CKD: Assessment: Executive Summary of Recommendations (2020)

CKD: Assessment: Executive Summary of Recommendations (2020)

Executive Summary of Recommendations 
Below are the recommendations and ratings for the Academy of Nutrition and Dietetics 2020 Chronic Kidney Disease (CKD) Assessment Evidence-Based Nutrition Practice Guideline. Use the links on the left to view the Guideline Introduction. Detailed recommendations, including the evidence supporting these recommendations, is available from the Major Recommendations tab.

• For  a description of the Academy Recommendation Rating scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.
• For a description of the GRADE Recommendation Rate scheme (Level 1 (1A, 1B, 1C, 1D), Level 2 (2A, 2B, 2C, 2D), click here

• Screening and Referral
  CKD: Routine Nutrition Screening

  In adults with CKD 3-5D or posttransplantation, it is reasonable to consider routine nutrition screening at least biannually with the intent of identifying those at risk of protein-energy wasting (OPINION).

  Consensus

  Conditional
  CKD: Nutrition Screening Tools

  In adults with CKD 3-5D or posttransplantation, there is limited evidence to suggest the use of one tool over others for identifying those at risk of protein-energy wasting (2D).

  Weak

  Conditional
• Nutrition Assessment
  CKD: Routine Nutrition Assessment

  In adults with CKD 3-5D or posttransplantation, it is reasonable that a registered dietitian nutritionist (RDN) or an international equivalent conduct a comprehensive nutrition assessment (including but not limited to appetite, history of dietary intake, biochemical data, anthropometric measurements, and nutrition-focused physical findings) at least within the first 90 days of starting dialysis, annually, or when indicated by nutrition screening or provider referral (OPINION).

  Consensus

  Conditional
  CKD: Skinfold Thickness

  In adults with CKD 1-5D (1B) or posttransplantation (OPINION), in the absence of edema, we suggest using skinfold thickness measurements to assess body fat.

  Strong

  Conditional
  CKD: Waist Circumference

  In adults with CKD 5D, we suggest that waist circumference may be used to assess abdominal obesity, but its reliability in assessing changes over time is low (2C).

  Weak

  Conditional
  CKD: Conicity Index

  In adults with CKD 5D on MHD, we suggest that the conicity index may be used to assess nutritional status (OPINION) and as a predictor of mortality (2C).

  Weak

  Conditional
  CKD: Creatinine Kinetics

  In adults with CKD 5D, we suggest that creatinine kinetics may be used to estimate muscle mass, though very high or very low dietary intake of meat and/or creatine supplements will influence accuracy of this measurement (2C).

  Weak

  Conditional
  CKD: Body Mass Index (BMI) as a Predictor of Mortality, Maintenance Hemodialysis (MHD)

  In adults with CKD 5D on MHD, we suggest that overweight/obese status (based on BMI) can be used as a predictor of lower mortality, whereas, underweight status and morbid obesity (based on BMI) can be used as a predictor of higher mortality (2B).

  Fair

  Conditional
  CKD: Body Mass Index (BMI) as a Predictor of Mortality, Peritoneal Dialysis (PD)

  In adults with CKD 5D on PD, we suggest that underweight status (based on BMI) can be used as a predictor of higher mortality (2C).

  Weak

  Conditional
  CKD: Body Mass Index (BMI) as a Predictor of Mortality, Non-Dialyzed

  In adults with CKD 1-5, it is reasonable to consider using underweight status (based on BMI) as a predictor of higher mortality, though the mortality risk associated with overweight or obesity status (based on BMI) is not clear (OPINION).

  Consensus

  Conditional
  CKD: Body Mass Index (BMI) as a Predictor of Mortality, Post-Transplant

  In posttransplantation adults, it is reasonable to consider using underweight and overweight/obesity status (based on BMI) as a predictor of higher mortality (OPINION).

  Consensus

  Conditional
  CKD: Body Composition and Body Weight/Body Mass Index (BMI)

  In adults with CKD 1-5D or posttransplantation, it reasonable to consider assessing body composition in combination with body weight/BMI at the first visit and to monitor overall nutrition status periodically over time (OPINION).

  Consensus

  Conditional
  CKD: Frequency of Body Weight/Body Mass Index (BMI) and Body Composition Assessment

  In adults with CKD 1-5D or posttransplantation who are clinically stable, it is reasonable to measure body weight and BMI and to monitor for changes in body weight/BMI and body composition as needed (OPINION).

  • At least monthly in MHD and PD patients
  • At least every 3 months in patients with CKD 4-5 or posttransplantation
  • At least every 6 months in patients with CKD 1-3 

  Consensus

  Conditional
  CKD: Assessment of Body Weight

  In adults with CKD 1-5D or posttransplantation, it is reasonable for a registered dietitian nutritionist (RDN) or an international equivalent or physicians to use clinical judgement to determine the method for measuring body weight (e.g. actual measured weight, history of weight changes, serial weight measurements, adjustments for suspected impact of edema, ascites and polycystic organs) due to absence of standard reference norms (OPINION).

