---
title: "KDOQI guideline adherence and reporting plausibility in Bangladeshi hemodialysis patients"
id: "plos-one-3-dietary-intake-patterns-and-kdoqi-guideline-compliance-among-hemodialysis"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-3-dietary-intake-patterns-and-kdoqi-guideline-compliance-among-hemodialysis"
content_type: "clinical_feed_article"
specialty: "Nephrology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360654"
published_at: "2026-10-12T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# KDOQI guideline adherence and reporting plausibility in Bangladeshi hemodialysis patients
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-3-dietary-intake-patterns-and-kdoqi-guideline-compliance-among-hemodialysis
- **Specialty:** [Nephrology](https://medichelpline.com/clinical-feed/nephrology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360654)
- **Published At:** 2026-10-12T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Cross-sectional study of 181 adults receiving maintenance **hemodialysis** at four hospital-based units in Bangladesh; 178 had complete dietary data for analyses. - Dietary intake measured by three non-consecutive 24-hour recalls (one dialysis day, one nondialysis day, one weekend day) and analysed with locally adapted food composition tables. - Reporting plausibility classified by the **EI:BMR** ratio with PAL = 1.2; cut-offs: 1.3 over-reporters. - Reporting distribution: 65.2% acceptable reporters, 32.0% under-reporters, 2.8% over-reporters. - Adherence to KDOQI energy target (30–35 kcal/kg/day) was 11.4% in the full cohort (20/176); protein ≥1.0 g/kg/day met by 33.0% (58/176). - After excluding implausible reporters, adherence estimates changed: energy adherence rose to 15.5%, protein adherence rose to 47.4% (for the stated thresholds). - Restriction-target adherence fell when implausible reports were excluded: sodium limit adherence from 73.6% to 65.5% and phosphorus limit adherence from 88.2% to 84.5%. - Phosphorus-to-protein ratio exceeded 12 mg/g in all but five participants. - Poor appetite (ADAT) was common (42.0%) but did not correspond to lower measured intake; appetite was associated with reporting plausibility (p = 0.024). - Study was descriptive: no formal a priori power calculation; small over-reporter subgroup (n=5) limits stability of comparisons; no multiple-comparisons correction was applied per authors.
## Clinical Analysis & Structured Key Points
Dietary intake patterns and KDOQI guideline compliance among hemodialysis patients in Bangladesh: Gaps, misreporting, and clinical implications | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Optimal nutrition is a central to the care of people receiving maintenance hemodialysis, yet dietary intake in these patients is usually measured by self-report, and self-report is known to be unreliable. Evidence from resource-limited dialysis settings is scarce. This cross-sectional study assessed dietary intake among 181 adults receiving maintenance hemodialysis at four hospital-based units in Bangladesh, and examined how screening reported intake for plausibility changes conclusions about guideline adherence. Intake was measured by three non-consecutive 24-hour recalls and compared with the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations. Reporting plausibility was classified from the ratio of energy intake to estimated basal metabolic rate. Appetite was assessed using the Appetite and Diet Assessment Tool. Of 178 participants with complete data, 65.2% reported acceptable, 32.0% under-reported and 2.8% over-reported energy intake. In the cohort as a whole, only 20 of 176 (11.4%) met the energy target of 30–35 kcal/kg/day and 58 (33.0%) met the protein target of at least 1.0 g/kg/day. Screening changed these estimates in opposite directions according to the type of target. For intake targets, adherence rose once implausible reports were excluded: energy from 11.4% to 15.5% and protein from 33.0% to 47.4%. For restriction targets the reverse occurred: apparent adherence to the sodium limit fell from 73.6% to 65.5% and to the phosphorus limit from 88.2% to 84.5%. The phosphorus-to-protein ratio exceeded 12 mg/g in all but five participants. Poor appetite was common (42.0%) but did not correspond to lower measured intake, and was instead associated with reporting plausibility (p = 0.024). Unscreened self-reported intake simultaneously overstates dietary inadequacy and understates dietary excess, and should not be used unfiltered to guide nutritional decisions in this population. Citation: Akter F, Rahman T, Ahmed S, Ripon MSH, Sultana M, Sultana N, et al. (2026) Dietary intake patterns and KDOQI guideline compliance among hemodialysis patients in Bangladesh: Gaps, misreporting, and clinical implications. PLoS One 21(10): e0360654. https://doi.org/10.1371/journal.pone.0360654 Editor: Mohamed E. Elrggal, Kidney and Urology Center, EGYPT Received: January 8, 2026; Accepted: September 29, 2026; Published: October 12, 2026 Copyright: © 2026 Akter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The minimal anonymized dataset underlying the findings is provided as S1 Dataset. