The estimation of protein equivalents of total nitrogen in Chinese CAPD patients: an explanatory study.

OBJECTIVE: The protein equivalent of total nitrogen appearance (PNA) formula, based on the urea nitrogen appearance (UNA), is popularly used by stable continuous ambulatory peritoneal dialysis (CAPD) patients to estimate dietary daily protein intake (DPI). However, we found that the estimated DPI was higher than that directly evaluated from the dietary records of most of our CAPD patients. Therefore, in the present study, we tried to determine possible bias in PNA estimation by UNA with a nitrogen balance study of our CAPD patients. METHODS: Thirty-one CAPD patients with stable clinical conditions were included. Their 3-day dietary records were reviewed by a dedicated dietitian to calculate their energy, protein, and nitrogen intake (NI). The nitrogen removal (NR) from urine and dialysate was measured by the Kjeldahl technique. Then, we calculated the proportion of urea nitrogen appearance (UNA) in total nitrogen appearance (TNA) and analyzed the possible factors that could affect this proportion. RESULTS: Among these patients, 17 males and 14 females, the mean age was 64.19 ± 12.42, and the dialysate drainage volume was 6700 (2540) ml/day. The percentage of UNA in TNA was 63.22 ± 6.66%. Compared with the other classic nitrogen balance studies in the CAPD population, the protein nitrogen and other nonurea nitrogen losses in this study were all lower. Based on these 31 nitrogen balance studies, we proposed a pair of new equations to estimate PNA by UNA. (1) PNA = 9.3 + 7.73 UNA; (2) PNA = PNPNA + TPL = 6.7 + 7.28 UNA + TPL. CONCLUSION: Our study suggested that the PNA formula generated from previous European studies overestimated DPI in our CAPD patients.

Use of a Phosphorus Points Education Program to Maintain Normal Serum Phosphorus in Pediatric Chronic Kidney Disease: A Case Report.

A 14-year-old male, with chronic kidney disease stage 4 (glomerular filtration rate 20 mL/min/1.73 m2) secondary to reflux nephropathy required dietary modification with evidence of renal osteodystrophy, presented with elevated serum phosphorus and parathyroid hormone. He was educated using a novel phosphorus point system where 1 point is equivalent to ∼50 mg of phosphorus. Dietary counseling was provided by a pediatric renal dietitian on phosphorus content of foods the patient typically consumed and converted to point system for daily tracking. The family reported limiting daily phosphorus points to less than 20 points daily for 15 months. The family completed a 3-day food record and provided points assigned to each food item. A Spearman's correlation of 0.7 (P < .001) was found between the family's and the dietitian's assignment of phosphorus points. The patient's recorded phosphorus intake remained below 1000 mg each day and met estimated calorie and protein needs. The patient also continued with age-appropriate weight gain and linear growth. Laboratory values showed phosphorus and intact parathyroid hormone remained within desired range. A phosphorus point system tool can be used to maintain normal serum phosphorus levels and subsequently prevent secondary hyperparathyroidism in patients with pediatric chronic kidney disease.

Prevalence and correlates of hyperkalemia in a renal nutrition clinic.

Hyperkalemia (HK) is a frequent complication of chronic kidney disease (CKD). Vegetable-based renal diets are considered at risk due to the high potassium (K) content. The aim of this study was to describe the prevalence and correlates of chronic hyperkalemia (HK) in CKD patients on nutritional care, and in particular, the risk of HK in patients on plant-based versus animal-based low-protein diets. We recruited adult patients affected by CKD not on dialysis, afferent to our renal nutrition clinic from November 2014 to May 2019. We evaluated a total of 870 accesses in 219 patients (172 m, 47 f, age 67 ± 13 years). HK was defined as mild when K serum level was 5.1-5.9 mEq/l, moderate when K serum level was 6.0-6.9 mEq/l, and severe HK when K serum level was ≥ 7 mEq/l. Biochemical, anthropometric data and medications were recorded. The prevalence of HK in all the renal nutrition visits was 26.1%; all but six cases were mild HK, whereas no severe HK was observed. The prevalence of HK was associated with decreased eGFR, up to 36.5% for eGFR < 20 ml/min. Medications were similar in hyperkalemic and normokalemic patients, RAASi being present in up to 85% of patients. In a follow-up of 40 ± 14 months, no association was found between HK and mortality, whereas HK, at the start of follow-up, showed a trend to increased ESRD risk. Serum potassium levels and prevalence of HK were not different between patients on animal-based low-protein diet and plant-based low-protein diet. In conclusion, chronic HK is quite prevalent in a renal nutrition clinic, especially when eGFR falls down below 60 ml/min, thereby reaching the highest prevalence in CKD stage 4. Hyperkalemia is mostly mild, being moderate to severe HK quite infrequent. Hyperkalemia was not associated with higher risk of mortality, whereas a trend, although not statistically significant, was observed for lower ESRD-free survival. Plant-based low-protein diet is not associated with significant higher prevalence of HK with respect to animal-based LPD at the same residual kidney function.

