Plant-Based Diet in Hemodialysis: Risk or Benefit?

Oh, I like avocados, but I am not supposed to eat them! Sound familiar?

In case you have not done so already, you can probably recycle your handouts containing long lists of foods and beverages for patients to avoid. Indeed, many of the underlying assumptions that guided the traditional low-potassium, low-phosphorus, high-protein dialysis diet plans have been comprehensively criticized over the last several years (1, 2), establishing the requisite clinical equipoise to justify exploring new dietary approaches and strategies in this population.

The traditional dialysis diet generally restricted otherwise healthy plant-based food options (including whole grains; high-potassium fruits and vegetables; and nuts, seeds, and legumes), along with low-fat dairy products, to manage hyperkalemia and hyperphosphatemia risk. At the same time, it promoted excess intake of eggs, meat, fish, and poultry to prevent protein-energy wasting (3). This diet is difficult to adhere to and not appreciated by most patients.

The term plant-based has been increasingly adopted in the literature to describe alternative diet plans that instead promote whole grains, encourage a balance of plant-based and animal-based protein foods, and/or eliminate restrictions on high-potassium fruits and vegetables (4). There is nothing unique about this plant-based diet; it simply emphasizes consuming a variety of healthy foods and is largely consistent with other healthy eating patterns such as the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets that have been found to have many potential health benefits (4).

There are many potential benefits of transitioning from the traditional nutrient-based dialysis diets to plant-based diets. Eliminating what were probably unnecessary dietary restrictions may enable patients to adopt a more varied, enjoyable diet while reducing the stress and burden of trying to follow a diet that allows peaches and tangerines, for example, but not nectarines and bananas (3, 5). Along with these modifications, the time and effort that had been dedicated to counseling patients to adopt this complicated, restrictive, and generally unhealthy eating pattern can be redirected to other potentially more positive aspects of health promotion such as increasing fruit and vegetable intake, enjoying more homemade meals, and reading food labels (6, 7).

With so many abandoning the rapidly sinking traditional diet “ship,” it seems destined to sail off and fade into the annals of medical misadventures. It shall not be missed. And although it may no longer guide care, the legacy of the nutrient-based dialysis diet can continue to instruct. The fact that such a diet was adopted for so long without being tested should serve as a reminder about the potential complexity of diet therapy and value that dietary intervention trials provide in promoting evidence-based dietetic practice.

That dearth persists today; so care. It is likely possible that plant-based diets may provide benefits and satisfaction to patients. However, it is also possible that some degree of moderation and restriction is still needed in some patients prone to certain complications (e.g., hyperkalemia) or during periods in which these complications can magnify. Indeed, the best diet for the average patient may not be the best diet for your patient, and as with all diets, potential pitfalls with plant-based diets have been identified (8).

Ultimately, there are still many avenues to study before the potential of diet therapy to prevent and manage nutrition-related complications in people with kidney diseases can be fully realized. But, as alternative dietary strategies are explored, dietetic professionals will be better equipped to provide tailored medical nutrition therapy that addresses nutrition-related complications while promoting a healthy diet. Although there is still much to do, given the many proposed diet and health benefits that could be derived from a more liberal, healthier, plant-based diet, there is good reason for optimism.