Chronic Kidney Disease Nutrition Guidelines

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Guideline Title

Chronic kidney disease evidence-based nutrition practice guideline.

Bibliographic Source(s)

American Dietetic Association. Chronic kidney disease evidence-based nutrition practice guideline. Chicago (IL): American DieteticAssociation; 2010 Jun. Various p. [205 references]

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical nutrition therapyprotocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.

Disease/Condition(s)

Chronic kidney disease (CKD) (non-dialysis)Co-morbidities of CKD

AnemiaDiabetesDyslipidemiaElectrolyte disordersObesityHypertension

Guideline Category

CounselingEvaluationManagementPreventionTreatment

Clinical Specialty

EndocrinologyFamily PracticeGeriatricsHematologyInternal MedicineNephrologyNutrition

Intended Users

Advanced Practice NursesDietitiansHealth Care ProvidersNursesPatientsPhysician AssistantsPhysiciansStudents

Guideline Objective(s)

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ScopeMethodologyRecommendationsEvidence Supporting the RecommendationsBenefits/Harms of Implementing the GuidelineRecommendationsContraindications

Qualifying StatementsImplementation of the GuidelineInstitute of Medicine (IOM) National Healthcare Quality ReportCategoriesIdentifying Information and AvailabilityDisclaimer

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Back to topMethodology

Guideline Objective(s)

Overall Objective

To provide medical nutrition therapy (MNT) guidelines for chronic kidney disease (CKD) to prevent and treat protein-energy malnutrition,mineral and electrolyte disorders, and to minimize the impact of other comorbidities on the progression of kidney disease, e.g., diabetes,obesity, hypertension and disorders of lipid metabolism

Specific Objectives

To define evidence-based CKD nutrition recommendations for registered dietitians (RDs) that are carried out in collaboration withother healthcare providersTo guide practice decisions that integrate medical, nutritional and behavioral strategiesTo reduce variations in practice among RDsTo provide the RD with data to make recommendations to adjust medical nutrition therapy (MNT) or recommend other therapies toachieve desired outcomesTo develop guidelines for interventions that have measurable clinical outcomesTo define the highest quality of care within cost constraints of the current healthcare environment

Target Population

Adults diagnosed with chronic kidney disease

Interventions and Practices Considered

Evaluation

1. Referral to a registered dietitian2. Nutrition assessment

Client history including medical, social, and personal history and history of medications and supplementsBiochemical data and relevant laboratory valuesAnthropometric measurements including height, weight, body mass index (BMI), waist circumference, and weight change rateNutrition history including food intake, physical activity and exercise, food availability, psychosocial and economic issuesimpacting nutrition therapy, and consideration of co-morbid conditionsPhysical examination findings

Management/Treatment

1. Individualized prescription based on:

Nutrition intervention such as intake of protein, energy, phosphorus, sodium, calcium and vitamin D and multivitaminsupplements, fish oil/omega-3 fatty acids, iron supplementationPhysical activity interventionsBehavioral interventionsManagement of co-morbidities such as anemia, hyperglycemia, dyslipidemia, and hypertension

2. Coordination of nutrition care3. Monitoring of progress

Major Outcomes Considered

Nutritional status (weight, muscle and fat stores, serum albumin)Glomerular filtration rates (GFRs)Blood pressure levelsProgression of kidney diseaseSerum phosphorus levelsBlood glucose levels

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

General Methods for Collecting/Selecting the Evidence

The following list provides an overview of the steps which the American Dietetic Association (ADA) evidence analysis team goes through toidentify research through database searches.

1. Plan the search strategy to identify the "current best evidence" relevant to the question. The plan for identification and inclusion ofarticles and reports should be systematic and reproducible, not haphazard. Write out the original search strategy and documentadjustments to the strategy if they occur. Allow for several iterations of searches.

2. List inclusion and exclusion criteria. The work group will define the inclusion and exclusion criteria. These criteria will be used indefining the search strategy and for filtering the identified research reports. ADA uses only peer-reviewed research; that is, articlesaccepted for evidence analysis must be peer-reviewed and published in a juried publication. Additionally, ADA only uses humansubjects in its research and does not include animal studies in its evidence analysis.

3. Identify search words. During the process of considering outcomes, interventions, nutrition diagnoses, and assessments, the workgroup may have identified a number of specific terms or factors that were important, but were not included in the actual question.These terms can be used as additional search terms to help identify relevant pieces of research. Both text word search andkeyword search using Medical Subject Headings (MeSH) definitions may be used.

4. Identify databases to search. PubMed, Medline, CINAHL, EMBASE, Cochrane, Agricola, DARE, TRIP, AHRQ and ERIC are somecommon databases for clinical nutritional research. Note that search terms can vary depending on the database.