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Chronic kidney disease (CKD) is a growing global public health challenge, affecting an estimated 8–16% of adults worldwide [ 1 ], and characterized by the progressive loss of kidney function over time [ 2 ]. In 2017, approximately 850 million people were living with CKD [ 3 ]. The burden is disproportionately high in low- and middle-income countries (LMICs), including Bangladesh, where CKD prevalence ranges from 17.3% to 22.4% [ 4 ]. Each year, 35,000–40,000 Bangladeshis progress to end-stage renal disease (ESRD), and nearly 40,000 die due to CKD-related complications [ 5 ]. Once ESRD develops, renal replacement therapy, usually hemodialysis in resource-limited settings becomes essential for survival [ 6 ]. Nutrition plays a central role in preserving residual kidney function and improving clinical outcomes among CKD and hemodialysis patients [ 7 ]. Yet, inadequate dietary intake is common during maintenance dialysis, and patients frequently fail to meet nutrient requirements outlined by the NKF/KDOQI guidelines [ 8 ]. These guidelines specify individualized targets for macro- and micronutrient consumption to reduce risks of hyperphosphatemia, hyperkalaemia, hypertension, and fluid overload [ 9 ]. Evidence suggests that higher-quality diets may lower the risk of ESRD progression and mortality among patients with CKD stages 3–5 [ 10 ]. However, many patients have limited knowledge of renal-specific dietary recommendations, leading to poor adherence and suboptimal nutritional status [ 11 ]. Adequate nutritional management is therefore essential to maintain serum biochemical balance and prevent protein-energy wasting [ 12 ]. Accurate dietary assessment is equally critical. Misreporting of food intake, particularly underreporting can distort clinical interpretation and lead to inappropriate dietary counselling, exacerbating complications such as hyperkalaemia, fluid overload, malnutrition, and mineral-bone disorders [ 13 ]. Misreporting remains a persistent challenge in hemodialysis research and practice [ 14 ], with higher prevalence among women, younger individuals, and those with elevated body weight [ 15 ]. Biomarkers such as the energy intake–basal metabolic rate ratio (EI:BMR) are commonly used to detect implausible intake reports and strengthen data validity [ 16 ]. Appetite is another key determinant of dietary intake in hemodialysis patients. Reduced appetite is widely reported across diverse populations with kidney disease and contributes to protein-energy malnutrition, affecting 30–75% of hemodialysis patients [ 17 , 18 ]. Appetite assessment tools, including the single-item Appetite and Diet Assessment Tool (ADAT), offer a simple yet informative measure for identifying patients at nutritional risk [ 19 ]. Despite the high and rising burden of CKD in Bangladesh, evidence on dietary intake, misreporting patterns, appetite status, and adherence to KDOQI recommendations among hemodialysis patients remains scarce. Understanding these factors is particularly important in resource-poor settings, where dietary counselling services, nutrition education, and trained renal dietitians are limited. This study therefore had two aims. The primary aim was to determine how screening self-reported dietary intake for plausibility alters estimates of adherence to KDOQI energy, protein and mineral targets in a Bangladeshi hemodialysis cohort. The secondary aims were to quantify macronutrient and micronutrient intake using a three-day 24-hour recall analysed with locally adapted food composition data, to identify independent predictors of under-reporting, and to examine whether self-rated appetite corresponds to measured intake. Together, these objectives were designed to generate context-specific evidence that can guide more accurate nutritional assessment and inform targeted dietary interventions in resource-limited hemodialysis settings. Methodology Study design and population A descriptive cross-sectional study was conducted across four districts in Bangladesh (Dhaka, Cumilla, Noakhali, and Mymensingh). A total of 181 adult patients undergoing maintenance hemodialysis were recruited from four hospital-based dialysis units, one in each study district. Participants were enrolled by consecutive convenience sampling: every patient attending a scheduled dialysis session during the recruitment window who met the eligibility criteria was invited to take part, and no stratification or randomisation by centre was applied. Eligibility criteria were applied as follows. Inclusion criteria were: (i) age ≥ 18 years; (ii) receipt of maintenance