Vidafuel’s dietitians provide the abridged version to the recently updated Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines
Can you believe it has been 20 years since the last KDOQI guideline release?! We are excited to share with you some highlights from their recent update. This review from Vidafuel will provide key takeaways of Guidelines 1-4 with a particular focus Nutritional Supplementation recommendations.
The Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines aim to improve patient survival, quality of life and efficacy of care for those suffering from chronic kidney disease (CKD) at all stages. Goals include assessing, preventing, and treating protein energy wasting (PEW), electrolyte imbalances, and disorders of mineral metabolism. This update is a collaboration between the National Kidney Foundation and the Academy of Nutrition and Dietetics to merge, update, and expand the Evidence Analysis Library (EAL) CKD project and the KDOQI Nutrition Guidelines.
When specified, level of evidence is designated in parenthesis after the guideline.
Guideline 1: Nutrition Assessment
- 1.5 Statements on Composite Nutritional Indices: Recommend using subjective global assessment (SGA) or malnutrition inflammation score (MIS) screening tools at the initial visit and any time there is a change in status, or during annual review.
- Body mass index (BMI) as a predictor of mortality; 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. Also take into consideration the age of your patient.
- 1.2 Statements on Assessment with Laboratory Measures: In adults with CKD stages 1-5D and post-transplant, biomarkers such as normalized protein catabolic rate (nPCR), serum albumin and/ or serum prealbumin 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).
- Non-nutritional factors include: inflammation, illness, comorbidities (such as liver disease), volume status, urinary or dialysate protein loss.
- 1.2.2 Statements on Serum Albumin Levels: In adults with CKD on maintenance dialysis, serum albumin may be used as a predictor of hospitalization and mortality, with lower levels associated with higher risk (1A).
- No longer specifies albumin > 4.0. Higher albumin levels are associated with better outcomes, and lower albumin levels (i.e. < 3.5) are associated with higher mortality.
- Use albumin in combination with other assessment tools, not as a standalone.
Guideline 2: Medical Nutrition Therapy
- 2.0 Statements on Medical Nutrition Therapy (MNT): MNT to Improve Outcomes; in adults with CKD 1-5D we recommend that a registered dietitian nutritionist (RDN) in close collaboration with a physician or other provider (nurse practitioner or physician assistant) provide MNT. Goals are to optimize nutritional status, and to minimize risks imposed by comorbidities and alterations in metabolism on the progression of kidney disease and on adverse clinical outcomes (OPINION).
- 2.1.1 MNT to Improve Outcomes: More of a focus on early intervention, prevention and delaying onset for need of renal replacement therapy. There is hope for expansion of MNT utilization and reimbursement.
Guideline 3: Protein & Energy Intake
- 3.1 Statement on Energy Intake: In adults with CKD1-5D (1C) and post-transplant (OPINION) we recommend a prescribing an energy intake of 23-35kcal/kg ideal body weight per day based on age, gender, level of physical activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation to maintain normal nutritional status.
- 3.1.1: Statements on Protein Amount: 3.1.1 Protein restriction is recommended in CKD 3-5, 0.55-0.6g/kg, if patients are metabolically stable, with a focus on vegetable (plant) protein sources to reduce neat acid production, and metabolic acidosis to delay onset of need for renal replacement therapy. CKD patients who have diabetes mellitus (DM), should be prescribed slightly more protein 0.8-0.9g/kg to maintain stable nutritional status and optimize glycemic control.
- 3.1.2: In adults with CKD on maintenance hemodialysis (MHD) (1C) and peritoneal dialysis (PD) (OPINION) who are metabolically stable, we recommend prescribing a dietary protein intake of 1.0-1.2g/kg ideal body weight to maintain a stable nutritional status. Higher levels of dietary protein may be needed in patients with DM at risk of hyper and/or hypoglycemia to maintain glycemic control (OPINION).
Guideline 4: Nutritional Supplementation
- 4.1.1 Oral Protein-Energy Supplementation: In adults with CKD 3-5D (2D) and post-transplant (OPINION) at risk of, or with protein-energy wasting, we suggest a minimum of a 3-month trial of oral nutritional supplements to improve nutritional status if dietary counselling alone does not achieve sufficient energy and protein intake to meet nutritional requirements.
- When dietary counseling alone proves insufficient to bridge the gap between protein-energy intake and target requirements in patients with CKD, provision of oral nutritional supplements (ONS) is often the next appropriate step to prevent and treat PEW.
- ONS should be prescribed 2-3 times daily and patients should be advised to take ONS preferably 1 hour after meals, rather than as a meal replacement to maximize benefit.
- Monitored in-center provision of high-protein meals or ONS during MHD may be a useful strategy to increase total protein and energy intake. Many of the perceived negative effects of intradialytic feeding such as postprandial hypotension, aspiration risk, infection control and hygiene, as well as diabetes and phosphorus control, can be avoided with careful monitoring.
- ONS prescription should take into account patient preference. The acceptability of ONS in terms of appearance, smell, taste, texture, and type of preparation (milkshake type, juice type, pudding type, protein/energy bar, or fortification powder) should be carefully considered. The tolerability of ONS should also be carefully monitored because some patients may develop gastrointestinal symptoms with ONS.
- Energy-dense and low-electrolyte renal-specific ONS may be necessary to increase protein and energy intake and avoid overload and electrolyte derangements.
- Gastrointestinal side effects can influence adherence to ONS, and extended periods of monotonous supplementation can lead to flavor and taste fatigue, as well as nonadherence to the prescribed ONS. Therefore, regular monitoring and evaluation during the supplementation period are crucial and adjustments to the ONS prescription may be necessary to improve adherence and optimize effectiveness. Nutritional status should be monitored regularly throughout the supplementation period to evaluate the effectiveness of ONS.
Source- 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.
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