each patient should ideally be involved in the decision-making process.

High-volume online haemodiafiltration improves erythropoiesis-stimulating agent (ESA) resistance in comparison with low-flux bicarbonate dialysis: results of the REDERT study.

BACKGROUND: In haemodialysis (HD) patients, anaemia is associated with reduced survival. Despite treatment with erythropoiesis-stimulating agents (ESAs), a large number of patients with chronic kidney disease show resistance to this therapy and require much higher than usual doses of ESAs in order to maintain the recommended haemoglobin (Hb) target, and recent studies suggest that hepcidin (HEP) may mediate the ESA resistance index (ERI). High-volume online haemodiafiltration (HV-OL-HDF) has been shown to improve anaemia and to reduce the need for ESAs in HD patients; this effect is associated with a reduced inflammatory state in these patients. The aim of the REDERT study (role of haemodiafiltration on ERI) was to investigate the effect of different dialysis techniques on ERI and HEP levels in chronic dialysis patients. METHODS: A single cross-over, randomized, multicentre study (A-B or B-A) was designed. Forty stable HD patients from seven different dialysis units (male 65%, mean age 67.6 ± 14.7 years and mean dialytic age 48 ± 10 months) were enrolled. Patients were randomized to the standard bicarbonate dialysis (BHD) with low-flux polysulfone (PS) membrane group or to the HV-OL-HDF group with high-flux PS membranes and exchange volume of >20 L/session. After 6 months, patients were shifted to the other dialytic group for a further 6 months. Clinical data, Hb, ESA doses and iron metabolism were recorded every month. HEP, beta2-microglobulin (b2MG) and C-reactive protein (CRP) were determined every 3 months, and ERI was calculated monthly as the weekly ESA dose per kilogram of body weight divided by Hb level. Data were analysed using paired-samples t-test, Wilcoxon signed-rank test and Spearman's correlation coefficient. RESULTS: Dialysis efficiency for small molecules assessed as Kt/V was significantly increased in HV-OL-HDF from 1.47 ± 0.24 to 1.49 ± 0.16; P < 0.01. A significant reduction of b2MG was obtained in HV-OL-HDF from month 3 whereas CRP values were not significantly changed during the study period either in BHD or HV-OL-HDF.ERI was significantly reduced in HV-OL-HDF at month 3 and 6 (from 9.1 ± 6.4 UI/weekly/Kg/Hb to 6.7 ± 5.3 UI/weekly/Kg/Hb; P < 0.05) due to a higher ESA consumption in BHD in spite of similar Hb levels. HEP levels were reduced in HV-OL-HDF with respect to BHD after 3 and 6 months. Iron consumption was not significantly different during BHD or HV-OL-HDF treatment as well as transferrin, ferritin and TSAT levels. A significant positive linear correlation between HEP and ERI (r(2) = 0.258, P < 0.001) was observed. CONCLUSIONS: In a uraemic patient population with low-grade inflammation treated with HV-OL-HDF, we observed a significant reduction of ERI values as well as HEP levels. The positive correlation between these two parameters supports a role for HEP in the development of ERI in the dialytic population. Moreover, the lower b2MG and the higher Kt/V achieved in HV-OL-HDF confirms the better depurative effect of this technique in comparison with BHD with respect to middle molecules and small-molecular-weight molecules.

Dialysis exercise team: the way to sustain exercise programs in hemodialysis patients.

Patients affected by end-stage renal disease (ESRD) show quite lower physical activity and exercise capacity when compared to healthy individuals. In addition, a sedentary lifestyle is favoured by lack of a specific counseling on exercise implementation in the nephrology care setting. Increasing physical activity level should represent a goal for every dialysis patient care management. Three crucial elements of clinical care may contribute to sustain a hemodialysis exercise program: a) involvement of exercise professionals, b) real commitment of nephrologists and dialysis professionals, c) individual patient adaptation of the exercise program. Dialysis staff have a crucial role to encourage and assist patients during intra-dialysis exercise, but other professionals should be included in the ideal "exercise team" for dialysis patients. Evaluation of general condition, comorbidities (especially cardiovascular), nutritional status and physical exercise capacity are mandatory to propose an exercise program, in either extra-dialysis or intra-dialysis setting. To this aim, nephrologist should lead a team of specialists and professionals including cardiologist, physiotherapist, exercise physiologist, renal dietician and nurse. In this scenario, dialysis nurses play a pivotal role since they guarantee a constant and direct approach. Unfortunately dialysis staff may often lack of information and formation about exercise management while they take care patients during the dialysis session. Building an effective exercise team, promoting the culture of exercise and increasing physical activity levels lead to a more complete and modern clinical care management of ESRD patients.

