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Beyond traditional approaches: Innovative salt reduction education for optimising fluid management in end-stage renal disease
*Corresponding author: Tamer A. Addissouky, Department of Biochemistry, Minufya University, Alexandria, Egypt. tedesoky@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Addissouky TA. Beyond traditional approaches: Innovative salt reduction education for optimising fluid management in end-stage renal disease. Karnataka Med J. 2025;48:6-13. doi: 10.25259/KMJ_50_2024
Abstract
Background:
Excessive interdialytic weight gain (IDWG) is a significant concern for haemodialysis patients, associated with increased cardiovascular risk and mortality. Dietary sodium intake plays a crucial role in determining IDWG, making salt reduction a key component of patient management. However, adherence to salt restriction remains challenging due to various factors, including dietary habits, cultural influences and lack of knowledge.
Objectives:
This review aims to evaluate the effectiveness of salt reduction education strategies in haemodialysis patients and their impact on IDWG, exploring both traditional and innovative approaches.
Methods:
Salt intake assessment methods, including dietary recalls and validated questionnaires, are discussed, along with their correlation to actual intake. The review examines various educational interventions, from conventional group sessions to personalised approaches based on questionnaire results. The integration of technology, such as mobile applications and virtual counselling, shows promise in enhancing engagement and self-monitoring. Short-term effects of education on IDWG are generally positive, but long-term sustainability remains a challenge. Physiological mechanisms underlying the relationship between salt intake and fluid balance are explored, including hormonal responses and cardiovascular implications. Psychological aspects, such as patient motivation and quality of life, are considered in the context of dietary restrictions.
Conclusion:
While salt reduction education strategies have evolved to include personalised and technology-driven approaches, challenges persist in achieving long-term adherence. Future directions include the development of novel interventions, integration of artificial intelligence for personalised strategies and comprehensive care models that address the multifaceted nature of dietary management in haemodialysis patients.
Keywords
Dietary sodium intake
Haemodialysis
Interdialytic weight gain
Patient adherence
Salt reduction education
INTRODUCTION
Haemodialysis is a life-sustaining treatment for individuals with end-stage renal disease (ESRD), which involves the removal of waste products and excess fluid from the body through an extracorporeal circuit. During the interdialytic period, patients experience fluid and solute accumulation, leading to interdialytic weight gain (IDWG). Excessive IDWG is associated with various complications, including hypertension, cardiovascular events and increased mortality risk.[1] Sodium intake plays a crucial role in determining IDWG and fluid status in haemodialysis patients. High dietary sodium consumption leads to increased thirst and fluid intake, exacerbating fluid overload and contributing to IDWG. Consequently, salt restriction is an essential component of dietary management for haemodialysis patients, as it can help minimise IDWG and its associated complications.[2]
Despite the well-recognised benefits of salt restriction, adherence to dietary recommendations remains a significant challenge for many haemodialysis patients. Factors contributing to poor adherence include dietary habits, cultural influences, taste preferences, lack of knowledge and socioeconomic barriers. Addressing these challenges through effective educational interventions is crucial for improving salt reduction adherence and optimising patient outcomes.[3] Patient education plays a key role in empowering individuals with ESRD to make informed dietary choices and adhere to recommended dietary restrictions, including salt reduction. Effective educational interventions can enhance patients’ knowledge, promote self-management skills and ultimately improve their overall health and quality of life.[4-6]
SALT INTAKE ASSESSMENT IN HAEMODIALYSIS PATIENTS
Methods of salt intake evaluation
Accurate assessment of salt intake in haemodialysis patients is essential for tailoring dietary interventions and monitoring adherence. Various methods are employed to evaluate salt intake, including dietary recalls, food frequency questionnaires and objective measures such as 24-h urine collection and salivary sodium analysis.[7]
SALT QUESTIONNAIRES: TYPES AND VALIDITY
Salt questionnaires are widely used tools for assessing dietary sodium intake in haemodialysis patients. These questionnaires can be self-administered or conducted through interviews, and they typically evaluate the frequency and portion sizes of sodium-rich foods consumed. The validity and reliability of these questionnaires have been extensively studied, and they have been shown to correlate reasonably well with objective measures of sodium intake.[8]