Low protein diets for non-diabetic adults with chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is defined as reduced function of the kidneys present for 3 months or longer with adverse implications for health and survival. For several decades low protein diets have been proposed for participants with CKD with the aim of slowing the progression to end-stage kidney disease (ESKD) and delaying the onset of renal replacement therapy. However the relative benefits and harms of dietary protein restriction for preventing progression of CKD have not been resolved. This is an update of a systematic review first published in 2000 and updated in 2006, 2009 and 2018. OBJECTIVES: To determine the efficacy of low protein diets in preventing the natural progression of CKD towards ESKD and in delaying the need for commencing dialysis treatment in non-diabetic adults. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 7 September 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi RCTs in which adults with non-diabetic CKD (stages 3 to 5) not on dialysis were randomised to receive a very low protein intake (0.3 to 0.4 g/kg/day) compared with a low protein intake (0.5 to 0.6 g/kg/day) or a low protein intake compared with a normal protein intake (≥ 0.8 g/kg/day) for 12 months or more. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies and extracted data. For dichotomous outcomes (death, all causes), requirement for dialysis, adverse effects) the risk ratios (RR) with 95% confidence intervals (CI) were calculated and summary statistics estimated using the random effects model. Where continuous scales of measurement were used (glomerular filtration rate (GFR), weight), these data were analysed as the mean difference (MD) or standardised mean difference (SMD) if different scales had been used. The certainty of the evidence was assessed using GRADE. MAIN RESULTS: We identified 17 studies with 2996 analysed participants (range 19 to 840). Four larger multicentre studies were subdivided according to interventions so that the review included 21 separate data sets. Mean duration of participant follow-up ranged from 12 to 50 months. Random sequence generation and allocation concealment were considered at low risk of bias in eleven and nine studies respectively. All studies were considered at high risk for performance bias as they were open-label studies. We assessed detection bias for outcome assessment for GFR and ESKD separately. As GFR measurement was a laboratory outcome all studies were assessed at low risk of detection bias. For ESKD, nine studies were at low risk of detection bias as the need to commence dialysis was determined by personnel independent of the study investigators. Five studies were assessed at high risk of attrition bias with eleven studies at low risk. Ten studies were at high risk for reporting bias as they did not include data which could be included in a meta-analysis. Eight studies reported funding from government bodies while the remainder did not report on funding. Ten studies compared a low protein diet with a normal protein diet in participants with CKD categories 3a and b (9 studies) or 4 (one study). There was probably little or no difference in the numbers of participants who died (5 studies 1680 participants: RR 0.77, 95% CI 0.51 to 1.18; 13 fewer deaths per 1000; moderate certainty evidence). A low protein diet may make little or no difference in the number of participants who reached ESKD compared with a normal protein diet (6 studies, 1814 participants: RR 1.05, 95% CI 0.73 to 1.53; 7 more per 1000 reached ESKD; low certainty evidence). It remains uncertain whether a low protein diet compared with a normal protein intake impacts on the outcome of final or change in GFR (8 studies, 1680 participants: SMD -0.18, 95% CI -0.75 to 0.38; very low certainty evidence). Eight studies compared a very low protein diet with a low protein diet and two studies compared a very low protein diet with a normal protein diet. A very low protein intake compared with a low protein intake probably made little or no difference to death (6 studies, 681 participants: RR 1.26, 95% CI 0.62 to 2.54; 10 more deaths per 1000; moderate certainty evidence). However it probably reduces the number who reach ESKD (10 studies, 1010 participants: RR 0.65, 95% CI 0.49 to 0.85; 165 per 1000 fewer reached ESKD; moderate certainty evidence). It remains uncertain whether a very low protein diet compared with a low or normal protein intake influences the final or change in GFR (6 studies, 456 participants: SMD 0.12, 95% CI -0.27 to 0.52; very low certainty evidence). Final body weight was reported in only three studies. It is uncertain whether the intervention alters final body weight (3 studies, 89 participants: MD -0.40 kg, 95% CI -6.33 to 5.52; very low certainty evidence).Twelve studies reported no evidence of protein energy wasting (malnutrition) in their study participants while three studies reported small numbers of participants in each group with protein energy wasting. Most studies reported that adherence to diet was satisfactory. Quality of life was not formally assessed in any studies. AUTHORS' CONCLUSIONS: This review found that very low protein diets probably reduce the number of people with CKD 4 or 5, who progress to ESKD. In contrast low protein diets may make little difference to the number of people who progress to ESKD. Low or very low protein diets probably do not influence death. However there are limited data on adverse effects such as weight differences and protein energy wasting. There are no data on whether quality of life is impacted by difficulties in adhering to protein restriction. Studies evaluating the adverse effects and the impact on quality of life of dietary protein restriction are required before these dietary approaches can be recommended for widespread use.