Barriers to physical activity in chronic hemodialysis patients: a single-center pilot study in an Italian dialysis facility.

BACKGROUND/AIMS: In patients on chronic dialysis a sedentary lifestyle is a strong, yet potentially modifiable, predictor of mortality. The present single-center pilot study evaluated social, psychological and clinical barriers that may hinder physical activity in this population. METHODS: We explored the association between barriers to physical activity and sedentarism in adult patients at a chronic dialysis facility in Parma, Italy. We used different questionnaries exploring participation in physical activity, physical functioning, patient attitudes and preferences, and barriers to physical activity perceived by either patients or dialysis doctors and nurses. RESULTS: We enrolled 104 patients, (67 males, 65%), mean age 69 years (79% of patients older than 60 years); median dialysis vintage 60 months (range 8-440); mean Charlson score 5.55, ADL (Activities of Daily Living) score 5.5. Ninety-two participants (88.5%) reported at least one barrier to physical activity. At multivariable analysis, after adjusting for age and sex, feeling to have too many medical problems (OR 2.99, 95% CI 1.27 to 7.07; P=0.012), chest pain (OR 10.78, 95% CI 1.28 to 90.28; P=0.029) and sadness (OR 2.59, 95% CI 1.10 to 6.09; P=0.030) were independently associated with physical inactivity. Lack of time for exercise counseling and the firm belief about low compliance/interest by the patients toward exercise were the most frequent barriers reported by doctors and nurses. CONCLUSION: We identified a number of patient-related and health personnel-related barriers to physical activity in patients on chronic dialysis. Solutions for these barriers should be addressed in future studies aimed at increasing the level of physical activity in this population.

Physical activity and renal transplantation.

Renal transplantation is burdened by high cardiovascular risk because of increased prevalence of traditional and disease-specific cardiovascular risk factors and, consequently, patients are affected by greater morbidity and mortality. In renal transplanted patients, healthy lifestyle and physical activity are recommended to improve overall morbidity and cardiovascular outcomes. According to METs (Metabolic Equivalent Task; i.e. the amount of energy consumed while sitting at rest), physical activities are classified as sedentary (<3.0 METs), of moderate-(3.0 to 5.9 METs) or vigorous-intensity (≥ 6.0 METs). Guidelines suggest for patients with chronic kidney disease an amount of physical activity of at least 30 minutes of moderate-intensity activity five times per week (min 450 MET-minutes/week). Data on physical activity in renal transplanted patients, however, are limited and have been mainly obtained by mean of non-objective methods. Available data suggest that physical activity is low either at the start or during renal transplantation and this may be associated with poor patient and graft outcomes. Therefore, in renal transplanted patients more data on physical activity obtained with objective, accelerometer-based methods are needed. In the meanwhile, physical activity have to be considered as an essential part of the medical care for renal transplanted recipients.

Physical activity and exercise training: a relevant aspect of the dialysis patient's care.

Sedentary lifestyle is frequent in hemodialysis patients whose physical capabilities are largely reduced when compared with healthy subjects, and evidence exists that sedentary dialysis patients are at higher risk of death as compared to non-sedentary ones. Dialysis patients may suffer from cardiovascular disease, diabetes, malnutrition, depression, which limits their exercise capacity; conversely, regular physical exercise may favor rehabilitation and correction of several cardiovascular, metabolic and nutritional abnormalities. Many observational, population-based studies show that the level of physical activity is related to quality of life and nutritional status, as well as to the survival probability. Intervention studies are instead lacking; a randomized controlled multicenter trial is in progress in Italy to assess the effect of home-based exercise programs on survival and hospitalization rate in stable dialysis patients. Implementation of physical activity should be one of the goals of dialysis care management, but several barriers prevent a widespread implementation of physical exercise programs in the dialysis units. A lack of patients' or care-givers' motivation or willingness, and structural or functional resources are the most frequent obstacles to exercise implementation. Since the hemodialysis population is quite heterogeneous for physical abilities and comorbidities, exercise in not for everyone and individual prescription is required for a correct and safe implementation of physical activity.

Massively calcified intravascular cast after removal of a tunneled central vein catheter for hemodialysis.

