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Recommendations Summary

CKD: Medical Nutrition Therapy (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CKD: MNT to Improve Outcomes

    In adults with CKD 1-5D, we recommend that a registered dietitian nutritionist (RDN) or an international equivalent,  in close collaboration with a physician, or other provider (nurse practitioner or physician assistant), provide medical nutrition therapy (MNT). Goals are to optimize nutritional status, and to minimize risks imposed by co-morbidities and alterations in metabolism on the progression of kidney disease (1C) and on adverse clinical outcomes (OPINION).

    Rating: Fair
    Imperative

    CKD: MNT Content

    In adults with CKD 1-5D or posttransplantation, it is reasonable to prescribe MNT that is tailored to the individuals’ needs, nutritional status and co-morbid conditions (OPINION).

    Rating: Consensus
    Imperative

    CKD: MNT Monitoring and Evaluation

    In adults with CKD 3-5D or posttransplantation, it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent to monitor and evaluate appetite, dietary intake, body weight changes, biochemical data, anthropometric measurements, and nutrition-focused physical findings to  assess the effectiveness of medical nutrition therapy (OPINION).

    Rating: Consensus
    Imperative

    • Risks/Harms of Implementing This Recommendation

      There are no obvious risks or harms association with Medical Nutrition Therapy.

    • Conditions of Application

      Special Discussions
      The full utility and value of MNT provided by the RDN on both nutrition outcomes and risk of morbidity, mortality and hospitalizations has not yet been fully identified. The impact of the RDN in many disease states and the value of repeated contacts with an RDN on specific nutrition parameters has been documented in the literature (Evidence Analysis Library 2015, Sikand et al, Muscaritoli et al).This is particularly true for CKD patients as well as in other disease states and metabolic phenotypes such as obesity that affect CKD risk and exacerbation of CKD progression. While MNT outcomes research is still in its infancy, the studies that do exist exhibit important relationships on nutrition parameters and other outcomes. An MNT database that monitors MNT intervention effectiveness on nutrition and overall outcome parameters would enable the formalization of this analysis. Studies that prove causality or significant association between MNT application and patient outcomes is currently in progress. In addition, the strength of the evidence in studies reviewed prohibits strong recommendations due to the variability in study populations, protocols and analyses. Therefore, this section included recommendations that are opinion based.

      MNT facilitates the delivery of Nutrition Practice Guidelines through a systemic approach of delivery that is based on scientific evidence and expert opinion. The education, content and practice expertise for the provision of MNT individualized care is found within the scope of practice of the RDN with expertise in nephrology.

      Implementation Considerations

      • Evidence based protocols are inherent to MNT but do not replace individualized modification.
      • Implementation of MNT for CKD patients requires the formation of a fiscal structure that will support the integration of MNT into routine medical management of CKD patients. The interest level to integrate MNT into clinical practice exists by many nephrology and general medicine clinics, however, the lack of adequate reimbursement for RDN services precludes the opportunity to pursue implementation.
      • Demand for MNT is growing as the prevalence of CKD in the USA increases. Reimbursement policies for disease prevention need to include MNT. Legislation awareness is needed to disseminate the value of MNT.
      • MNT may be delivered through telehealth options, in order to improve patient education and successful maintenance of nutrition interventions and adherence.

      Monitoring and Evaluation
      Monitoring and evaluation of MNT on patient’s nutritional parameters is an essential component of treatment and includes assessment of patient’s labs, nutritional status, etiology of kidney disease, lifestyle (stress, exercise, evaluation of smoking and alcohol use, etc.), and patient identified nutrition goals.

    • Potential Costs Associated with Application

      There are no obvious costs in implementing these recommendations. Implementation of MNT Therapy for CKD patients requires the formation of a fiscal structure that will support the integration of MNT therapy into routine medical management of CKD patients. The interest level to integrate MNT into clinical practice exists by many nephrology and general medicine clinics however the lack of adequate reimbursement for RDN services precludes the opportunity to pursue implementation.

      Demand for MNT is growing as the prevalence of CKD in the USA increases. Reimbursement policies for disease prevention need to include MNT. Legislation awareness is needed to disseminate the value of MNT.

    • Recommendation Narrative

      Individualized management of nutritional intake is a crucial aspect of care for individuals diagnosed with any stage of CKD, including those on dialysis and those who have received a kidney transplant. These patients are vulnerable for malnutrition, which is associated with higher risk for morbidity, mortality, and length of hospital stay. Nutritional needs change throughout the disease course, from the earlier stages of CKD to the post-transplant period. The metabolic abnormalities and co-morbid diseases that often accompany CKD further emphasize the need for specialized nutrition health care. Therefore, it is essential that such individuals receive tailored nutrition assessment and counseling in the form of MNT. MNT is a collaborative approach that typically requires the medical expertise and prescription of MNT by a physician or other provider (nurse practitioner, physician assistant) and implementation by an RDN, or international equivalent). These roles are not mutually exclusive and involve ongoing team-patient analysis and discussion. Participating providers and RDN are recommended to have received specialized education and training in nutrition and CKD in accordance with the requirements set forth by local regulations.

      In 2002, the then American Dietetic Association published a nutrition care model that provided evidence-based, high-quality standardized care for patients with CKD, non-dialyzed and post-transplant. The document was later revised in 2010, which reported that nutrition care provided by an RD up to twice monthly over a one-year period can have a valuable role in the medical care of the CKD patients by:

      • Providing nutrition assessment and interventions to delay kidney disease progression in addition to co-morbid conditions such as diabetes mellitus, cardiovascular disease, dyslipidemia, gout, nephrolithiasis;
      • Utilizing behavioral methods to individualize the approach and minimize barriers to individualized goals;
      • Providing individualized meal plans and follow up on adherence and successful implementation. Interventions include but are not limited to weight management and maintenance/repletion of patient nutritional status;
      • Addressing inflammation, supporting obtaining a euvolemic state, contributing to correction of electrolyte abnormalities, assisting in anemia management and managing bone disease through nutrition assessment and dietary interventions including individualized meal plans;    
      • Assisting identifying medication errors and need for adjustment- in collaboration with nephrology Provider (Medical Doctor, Nurse Practitioner, Physician Assistant);
      • Providing and update nutrition therapy as new knowledge indicates such as incorporating plant proteins and addressing the acid nature of dietary intake.

      Detailed Justification
      MNT requires nutrition screening and assessment of nutritional status to provide individualized treatment for specific disease states. CKD patients are on a dynamic nutrition trajectory according to their disease stage and MNT is needed at each stage of CKD. Metabolic abnormalities, acid base, fluid and electrolyte balances often change as CKD progresses. For example, a patient can be hypokalemic during Stage 2 CKD requiring potassium supplementation and a high potassium diet. Months or years later, this same patient during Stage 4 CKD might become hyperkalemic, requiring medication adjustment and dietary potassium restriction rather than supplementation. Should this same patient receive a kidney transplant, they might stabilize potassium balance and have no need for potassium supplementation or dietary potassium restriction. This type of complicated CKD patients requires specialized nutrition health care and ongoing monitoring by a nephrology RDN.

      Sixteen RCTs examining the effect of MNT on nutrition-related outcomes were identified in the systematic review. However, these studies were heterogeneous in terms of the populations (five studies included patients who were non-dialyzed, nine included patients on MHD, one included patients on CAPD, and one included patients post-transplant); interventions (ex: RDNs utilized various methods of nutritional counseling among the studies); and outcomes (ex: protein intake, serum phosphate, serum albumin, BMI, and dyslipidemia. Intervention durations ranged from four weeks to two years.

      CKD Progression
      In four of the studies ranging from 4 weeks to 4 months, authors found no effect of MNT on CKD progression in non-dialyzed patients compared to participants receiving standard nutrition education for CKD, which may or may not have also been provided by an RDN. Interventions ranged from one in-person contact plus phone contacts with the RDN for 12 weeks (Stage 4 CKD) (Campbell et al 2008) to a multi-disciplinary intervention including 4 weeks of weekly counselling with an RDN (Stages 3-4 CKD) (Howden et al 2013) to 2, two-hour cooking classes and a shopping tour (Stages 2-4 CKD) (Flesher et al 2011) to nutrition counselling plus nutrition education for four months (Stages 3-5 CKD) (Paes-Barreto et al 2013).

      SGA Scores
      Three RCTs, including two study populations, reported on the effect of MNT on SGA scores. Campbell et al. demonstrated that malnourished Stage 4 CKD patients’ SGA scores significantly improved in the intervention group compared to the control group, for whom malnutrition by SGA score increased (Campbell et al 2008). The intervention consisted of nutritional counselling from an RDN for 12 weeks, with an emphasis on self-management techniques, face-to-face consultation at baseline, and  telephone consultation every two weeks for the first month, and then monthly for the next 2 months.  In Leon, et al., MHD participants received monthly consultation by RDN for 12 months (Leon et al 2001). Intervention RDNs were trained to determine potential barriers to achieving normal albumin levels for each patient, to attempt to overcome the barriers, and to monitor for improvements in  barriers. There was no difference in the percentage of participants that had improved or decreased SGA scores between groups.

      BMI
      Four RCTs examined the effect of MNT interventions on BMI, including two studies with non-dialyzed patients (Stages 3-5 CKD) (Paes-Barreto et al 2013 and Howden et al 2013),  one study with MHD participants (Leon et al 2001) and one with post-transplant patients (Orazio et al 2011).  Howden, et al., examined the effect of a 12-month multi-disciplinary lifestyle intervention on BMI in patients with stages 3-4 CKD (Howden et al 2013). The intervention group received 4 weeks of group behavioral and lifestyle modification sessions provided by an RDN and a psychologist. Mean BMI significantly decreased in the intervention group compared to the standard care group (p<0.01). Paes-Barreto, et al., examined the effect of MNT on BMI in participants with stages 3-5 CKD who received individualized dietary counselling monthly for four months. In addition to the routine counselling, an intervention group received intensive counselling, which included nutrition education materials emphasizing a low-protein and  low-sodium diet. There was a significantly greater decrease in BMI in the intervention group compared to the standard care group (p<0.01).  In Leon, et al., MHD participants received monthly consultation by an RDN to determine and address barriers to reaching normal serum albumin levels for 12 months. There was no effect on BMI, though this was not the objective of the intervention. Finally, in Orazio, et al., intervention participants received RDN counselling using a Mediterranean-style diet, which consisted of a low glycemic index and moderate energy deficit. MNT counselling was based the Stages of Change Model. There was no difference in change in BMI between groups after 2 years. 

      In a pooled analysis of two studies (Paes Barreto et al 2013 and Howden et al 2013), participants who received MNT had a greater mean (95% CI) decrease in BMI compare to the control groups [-0.89 (=1.52, -0.25) kg/m2]. Results regarding effect of MNT on arm and waist circumference as well as body composition were limited and unclear.

      Phosphate Levels
      Eight studies examined the effect of MNT on phosphorus/phosphate levels in MHD patients for durations ranging from 8 weeks to 6 months. In Ashurst, et al. and Lou, et al., phosphorus-focused education, provided once and monthly for 6 months, respectively, significantly improved (decreased) mean serum phosphate levels. In Karavetian, et al. weekly education nutrition counselling for 2 months also decreased phosphate levels (p<0.01). However, Morey et al. also used phosphorus-focused RDN counselling and education, monthly for 6 months, and found no difference in change in phosphate levels between groups at 6 months.

      Participants receiving a multi-disciplinary nutrition education program did not have any changes in phosphate levels compared to participants receiving an oral nutrition supplement (ONS) (Hernandez et al 2014). In Reese, et al., participants who were coached by a trained RDN about dietary and medication adherence (≥3 times a week) for 10 weeks were compared to patients receiving a financial incentive or usual care. There were no between-group differences in change in phosphate levels.  There was no effect of MNT in the form of dietary counselling in CAPD patients (Sutton et al 2007) or in the form of RDN counselling plus low-protein and low-sodium diet education in non-dialyzed patients (Paes-Barreto et al 2013) on phosphate levels, but the objectives of these studies were to improve energy, protein and sodium intake. 

      Meta-analysis of four studies with comparable data revealed that, mean (95% CI) phosphorus/phosphate levels were decreased -0.715 (-1.395, -0.034) mg/dL, however heterogeneity is high (I2=67.71%, p=0.015). Thus, there was evidence that MNT decreased phosphorus/phosphate levels in MHD patients (Hernandez-Morante et al 2014, Morey et al 2008, Karavetian et al 2013),  but effect on phosphorus/phosphate levels as well as the effect on calcium or potassium levels in non-dialyzed patients (Paes-Barreto et al 2013),  was unclear.

      Lipid Profile
      Three RCTs examined the effect of MNT from an RDN on lipid profile (Hernandez-Morante et al 2014, Howden et al 2013, Flesher et al 2011). In Hernandez-Morante, et al., MHD participants in the intervention group received a 12-session multi-disciplinary Nutrition Education Program over four months, including group and individual therapy, while control participants received an oral nutrition supplement three days/week. Within group analysis showed no significant changes in mean triglycerides and total cholesterol levels over 4 months. There was a significant increase in mean low-density lipoprotein cholesterol (LDL-C) and a significant decrease in mean high-density lipoprotein cholesterol (HDL-C) in both groups over the 4-month study period (p<0.001 for each measure). Between-group analysis was not reported.

      Both Howden, et al. and Flesher, et al. examined the effect of MNT in Stages 3-4 CKD participants. In Howden, et al., intervention participants received a multi-disciplinary lifestyle intervention for 12 months. It included 4 weeks of group behavioral and lifestyle modification by an RDN and a psychologist. No significant changes were observed in triglyceride or total, HDL or LDL cholesterol levels between the 2 groups. In Flesher, et al., in addition to the standard nutrition care for CKD, the intervention group received cooking classes over 4 weeks for 2 hours per session and a shopping tour led by an RDN. No significant difference was observed in mean total cholesterol level between the 2 groups. Pooled analysis confirmed no effect of MNT on total cholesterol and triglyceride levels. However, in pooled analysis, LDL levels were decreased by MNT (Mean (95% CI): -6.022 (-7.754, -4.290) mg/dL. There was no clear effect of MNT on blood pressure (BP).

      Protein intake
      Six RCTs examined the effect of MNT on protein intake in CKD patients (Paes-Barreto et al 2013, Leon et al 2011, Howden et al,  Campbell et al 2008, Sutton et al 2007 and Orazio et al 2011). Two of those studies targeted protein intake as their primary outcome of the MNT provided to the participants.  Paes-Barreto, et al. educated non-dialysis patients on eating a low protein diet,  while Leon, et al. counseled MHD participants on following a high protein diet. Both studies showed high compliance of recommended protein intake among the participants in the intervention group as compared to the control group. The other four studies did not show any significant differences in protein intake between the intervention and control groups, but protein intake was not the primary outcome.

      The utilization of MNT protocols has the potential to preserve nutritional status, modify risk factors for progression of kidney disease, as well as assist with living with CKD from a diet and lifestyle prospective through teaching patients healthy food choices in an individualized manner.

    • Recommendation Strength Rationale

      The evidence supporting the recommendation on improved outcomes is based on Grade III /Grade C evidence and Consensus/expert opinion. The remaining MNT recommendations are based on Consensus/expert opinion. 

      The full utility and value of the MNT intervention by the RDN on both nutrition outcomes and risk of morbidity, mortality and hospitalizations has not yet been fully identified. The impact of the RDN in many disease states and the value of repeated contact visits of RDN with patient on specific nutrition parameters has been documented in the literature. This is particularly true for CKD patients as well as in other disease states and metabolic phenotypes such as obesity that affect CKD risk and exacerbation of CKD progression. In consideration that MNT outcomes research is still in its infancy, the studies that do exist exhibit important associations on nutrition parameters and outcomes as reviewed in this document. An MNT database that monitors MNT intervention effectiveness on nutrition and overall outcome parameters would enable the formalization of this analysis. Studies that prove causality or significant association between MNT application and patient outcomes is currently a work in progress. In addition, the strength of the evidence in studies reviewed prohibits strong grading due to the variability in study population sizes, protocol and statistical structuring. Retrospective cohort analysis trials were not included here. Therefore, suggestions from this section are opinion based.

      MNT facilitates the delivery of Nutrition Practice Guidelines through a systemic approach of delivery that is based on scientific evidence and expert opinion. The education, content and practice expertise for the provision of MNT individualized care is found within the scope of practice of the RDN with expertise in nephrology.

    • Minority Opinions

      Consensus reached.