u/Riquelmemessi

Hi all,

I’ve been reading about nutrition in haemodialysis (HD) patients, and one thing that keeps coming up is how common poor adherence to dietary recommendations is.

Even when patients receive structured advice, many still struggle to follow it. I imagine this isn’t just about “patient motivation”, but also about how complex and restrictive these diets can be, and how they impact quality of life.

I came across this review while looking into the topic, which touches on some of these barriers:

https://academic.oup.com/ckj/article/doi/10.1093/ckj/sfag117/8655904?login=false

From a dietitian’s perspective:

👉 What do you think are the main drivers of poor adherence in HD patients?

👉 Are there specific strategies (education, counseling approaches, flexibility in diet, etc.) that you’ve found actually improve adherence in practice?

Would really appreciate hearing your experience or any evidence-based approaches that have worked for you.

Personalised Nutrition in Haemodialysis: A Scoping Review of Studies Published Between 2015 and 2025

🔗 https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfag117/8655904

​

DOI: 10.1093/ckj/sfag117

🔗 https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfag117/8655904

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If you are on dialysis and you struggle with your diet, you have probably been told at some point — directly or indirectly — that you are not trying hard enough. That you need more willpower. That non-compliance is dangerous and it is your responsibility to fix it.

A scoping review just published in one of the top nephrology journals in the world says something very different.

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THE ACTUAL NUMBERS

60% of dialysis patients globally do not follow their dietary recommendations. Not 5%. Not 10%. Six in ten. That number has barely moved in decades despite all the dietary counselling, all the education sessions, all the restrictions.

If 60% of patients are failing, the question worth asking is not what is wrong with the patients. The question is what is wrong with the approach.

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WHAT THE SCIENCE ACTUALLY SAYS

The review synthesised 30 studies published between 2015 and 2025 and found that non-adherence in dialysis patients is not primarily a willpower problem. It is a predictable consequence of a care model that:

Imposes restrictions that feel impossible to maintain in real daily life. Gives contradictory advice from different members of the healthcare team. Fails to account for your cultural background, your food preferences, or what actually matters to you. Ignores the exhaustion, the emotional burden, and the cognitive load that comes with being a dialysis patient.

The science calls non-adherence a marker of vulnerability. Not a character flaw.

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THE DIET YOU WERE GIVEN MAY BE OUTDATED

The so-called "universal renal diet" — the long list of foods you cannot eat, the rigid potassium and phosphorus restrictions, the rules that seem to change depending on who you ask — is being seriously questioned by current evidence.

Studies now show that supervised plant-based dietary patterns can be safe for dialysis patients without raising potassium dangerously. That more flexible, culturally adapted, enjoyable diets can work better for adherence and quality of life than strict restriction models. That blanket bans on vegetables while nobody monitors ultra-processed food consumption is a clinical contradiction that the research is beginning to address openly.

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THE TOOL PROBLEM

Here is something most dialysis patients are never told. The blood tests your team uses to assess your nutritional status — mainly albumin and body weight — are not very good at detecting the real problem. In dialysis patients, fluid shifts, inflammation, and changes in body composition mean that these numbers can look normal while muscle mass is quietly declining.

Better tools exist. Muscle ultrasound. Body composition analysis. Grip strength testing. A scoring system called the Malnutrition-Inflammation Score. These tools detect nutritional problems earlier and more accurately. The review found that fewer than 25% of dialysis centres use them routinely.

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THE DIETITIAN GAP

Only 36% of dialysis centres worldwide have a permanent renal dietitian on the team. In many countries, nutrition is not even formally recognised as part of kidney care. That means millions of dialysis patients are navigating one of the most complex diets in medicine with minimal professional support — and then being told they are not doing it right.

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WHAT THIS MEANS FOR YOU

This research does not mean diet does not matter on dialysis. It does, significantly. But it does mean that if you are struggling, the struggle is not entirely your fault. And it means that a growing body of evidence supports a different kind of nutritional care — one that is built around your life, your preferences, your culture, and your real circumstances — not a one-size-fits-all list of prohibitions.

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If your centre has a renal dietitian, use them. If it does not, you can advocate for access to one. And if you have been made to feel like a bad patient because of your diet, this paper might be worth showing your team.