Sodium Intake and Chronic Kidney Disease.

In Chronic Kidney Disease (CKD) patients, elevated blood pressure (BP) is a frequent finding and is traditionally considered a direct consequence of their sodium sensitivity. Indeed, sodium and fluid retention, causing hypervolemia, leads to the development of hypertension in CKD. On the other hand, in non-dialysis CKD patients, salt restriction reduces BP levels and enhances anti-proteinuric effect of renin-angiotensin-aldosterone system inhibitors in non-dialysis CKD patients. However, studies on the long-term effect of low salt diet (LSD) on cardio-renal prognosis showed controversial findings. The negative results might be the consequence of measurement bias (spot urine and/or single measurement), reverse epidemiology, as well as poor adherence to diet. In end-stage kidney disease (ESKD), dialysis remains the only effective means to remove dietary sodium intake. The mismatch between intake and removal of sodium leads to fluid overload, hypertension and left ventricular hypertrophy, therefore worsening the prognosis of ESKD patients. This imposes the implementation of a LSD in these patients, irrespective of the lack of trials proving the efficacy of this measure in these patients. LSD is, therefore, a rational and basic tool to correct fluid overload and hypertension in all CKD stages. The implementation of LSD should be personalized, similarly to diuretic treatment, keeping into account the volume status and true burden of hypertension evaluated by ambulatory BP monitoring.

Improving access to phosphorus- and sodium-restricted foods for people living with chronic kidney disease in remote First Nations.

CONTEXT: Food insecurity in northern, remote Canadian communities has become increasingly recognised as a significant issue in rural health research and policy. Over the past decade, numerous government and academic reports have emerged, documenting the severity of this issue for the health people living in the Canadian north. People living in northern and remote Canadian communities experience significant challenges related to the cost, quality, and variety of market (store-bought) foods. These issues may be of particular concern for those living with chronic diseases that require therapeutic diets, such as chronic kidney disease (CKD). ISSUES: There is little to no research that documents the impact of food insecurity on disease management and quality of life for those living with CKD and end-stage renal disease (ESRD). There is also limited literature on food access for people living with ESRD in northern and remote communities. People living with food insecurity and CKD in remote communities might experience significant challenges in accessing the foods necessary for adhering to dietary guidelines. LESSONS LEARNED: This commentary examines northern food insecurity and draws attention to dietary challenges for residents of remote communities who are living on restricted or therapeutic diets due to chronic disease. In particular we point to the needs of those living with late-stage CKD and ESRD. We call attention to the need for clinicians to understand the capacity of patients to adhere to therapeutic dietary guidelines in remote communities.

[Hygieno-dietetic recommendations in the prevention of accumulation of advanced glycation products]. / Place des recommandations hygiéno-diététiques dans la prévention de l'accumulation des produits de glycation avancée.