  Consensus

  Conditional
  CKD: Body Mass Index (BMI) and Protein Energy Wasting (PEW)

  In adults with CKD 1-5D or posttransplantation, BMI alone is not sufficient to establish a diagnosis of PEW unless the BMI is very low (<18 kg/m2) (OPINION).

  Consensus

  Conditional
  CKD: Bioelectrical Impedance for Patients on Maintenance Hemodialysis (MHD)

  In adults with CKD 5D on MHD, we suggest using bioimpedance and preferably multi-frequency bioelectrical impedance (MF-BIA) to assess body composition when available. Bioimpedance assessments should ideally be performed a minimum of 30 minutes or more after the end of the hemodialysis session to allow for redistribution of body fluids (2C).

  Weak

  Conditional
  CKD: Bioelectrical Impedance for Patients, Non-Dialyzed and on Peritoneal Dialysis (PD)

  In adults with CKD 1-5 or CKD 5D on PD, there is insufficient evidence to suggest using bioelectrical impedance to assess body composition (2D).

  Weak

  Conditional
  CKD: Dual-Energy X-Ray Absorptiometry (DXA) for Body Composition Assessment

  In adults with CKD 1-5D or posttransplantation, it is reasonable to use DXA when feasible as it remains the gold standard for measuring body composition despite being influenced by volume status (OPINION).

  Consensus

  Conditional
  CKD: Single Biomarker Measurements

  In adults with CKD stages 1-5D or posttransplantation, biomarkers such as normalized protein catabolic rate (nPCR),  serum albumin and/or serum prealbumin (if available) may be considered complementary tools to assess nutritional status. However, they should not be interpreted in isolation to assess nutritional status as they are influenced by non-nutritional factors (OPINION).

  Consensus

  Conditional
  CKD: Serum Albumin Levels

  In adults with CKD 5D on MHD, serum albumin may be used as a predictor of hospitalization and mortality, with lower levels associated with higher risk (1A).

  Strong

  Imperative
  CKD: Handgrip Strength

  In adults with CKD 1-5D, we suggest that handgrip strength may be used as an indicator of protein-energy status and functional status when baseline data (prior measures) are available for comparison (2B).

  Fair

  Conditional
  CKD: Assessment of Resting Energy Expenditure

  In adults with CKD 1-5D or posttransplantation, it is reasonable to use indirect calorimetry to measure resting energy expenditure when feasible and indicated, as it remains the gold standard for determining resting energy expenditure (OPINION).

  Consensus

  Conditional
  CKD: Resting Energy Expenditure Equations

  In adults with CKD 5D who are metabolically stable, we suggest that in the absence of indirect calorimetry, disease-specific predictive energy equations may be used to estimate resting energy expenditure as they include factors that may influence the metabolic rate in this population  (2C).

  Weak

  Conditional
  CKD: 7-Point Subjective Global Assessment (SGA)

  In adults with CKD 5D, we recommend the use of the 7-point Subjective Global Assessment as a valid and reliable tool for assessing nutritional status (1B).

  Strong

  Imperative
  CKD: Malnutrition Inflammation Score (MIS)

  In adults with CKD 5D on MHD or posttransplantation, Malnutrition Inflammation Score may be used to assess nutritional status (2C).

  Weak

  Conditional
  CKD: Considerations when Assessing Dietary Intake

  In adults with CKD 3-5D or posttransplantation, it is reasonable to assess factors beyond dietary intake (e.g. medication use, knowledge, beliefs, attitudes, behavior and access to food, depression, cognitive function etc.) to effectively plan nutrition interventions. (OPINION).

  Consensus

  Conditional
  CKD: 3-Day Food Records to Assess Dietary Intake

  In adults with CKD 3-5D, we suggest the use of a 3-day food record, conducted during both dialysis and non-dialysis treatment days (when applicable), as a preferred method to assess dietary intake (2C).

  Weak

  Conditional
  CKD: Alternative Methods of Assessing Dietary Intake in CKD 3-5

  In adults with CKD 3-5 (OPINION), 24-hour food recalls, food frequency questionnaires and normalized protein catabolic rate (nPCR) may be considered as alternative methods of assessing dietary energy and protein intake.

  Consensus

  Conditional
  CKD: Alternative Methods of Assessing Dietary Intake in CKD 5D

  In adults with CKD 5D (2D), 24-hour food recalls, food frequency questionnaires and normalized protein catabolic rate (nPCR) may be considered as alternative methods of assessing dietary energy and protein intake (2D).

  Weak

  Conditional