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Rojas-Pérez JF, González-Salvatierra S, Oncina-Cánovas A, Padial M, López-Jiménez V, Olveira G. Personalised Nutrition in Haemodialysis: A Scoping Review of Studies Published Between 2015 and 2025. Clinical Kidney Journal, 2026. DOI: 10.1093/ckj/sfag117

​

DOI: 10.1093/ckj/sfag117

🔗 https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfag117/8655904

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A scoping review of 30 studies just published in the Clinical Kidney Journal (Oxford/ERA, 2026) makes a compelling case that the way we currently manage nutrition in haemodialysis is fundamentally broken — and that the patients are paying the price for it.

Here is what the evidence actually says.

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60% OF DIALYSIS PATIENTS DON'T FOLLOW THEIR DIET. IT'S NOT THEIR FAULT.

Six in ten haemodialysis patients globally do not adhere to their dietary recommendations. The instinctive response from many clinicians is to attribute this to patient non-compliance. The evidence says that framing is wrong.

The reviewed literature consistently shows that non-adherence is a predictable consequence of a care model that imposes overly restrictive, culturally tone-deaf, and often contradictory dietary rules on people who are already exhausted, unwell, and carrying an enormous treatment burden. Patients describe frustration, confusion, fear, and a complete inability to reconcile dietary restrictions with any semblance of normal daily life.

Non-adherence in HD is not a behaviour problem. It is a symptom of a system that has never properly adapted to the patient.

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THE TOOLS WE USE TO DETECT MALNUTRITION ARE WRONG

Most HD units still rely on serum albumin and BMI to assess nutritional status. Both are widely recognised in the literature to be poor indicators in this population — yet both remain standard practice in the majority of centres.

Why are they unreliable? Fluid shifts between sessions, chronic inflammation, and sarcopenic obesity all independently alter these values in ways that have nothing to do with actual nutritional status. A patient can have a normal BMI and normal albumin while simultaneously losing significant muscle mass and functional capacity.

The tools that actually work — muscle ultrasonography, multifrequency BIA phase angle, handgrip dynamometry, and the Malnutrition-Inflammation Score — are non-invasive, accessible, and validated. Fewer than 25% of HD centres use them routinely.

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ONLY 36% OF DIALYSIS CENTRES HAVE A PERMANENT RENAL DIETITIAN

This is perhaps the most damning finding in the entire review. Only 36% of HD centres worldwide employ a permanent renal dietitian. In more than 40% of countries, clinical nutrition is not even formally recognised as a regulated discipline within nephrology.

The review is unambiguous: without sustained professional presence at the clinical interface, no nutritional framework — however evidence-based — can translate into meaningful outcomes for patients.

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PLANT-BASED FOODS ARE NOT THE ENEMY

One of the more striking findings is the growing evidence supporting supervised plant-forward dietary patterns in HD patients. For decades, plant foods have been largely restricted due to concerns about hyperkalaemia. The reviewed studies consistently show that well-planned, professionally supervised plant-based approaches are compatible with stable serum potassium while improving phosphorus metabolism, FGF-23 concentrations, and inflammatory markers.

The blanket restriction of vegetables and plant proteins in dialysis patients appears increasingly difficult to justify on current evidence.

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WHAT THE REVIEW PROPOSES

The authors identify a fundamental problem: "personalised nutrition" in HD has been referenced everywhere in the literature but never actually defined. The result is a chaotic mix of studies using "individualised," "tailored," and "personalised" interchangeably, with no shared framework and no way to compare results across trials.

The review proposes the first operational definition:

"The tailoring of dietary strategies to an individual's clinical phenotype, morphofunctional status, metabolic profile, and personal preferences, integrating nutritional intervention, functional assessment, and behavioural dimensions within a patient-centred framework."

Five dimensions: clinical profile, morphofunctional assessment, dietary factors, psychosocial determinants, and contextual factors.

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THE UNCOMFORTABLE TRUTH

The review is honest about its limitations. Most of the underlying studies are small, short-term, and dominated by surrogate outcomes. Hard endpoints like mortality and hospitalisation remain largely absent from the nutritional literature in HD. The proposed framework is evidence-grounded but not yet prospectively validated.