Vascular calcifications usually affect the arteries, while central vein calcifications are rare. A 45-year-old hemodialysis patient underwent a chest CT scan before central vein catheterization required for arteriovenous access thrombosis, in July 2011. He was on hemodialysis since 1995 and from 2005 on warfarin treatment because of repeated thrombosis and dysfunction of arteriovenous fistula and central vein catheters (CVC). A previous tunneled CVC placed in the left external jugular vein was removed in December 2010. Eight months later a chest CT scan showed a 79-mm irregular, linear, tubular radiopaque density in the superior vena cava and left brachiocephalic vein. The possibility of a retained catheter fragment was considered, but the final diagnosis was: calcified "cast" adherent to the vessel wall. This is the first report of an intravenous calcified "cast" (originating from peri-catheter calcification) retained after removal of a tunneled dialysis CVC. This finding is significant because it mimics a retained catheter fragment possibly leading to misdiagnosis and exposing patients to additional risk for unnecessary retrieving interventions. Catheter removal or over the wire substitution in the presence of a calcified cast could also be considered a risky procedure. Retained calcified cast should be included among the long-term complications of hemodialysis CVCs. At the time of publication, the patient is alive without any complication related to the pathology reported.

Upper limb disability in hemodialysis patients: evaluation of contributing factors aside from amyloidosis.

This cross-sectional case-control study evaluated upper limb muscle strength and shoulder mobility in hemodialysis (HD) patients with arteriovenous fistula or graft. Twenty-five adult patients on thrice-a-week HD treatment for 6 months at least, were selected for the study. In all the patients and control subjects, handgrip tests and tests of range of motion in the upper extremities were evaluated by physiotherapy tests. Patients on HD showed lower muscle strength than age and sex matched subjects without severe chronic kidney disease (right: 30.1 ± 11.6 vs 40.5 ± 15.1 kg, P < 0.001; left 29.1 ± 12.9 vs 40.7 ± 11.1 kg, P < 0.01), and a reduced range of shoulder mobility. The presence of fistula or graft was associated with a greater limitation of both active (74.0 ± 18.3 vs 85.2 ± 8.8 °, P < 0.01) and passive (82.2 ± 9.9 vs 87.2 ± 6.6 °, P < 0.05) extra-rotation than the contralateral limb, with a higher prevalence of impingement (72 vs 36%, P < 0.05). Muscle strength was related to albumin and inversely to age; whereas ß(2) -microglobulin and CRP serum levels were associated with impairment of passive and active extra-rotation of the shoulder that was free from the fistula or graft. In summary, patients on HD have a reduced range of shoulder mobility and marked reduction of muscle strength. The abnormalities are more prevalent in upper limbs with fistula or grafts. The arteriovenous fistula or graft may worsen the disability of the patient's upper limbs presumably due to the obligate position required during the HD sessions. Proper pre- and post-dialysis exercise programs should be implemented to maintain mobility and strength of the upper limbs.

Nutritional knowledge in hemodialysis patients and nurses: focus on phosphorus.

OBJECTIVE: To assess the knowledge of adult hemodialysis patients and nurses working in dialysis units, specifically with regard to knowledge of phosphorus and other nutrients related to dietary management of end-stage renal disease. DESIGN: Cross-sectional cohort study. SETTING: Hemodialysis unit. SUBJECTS: One hundred ninety-one hemodialysis patients and 105 dialysis nurses, as well as 86 control hospital employees who are not health professionals. INTERVENTION: Nutritional knowledge was assessed by a 25-item chronic kidney disease knowledge assessment tool for nutrition, which includes 15 questions on phosphorus and 10 questions on protein, sodium, and potassium knowledge. RESULTS: The scores obtained by patients were much lower than those of nurses (11.6 ± 3.9 vs. 16.0 ± 2.2, P < .001) but slightly higher than those of controls (10.6 ± 3.2, P < .05). Patients with phosphorus serum level >5.5 mg/dL showed chronic kidney disease knowledge assessment tool for nutrition scores similar to those of patients with a serum phosphorus level <5.5 mg/dL. The prevalence of right answers to questions regarding knowledge of phosphorus was lower than that regarding knowledge of the other nutrients, both for patients (38.4% ± 17.8% vs. 57.3% ± 19.9%, P < .001) and nurses (55.6% ± 11.1% vs. 74.8% ± 11.7%, P < .001) as well as for controls (30.7% ± 14.5% vs. 60.1% ± 17.4%, P < .001). CONCLUSIONS: Our study suggests that nutritional knowledge of hemodialysis patients, although higher than the general population, is lower for phosphorus with respect to the other nutrients, such as protein, sodium, and potassium. This occurs even in patients with hyperphosphatemia or those taking phosphate binder medications. Nurses showed the best scores; however, improvement is necessary, especially with regard to knowledge of phosphorus. Training programs on nutrition for nurses and on information for patients should be implemented. They can contribute to achievement of a more effective control of phosphate balance, reduction of costs, and improvement of the quality of care for hemodialysis patients.