5. Conduct the search. Depending on the number and type of sources found in the initial search, adjustments might have to be madein the search strategy and to inclusion/exclusion criteria, and additional searches run. Changes to the search plan should berecorded for future reference. Document the number of sources identified in each search.

6. Review titles and abstracts. At this point, filtering procedure is used to determine whether a research article matches the inclusion

criteria and is relevant to the work group's questions. Typically, the lead analyst, along with a member of the expert workgroup,first reviews the citations and abstracts to filter out reports that are not applicable to the question. If a determination cannot bemade based on the citation and abstract, then the full text of the article is obtained for review.

7. Gather all remaining articles and reports. Obtain paper or electronic copies of research articles that remain on the list following thecitation and abstract review. If there are less than six citations, it could mean that the search was too specific to identify relevantresearch or that research has not been done on this topic. A broadened search should be tried. When there is a long list ofcitations, ascertain whether it includes articles that are tangential to the question or address the question in only a general way. Inthis case a more focused search strategy may be necessary.

Specific Methods for This Guideline

The recommendations in the guideline were based on a systematic review of the literature. Searches of PubMed, CENTRAL, and CINAHL andhand searches of other relevant literature were performed on the following topics:

Medical nutrition therapy and dietitian interventionEnergy needsProtein needsChronic kidney disease (CKD)-bone mineral disorderAnemiaDiabetesObesityHypertensionDisorders of lipid metabolismPhysical activityFish oil therapy

Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and Results can be found.Here the reader can view when the search plan was performed, specific inclusion and exclusion criteria, search terms, data bases that weresearched, and the excluded articles.

Number of Source Documents

The number of supporting documents for the recommendations is 24.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Conclusion Grading Table

Strength of

Evidence

Elements

Grade I

Good/Strong

Grade II

Fair

Grade III

Limited/Weak

Grade IV

Expert Opinion Only

Grade V

Grade Not

Assignable

Quality

Scientificrigor/validityConsidersdesign andexecution

Studies of strong design forquestion

Free from design flaws, biasand execution problems

Studies ofstrong designfor question withminormethodologicalconcerns

OR

Only studies ofweaker studydesign forquestion

Studies of weak design foranswering the question

OR

Inconclusive findings dueto design flaws, bias orexecution problems

No studies available

Conclusion based on usualpractice, expert consensus,clinical experience, opinion,or extrapolation from basicresearch

No evidencethatpertains toquestionbeingaddressed

Consistency

Of findings acrossstudies

Findings generally consistent indirection and size of effect ordegree of association, andstatistical significance withminor exceptions at most

Inconsistencyamong results ofstudies withstrong design

OR

Consistency with

minorexceptionsacross studies ofweaker designs

Unexplained inconsistencyamong results fromdifferent studies

OR

Single study unconfirmedby other studies

Conclusion supportedsolely by statements ofinformed nutrition ormedical commentators

NA

Quantity

Number ofstudiesNumber ofsubjects instudies

One to several good qualitystudies

Large number of subjectsstudied

Studies with negative resultshaving sufficiently large samplesize for adequate statisticalpower

Several studiesby independentinvestigators

Doubts aboutadequacy ofsample size toavoid Type I andType II error

Limited number of studies

Low number of subjectsstudied and/or inadequatesample size within studies

Unsubstantiated bypublished studies

Relevantstudieshave notbeen done

Clinical Impact

Importance

Studied outcome relates directlyto the question

Some doubtabout the

Studied outcome is anintermediate outcome or

Objective data unavailable Indicatesarea for

Importanceof studiesoutcomesMagnitudeof effect

to the question

Size of effect is clinicallymeaningful

Significant (statistical)difference is large

about thestatistical orclinicalsignificance ofeffect

intermediate outcome orsurrogate for the trueoutcome of interest

OR

Size of effect is small orlacks statistical and/orclinical significance

area forfutureresearch

Generalizability

To population ofinterest

Studied population, interventionand outcomes are free fromserious doubts aboutgeneralizability

Minor doubtsaboutgeneralizability

Serious doubts aboutgeneralizability due tonarrow or different studypopulation, interventionor outcomes studied

Generalizability limited toscope of experience

NA

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading.Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Step 1: Formulate Evidence Analysis Question

Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being considered. Include thepatient type and special needs of the target population involved, the alternatives under consideration, and the outcomes of interest (PICOformat).

Step 2: Gather and Classify Evidence

Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and classify them by typeof evidence. Classes differentiate primary reports of new data according to study design, and distinguish them from secondary reports thatinclude systematic and/or narrative review.

Step 3: Critically Appraise Each Article

Review each article for relevance to the question and use the checklist of questions to evaluate the research design and implementation.Abstract key information from the report.

Step 4: Summarize Evidence

Synthesize the reports into an overview table and summarize the research relevant to the question.