But the uncomfortable conclusion is hard to escape: haemodialysis patients have been managed with restrictive, biochemistry-driven, one-size-fits-all dietary approaches for decades. The evidence for doing it differently has been building for years. The barrier is not scientific — it is structural, organisational, and professional.

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Rojas-Pérez JF, González-Salvatierra S, Oncina-Cánovas A, Padial M, López-Jiménez V, Olveira G. Personalised Nutrition in Haemodialysis: A Scoping Review of Studies Published Between 2015 and 2025. Clinical Kidney Journal, 2026. DOI: 10.1093/ckj/sfag117

Hi r/Nephrology,

A scoping review on personalised nutrition in haemodialysis was just published in the Clinical Kidney Journal (Oxford University Press / European Renal Association). Sharing the key findings here as they seem highly relevant for clinical practice and worth discussing.

The paper: "Personalised Nutrition in Haemodialysis: A Scoping Review of Studies Published Between 2015 and 2025"

🔗 https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfag117/8655904

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WHY THIS PAPER MATTERS

The term "personalised nutrition" is everywhere in HD literature — but no operational definition existed. Studies use "individualised," "tailored," and "personalised" interchangeably, creating massive heterogeneity and making cross-trial comparison almost impossible. This review maps the evidence and proposes a working conceptual framework.

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KEY FINDINGS (30 studies, 2015–2025)

On dietary non-adherence:

Around 60% of HD patients globally don't follow dietary recommendations. The evidence frames this as a structural problem rather than a behavioural one — prescriptions are perceived as overly restrictive, culturally misaligned, and disconnected from daily life. Non-adherence appears to be a marker of broader vulnerability, not wilful non-compliance.

On the renal dietitian gap:

Only 36% of HD centres worldwide employ permanent renal dietitians. Clinical nutrition is not formally recognised as a regulated discipline within nephrology in more than 40% of countries. The authors identify this as arguably the single biggest modifiable barrier to improving nutritional outcomes in HD.

On nutritional assessment:

Serum albumin and BMI consistently underestimate nutritional risk in HD — fluid shifts, inflammation, and sarcopenic obesity all confound them. Muscle ultrasonography (sensitivity 83%, specificity 78% for sarcopenia), MF-BIA phase angle, handgrip dynamometry, and the Malnutrition-Inflammation Score perform significantly better and are feasible in routine HD unit settings.

On dietary strategies:

Individualised oral supplementation showed improvements in albumin, prealbumin, MIS, and quality of life. Supervised plant-forward diets were compatible with stable potassium and associated with improvements in FGF-23 and phosphorus metabolism. Probiotics, prebiotics and synbiotics reduced CRP, IL-6 and uraemic toxins. Omega-3 and antioxidant interventions showed cardiometabolic and anti-inflammatory benefits. Oral creatine showed promising results for muscle mass and functional capacity.

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PROPOSED DEFINITION OF PERSONALISED NUTRITION IN HD

"The tailoring of dietary strategies to an individual's clinical phenotype, morphofunctional status, metabolic profile, and personal preferences, integrating nutritional intervention, functional assessment, and behavioural dimensions within a patient-centred framework."

Five core dimensions: clinical profile, morphofunctional assessment, dietary factors, psychosocial determinants, and contextual factors.

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HONEST LIMITATIONS

Most interventional studies enrolled fewer than 100 participants with follow-up of only 6–16 weeks. Surrogate biochemical outcomes dominate — hard endpoints such as mortality and hospitalisation are underreported. The framework is evidence-grounded but not yet prospectively validated. The authors explicitly warn that "personalisation" risks becoming rhetorical without structural investment in dietitian integration and standardised assessment protocols.

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QUESTIONS FOR THE COMMUNITY

1. How many of your HD units have a permanent renal dietitian integrated into the multidisciplinary team?

2. Are you using morphofunctional tools such as BIA, muscle ultrasound or MIS routinely, or still relying primarily on albumin?

3. Do you think the shift away from the universal renal diet toward more flexible, patient-centred models is realistic in your setting?

Full open-access paper at the link above.

Rojas-Pérez JF et al. Clinical Kidney Journal, 2026. DOI: 10.1093/ckj/sfag117