Advanced glycation products are proteins whose structural and functional properties have been modified by a process of oxidative glycation. The accumulation of advanced glycation products in most tissues and the oxidative stress and inflammatory reactions that accompany it, account for the multi-systemic impairment observed particularly in the elderly, diabetics and in chronic renal failure. The advanced glycation products endogenous production is continuous, related to oxidative stress, but the most important source of advanced glycation products is exogenous, mainly of food origin. Exogenous advanced glycation products are developed during the preparation of food and beverages. The advanced glycation products content is higher for animal foods, but it is mainly the preparation and cooking methods that play a decisive role. Dietary advice is based on the selection of foods and the choice of methods of preparation. Several randomized controlled studies have confirmed the favorable effect of these recommendations on serum advanced glycation products concentrations. In humans, as in animals, regular physical activity also results in a reduction of serum and tissue concentrations of advanced glycation products. There is a need for prospective clinical study to confirm the effects of hygienic and dietary recommendations that have only been appreciated, so far, on biological markers.

Depressive symptoms and dietary non-adherence among end stage renal disease patients undergoing hemodialysis therapy: systematic review.

BACKGROUND: Research suggests that patients with end stage renal disease undergoing hemodialysis have a higher rate of depression and dietary non adherence leading to hospitalization and mortality. The purpose of this review was to synthesize the quantitative evidence on the relationship between depressive symptoms and dietary non adherence among end stage renal disease (ESRD) patients receiving hemodialysis. METHODS: A systematic review was undertaken. Three electronic databases were searched including PubMed, CINHAL and Web of Science. Only quantitative studies published between 2001 and 2016 were included in the review. RESULT: A total of 141 publications were reviewed during the search process and 28 articles that fulfilled the inclusion criteria were included in the review. Eleven studies (39.3%) reported on the prevalence of depressive symptoms or depression and its effect on patient outcomes. Ten studies (35.7%) focused on dietary adherence/non adherence in patients with ESRD and the remaining seven (25%) articles were descriptive studies on the relationship between depressive symptoms and dietary non adherence in patients with ESRD receiving hemodialysis. The prevalence of depressive symptoms and dietary non adherence ranged as 6-83.49% and from 41.1-98.3% respectively. Decreased quality of life & increased morbidity and mortality were positively associated with depressive symptoms. Other factors including urea, hemoglobin, creatinine and serum albumin had also association with depressive symptoms. Regarding dietary non adherence, age, social support, educational status, behavioral control and positive attitudes are important factors in ESRD patients receiving hemodialysis. Having depressive symptoms is more likely to increase dietary non adherence. CONCLUSION: Depressive symptoms and dietary non adherence were highly prevalent in patients with end stage renal disease receiving hemodialysis therapy. Nearly all of the articles that examined the relationship between depressive symptoms and dietary non adherence found a significant association. Future research using experimental or longitudinal design and gold standard measures with established cut-points is needed to further explain the relationship.

Nonadherence in Hemodialysis Patients and Related Factors: A Multicenter Study.

BACKGROUND: Nonadherence to dietary and fluid restrictions, hemodialysis (HD), and medication treatment has been shown to increase the risks of hospitalization and mortality significantly. Sociodemographic and biochemical parameters as well as psychosocial conditions such as depression and anxiety are known to affect nonadherence in HD patients. However, evidence related to the relative importance and actual impact of these factors varies among studies. PURPOSE: The aim of this study was to identify the factors that affect nonadherence to dietary and fluid restrictions, HD, and medication treatment. METHODS: This descriptive study was conducted on 274 patients who were being treated at four HD centers in Turkey. The parameters used to determine nonadherence to dialysis treatment were as follows: skipping multiple dialysis sessions during the most recent 1-month period, shortening a dialysis session by more than 10 minutes during the most recent 1-month period, and Kt/V < 1.4. The parameters used to determine nonadherence to dietary and fluid restriction were as follows: serum phosphorus level > 7.5 mg/dl, predialysis serum potassium level > 6.0 mEq/L, and interdialytic weight gain > 5.7% of body weight. The Morisky Green Levine Medication Adherence Scale was performed to determine nonadherence to medication treatment. A patient was classified as nonadherent if he or she did not adhere to one or more of these indices. The Hospital Anxiety and Depression Scale was used to identify patient risk in terms of anxiety and depression. Logistic regression was used to determine the predictors of nonadherence. RESULTS: The nonadherence rate was 39.1% for dietary and fluid restrictions, 33.6% for HD, and 20.1% for medication. The risk of nonadherence to dietary and fluid restriction was found to be 4.337 times higher in high school graduates (95% CI [1.502, 12.754], p = .007). The risk of nonadherence to HD treatment was 2.074 times higher in men (95% CI [1.213, 3.546], p = .008) and 2.591 times higher in patients with a central venous catheter (95% CI [1.171, 5.733], p = .019). Longer duration in HD resulted in 0.992 times decrease in risk of nonadherence to treatment (95% CI [0.986, 0.998], p = .005). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Educational status, being male, having a central venous catheter, and having a short HD duration were found to be risk factors for nonadherence. Nurses must consider the patient's adherence to the dietary and fluid restrictions, HD, and medication treatment at each visit.