Correlation between salt questionnaire results and actual intake
While salt questionnaires provide valuable insights into dietary sodium intake, their accuracy can be influenced by various factors, including recall bias, underreporting and the inherent variability in sodium content of foods. Studies have shown that salt questionnaire results generally correlate with actual sodium intake, but the strength of the correlation may vary depending on the specific questionnaire used and the population studied.[9]
SALT REDUCTION EDUCATION STRATEGIES
Traditional educational approaches
Traditional educational approaches for salt reduction in haemodialysis patients often involve group sessions, printed materials and one-on-one counselling by healthcare professionals. These methods aim to provide information on the importance of salt restriction, identify high-sodium foods and offer practical strategies for reducing dietary sodium intake.[10]
Personalised education based on salt questionnaire results
The consumption of calorie-dense Western diets combined with sedentary lifestyles induces a state of chronic metabolic inflammation termed metaflammation, contributing to the increasing global prevalence of obesity, insulin resistance and type 2 diabetes.[11,12] While dietary intake is known to cause complex metabolic perturbations in obesity, the underlying mechanisms are not fully understood. Multiple processes have been shown to contribute to the pro-inflammatory effects of Western diets, including oxidative stress, immune dysregulation and gut microbiota dysbiosis. In contrast, interventions utilising an anti-inflammatory diet such as the Mediterranean diet resulted in significant decreases in body weight, visceral adipose tissue and improvements in cardiometabolic and inflammatory profiles. The anti-inflammatory diet has, thus, been demonstrated as an effective approach for obesity management, as depicted in Figure 1.[13]
- Effectiveness of an anti-inflammatory diet for obesity management. ROS: Reactive oxygen species
Frequency and duration of educational interventions
The frequency and duration of educational interventions can influence their effectiveness in promoting salt reduction adherence. While some studies have investigated the impact of single educational sessions, others have explored the benefits of multiple sessions or ongoing education over an extended period.[14]
Use of technology in salt reduction education
With the advancement of technology, innovative approaches to salt reduction education have emerged. These include the use of mobile applications, interactive multimedia resources and virtual counselling sessions. Incorporating technology into educational interventions can enhance engagement, facilitate self-monitoring and provide real-time feedback and support to patients.[15,16]
IMPACT OF SALT REDUCTION EDUCATION ON IDWG
Relationship between salt intake and IDWG
Numerous studies have established a strong relationship between dietary sodium intake and IDWG in haemodialysis patients. Higher sodium consumption is associated with increased thirst, fluid intake and subsequent IDWG, which can lead to complications such as hypertension, cardiovascular events and an increased risk of hospitalisation. Excessive dietary salt intake is strongly associated with increased risks of cardiovascular diseases and liver disease.[17] Higher sodium consumption leads to increased fluid retention and subsequent volume overload in haemodialysis patients, resulting in IDWG. This excessive fluid build-up can lead to complications such as hypertension, heart failure and cardiovascular events that are major causes of mortality in this population. In addition, high sodium intake is directly linked to the development of hypertension in the general population.[18,19] Hypertension is a major risk factor for heart attacks, strokes, heart failure and other cardiovascular diseases. Emerging evidence also suggests that a high-salt diet may directly damage the liver by increasing oxidative stress and inflammation. This can accelerate the progression of non-alcoholic fatty liver disease to more advanced fibrosis and cirrhosis. Therefore, reducing dietary salt intake through modifications to processed foods and individual lifestyle changes could help lower the risks of cardiovascular diseases and liver disease through mechanisms of fluid balance control and direct organ protection from oxidative and inflammatory injury.[20,21]
Short-term effects of education on IDWG
Educational interventions aimed at promoting salt reduction have been shown to have a positive impact on IDWG in the short term. Several studies have reported significant reductions in IDWG following educational programs, suggesting that increased knowledge and awareness of salt restriction can translate into improved dietary adherence and better fluid management.[22]
Long-term sustainability of IDWG improvements
