Phosphorus retention occurs from higher dietary phosphorus intake relative to its renal excretion or dialysis removal. In the gastrointestinal tract the naturally existing organic phosphorus is only partially (∼60%) absorbable; however, this absorption varies widely and is lower for plant-based phosphorus including phytate (<40%) and higher for foods enhanced with inorganic phosphorus-containing preservatives (>80%). The latter phosphorus often remains unrecognized by patients and health care professionals, even though it is widely used in contemporary diets, in particular, low-cost foods. In a nonenhanced mixed diet, digestible phosphorus correlates closely with total protein content, making protein-rich foods a main source of natural phosphorus. Phosphorus burden is limited more appropriately in predialysis patients who are on a low-protein diet (∼0.6 g/kg/d), whereas dialysis patients who require higher protein intake (∼1.2 g/kg/d) are subject to a higher dietary phosphorus load. An effective and patient-friendly approach to reduce phosphorus intake without depriving patients of adequate proteins is to educate patients to avoid foods with high phosphorus relative to protein such as egg yolk and those with high amounts of phosphorus-based preservatives such as certain soft drinks and enhanced cheese and meat. Phosphorus rich foods should be prepared by boiling, which reduces phosphorus as well as sodium and potassium content, or by other types of cooking-induced demineralization. The dose of phosphorus-binding therapy should be adjusted separately for the amount and absorbability of phosphorus in each meal. Dietician counseling to address the emerging aspects of dietary phosphorus management is instrumental for achieving a reduction of phosphorus load.

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.

Objective

Assessment of the quantity and chemical type of phosphorus (P) content in cooked ham products with or without preservatives using a novel biochemical procedure.

Methods

We examined the quantity and types of P in 40 samples of cooked ham, including 20 without and 20 with P-containing preservatives, which were purchased randomly from a grocery store in Italy. Food samples were analyzed for dry matter, nitrogen, fat, and P content. Novel spectrophotometric methods were used to measure total P and 3 different P subtypes, that is, water-soluble (inorganic) P including added preservatives and natural P derived from phospholipids and phosphoproteins, separately.

Results

Compared with hams without preservatives, hams with P-containing preservatives had significantly lower dry matter and protein and fat contents. There was 66% more inorganic P (IP) in ham with preservatives than in samples without preservatives (169 ± 36 vs. 102 ± 16 mg/100 g, P < .001, respectively). There were no significant differences in P contents derived from proteins or lipids. The P-to-protein ratio was higher in ham samples with preservatives than in those without preservatives (16.1 ± 4.0 and 9.8 ± 0.8 mg/g, P < .001). The sum of measured IP and P from phospholipids and phosphoproteins was 91% ± 4% of measured total P (207.1 ± 50.7 vs. 227.2 ± 54.4 mg/100 g), indicating a small portion of unspecified P and/or under measurement.

Conclusions

Novel differential dietary P measurement detects added P-containing preservatives. Cooked ham with preservatives has 66% more measurable IP and 64% higher P-to-protein ratio than ham without preservatives. The contribution of food added with P-containing preservatives to global dietary P burden can negatively influence chronic kidney disease outcome and counteract the efficacy of P-binder medications: this is an important topic that warrants additional investigations.

Phosphorus is an important natural nutrient, but high dietary phosphorus intake, including that sourced from added preservatives, is of great concern in renal patients. In this context a reliable analytical method able to quantify differential phosphorus in food could be a valuable tool for monitoring diet composition This paper presents a novel analytical procedure to quantify the following kinds of phosphorus in cooked ham: total (TP), inorganic (IP), from phospholipids (PL), and from phosphoproteins (PP). This technique is based on a suitable sample preparation followed by spectrophotometric analyses. Analytical performances of each method were evaluated, taking advantage also of food industry certified material and in-house reference samples. Limit of detection and limit of quantification values for TP, IP, PP-derived, and PL-derived phosphorus were 13 and 37, 11 and 33, 2 and 20, and 6 and 16 mg P/100 g fresh mass, respectively. Similar results were obtained when this procedure was used to quantify different types of phosphorus present in cooked ham samples. In conclusion, this procedure is effective for quantifying the content of different types of phosphorus present in cooked ham, which can be contributed by different phosphorus-containing ingredients and additives. To the best of the authors' knowledge, this is the first time that simultaneous determination of TP, IP, PL, and PP in cooked ham has been reported.

Initiation of thrice-weekly hemodialysis often results in a rapid loss of residual kidney function (RKF) including reduction in urine output. Preserving RKF longer is associated with better outcomes including greater survival in dialysis patients. An alternative approach aimed at preserving RKF is an incremental transition with less frequent hemodialysis sessions at the beginning with gradual increase in hemodialysis frequency over months. In addition to favorable clinical and economic implications, an incremental transition would also enhance a less stressful adaptation of the patient to dialysis therapy. The current guidelines provide only limited recommendations for incremental hemodialysis approach, whereas the potential role of nutritional management of newly transitioned hemodialysis patients is largely overlooked. We have reviewed previous reports and case studies of once-weekly hemodialysis treatment combined with low-protein, low-phosphorus, and normal-to-high-energy diet especially for nondialysis days, whereas on dialysis days, high protein can be provided. Such an adaptive dietary regimen may elicit more favorable outcomes including better preserved RKF, lower β2-microglobulin levels, improved phosphorus control, and lower doses of erythropoiesis-stimulating agents. Clinical and nutritional status and RKF should be closely monitored throughout the transition to once and then twice-weekly regimen and eventually thrice-weekly hemodialysis. Further studies are needed to verify the long-term safety and implications of this approach to dialysis transition.

Background

Maintenance hemodialysis is typically prescribed thrice weekly irrespective of a patient's residual kidney function (RKF). We hypothesized that a less frequent schedule at hemodialysis therapy initiation is associated with greater preservation of RKF without compromising survival among patients with substantial RKF.

Study design

A longitudinal cohort.

Setting & participants

23,645 patients who initiated maintenance hemodialysis therapy in a large dialysis organization in the United States (January 2007 to December 2010), had available RKF data during the first 91 days (or quarter) of dialysis, and survived the first year.

Predictor

Incremental (routine twice weekly for >6 continuous weeks during the first 91 days upon transition to dialysis) versus conventional (thrice weekly) hemodialysis regimens during the same time.

Outcomes

Changes in renal urea clearance and urine volume during 1 year after the first quarter and survival after the first year.

Results

Among 23,645 included patients, 51% had substantial renal urea clearance (≥3.0mL/min/1.73m(2)) at baseline. Compared with 8,068 patients with conventional hemodialysis regimens matched based on baseline renal urea clearance, urine volume, age, sex, diabetes, and central venous catheter use, 351 patients with incremental regimens exhibited 16% (95% CI, 5%-28%) and 15% (95% CI, 2%-30%) more preserved renal urea clearance and urine volume at the second quarter, respectively, which persisted across the following quarters. Incremental regimens showed higher mortality risk in patients with inadequate baseline renal urea clearance (≤3.0mL/min/1.73m(2); HR, 1.61; 95% CI, 1.07-2.44), but not in those with higher baseline renal urea clearance (HR, 0.99; 95% CI, 0.76-1.28). Results were similar in a subgroup defined by baseline urine volume of 600mL/d.

Limitations

Potential selection bias and wide CIs.

Conclusions

Among incident hemodialysis patients with substantial RKF, incremental hemodialysis may be a safe treatment regimen and is associated with greater preservation of RKF, whereas higher mortality is observed after the first year of dialysis in those with the lowest RKF. Clinical trials are needed to examine the safety and effectiveness of twice-weekly hemodialysis.