New KDOQI guidelines offer a reset on nutrition
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Editor’s note: This article was written from a review of the Kidney Disease Outcomes Quality Initiative guideline public draft, which is still undergoing revisions based on public commentary.
The long-awaited publication of the Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2019 Update will be available this year. The public review of the guidelines late last year revealed a pointed evidence-based methodology, as well as a current approach to nutrition care for chronic kidney disease in all stages. The updated guidelines continue the primary goal of the Kidney Disease Outcomes Quality Initiative “to improve patient survival, reduce patient morbidity, improve the quality of life of dialysis patients and increase efficiency of care.”
The workgroup that created the original guidelines, published in 2000, developed recommendations from research available at the time; the multidisciplinary workgroups for this update took the process a step further and utilized more direct question development, literary search and study selection via guidance of the Academy of Nutrition and Dietetics systematic review methodology for more precise analysis.
Assessments get attention
Areas of assessment provide more detail and specifics on routine nutritional assessment timelines and anthropometric measures. A significant update in the assessment section is in the laboratory measurements. While serum albumin is still regarded as a predictor of hospitalization and mortality, there is no approximate goal outcome as previously recommended. A combination of biomarkers, physical assessment and composite indices are encouraged as overall evaluation of nutritional status.
Medical nutrition therapy (MNT) by a registered dietitian nutritionist (RDN) in close collaboration with the physician is a primary intervention to make positive improvements in patient outcomes. Customization of various diet components by the dietitian and even liberalization from the original guidelines with a whole foods approach is found throughout the updated guidelines.
The following are key guidelines in clinical practice that have had significant adjustments in recommendations:
Energy and protein
- Dietary energy and protein intake see a slight reduction in range.
- Energy intake lowered to 25 kcal/kg/day to 35 kcal/kg/day for CKD 1 to 5D, allowing the clinician to determine the best amount based on age, gender, physical activity and other factors affecting the patient.
- Although patients with CKD and diabetes have a slightly higher recommended range, protein recommendations for CKD stages 3 to 5 nondialysis remain significantly low at 0.55 g to 0.60 g dietary protein/kg ideal body weight/day. It is pertinent to note that specifications have been made in relation to meal patterns and Mediterranean-based diets for CKD 1 to 5 (nondialysis) and post-transplant. Diets high in fresh fruits and vegetables are suggested for overall improvements in lipid, body weight, blood pressure and net acid production in CKD stages 1 to 4.
- Maintenance hemodialysis and peritoneal dialysis has a slight dip in protein range that parallels the energy intake at 1 g/kg to 1.2 g /kg ideal body weight per day. There is no specificity to the need for high biological value.
Nutritional supplementation
In the updated guidelines, we see specific recommendations for oral, enteral and intradialytic nutritional supplementation, respectively.
Oral nutrition supplementation is suggested with at least a 3-month trial if nutrition counseling by itself does not improve energy and protein intakes to meet patient needs in CKD stages 1 to 5D and post-transplant. Implementation based on research suggests a prescribed consumption of two to three times per day and an hour after meals instead of as a meal replacement in order to provide the best overall benefit. Providing in-center oral nutrition supplementation is viewed as advantageous with proper monitoring. The RDN has an essential role to ensure patient preference is met as this improves acceptance and increases the potential of successful nutritional outcomes.
Reasonable trials of enteral nutrition are suggested for those CKD stages 1 to 5D whose nutritional needs cannot be met with nutrition counseling and oral nutrition supplementation. Finally, in those with protein energy wasting whom oral nutrition and enteral intakes cannot meet nutritional needs, more intense therapies are recommended — total parenteral nutrition (TPN) for CKD, intradialytic parenteral nutrition (IDPN) for maintenance hemodialysis and amino acid dialysate for patients on PD. Basic IDPN criteria are outlined within implementation suggestions, as well as the notation that IDPN is not viewed as a long-term solution.
Vitamin D insufficiency
As an area that has been under scrutiny in the guidelines for some time, vitamin D insufficiency is addressed and recommended for repletion in all stages of CKD, including patients on dialysis. Ergocalciferol or cholecalciferol are suggested to correct 25(OH)D deficiency/insufficiency. Research reveals supplementation should reflect that of the general population but also customized considering other patient comorbid conditions, etc.
As previously mentioned, whole fruits and vegetables are a common theme throughout the updated guidelines. An increase in fruits and vegetables is the suggestion as dietary management of net acid production as a way to reduce decline in residual kidney function for CKD stages 1 to 4. We again see how the RDN plays a substantial role in helping patients navigate their diet appropriately to help delay advancement in the CKD stages.
Phosphorus
There has been a major facelift to the phosphorus recommendations. While previously KDOQI guidelines called out specified ranges ideal for patients with CKD, especially those on dialysis, updates steer clinicians more toward the normal range for serum phosphate levels. As we have seen in recent years, the type or source of the phosphorus can have a significant impact on the patient and how much of that phosphorus is absorbed. Once again, we see where clinicians must provide specific guidance to patients and assist them in navigating the bioavailability of phosphorus among animal, vegetable and food additives.
Research reveals the strength of plant-based food in the CKD diet. Specific recommendations for phosphorus consumed is omitted and guidance falls to the clinician to recommend according to the patient’s level of hyper or hypophosphatemia. Again, customization and intensive education is key.
Potassium and sodium
As with phosphorus, similar changes are seen with recommendations to move toward normal levels of serum potassium. MNT remains at the forefront to correcting cases of hyperkalemia or hypokalemia. Potassium binders were considered outside the scope of the current guidelines; therefore, we look for further guidance on its role later.
While sodium recommendations do not see a major change going from 2.4 g/day to 2.3 g/day, special attention should be paid to the implementation. This will come as no surprise to the RDN; cooking strategies and label reading vanguard education efforts to reduce dietary sodium intake. Research still falls short to support long-term adherence to dietary sodium reduction. A multifaceted effort is essential to reduce dietary sodium, which includes widespread strategies to reduce the availability of sodium in foods in combination with individual dietary choices.
As this is a short overview, each clinician should read the final guideline updates in their entirety. The background, rationale and implementation sections provide detail regarding each guideline, why conclusions were made and help define everyday application.
Research is ongoing; the guideline update is from literature published as of April 2017. It is important to remember the guidelines are recommendations not to be used exclusively as prescribing management and do not imply a protocol. Clinicians must use clinical judgment and thought processes accompanied by current research to provide the best nutritional care possible for each patient.
Support the effort
As the climate and focus around the prevention of CKD is heightened, we see the need within the research of the revised nutrition guidelines to be able to adequately support this effort. Lack of adequate reimbursement for MNT within nephrology and general medicine clinics requires evaluation. Implementation outlines that legislative awareness and reimbursement policies for disease prevention are needed to reflect the value of MNT. Earlier detection, prevention and treatment of kidney disease requires a drastic increase in the utilization of the RDN.
A review of the nutrition guidelines will take place at the National Kidney Foundation Spring Clinicals Meeting (general session #270), starting at 8:15 a.m. on Thursday, March 27, 2020.
- For more information:
- Valarie M. Hannahs MS, RD, LD, is the corporate manager of renal nutrition for American Renal Associates, 7600 Farmsbury Dr., Suite 100, Reynoldsburg, OH 43068; cdteam@americanrenal.com. She is also a Nephrology News & Issues Editorial Advisory Board Member.