EAL

CKD: MNT (2010)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To help with establishing education programs, determine staffing guidelines, and planning future endeavors, the National Kidney Foundation Council on Renal Nutrition conducted a survey of their members.

Inclusion Criteria:

Members of the National Kidney Foundation Council on Renal Nutrition.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

Members of the National Kidney Foundation Council on Renal Nutrition.

Design

Cross-sectional study.

Blinding used

Not applicable.

Intervention

Not applicable.

Statistical Analysis

Some of the data are presented as mean±standard deviation, with the reported n representing the number of responses to that particular query
If the data reported as percentages do not equal 100%, the missing percentage is caused by no response to that particular question by some of the respondents.

Data Collection Summary:

Timing of Measurements

One-time survey designed to assess the current demographic profile and clinical practice elements of practicing renal dietitians.
Surveys were distributed as a section of the 1999-2000 winter issue of the CRN Quarterly Newsletter.

Dependent Variables

Patient care settings
Number of facilities covered
Patient age
Patient treatment modalities
Dietitian contact hours required to effectively educate pre end-stage renal disease (ESRD) patients on a low-protein diet and to ensure optimal nutrition status for the patients with chronic kidney disease (CKD).

Independent Variables

Demographic profile.

Description of Actual Data Sample:

Initial N: 1,748 members received the newsletter

Attrition (final N): 353 members responded (20%)

Age: Not reported

Ethnicity: Not reported

Location: International membership.

Summary of Results:

Findings

The dietitians had practiced dietetics for 14.5±8.6 years and renal nutrition for 9.15±6.9 years
The average renal dietitian sees approximately 24 chronic dialysis patients per month as inpatients and 105 chronic dialysis patients per month as outpatients; calculations allowed approximately 43 minutes per patient per month (11 minutes per week)
26% of the dietitians spent time on inpatient care, 7% with post-transplantation care, 10% with acute renal failure, and 13% spent the majority of their time with pre-ESRD patients
Dietitians spent an average of 35.1% of their time doing administrative duties
After the initial nutrition consultation, 48.7% of the pre-ESRD patients seen received no follow-up, 13.1% of patients received only one follow-up, 9.49% of patients received more than one follow-up and 17.1% of patients had unlimited follow-up visits with the dietitian
Of the 339 respondents, 88 used actual body weight when assessing nutrients; 19 used usual body weight; 171 used ideal body weight; 52 used a combination of actual, usual, and ideal; and nine used a method other than those listed
Average daily caloric intake prescribed for the pre-ESRD patients was 31.2kcal per kilogram of body weight, with a range of 20kcal per kilogram body weight to 36kcal per kilogram body weight
Respondents indicated that more than two hours are required to adequately teach the diet to new ESRD and pre-ESRD patients
The survey data showed a discrepancy between what the clinical practices were in 1999 and what the current recommendations are, based on the Kidney Disease Outcomes Quality Initiatives (K/DOQI) Clinical Practice Guidelines
Of the respondents, 67% stated that there was no reimbursement for pre-ESRD nutritional counseling, 11% were being reimbursed and 22% did not respond.

Author Conclusion:

To summarize the results from this survey in developing future strategic planning:

Nutritional intervention must start at least 12 months before the initiation of maintenance dialysis
The patient-dietitian ratio should be adjusted for adequate time availability for the patient to be counseled by a qualified renal dietitian
Strive together as the renal health care team to educate regarding the importance and impact of this issue and to bring third-party payers into the loop
Work to mobilize renal dietitians, patient advocacy organizations and other health care organizations involved in patient care to emphasize the need for additional medical nutrition therapy (MNT) legislative coverage
Foster research into the areas that show the positive effects that nutrition counseling and education have with the pre-ESRD patient for prioritizing quality-of-life issues
Development of education materials to assist the RD in improving MNT counseling skills required for the nutritional care of the ESRD patient with protein-energy malnutrition (PEM) is of the utmost importance
Stress the importance of making the chronic renal failure patient's medical conditions a reason to initiate MD early on. Evidence from studies has indicated that once dietary protein intake is less than 0.7g per kilogram body weight, preservation of residual kidney function becomes less advantageous, leading to PEM.

The data from this survey show the increasing need for adequate coverage by qualified renal dietitians for MNT counseling of the CKD patient. Evidence in the literature indicates that not only would this increase the quality-of-life for the patient, but also fewer hospitalizations and fewer co-morbid complications, which in turn would save the renal health care system a considerable amount of financial burden.

Funding Source:

Not-for-profit

National Kidney Foundation Council on Renal Nutrition

Reviewer Comments:

Only members of the National Kidney Foundation Council on Renal Nutrition were surveyed, and only 20% of those surveyed responded; sample may not be representative. Questionnaire not shown to be valid or reliable.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	N/A
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	No
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		???
	4.1.	Were follow-up methods described and the same for all groups?	???
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	???
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	???
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		N/A
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	N/A
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		N/A
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		???
	7.1.	Were primary and secondary endpoints described and relevant to the question?	N/A
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	???
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	???
	7.5.	Was the measurement of effect at an appropriate level of precision?	???
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	???
	7.7.	Were the measurements conducted consistently across groups?	N/A
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	N/A
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	N/A
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		???
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	No
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes