1. Mnt in adults with CKD: practice for the generalist registered dietitian
Paula Rose
Wade Park Nutrition Clinic
Preceptors: Elizabeth Koustis & Pamela Jessup

2. Judith A. Beto, PhD, RDN, LD, FAND
RESEARCH
Research and Practice Innovations
Medical Nutrition Therapy in Adults with Chronic Kidney Disease: Integrating Evidence and Consensus into Practice for the Generalist Registered Dietitian Nutritionist1
Judith A. Beto, PhD, RDN, LD, FAND
Wendy E. Ramirez, PharmD
Vinod K. Bansal, MD
Beto JA, Ramirez WE, Bansal VK.
J Acad Nutr Diet. 2014;114(7).

3. Background3 Chronic kidney disease (CKD) With progression
Includes conditions that damage your kidneys
Diabetes and high blood pressure
Glomerulonephritis (glow-mare-you-low-nephritis)
Polycystic kidney disease
Malformations that cause infections
Lupus (systemic)
Obstructions
Repeated UTI’s
With progression
Waste builds to high levels in your blood
Complications
High blood pressure
Anemia (low blood count)
Weak bones
Poor nutritional health and nerve damage
Increases your risk of having heart and blood vessel disease
Early detection and treatment can keep CKD from getting worse
Kidney failure
Requires dialysis or a kidney transplant to maintain life

4. Background CKD- Classified in stages 1-5 Stages
Originally developed by national kidney foundation
Revised in 2012 by the international group Kidney Disease: Improving Global Outcomes Table1
Stages
Measured as estimated glomerular filtration rate (eGFR)
G1-G5
Including the degree of albuminuria (albumin in urine)
A1-A3

5. Persistent albuminuria category
Table 1. Kidney Disease Improving Global Outcomes’ terminology used to describe varying degrees of chronic kidney disease function and persistent albuminuriaa
CKDb stages
GFRc category
Description and GFR range 1 G1
Normal/high
GFR≥90 mL/min/1.73 m2 2 G2
Mildly decreased
GFR 60 to 89 mL/min/1.73 m2 3
G3a
Mildly to moderately decreased
GFR 45 to 59 mL/min/1.73 m2
G3b
Moderately to severely decreased
GFR 30 to 44 mL/min/1.73 m2 4 G4
Severely decreased
GFR 15 to 29 mL/min/1.73 m2 5 G5
Kidney failure
GFR <15 mL/min/1.73 m2
Persistent albuminuria category
Description and albuminuria range A1
Normal/mildly increased
<30 mg/g or <3 mg/mmol A2
Moderately increased
30 to 300 mg/g or 3 to 300 mg/mmo A3
Severely increased
>300 mg/g or >30 mg/mmol a
b CKD=chronic kidney disease;
c GFR=glomerular filtration rate
Beto JA, Ramirez WE, Bansal VK.
J Acad Nutr Diet. 2014;114(7).

6. Why it matters Generalist registered dietitian nutritionist (RDN)
MNT is covered by Medicare for GFR mL/min for patients not on renal replacement therapy (RRT)2
This includes stages G3a-5
Reimbursement based on clinical evidence that
MNT, particularly protein modification can slow or delay progression to kidney failure
Would then require RRT
RRT in stage 5
MNT treatment requires specialty level of practice
Very costly and paid through bundling
Delaying the progression to RRT is cost effective
Generalist RDN’s will occasionally run into a stage 5 patient
Need to be aware of MNT parameters
Purpose of article: provide an update on recommendations for screening, diagnosing, and treatments for adults with CKD for application in clinical practice for the generalist registered dietitian nutritionist.

7. Screening Who is at risk? Components of screening
HTN with or without CVD
Type 1 and 2 DM
Family hx of CKD
Polycystic kidney disease
Unique ethnicity ( American Native Indians, African Americans, Hispanics)
Lifestyle risk factors (obesity)
>60 yrs. old
Shouldn’t screen on age alone
Components of screening
eGFR (calculated)
Can be effected by: >85 yrs. old, very low or high BMI, very low or high protein diet, meds that effect excretion of creatinine
Urine albumin dipstick: sufficient for further investigation
Not standard
Albumin/creatinine ratio: quick and good for screening
24 hr. urine collection
Significant decline in use

8. Classification and medical diagnosis
Grouped by eGFR level
eGFR + persistent albuminuria- further define risk of progression
Low, moderate increased, high, very high
Etiology is multifactorial
No role in treatment
Classification drives interventions
M/E response to treatment
Stages 2-3: key intervention is to delay progression
Stage 4: more complicated MNT to delay progression & maintain nutritional adequacy before RRT
Received transplant
Categorized with same nomenclature based on eGFR and albuminuria

9. Common symptoms Mostly asymptomatic but could be Urine output
Vague symptoms of fatigue
Non-specific nausea, vomiting
Decreased appetite –usually caused by uremia
Urine output
Doesn’t typically decline until stage 5

10. Assessment Evaluate patient for
Basic knowledge, health literacy, motivation factors, and barriers to change: similar to core standards of practice parameters for the generalist RDNs
Labs: Note key changes in-- serum albumin, HGB, creatinin, BUN, and eGFR
Medication burden is high in population
~19pills/day, can change a lot
Be sure to investigate ALL meds: including OTC and CAM
Body weight to calculate nutrient needs
Use clinical judgement– with repeated measurements
Consider: changes in fluid status, kidney function, body comp
Body comp
No current methodology or assessment reference
Clinical judgement and frequent measures over time are suggested
Mineral and bone disorders should be assessed
Medical and health history for comorbidities

11. Diagnosis Specific goal for stages 3-4 Overall goal Common diagnosis
Reduce metabolic byproducts from dietary intake
Stop or slow progression to kidney failure
Overall goal
Match diet intake with existing kidney function or RRT while preventing nutritional deficiencies
Common diagnosis
Excessive or inadequate dietary intake
Protein, sodium, potassium, phosphorus
Body composition changes
Weight loss, muscle mass change
Behavioral/compliance
Knowledge deficit
Motivation
Lifestyle change issues
Usually more than one PES

12. Interventions and M/E Interventions M/E
Vitamin D supplement should be recommended
Monitor anemia
Iron supplement if ferritin <100 ng/mL or transferrin saturation <20%
B12 and folic acid when serum levels inadequate and MCV >100 fL
Diabetic nephropathy: A1c of ~7%
M/E
Stages 3-4 require progressive cycles
Visit every 1-3months
@least 2 hrs./month for a year
Biochemical parameters
Adherence to nutrition and lifestyle changes

13. Nutritional parameters
Following are for the generalist treating stage patients with stages 3-5 without RRT
– MNT for stage 5 with RRT is done by specialist**
Prime focus: matching diet intake with kidney function
Re-assessed at each encounter
Because kidney function is not stable over time
Nutrition prescription
Know each component well- priority often changes with treatment
Protein, energy, fat, sat fat, sodium, potassium, calcium, phosphorus, fiber, fluid
Protein
.6-.8 g/kg a day
Requirements assessed by serum creatinine, BUN, eGFR
@least 50% HBV
For tissue repair and maintenance
Vegetarian diets require more specific awareness and strategies

14. Nutritional parameters (cont.)
Calories
25-35kcal/kg a day
Drives repair rather than energy
BMI controversy*
Fat/CVD
Adult treatment panel III & American Heart Association guidelines in CKD
<30% of total calories
Emphasis of healthy fats
Sat fat
General population recommendation
<7% of total fat
Sodium
<2.4 g/day
Salt substitutes– contain potassium chloride and should be avoided

15. Nutritional parameters (cont.)
Potassium
Typically not restricted until hyperkalemia is present (usually stage 5)
Individualized
Serum elevated in stage 3-4 usually due to meds, not excessive intake
Calcium
No restriction
Phosphorus
Not restricted until hyperphosphatemia
Individualized with diet or phosphate binders
Fiber
Same as general population
25-35g/day
Fluid
Usually No restriction unless with comorbidities (CHF)
Monitor patients for rapid increase in weight change
Not related to LBM
constant re-evaluation

16. Nutritional parameters (cont.)
Phosphorus/calcium/PTH
Elevations as early as stage 3
Trigger clinical outcomes
Decrease vitamin D
Mineral and bone disorders
Vascular calcification
Dairy may need to be monitored
Conflicts with HTN prevention
Fortified foods or drinks (calcium)
Other
Anemia common
Supplement with vitamin D
Fiber
Phosphate binders and other meds cause constipation
Fish oil
Some benefit, needs research
L-caritine (AA)
Not effective

17. Other Physical activity Lots of room for research!
Encouraged and promoted
Match to patient ability
Lots of room for research!
Long term data and cost efficacy of services rendered to CKD patients by RDN’s
Chronic education linking RDN services to delay or slowing of progression
Prebiotic and probiotic use
Management of malnutrition and inflammation, and use of antioxidant rich foods

18. Beto JA, Ramirez WE, Bansal VK. J Acad Nutr Diet. 2014;114(7).
Table 2. Selected medical nutrition therapy guidelines for adults with chronic kidney disease (CKD) by stagea
Nutrient
CKDb stages 3 to 5 without RRTc
(GFRd categories 3 to 5)
CKD stage 5 with RRT (kidney failure)
Post-transplantation
(guided by CKD stage/
category of kidney function)
Proteine
0.6 to 0.8 g/kg of BWf/day with at least 50% HBVg to potentially slow disease progression (particularly in patients with diabetes) and achieve/maintain adequate serum albumin
1.1 to 1.5 g/kg of BW/day (HDh with at least 50% HBV to achieve/ maintain adequate serum albumin levels in conjunction with sufficient protein-sparing caloric intake
0.8 to 1.0 g/kg of BW/day with 50% coming HBV
Energy
25 to 35 kcal/kg of BW/day to achieve or maintain goal body weight
25 to 35 kcal/kg of BW/day to achieve or maintain goal body weight; include estimated caloric absorption from PDi fluid as applicable
25 to 35 kcal/kg of BW/day to
achieve or maintain goal body weight
Fat
General population recommendation of <30% of total calories from fat; emphasis on healthy fat sources
Focus on type of fat and carbohydrate to manage dyslipidemia, if present
Focus on type of fat and carbohydrate to reduce cardiovascular risk or manage immunosuppressant medication adverse effect (eg, dyslipidemia, glucose intolerance)
Saturated fat
Same as for general population; <7% of total fat
Reduce and substitute saturated fat sources with healthier fat sources
Reduce and substitute saturated fat sources with healthier fat sources
a Data from references 7-15 and 28-33; b CKD=chronic kidney disease; c RRT=renal replacement therapy (hemodialysis, peritoneal dialysis);
d GFR=glomerular filtration rate; e See special considerations for vegetarians in Pagenkemper; f BW=body weight; see text for discussion of body weight determination factor; g HBV=high biological value; h HD=hemodialysis; i PD=peritoneal dialysis
Beto JA, Ramirez WE, Bansal VK.
J Acad Nutr Diet. 2014;114(7).

19. Beto JA, Ramirez WE, Bansal VK. J Acad Nutr Diet. 2014;114(7).
Table 2. Selected medical nutrition therapy guidelines for adults with chronic kidney disease (CKD) by stagea
Nutrient
CKDb stages 3 to 5 without RRTc
(GFRd categories 3 to 5)
CKD stage 5 with RRT (kidney failure)
Post-transplantation
(guided by CKD stage/
category of kidney function)
Sodium
General population recommendation of ≤2.4 g/day
2.0 to 3.0 g/day (HD) to control interdialytic fluid gain; 2.0 to 4.0 g/day (PD) to control hydration status
Potassium
Typically not restricted until hyperkalemia is present, then Individualized
2.0 to 4.0 g/day or 40 mg/kg of BW/day in HD or individualized in PD to achieve normal serum levels
No restriction unless hyperkalemia is present, then individualized
Calcium
No restriction
2 g elemental/day from dietary and
medication sources
Individualized to kidney function
Phosphorus
Typically not restricted until hyperphosphatemia is present, then individualized to maintain normal serum levels by diet and/or
phosphate binders
800 to 1,000 mg/day to achieve goal
serum level of 3.5 to 5.5 mg/dLj or
below; coordinate with oral
phosphate binder prescription
Individualized to stage of
kidney function
Fiber
Same as general population;
25 to 35 g/day
Fluid
1,000 mL/day (+ urine output if
present) in HD; greater in PD
individualized to fluid status
No restriction; matched to urine
output if appropriate
a Data from references 7-15 and 28-33; b CKD=chronic kidney disease; c RRT=renal replacement therapy (hemodialysis, peritoneal dialysis);
d GFR=glomerular filtration rate; e See special considerations for vegetarians in Pagenkemper; f BW=body weight; see text for discussion of body weight determination factor; g HBV=high biological value; h HD=hemodialysis; i PD=peritoneal dialysis; j To convert mg/dL phosphorus to mmol/L, multiply mg/dL by To convert mmol/L phosphorus to mg/dL, multiply mmol/L by Phosphorus of 3.10 mg/dL¼1.00 mmol/L.
Beto JA, Ramirez WE, Bansal VK.
J Acad Nutr Diet. 2014;114(7).

20. References
1. Beto J, Ramirez W, Bansal V. Medical Nutrition Therapy in Adults with Chronic Kidney Disease: Integrating Evidence and Consensus into Practice for the Generalist Registered Dietitian Nutritionist. Journal of the Academy of Nutrition and Dietetics. 2014;114(7): doi: /j.jand
2. Cms.gov. Decision Memo for Medical Nutrition Therapy Benefit for Diabetes & ESRD (CAG-00097N) Available at: decision- memo.aspx?NCAId=53&NCDId=252&ncdver=1&NcaName=Medi cal+Nutrition+Therapy+Benefit+for+Diabetes. Accessed September 18, 2015.
3. The National Kidney Foundation. About Chronic Kidney Disease Available at: Accessed September 18, 2015.