To the Editor: The clinical trial by Dr Sullivan and colleagues1 showed that the serum phosphorus concentration can be reduced in patients on maintenance hemodialysis by avoiding phosphorus-containing food additives. The results are potentially useful to guide educational interventions aimed at improving the nutritional care of hemodialysis patients. The findings also have public health importance, considering that high serum phosphorus concentration is a risk factor for adverse cardiovascular events and bone disease among patients at earlier stages of chronic kidney disease.2
However, to translate the results into clinical practice recommendations for the care of patients on maintenance hemodialysis it is necessary to take into account limitations of the study, particularly regarding the absence of information about the effect of the intervention on protein intake. Lack of appetite is very common among hemodialysis patients.3 Phosphorus-containing additives are often added to enhance the flavor of processed foods, which may contribute to food choices by hemodialysis patients, particularly among those with lack of appetite. It is therefore important to know whether the patients who were randomized to receive education on avoiding foods with phosphorus additives reduced protein intake.
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative has recommended the use of normalized protein nitrogen appearance (also referred to as normalized protein catabolic rate) to assess dietary protein intake.4 It would be interesting if the authors could provide information on change in protein intake after 3 months assessed by normalized protein catabolic rate or other validated measure of protein intake. This additional finding would be very important to support clinical practice recommendations, given evidence that mortality may be increased among hemodialysis patients when the dietary restriction of phosphorus is associated with a concomitant decline in protein intake.5
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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