Should we eat more potassium to better control blood pressure in hypertension?

Changes in lifestyle and nutrition are recommended as the first-step approach to the management of hypertension by all national and international guidelines. Today, when considering nutritional factors in hypertension, almost all the attention is focused on the reduction of salt intake to improve blood pressure (BP) control. Changes in potassium intake are only briefly evoked in guidelines. Few physicians actually think about proposing to eat more foods that are high in potassium (fruits, vegetables, nuts) to better control BP. Yet, during the last 40 years, increasing evidence has accumulated demonstrating that increasing potassium intake, either with food products or with supplements, is associated with significant reductions of both systolic and diastolic BP. The hypotensive effect of potassium is particularly marked in patients with hypertension and in subjects with a very high sodium intake, suggesting that potassium counterbalances the effects of sodium. In addition, several meta-analyses have now confirmed that high potassium intake reduces the risk of stroke by ∼ 25%. Finally, increasing potassium in the diet may perhaps be beneficial for some renal patients, as post hoc analyses have suggested that a high potassium intake may retard the decline of renal function in patients with early chronic kidney disease (CKD) stages. However, high potassium intake may be risky and sometimes even dangerous in hypertensive patients with CKD stages 3-5, specifically diabetics. In this context, however, as the level of evidence remains low, more prospective clinical studies are needed. The goal of this review is to discuss the actual evidence that supports the recommendation to eat more potassium in order to better control BP in essential hypertension and to review the restrictions in CKD patients with hypertension.

Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet.

AIM: Dietary modification is integral to the management of end stage kidney disease. However, adherence to the renal diet is poor. Few studies have explored the perspectives of renal dietitians and how they work with patients to facilitate dietary change. The objectives of this study were to explore the experiences of renal dietitians about educating patients with end stage kidney disease; and to describe the strategies perceived to help patients understand the renal diet. METHODS: Semi-structured interviews based on Sensemaking theory were conducted with renal dietitians (n = 27) working in Australia and New Zealand from a range of metropolitan, regional and remote areas. RESULTS: Five major themes across two categories were derived from the data. The renal dietitians in this study experienced feelings of frustration, frequently worked in practice environments with limited or inadequate resources and perceived that establishing trust and demonstrating empathy were important to sense making. Renal dietitians helped patients make sense of and understand the diet by clarifying ambiguities and conflicting information; and simplifying complexity by using simple explanations, individualised advice and practical support. These strategies were considered critical to the renal diet sense making process. CONCLUSIONS: The experience of providing renal diet advice to adults with end stage kidney disease was emotionally and professionally challenging. Alternative approaches to patient education may help dietitians to empower patients to better understand the renal diet. Further research exploring the experiences of learning about the renal diet from the patient and carer perspective would also help to inform future alternative approaches.

Adequacy of Plant-Based Proteins in Chronic Kidney Disease.

Concerns regarding protein and amino acid deficiencies with plant-based proteins have precluded their use in chronic kidney disease (CKD) patients. Many of these concerns were debunked years ago, but recommendations persist regarding the use of "high-biological value" (animal-based) proteins in CKD patients, which may contribute to worsening of other parameters such as blood pressure, metabolic acidosis, and hyperphosphatemia. Plant-based proteins are sufficient in meeting both quantity and quality requirements. Those eating primarily plant-based diets have been observed to consume approximately 1.0 g/kg/day of protein, or more. CKD patients have been seen to consume 0.7-0.9 g/kg/day of mostly plant-based protein without any negative effects. Furthermore, those substituting animal-based proteins for plant-based proteins have shown reductions in severity of hypertension, hyperphosphatemia, and metabolic acidosis. Plant-based proteins, when consumed in a varied diet, are not only nutritionally adequate but have pleiotropic effects which may favor their use in CKD patients.

Moderate Protein Restriction in Advanced CKD: A Feasible Option in An Elderly, High-Comorbidity Population. A Stepwise Multiple-Choice System Approach.

