Moderate stepwise restriction of potassium intake to reduce risk of hyperkalemia in chronic kidney disease: A literature review

Table 2 Recommended potassium intake for adult patients with chronic kidney disease

Source	Advice
KDOQI
2000[36]	CKD 1-5 ND: Unrestricted intake unless serum potassium level is elevated; HD: Intake up to 2.7-3.1 g/d; PD: Intake close to 3-4 g/d
2004[18]	CKD 1-2: intake > 4 g/d; CKD 3-4: intake 2-4 g/d
2020[6]; with the Academy of Nutrition and Dietetics	Statement 3.3.2: in adults with CKD 1–4, we suggest that prescribing increased fruit and vegetable intake may decrease body weight, blood pressure, and net acid production (2C); Statement 6.1.1: in adults with CKD 1–4, we suggest reducing net acid production through increased dietary intake of fruits and vegetables (2C) to reduce the rate of decline of residual kidney function; Statement 6.4: Adjust dietary potassium intake to maintain serum potassium within the normal range for adults with CKD 3–5D (opinion)
2019[19]; NKF educational website	A potassium restricted diet is typically about 2 g/d. A physician or dietitian will advise patient on the specific level of restriction needed based on individual health
EBPG
2007[37]	Recommendation of 4.2 g/d; in patients with pre-dialysis serum potassium greater than 6 mmol/L, a daily intake of potassium of 1950–2730 mg or 1 mmol/kg IBW is recommended
Spanish Society of Nephrology
2008[38]	A low-potassium diet (1.5–2.0 g/d) is recommended for GFR < 20 mL/min or GFR < 50 mL/min if potassium-increasing drugs are taken
Academy of Nutrition and Dietetics
2010[39]	Daily potassium intake of less than 2.4 g for CKD stages 3-5 who exhibit hyperkalemia
2014[40]	CKD stages 3-5 not on dialysis: no restriction until hyperkalemia is present, then individualized; HD: 2-4 g/d or 40 mg/kg of BW/d; PD: individualized to achieve normal serum levels
Australian guidelines
2005[41]	Reduced potassium diet should commence when serum potassium in pre-dialysis patients is > 5.5 mmol/L (Opinion). A reduced potassium diet limits the 24-h intake to about 3.1 mg
2013[42]	Early CKD patients with persistent hyperkalemia restrict their dietary potassium intake with the assistance of an appropriately qualified dietitian (2D)
Italian Society of Nephrology
2019[43]	Statement 1.2: serum potassium ≥ 5 mmol/L must be considered pathologic in CKD; Statement 1.3: restriction of potassium intake for non-dialysis CKD of mild-to-moderate degree is not recommended unless potassium levels are above 5 mmol/L in the absence of any other apparent cause. Then, it is recommended to limit food with high potassium content, especially if low in fiber, and pretreat (soaking and boiling) before cooking to remove potassium; Statement 2.3: restrict potassium intake to 2-3 g/d for advanced CKD and HD patients
Renal Association
2020[17]	A low potassium diet should be instituted for patients with advanced CKD and ESKD with persistent hyperkalemia with serum potassium > 5.5 mmol/L; a low potassium diet is defined by a dietary intake of 2-3 g/d
Cupisti et al[5]	Limit intake to 2.5-3.0 g/d or 1 mmol/kg/IBW for mild hyperkalemia of 5.0-5.5 mmol/L; limit intake to 2.0-2.5 g/d for moderate hyperkalemia of 5.5-6.0 mmol/L; 1.5-2.0 g/d for severe hyperkalemia of 6.0-6.5 mmol/L
Yamada et al[7]	Limit intake to ≤ 2 g/d for eGFR ≥ 30 and ≤ 1.5 g/d for eGFR < 30; limit intake to ≤ 2 g/d for HD and 2.0-2.5 g/d for PD
Kalantar-Zadeh et al[44]	Recommended potassium intake is the same as for the general population: (1) eGFR ≥ 60 mL/minute/1.73 m2 without substantial proteinuria (< 0.3 g of protein/d) but high risk for CKD because of DM, HTN, PCKD, or a solitary kidney, etc; or (2) eGFR of 30-59 mL/minute/1.73 m2 without substantial proteinuria (unless frequent or severe hyperkalemia episodes are likely); Limit potassium intake to < 3 g/d: (1) eGFR < 30 mL/minute/1.73 m2 if hyperkalemia occurs frequently during high-fiber intake; (2) Any eGFR if there is substantial proteinuria and frequent hyperkalemia during high-fiber intake; (3) Patients with good residual kidney function transitioning to dialysis if hyperkalemia occurs frequently during high-fiber intake; or (4) Dialysis patients or patients at any stage with existing or imminent protein-energy wasting defined according to the International Society of Renal Nutrition and Metabolism criteria
Clegg et al[13]	Limit potassium intake to 3 g/d

BW: Body weight; CKD: Chronic kidney disease; DM: Diabetes mellitus; EBPG: European Best Practice Guidelines; eGFR: Estimated glomerular filtration rate; ESKD: End-stage kidney disease; GFR: Glomerular filtration rate; HD: Hemodialysis; HTN: Hypertension; IBW: Ideal body weight; KDOQI: Kidney Disease Outcomes Quality Initiative; ND: Not on dialysis; NKF: National Kidney Foundation; PCKD: Polycystic kidney disease; PD: Peritoneal dialysis.