hemodialysis for at least three months; (iii) exclusively oral food intake, with or without oral nutritional supplements; (iv) clinically stable condition, defined as no hospitalisation or acute intercurrent illness in the preceding two weeks; and (v) ability and willingness to provide written informed consent. Exclusion criteria were: (i) enteral tube feeding or parenteral nutrition; (ii) acute kidney injury superimposed on CKD, active infection or sepsis at the time of assessment; (iii) cognitive, hearing, or language impairment precluding reliable completion of a 24-hour dietary recall; (iv) pregnancy or lactation; and (v) incomplete dietary or anthropometric records required for the calculation of reporting validity. No formal a priori power calculation was performed, because the study was designed to describe dietary intake patterns and guideline adherence rather than to test a pre-specified hypothesis. The achieved sample of 181 participants was determined by the number of eligible patients attending the participating units during the six-month recruitment period. For a descriptive proportion of approximately 50%, this sample size yields a two-sided 95% confidence interval of about ±7.3 percentage points, which was considered adequate for the descriptive objectives of the study. Ethical considerations Data were collected between January 2022 and June 2022 using a pre-tested questionnaire administered during HD sessions. All participants provided written informed consent prior to data collection. Ethical approval was granted by the Research Cell Committee of Noakhali Science and Technology University (NSTU/RC-FTNS/MS/21/72). Permissions were also obtained from all participating dialysis centers in the four study districts. Dietary assessment Dietary intake was evaluated using a validated three-day 24-hour dietary recall (3DDR), which included one dialysis day, one non-dialysis day, and one weekend day. All recalls were administered face-to-face at the dialysis unit by nutrition graduates of the Department of Food Technology and Nutrition Science, Noakhali Science and Technology University, who were trained in the multiple-pass 24-hour recall method and supervised by the study nutritionists; a standardised probing script was used to reduce interviewer variability. Standardized household measuring tools and an electronic kitchen scale were used to estimate portion sizes. Collected food items and recipes were entered into Nutritionist Pro™ (Axxya Systems LLC, Stafford, TX, USA) using food composition data from the Food Composition Table for Bangladesh [ 20 ]. Approximately 381 food items and 150 mixed Bangladeshi recipes were incorporated. Nutrient intakes, including energy, macronutrients, and selected micronutrients were quantified and compared against current NKF/KDOQI nutrition recommendations for maintenance dialysis [ 7 , 21 ]. Reference standards and definition of adherence. Dietary adequacy was benchmarked against the KDOQI clinical practice guideline for nutrition in CKD [ 7 , 21 ]. Energy adequacy was defined as a dietary energy intake (DEI) of 30–35 kcal/kg of post-dialysis body weight per day. For protein, the 2020 KDOQI update recommends a dietary protein intake (DPI) of 1.0–1.2 g/kg/day for metabolically stable patients on maintenance hemodialysis [ 21 ]; we therefore report adherence against both bounds of this range, using ≥1.2 g/kg/day as the primary (upper-bound) target for comparability with earlier literature and ≥1.0 g/kg/day as a secondary (minimum acceptable) target. Throughout this paper, ‘compliance’ refers to adherence to a single, explicitly named nutrient target and not to a composite score. Specifically, energy compliance denotes the proportion of patients with DEI of 30–35 kcal/kg/day, and protein compliance denotes the proportion with DPI at or above the stated threshold. Composite adherence, defined as meeting the energy and protein targets simultaneously, is reported separately and is identified as such wherever it appears. Weight-adjusted intake data were available for 176 of the 178 participants in the analytic sample, and this is the denominator for every adherence figure reported. Assessment of Reporting Plausibility To identify misreporting, the ratio of energy intake to basal metabolic rate (EI:BMR) was calculated. The ratio was adjusted for an assumed physical activity level (PAL) of 1.2 reflecting the characteristically sedentary lifestyle of maintenance hemodialysis patients and consistent with a comparable cut-off applied in this same clinical population [ 22 ]. This PAL value also corresponds to the lower bound of physiologically plausible activity described in doubly-labelled-water studies of chair- or bed-bound individuals [ 23 ]. Cut-off values of 1.3 were used to classify under reporters, acceptable reporters, and over reporters, respectively [ 23 , 24 ]. These thresholds correspond