BACKGROUND: Protein restriction may retard the need for renal replacement therapy; compliance is considered a barrier, especially in elderly patients. METHODS: A feasibility study was conducted in a newly organized unit for advanced kidney disease; three diet options were offered: normalization of protein intake (0.8 g/kg/day of protein); moderate protein restriction (0.6 g/kg/day of protein) with a "traditional" mixed protein diet or with a "plant-based" diet supplemented with ketoacids. Patients with protein energy wasting (PEW), short life expectancy or who refused were excluded. Compliance was estimated by Maroni-Mitch formula and food diary. RESULTS: In November 2017⁻July 2018, 131 patients started the program: median age 74 years (min⁻max 24-101), Charlson Index (CCI): 8 (min-max: 2⁻14); eGFR 24 mL/min (4⁻68); 50.4% were diabetic, BMI was ≥ 30 kg/m² in 40.4%. Normalization was the first step in 75 patients (57%, age 78 (24⁻101), CCI 8 (2⁻12), eGFR 24 mL/min (8⁻68)); moderately protein-restricted traditional diets were chosen by 24 (18%, age 74 (44⁻91), CCI 8 (4⁻14), eGFR 22 mL/min (5⁻40)), plant-based diets by 22 (17%, age 70 (34⁻89), CCI 6.5 (2⁻12), eGFR 15 mL/min (5⁻46)) (p < 0.001). Protein restriction was not undertaken in 10 patients with short life expectancy. In patients with ≥ 3 months of follow-up, median reduction of protein intake was from 1.2 to 0.8 g/kg/day (p < 0.001); nutritional parameters remained stable; albumin increased from 3.5 to 3.6 g/dL (p = 0.037); good compliance was found in 74%, regardless of diets. Over 1067 patient-months of follow-up, 9 patients died (CCI 10 (6⁻12)), 7 started dialysis (5 incremental). CONCLUSION: Protein restriction is feasible by an individualized, stepwise approach in an overall elderly, high-comorbidity population with a baseline high-protein diet and is compatible with stable nutritional status.

Pruritus in hemodialysis patients: association with phosphorus intake and serum calcium level. / Prurido no paciente em hemodiálise: associação com ingestão de fósforo e nível sérico de cálcio.

OBJECTIVE: To analyze the association between the occurrence of pruritus and adherence to the prescribed diet, biochemical indicators of renal function and the quality of hemodialysis in chronic renal patients. METHOD: A cross-sectional study performed at a dialysis clinic in the Northeast of Brazil, with 200 patients undergoing hemodialysis in the first half of 2015.To analyze the data, inferential statistics were used, using Chi-Square and Fisher's Exact tests; and Mann Whitney U test. RESULTS: The pruritus was present in 51% of the sample, being associated statistically with phosphorus consumption (P = 0.024) and elevation of serum calcium (P = 0.009). CONCLUSION: Pruritus in chronic renal patients undergoing hemodialysis is influenced by adequate nonadherence to the prescribed diet, in addition to the elevation of biochemical indicators of renal function.

Dietary Approach to Recurrent or Chronic Hyperkalaemia in Patients with Decreased Kidney Function.

Whereas the adequate intake of potassium is relatively high in healthy adults, i.e., 4.7 g per day, a dietary potassium restriction of usually less than 3 g per day is recommended in the management of patients with reduced kidney function, especially those who tend to develop hyperkalaemia including patients who are treated with angiotensin pathway modulators. Most potassium-rich foods are considered heart-healthy nutrients with high fibre, high anti-oxidant vitamins and high alkali content such as fresh fruits and vegetables; hence, the main challenge of dietary potassium management is to maintain high fibre intake and a low net fixed-acid load, because constipation and metabolic acidosis are per se major risk factors for hyperkalaemia. To achieve a careful reduction of dietary potassium load without a decrease in alkali or fibre intake, we recommend the implementation of certain pragmatic dietary interventions as follows: Improving knowledge and education about the type of foods with excess potassium (per serving or per unit of weight); identifying foods that are needed for healthy nutrition in renal patients; classification of foods based on their potassium content normalized per unit of dietary fibre; education about the use of cooking procedures (such as boiling) in order to achieve effective potassium reduction before eating; and attention to hidden sources of potassium, in particular additives in preserved foods and low-sodium salt substitutes. The present paper aims to review dietary potassium handling and gives information about practical approaches to limit potassium load in chronic kidney disease patients at risk of hyperkalaemia.