While the short-term effects of salt reduction education on IDWG are well-documented, the long-term sustainability of these improvements remains a subject of investigation. Some studies have reported sustained reductions in IDWG over extended periods, while others have observed a gradual decline in adherence and a return to baseline IDWG levels over time.[23]
Factors influencing the effectiveness of salt reduction education
The effectiveness of salt reduction education can be influenced by various factors, including patient characteristics (e.g., age, socioeconomic status and cultural background), the intensity and duration of the educational intervention, the involvement of family members or caregivers and the presence of comorbidities or cognitive impairments that may impact adherence.[24]
PHYSIOLOGICAL MECHANISMS
Salt intake and fluid balance in haemodialysis patients
Dietary sodium intake plays a critical role in fluid balance regulation in haemodialysis patients. High sodium consumption leads to increased extracellular fluid volume and osmotic shifts, resulting in thirst and increased fluid intake. This, in turn, contributes to IDWG and the associated complications.[25]
Hormonal responses to salt reduction
Salt reduction can trigger hormonal responses that affect fluid balance and blood pressure regulation. Specifically, a decrease in dietary sodium intake can lead to a reduction in plasma volume and subsequent activation of the reninangiotensin-aldosterone system, which can help maintain blood pressure and promote sodium and fluid retention.[26]
Impact on blood pressure and cardiovascular outcomes
By reducing IDWG and promoting better fluid management, salt reduction education can have a positive impact on blood pressure control in haemodialysis patients. Furthermore, improved blood pressure control and reduced IDWG may contribute to better cardiovascular outcomes and decreased mortality risk in this patient population.[27]
PSYCHOLOGICAL ASPECTS OF SALT REDUCTION EDUCATION
Patient motivation and adherence
Patient motivation and adherence to dietary recommendations are crucial for the success of salt reduction education programs, as depicted in Table 1. Factors influencing motivation include perceived benefits, self-efficacy, cultural beliefs and social support. Addressing psychological barriers and fostering a collaborative approach between patients and healthcare providers can enhance adherence and long-term sustainability.[28]
| Factor | Mechanism of influence | Impact on adherence | Potential interventions |
|---|---|---|---|
| Thirst | High sodium intake increases osmolality, triggering thirst | Increased fluid intake, leading to higher IDWG | - Gradual salt reduction strategies -Education on alternative thirst-quenching methods -Use of sugar-free gum or ice chips |
| Taste preferences | Salt enhances food flavour, making low-sodium diets less palatable | Reduced adherence due to dissatisfaction with food taste | - Cooking classes focusing on flavour enhancement without salt - Gradual taste adaptation strategies - Introduction of salt substitutes |
| Cultural dietary habits | Traditional dishes may be high in sodium | Difficulty in modifying long-standing dietary patterns | - Culturally tailored education materials - Adapting traditional recipes to lower sodium versions - Involving family members in education sessions |
| Knowledge deficit | Lack of understanding about salt sources and health implications | Unintentional non-adherence due to ignorance | - Comprehensive education on hidden salt sources -Regular reinforcement of salt-health connection -Practical label-reading workshops |
| Self-efficacy | Belief in one’s ability to successfully reduce salt intake | Higher self-efficacy correlates with better adherence | -Goal-setting exercises - Positive reinforcement of successful salt reduction - Peer support groups |
| Psychological stress | Stress may lead to comfort eating, often involving high-sodium foods | Stress-induced lapses in adherence | - Stress management techniques -Cognitive-behavioural therapy - Mindfulness training |
| Social support | Family and peer influence on dietary choices | Strong support network enhances adherence | - Family education sessions - Peer mentoring programs - Support group participation |
| Comorbidities | Presence of other health conditions affecting diet | Competing dietary requirements may complicate adherence | - Integrated dietary planning addressing multiple health needs - Collaboration with multidisciplinary healthcare team - Personalised meal plans |
| Socioeconomic factors | Limited access to fresh, low-sodium food options | Financial constraints may lead to reliance on processed, high-sodium foods | -Education on budget-friendly low-sodium options - Community partnerships for fresh food access - Cooking demonstrations using affordable ingredients |
| Cognitive function | Impaired memory or executive function | Difficulty in remembering or implementing dietary recommendations | - Simplified education materials - Use of memory aids and reminders - Involvement of caregivers in education process |
IDWG: Interdialytic weight gain
Quality of life implications
