Dietetic Management of Hyperkalemia in Chronic Kidney Disease: An International Mixed-Methods Study with Practice-Informed Recommendations

Objective

To describe and interpret the experiences and practice patterns of renal dietitians regarding the dietary management of hyperkalemia in people with chronic kidney disease.

(Design and) Methods

Sequential explanatory mixed-methods study comprising a global cross-sectional survey and follow-up qualitative interviews. An online questionnaire was distributed internationally and explored thresholds for dietary potassium restriction, sources of conflict in clinical practice, and prioritization of dietary strategies. Free-text question responses and interview transcripts were analyzed using inductive thematic analysis.

Results

Renal dietitians (n = 203) from 14 countries (94% female; mean age 42.2 years ± 10.9; mean number of years of renal dietetic experience was 12.6 years ± 9.1) completed the questionnaire. Eight renal dietitians from 3 countries subsequently participated in semi-structured interviews (100% female; mean age 42.1 years ± 8.7; mean years of experience 14.9 years ± 7.2). Practice patterns varied significantly across countries, with dietitians reporting differences in professional autonomy, potassium thresholds for dietary restriction, and use of pharmacological adjuncts. Almost 60% reported that concerns about nonadherence and mortality risk influenced decision-making. Dietitians prioritized addressing nondietary factors, potassium additives, and processed foods before restricting fruits and vegetables. Four qualitative themes contextualized these findings: diverse referral pathways, triage and prioritization, holistic assessment, and professional and emotional labor. These highlighted fragmented referral systems, workload pressures, and the ethical tension between patient safety, diet adequacy, and quality of life.

Conclusions

Dietetic management of hyperkalemia in chronic kidney disease is complex, variable, and influenced by systemic, cultural, and professional factors. Dietitians adopt pragmatic, patient-centered strategies but face challenges of autonomy, conflict, and workload. International consensus and clearer evidence-based guidance are needed to support consistent, high-quality dietetic care in hyperkalemia.