Perspectives of healthcare providers on the nutritional management of patients on haemodialysis in Australia: an interview study.

OBJECTIVE: To describe the perspectives of healthcare providers on the nutritional management of patients on haemodialysis, which may inform strategies for improving patient-centred nutritional care. DESIGN: Face-to-face semistructured interviews were conducted until data saturation, and thematic analysis based on principles of grounded theory. SETTING: 21 haemodialysis centres across Australia. PARTICIPANTS: 42 haemodialysis clinicians (nephrologists and nephrology trainees (15), nurses (12) and dietitians (15)) were purposively sampled to obtain a range of demographic characteristics and clinical experiences. RESULTS: Six themes were identified: responding to changing clinical status (individualising strategies to patient needs, prioritising acute events, adapting guidelines), integrating patient circumstances (assimilating life priorities, access and affordability), delineating specialty roles in collaborative structures (shared and cohesive care, pivotal role of dietary expertise, facilitating access to nutritional care, perpetuating conflicting advice and patient confusion, devaluing nutritional specialty), empowerment for behaviour change (enabling comprehension of complexities, building autonomy and ownership, developing self-efficacy through engagement, tailoring self-management strategies), initiating and sustaining motivation (encountering motivational hurdles, empathy for confronting life changes, fostering non-judgemental relationships, emphasising symptomatic and tangible benefits, harnessing support networks), and organisational and staffing barriers (staffing shortfalls, readdressing system inefficiencies). CONCLUSIONS: Organisational support with collaborative multidisciplinary teams and individualised patient care were seen as necessary for developing positive patient-clinician relationships, delivering consistent nutrition advice, and building and sustaining patient motivation to enable change in dietary behaviour. Improving service delivery and developing and delivering targeted, multifaceted self-management interventions may enhance current nutritional management of patients on haemodialysis.

[Infrequent and incremental dialysis: differences and definitions].

The purpose of this review is to give dignity at the Incremental Dialysis, which cannot be confused with the term and the therapeutic choice defined as Infrequent Dialysis. The Infrequent Dialysis is defined by each and every hemodialytic therapeutic choice like rhythms below thrice-weekly-hemodialytic treatments. Nonetheless, Infrequent Dialysis is a choice of replacement hemodialysis therapy with pays more special clinical attentions and nutritional monitoring and should also be accompanied by a slightly hypoproteic controlled nutrition. When talking about the Incremental Dialysis (CDDP) it is defined as a well-defined therapeutic program that requires a significant clinical attention. The CDDP begins with the pre-dialysis outpatient clinic in the short period of time when the patient passes, after a severe nutrition compliance assessment with a VFG of 5-10 mL / min / 1.73mq, from the conservative treatment to an hypoproteic diet composed of 0.6g/ Kg / day with or without essential amino acids and hyposaline diet supplemented by One-Weekly Dialysis. The Incremental Dialysis program is strictly tailored on the trend of Residual Renal Function (FRR). CDDP is a time variable therapeutic "bridge" that must provide a good metabolic status and a good quality of life of the treated patients. Recent studies have shown a lower mortality compared with thrice-weekly-dialysis and a neutral input/output balance of phosphorus pool due to the phosphaturia contribution compared to the thrice-weekly-patients who lose early their FRR. Further studies are needed to confirm the safety and validity of this therapeutic choice.

[Practical procedures to launch a once-weekly-dialysis program integrated into a personalized hypoproteic nutrition (CDDP)].

This work is aimed for showing in detail to the nephrologists the methodology applied in the Combined Diet Dialysis Program (CDDP) in selected patients especially with the use of the Urea Nitrogen Appearance which allows to verify the sustainability and collaboration of patients on the 0.6 g/Kg/day hypoproteic diet by calculating the Protein Catabolic Rate in patients with metabolic steady state. It is also confirmed that the combined action of nutrition and the minimal contact with hemodialysis may allow a longer maintenance of the residual renal function with the further possibility of a greater excretion of Protein Bound Uremic Toxins and to obtain a phosphate balance thanks for a good maintenance of phosphaturia. In this paper are described in detail all the necessary steps and calculations. But it is mandatory a greater clinical commitment to achieve the achievement of a personalized therapeutic protocol like CDDP that is easily applicable in everyday clinical practice.