Liberalizing Potassium Restrictions in Patients Receiving Hemodialysis

Overview

People with end-stage kidney disease who receive hemodialysis are often told to strictly limit foods high in potassium, such as fruits, vegetables, legumes, nuts, and whole grains. This advice is intended to prevent high blood potassium levels (hyperkalemia), which can cause dangerous heart rhythm problems. However, these restrictions can make eating difficult, reduce diet quality, and lower quality of life. New research suggests that not all sources of potassium affect the body in the same way. Potassium added to highly processed foods is more easily absorbed than potassium naturally found in whole foods like fruits and vegetables. Large studies have found little evidence that eating potassium-rich whole foods increases blood potassium levels in people on dialysis. Clinical guidelines are beginning to shift, but no high-quality clinical trial has tested whether a more flexible, food-based approach is safe for people receiving hemodialysis. This study will compare two dietary approaches in 148 adults on hemodialysis: the usual low potassium diet and a "liberalized" potassium diet that encourages minimally processed foods while limiting highly processed foods with potassium additives. Participants will receive dietitian support and grocery assistance for 12 weeks. The investigators will closely monitor blood potassium levels to ensure safety. The investigators will also examine whether the liberalized diet is as safe as standard care, and whether it improves diet quality and quality of life. The investigators will also study factors that influence the participant's ability to follow the diet in real-world settings. If safe, this approach could reduce unnecessary food restrictions, improve diet quality, and enhance quality of life for people receiving hemodialysis, while maintaining patient safety.

Current potassium guidelines are highly restrictive, limit nutritious whole foods, and contribute to poor diet quality and reduced quality of life - yet largely rely on expert consensus rather than robust trial evidence. To our knowledge, LIBERATE K-HD would be the first RCT to evaluate the safety and sustainability of a liberalized potassium diet in patients receiving hemodialysis, directly addressing this critical evidence gap. By shifting the focus from strict potassium restriction to whole, minimally processed foods, this approach has the potential to simplify dietary advice, improve patient satisfaction, and enhance overall nutrition without increasing the risk of hyperkalemia. The results will directly inform clinical practice guidelines and renal dietetic practice, providing patient-centered evidence to support more flexible and equitabledietary recommendations. The behavioural and adherence data generated will further identify key determinants of sustained dietary change, including food literacy, self-efficacy, and dietary burden, offering guidance for behaviour change counselling and responsible implementation of a liberalized potassium approach in routine dialysis care. If effective, it could support more flexible and patient-centered dietary recommendations that improve both health outcomes and patient well-being.