Dietary restrictions, including salt reduction, can impact the quality of life of haemodialysis patients. Educational interventions that promote better understanding of the benefits of salt restriction and provide practical strategies for maintaining a palatable and enjoyable diet can help mitigate the negative impact on quality of life.[29]
Role of family and social support
Family members and social support networks play a crucial role in promoting adherence to dietary recommendations, including salt reduction. Involving family members in educational interventions and leveraging social support can reinforce positive behaviours and provide practical assistance in meal planning and preparation.[30]
CHALLENGES AND LIMITATIONS
Accuracy of self-reported salt intake
Self-reported salt intake measures, such as dietary recalls and food frequency questionnaires, are subject to limitations related to recall bias, underreporting and variability in sodium content of foods. These limitations can impact the accuracy of salt intake assessment and the tailoring of educational interventions.[31]
Variability in patient responses to education
Individual patient responses to educational interventions can vary significantly, influenced by factors such as cognitive abilities, cultural backgrounds and personal preferences. This variability can pose challenges in designing effective onesize-fits-all educational programs and may necessitate more personalised approaches.[32]
Confounding factors affecting IDWG
While salt reduction education aims to improve IDWG, other factors, such as comorbidities, medication use and adherence to fluid restrictions, can also influence IDWG. Isolating the specific impact of salt reduction education on IDWG can be challenging in the presence of these confounding variables.[33]
FUTURE DIRECTIONS
Novel educational interventions
As technology continues to evolve, novel educational interventions may emerge, leveraging virtual reality, gamification or personalised coaching through artificial intelligence (AI). These innovative approaches could enhance engagement, increase accessibility and tailor educational content to individual patients’ needs and preferences.[34]
Integration of salt reduction education into comprehensive care models
Salt reduction education should be integrated into comprehensive care models for haemodialysis patients, encompassing not only dietary management but also medication adherence, lifestyle modifications and psychological support. This holistic approach can optimise patient outcomes and promote overall well-being.[35]
Potential for AI in personalised salt reduction strategies
The advent of AI and machine learning holds promise for personalised salt reduction strategies. By analysing complex patient data, including dietary patterns, physiological responses and psychological factors, AI algorithms could potentially generate tailored educational content, predict adherence challenges and provide real-time feedback and support to patients [Table 2].[36]
| Strategy | Methods | Effectiveness | Advantages | Limitations |
|---|---|---|---|---|
| Traditional approach | - Group sessions - Printed materials -One-on-one counselling |
- Moderate -Short-term improvements in IDWG -Variable long-term adherence |
-Cost-effective - Familiar to healthcare providers -Allows for face-to-face interaction |
- Limited personalisation -Time-consuming for staff - May not engage all learning styles |
| Personalised education | - Tailored interventions based on salt questionnaires - Individual goal setting - Customised dietary plans |
- High -Better short-term adherence - Improved patient satisfaction |
- Addresses individual needs and preferences - Potentially higher engagement - Can adapt to patient progress |
-Resource-intensive - Requires skilled dietitians - May be challenging to scale |
| Technology-driven approaches | - Mobile applications - Virtual counselling - Interactive multimedia resources |
- Promising - Increased patient engagement -Potential for real-time monitoring |
- Accessible 24/7 - Appeals to younger patients -Facilitates self-monitoring |
- Requires patient technological literacy - Initial development costs - May exclude older or less tech-savvy patients |
| Family-centred education | - Family counselling sessions - Home visit programs -Family-oriented educational materials |
- Moderate to High - Improved adherence through support - Enhanced home environment for salt reduction |
- Leverages social support - Addresses cultural factors - Can improve overall family health |
- Requires family participation -May be time-consuming - Cultural sensitivities to consider |
| Peer support programs | -Patient-to-patient mentoring - Support group meetings - Shared experience workshops |
- Variable - Can significantly improve motivation - Mixed results on long-term adherence |
- Provides relatable experiences - Builds community among patients - Can address psychosocial aspects |
- Requires careful mentor selection and training - Quality of support may vary - May perpetuate misinformation if not properly guided |
