Nutrient Non-equivalence: Does Restricting High-Potassium Plant Foods Help to Prevent Hyperkalemia in Hemodialysis Patients?

Abstract

Hemodialysis patients are often advised to limit their intake of high-potassium foods to help manage hyperkalemia. However, the benefits of this practice are entirely theoretical and not supported by rigorous randomized controlled trials. The hypothesis that potassium restriction is useful is based on the assumption that different sources of dietary potassium are therapeutically equivalent. In fact, animal and plant sources of potassium may differ in their potential to contribute to hyperkalemia. In this commentary, we summarize the historical research basis for limiting high-potassium foods. Ultimately, we conclude that this approach is not evidence-based and may actually present harm to patients. However, given the uncertainty arising from the paucity of conclusive data, we agree that until the appropriate intervention studies are conducted, practitioners should continue to advise restriction of high-potassium foods.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

“…Only recently has attention focused on added phosphorus, distinguishing between processed and unprocessed foods [13,14,40,41,42,43,44,45,46,47]. …”

Assessment and misassessment of potassium, phosphorus, and protein in the hemodialysis diet

“…In contrast, hyperkalemia is thought to result from acute exposure to a high‐potassium meal, and from accumulation of potassium from consuming a high‐potassium diet. Of interest, only the former (acute exposure) association is supported by empirical evidence, as dietary potassium intakes have been found to be weakly, or not at all, associated with predialysis serum potassium concentrations . To put this in context, a 0.25 mmol/kg oral bolus of potassium chloride with 50 g of dextrose (683 mg for a 70‐kg patient) was associated with an average 3‐hour peak change in serum potassium concentrations of 0.4 mEq/L in HD patients .…”

Managing protein‐energy wasting in hemodialysis patients: A comparison of animal‐ and plant‐based protein foods

“…The current dietary guidelines for HD patients are based on standard assumptions of nutritional equivalence, which assert that the relationships of nutrient intakes with diet‐related health outcomes are independent of food sources. Prior studies have hypothesized that plant‐ and animal‐based potassium and phosphorus may differentially impact hyperkalemia and hyperphosphatemia, respectively . In this review, we examined how plant‐ and animal‐protein foods may affect PEW risk in HD patients.…”

“…In recent years, the necessity of limiting or avoiding plant foods to manage hyperkalemia and hyperphosphatemia has been questioned . This shift away from the standard, nutrient‐focused approach has sparked considerable interest in potential benefits of plant‐rich and liberalized diets in HD patients.…”

“…In recent years, the necessity of limiting or avoiding plant foods to manage hyperkalemia and hyperphosphatemia has been questioned. [23][24][25] This shift away from the standard, nutrient-focused approach has sparked considerable interest in potential benefits of plant-rich and liberalized diets in HD patients. However, given the high prevalence and severe consequences of PEW in HD patients, it is important to consider how liberalizing the diet to allow plants could affect PEW risk.…”