to the Goldberg cut-offs, which are derived from the physiological limits of sustainable energy balance and have been applied to dialysis and CKD cohorts in previous work, including studies of underreporting in maintenance hemodialysis [ 25 – 27 ]. Because the Goldberg approach assumes weight stability, and because interdialytic fluid gain inflates pre-dialysis weight, post-dialysis (dry) body weight was used for all BMR and weight-adjusted intake calculations in this study. BMR was estimated using the Harris–Benedict equation for men [66.5 + (13.75 × weight in kg) + (5.0 × height in cm) – (6.76 × age in years)] and women [655 + (9.6 × weight in kg) + (1.8 × height in cm) – (4.7 × age in years)] [ 28 ]. Anthropometric measurements Height and weight (pre- and post-dialysis) were extracted from patient records. BMI was calculated as post-dialysis weight (kg)/height (m 2 ) and categorized according to WHO standards [ 29 ]. Mid-arm circumference (MAC) was measured using a non-stretchable Lufkin® tape (Apex Tool Group, NC, USA), and triceps skinfold thickness (TSF) was assessed with Lange calipers (Power Systems, TN, USA). Mid-arm muscle circumference (MAMC) was computed using the formula:MAMC = MAC – (3.14 × TSF) [ 30 ]. Biochemical parameters Biochemical data were obtained from hospital case files and included serum albumin, total protein, creatinine, urea, sodium, potassium, calcium, phosphorus, and lipid profile components (total cholesterol and triglycerides). Appetite assessment Appetite was assessed using the validated single-item Appetite and Diet Assessment Tool (ADAT). Participants rated their appetite over the previous week on a 5-point scale (1 = very good to 5 = very poor). For analysis, responses were grouped into “good” (very good/good), “fair,” and “poor” (poor/very poor). Lower ADAT scores indicated better appetite [ 17 ]. Statistical analysis Descriptive statistics were reported as frequencies (percentages) or mean ± standard deviation. Group differences were analyzed using one-way ANOVA for continuous variables and Pearson’s χ 2 test for categorical variables. Because only five participants were classified as over reporters, several cross-tabulations contained expected cell counts below five; in these instances, Fisher’s exact test was used in place of Pearson’s χ 2 , and the test applied is indicated in the corresponding table footnote. To reduce the influence of this very small subgroup, a pre-specified sensitivity analysis was also performed in which under- and over reporters were combined into a single ‘invalid reporter’ category (n = 62) and compared with valid reporters (n = 116) using Welch’s independent-samples t-tests for continuous variables and χ 2 or Fisher’s exact tests for categorical variables. Given the descriptive nature of the study and the number of nutrients examined, no formal adjustment for multiple comparisons was applied; nominal p-values are therefore reported, and isolated significant findings should be regarded as hypothesis-generating rather than confirmatory. Statistical significance was set at P 23 kg/m 2 . No significant associations were found between reporting category and sex, age group, or BMI. Because only five participants were classified as over reporters, all comparisons involving this group are statistically unstable and are interpreted descriptively throughout. Anthropometric and clinical parameters Anthropometric characteristics are presented in Table 3 . After excluding three patients with unmeasurable weight, the mean BMI of the cohort was 22.8 ± 4.3 kg/m 2 . Most patients (64.0%) had a normal BMI (18.5–24.9 kg/m 2 ), while 13.5% were underweight, 16.9% overweight, and 5.6% obese. BMI differed significantly by sex, with women showing higher BMI values than men ( p < 0.01). Sex differences were also observed for height, TSF, and MAC, with women demonstrating significantly greater TSF and MAC. No significant differences in BMI categories were observed across acceptable reporters, under-reporters, and over-reporters. However, TSF was significantly higher among under-reporters compared to the other groups ( p = 0.03). Download: PNG larger image TIFF original image Table 3. Anthropometric characteristics of hemodialysis patients by sex and reporting accuracy. https://doi.org/10.1371/journal.pone.0360654.t003 Clinical and biochemical parameters are summarized in Table 4 . Sodium, glucose, and serum TIBC tended to be higher among over-reporters, but no clinical parameter differed significantly across reporting-accuracy groups. Missing biochemical data were excluded when not available in medical records. Download: PNG larger image TIFF original image Table 4. Clinical and biochemical parameters of hemodialysis patients according to reporting accuracy. https://doi.org/10.1371/journal.pone.0360654.t004 Macronutrient intake Macronutri
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