| Gamification and virtual reality | - Educational games - Virtual reality simulations -Achievement-based learning modules |
- Emerging - High engagement potential -Limited long-term data available |
- Highly engaging for some patients -Can simulate real-life scenarios - Potential for personalised learning paths |
- High initial development costs - May not appeal to all patient demographics - Requires specialised equipment |
| AI-driven personalised coaching | - Machine learning algorithms for personalised advice - Predictive modelling for adherence challenges - Automated, tailored feedback |
- Experimental - Promising early results -Long-term studies needed |
- Highly personalised - Potential for continuous adaptation - Can process complex patient data |
- Relies on accurate data input - Privacy and ethical considerations - May lack human touch in patient care |
| Comprehensive care model integration | - Multidisciplinary team approach - Integration with overall treatment plan - Regular reassessment and adjustment |
- High - Addresses multiple factors affecting adherence - Potential for sustained improvements |
- Holistic approach to patient care - Coordinates various aspects of treatment - Can address comorbidities |
- Requires coordination among healthcare providers - Can be complex to implement - May be resource-intensive |
IDWG: Interdialytic weight gain
Recommendations
Development and validation of more accurate and reliable methods for assessing salt intake in haemodialysis patients, potentially leveraging emerging technologies such as wearable devices or biomarkers
Investigation of novel educational interventions, including the use of virtual reality, gamification and AI-driven personalised coaching, to enhance engagement and tailor content to individual patient needs
Longitudinal studies to evaluate the long-term sustainability of IDWG improvements following salt reduction education and identify factors that contribute to sustained adherence over time
Exploration of the potential for AI and machine learning algorithms to analyse complex patient data and generate personalised salt reduction strategies, incorporating dietary patterns, physiological responses and psychological factors
Examination of the impact of salt reduction education on patient-reported outcomes, such as quality of life, self-efficacy and overall well-being, in addition to clinical outcomes
Evaluation of the cost-effectiveness and feasibility of implementing comprehensive salt reduction education programs within various healthcare settings and resource constraints
By addressing these research gaps, the nephrology community can continue to refine and optimise salt reduction education strategies, ultimately improving patient outcomes and enhancing the overall quality of care for individuals with ESRD undergoing haemodialysis.
CONCLUSION
Salt reduction education strategies have evolved from traditional approaches to personalised interventions tailored to individual patients’ needs and preferences. The use of technology has also emerged as a promising avenue for enhancing engagement and accessibility. While short-term reductions in IDWG have been observed following educational interventions, long-term sustainability remains a challenge. The physiological mechanisms underlying the relationship between salt intake and fluid balance in haemodialysis patients have been explored, including the role of hormonal responses and the impact on blood pressure and cardiovascular outcomes. In addition, the psychological aspects of salt reduction education, such as patient motivation, adherence and quality of life implications, have been addressed. Despite the progress made in this field, challenges and limitations persist, including the accuracy of self-reported salt intake, variability in patient responses and confounding factors affecting IDWG.
The findings of this review have significant clinical implications for nephrology practice. Healthcare professionals should prioritise salt reduction education as an integral component of comprehensive care for haemodialysis patients. Utilising validated salt questionnaires and tailoring educational interventions to individual patient needs can enhance the effectiveness of salt reduction strategies. Interdisciplinary collaboration among nephrologists, dietitians, nurses and psychologists is essential to address the multifaceted aspects of dietary management, including salt reduction. Involving family members and leveraging social support networks can further reinforce positive behaviours and promote long-term adherence.
Acknowledgements:
The author thanks all the researchers who have made great efforts in their studies. Moreover, we are grateful to this journal’s editors, reviewers and readers.
Authors’ contributions:
TAA: Completed the study protocol and was the primary organizer of data collection and the manuscript’s draft and revision process. The corresponding author wrote the article and ensured its accuracy.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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