Nutritional Issues with Incremental Dialysis: The Role of Low-Protein Diets.

A gentle start of dialysis is a welcome possibility for both patients and physicians. Incident dialysis patients often maintain residual kidney function (RKF) for a considerable period of time; the start of dialysis is often driven mainly by uremic symptoms. Recently, the combination of a low-protein diet, along with a less-frequent dialysis schedule, has regained interest as an alternative option in selected and motivated patients. In addition, there is renewed interest in a low-protein diet in patients with moderate to advanced chronic kidney disease (CKD). Dietary regimens have additional objectives now: obtaining better control of phosphate and potassium levels; preventing or reducing metabolic acidosis, protein catabolism, and malnutrition; and reducing uremic symptoms. In the eighties and early nineties, data from uncontrolled studies showed that combining a very low-protein diet with once weekly hemodialysis was a feasible approach. However, these diets were very demanding with poor patient compliance and had a high risk of smoldering malnutrition. However, recent experience has shown that the new protein-free foods have better palatability and nutritional properties; this has increased adherence to dietary prescriptions. Dietary regimens are now tailored to the patient's needs and habits. A multidisciplinary approach is considered crucial for updating medical needs and dietary prescriptions, ensuring adherence to the combined program, and avoiding the development of malnutrition and inadequate dialysis. Monitoring RKF is another key factor for the success of the program due to the importance of optimal timing of the transition to twice-weekly regimens and, eventually, thrice-weekly hemodialysis.