Professional Reasoning in Dietary Hyperkalaemia Management in Chronic Kidney Disease: Development of the PRIME-K Model

Abstract

Background

Dietary management of hyperkalaemia in chronic kidney disease has traditionally focused on potassium restriction. However, contemporary renal nutrition practice increasingly requires dietitians to balance biochemical safety with nutritional adequacy, dietary quality, treatment burden, and patient wellbeing. Limited empirical evidence has examined how renal dietitians reason through these competing priorities in routine practice.

Objective

To explore how renal dietitians approach dietary hyperkalaemia management in chronic kidney disease and to examine the professional reasoning underpinning dietary decision-making.

Methods

This qualitative study integrated free-text responses from an international online survey of renal dietitians with semi-structured interviews. Survey free-text responses provided breadth across practice settings, while interviews enabled more detailed exploration of clinical reasoning. Data from 203 survey respondents and eight interview participants were analysed consequently using reflexive thematic analysis to examine how dietitians prioritised, sequenced, and adapted dietary interventions.

Results

Dietitians described dietary hyperkalaemia management as a staged but flexible process of professional reasoning. Four interrelated themes were identified: consideration of non-dietary contributors before dietary restriction; prioritisation of potassium additives and highly processed foods; preservation of nutritional adequacy as a central boundary condition; and selective restriction of potassium-rich whole foods only when clinically indicated. Dietary restriction was not described as an automatic response to elevated serum potassium, but as one possible component of a broader reasoning process shaped by biochemical trends, nutritional status, clinical urgency, patient preferences, and psychosocial context. These findings informed development of the Prioritisation and Reasoning in the Management of Elevated Potassium in Chronic Kidney Disease model, known as PRIME-K.

Conclusions

Renal dietitians reported using flexible professional judgement to manage hyperkalaemia while minimising unnecessary dietary burden and protecting nutritional adequacy. The PRIME-K model offers a practice-informed representation of professional reasoning in dietary hyperkalaemia management and may support dietetic education, reflective practice, and the development of more context-sensitive approaches to dietary care in chronic kidney disease.