CKD dietitians can make a difference-but referrals are the missing link

Recognizing the important role that diet and registered dietitians play in chronic kidney disease management, the National Kidney Disease Education Program (www.nkdep.nih.gov) convened a panel of renal dietitians with expertise in CKD at the American Dietetic Association Food and Nutrition Conference held last fall in Denver. Our panel represented a wide array of experience from different settings: dialysis clinics, private practice, and teaching universities (see box for panel members).

The purpose was to develop a CKD diet initiative to transfer renal dietetic knowledge to general practice dietitians who are counseling CKD patients. But a key focus was also looking at ways to encourage primary care physicians (PCPs) to make referrals to RDs so we can start the education process.

It was the second gathering for dietitians on this subject; the NKDEP conducted a focus group with other renal dietitians in 2008 to gather feedback on draft CKD educational materials for general practice dietitians and for patients with CKD.

We know that altering the dietary habits of individuals with early stages of CKD may slow the progression of the disease. Preserving residual renal function as long as possible is good for the patient. But getting referrals is the key.

In some areas, the nephrologist uses the nurse practitioner as the educator on diet. Usually, the renal RD that is working for a dialysis services company does not have time (nor maybe the desire) to counsel CKD patients after working in the dialysis clinic all day.

I spent 30 years in the Miami, Fla. area working as a renal dietitian. I was lucky to receive referrals from nephrologists in a variety of settings. Depending on the nephrologists or the clinic, I saw these patients either during my work in the clinics (the end-stage dialysis patients) or after hours. My fee was based on the recommendation from the nephrologists-or sometimes it was done for nothing. In one of my clinics,
I conducted monthly classes in Spanish for groups of CKD patients and
their families.

The classes and one-on-one time with patients made a difference. Haewook Han, PhD, RD, LDN, one of our panel experts, sees about 80 CKD patients a month and teaches the general practice dietitians at Tufts University. But finding such a renal dietitian can be a challenge. Blessed is the PCP that has an RD with expertise in nephrology and a medical nutrition therapy (MNT) number who can offer consults with CKD patients one day a week. Having an MNT number allows the RD to bill for Medicare.

The presence of the dietitian in the office can not only help the patient preserve kidney function, but the PCP can still be the primary caregiver for the patient. Once the RD has trained the general practice dietitian, they can spend the rest of the week performing duties in the dialysis clinic.

The NKDEP has already developed a number of excellent educational materials for the general dietitian; our focus group felt a Web-based video that modeled patient counseling around various topics relevant to CKD would be favorable.

Summary
The best-case scenario would be to have an immediate response to the CKD Stage 1 patient who is showing signs of proteinuria (of course, it is important that the PCP makes sure these tests are done regularly). It has long been know that ace inhibitors and/or angiotensin 2 receptor blockers can reduce proteinuria. If the PCP doesn''t do the urinalysis, an opportunity to intervene is lost.

The renal dietitian''s knowledge and dietary services would best be utilized at Stage 3 CKD. Control of protein may limit the symptoms of uremia. Restriction of phosphorus may aid in the prevention of bone disease that can develop early on in CKD.

By partnering with the primary care physician, both renal dietitians, and general practice dietitians, once properly trained, can help to bring CKD under control.-by Peggy Harum, RD, LDN

Ms. Harum is a renal dietitian living in New Bern, N.C. She is also a member of NN&I''s Editorial Advisory Board.