By Stacey Phillips, MS, RDN
In August of 2020, the much–anticipated Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline on Nutrition in Chronic Kidney Disease (CKD) was released as a joint project between the National Kidney Foundation and the Academy of Nutrition and Dietetics. Originally published in 2000, this update expands beyond end-stage kidney disease patients and includes individuals with CKD Stages 1 to 5 and post-transplant recipients. With this expansion of patient inclusion, the guidelines reflect on six major areas in the CKD patient, including nutrition assessment, medical nutrition therapy, dietary protein and energy, supplementation, micronutrients, and the specific electrolytes of calcium, potassium, phosphorus and sodium. Summarized below are just a few of the highlights on areas that can be incorporated into your practice.
Tools for Assessment
Nutrition assessment of any patient with chronic disease can be a challenge. For the CKD patient, the updated recommendations suggest inclusion of appetite, intake, body weight, body mass index, laboratory panels, anthropometrics and a nutrition–focused physical exam. Focusing on appetite and intake alone, there are a number of tools available to help you gather baseline dietary intake from your patient. The new guidelines recommend the following for patients with CKD Stages 3 to 5D:
- 3-day food records
- 24-hour food recalls
- Food frequency questionnaires
- Normalized protein catabolic rate (nPCR)
In individuals on dialysis, use of the 3-day food record should include both dialysis and non-dialysis days to improve accuracy. Offering a pencil and paper option or tracking on a smart phone provides your patient with different methods to obtain this information.
Value of the Registered Dietitian (RD)
While the value of the RD is not news, the guidelines further support our role and importance as part of the interdisciplinary team. Through prescription of individualized and tailored MNT, the RD can optimize nutritional outcomes and support the patient with CKD and other comorbidities.
Protein and Energy Needs: Where to Start?
Adequate intake for the patient is necessary and increases in importance with disease progression to prevent protein-energy wasting often seen with later stages of CKD. Newer KDOQI guidelines reflect ranges for protein and energy intake to help optimize nutritional status with this population.
In metabolically stable individuals with CKD 3 to 5, not on dialysis and without diabetes, the following for protein is recommended:
- Low-protein diet: 0.55 to 0.60 g PRO/kg body weight/day
- Very low-protein diet: 0.28 to 0.43 g PRO/kg body weight/day with keto acid/amino acid analogs (KAA)
In CKD 3 to 5 patients with diabetes who are not on dialysis, the protein recommendation is slightly increased:
- 0.6 to 0.8 g PRO/kg body weight/day
Dialysis patients, with and without diabetes, due to numerous factors, have greater protein needs:
- 1.0 to 1.2 g PRO/kg body weight/day
When assessing the protein needs of your CKD patient, the use of clinical judgement is also necessary. The term ‘metabolically stable’ is highlighted within the recommendations, and it is reasonable to suggest that many of these individuals, especially if new to dialysis, do not fall into this category. In addition, for patients with diabetes, the daily goal for protein may need to be adjusted to help regulate blood glucose levels.
A change in previous energy need recommendations is also reflected in the updated KDOQI guidelines. Optimal energy can be difficult to predict in this patient population due to the lack of a validated resting energy equation. In place of this, a range of recommendations is provided for metabolically stable adults with CKD Stages 1-5D and post-transplant:
- 25-35 kcal/kg body weight/day
Experts recommend considering age, gender, physical activity, body composition, weight status, CKD stage and comorbidities when calculating energy needs. While actual body weight is used for the guidelines, in those individuals who are under– or overweight, clinical judgement is needed from the RD.
Building on the Renal Diet with CKD
Lack of variety with the renal diet can be a patient concern, particularly as CKD progresses. As outlined in the guidelines, there is evidence to support that increased dietary fruits and vegetables are recommended for adults with CKD Stages 1 to 4. With this dietary addition, research supports the approach of increasing fruits and vegetables for a positive impact on body weight, blood pressure and net acid production. In individuals requiring dialysis, working with an RD can help with diet variation.
CKD treatment and MNT can be complex not only for the patient but also for RD trying to best manage their care. While the updated KDOQI guidelines provided a starting point for education, understanding the recommendations and encouraging your patients to make dietary small changes can have a significant impact on disease management.
If you are interested in learning more about the updated 2020 KDOQI guidelines, click here for more information.
Stacey Phillips, MS, RD is a clinical dietitian working with general medicine, oncology, CKD, renal transplant recipients and living kidney donor patients. Outside of her work, Stacey is passionate about improving the resources available to individuals with chronic kidney disease and actively participates on several renal dietitian committees.
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Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.