Step 5: Write and Grade the Conclusion Statement

Develop a concise conclusion statement (the answer to the question). Assign a grade to indicate the overall strength or weakness ofevidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Moving From Analysis to the Evidence-Based Nutrition Practice Guideline

The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops thedisease-specific guideline. The guideline development involves the following steps.

Review the Conclusion Statements

The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the conclusion statements,evidence summaries and evidence worksheets.

Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis

The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various sections on therecommendation page. These include:

Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief and separatestatements. The first statement is "what" the dietitian should do or not do? The second statement describes the "why" of therecommendation. More than one recommendation may be formulated depending on a particular topic and the supporting conclusionstatements.Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the supportingconclusion statement(s) will be help determining this rating (see "Rating Scheme for the Strength of the Recommendation").Label of Conditional or Imperative: Each recommendation will have a label of "conditional" or "imperative". Conditionalstatements clearly define a specific situation, while imperative statements are broadly applicable to the target population withoutrestraints on their pertinence.Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or adverseconsequences associated with applying the recommendation(s) to the target population.Conditions of Application: Includes any organizational barriers or changes that would need to be made within an organization toapply the recommendation in daily practice. Also includes any conditions which may limit the application of the recommendation(s).For instance, application may be limited to only people in an inpatient setting, or not applicable for pregnant women. Conditionalrecommendations will always have conditions specified. Imperative recommendations may have some general conditions forapplication.Potential Costs Associated with Application: Includes any costs that may be associated with the application of this

recommendation such as specialized staff, new equipment or treatments.Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that determinedthe recommendation strength.Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions may be listedhere.Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to theformulation of this recommendation(s).References Not Graded in the American Dietetic Association's (ADA) Evidence Analysis Process: Recommendations willbe based on the summarized evidence from the analysis. Sources that were not analyzed during the evidence analysis process maybe used to support and formulate the recommendation or to support information under other categories on the recommendationpage, if the workgroup deems necessary. References must be credible resources (e.g., consensus reports, other guidelines, positionpapers, standards of practice, articles from peer-reviewed journals, nationally recognized documents or websites). Ifrecommendations are based solely on these types of references, they will be rated as "consensus."

Occasionally recommendations will include references that were not reviewed during the evidence analysis process but are relevantto the recommendation, risks and harms of implementing the recommendation, conditions of application, or potential costsassociated with application. These references will be listed on the recommendation page under "References Not Graded in ADA'sEvidence Analysis Process."

Develop a Clinical Algorithm for the Guideline

The workgroup develops a clinical algorithm based on ADA's Nutrition Care Process, to display how each recommendation can be usedwithin the treatment process and how they relate to the Nutrition Assessment, Diagnosis, Intervention, and Monitoring and Evaluation.

Complete the Writing of the Guideline

Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline, Statement ofIntent, Guideline Methods, Implementation, Benefits and Risks/Harms of Implementation), Background Information, and any necessaryAppendices. The workgroup develops these features.

Criteria Used in Guideline Development

The criteria used in determining the format and process for development of ADA's guidelines is based on the following tools and criteria forevidence-based guidelines:

Guideline Elements Model (GEM), which has been incorporated by the American Society for Testing and Materials (ASTM) as aStandard Specification for clinical practice guidelines.AGREE (Appraisal for Guidelines Research and Evaluation) InstrumentNational Guideline Clearinghouse (www.guideline.gov )

Rating Scheme for the Strength of the Recommendations

Criteria for Recommendation Rating

Statement

Rating

Definition Implication for Practice

Strong A Strong recommendation means that the workgroup believes that thebenefits of the recommended approach clearly exceed the harms (or thatthe harms clearly exceed the benefits in the case of a strong negativerecommendation), and that the quality of the supporting evidence isexcellent/good (grade I or II).* In some clearly identified circumstances,strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits stronglyoutweigh the harms.

Practitioners should follow a Strong

recommendation unless a clear andcompelling rationale for an alternativeapproach is present.

Fair A Fair recommendation means that the workgroup believes that thebenefits exceed the harms (or that the harms clearly exceed the benefits inthe case of a negative recommendation), but the quality of evidence is notas strong (grade II or III).* In some clearly identified circumstances,recommendations may be made based on lesser evidence when high-qualityevidence is impossible to obtain and the anticipated benefits outweigh theharms.

Practitioners should generally follow a Fair

recommendation but remain alert to newinformation and be sensitive to patientpreferences.

Weak A Weak recommendation means that the quality of evidence that exists issuspect or that well-done studies (grade I, II, or III)* show little clearadvantage to one approach versus another.

Practitioners should be cautious in decidingwhether to follow a recommendation classifiedas Weak, and should exercise judgment andbe alert to emerging publications that reportevidence. Patient preference should have asubstantial influencing role.

Consensus A Consensus recommendation means that Expert opinion (grade IV)*supports the guideline recommendation even though the available scientificevidence did not present consistent results, or controlled trials were lacking.

Practitioners should be flexible in decidingwhether to follow a recommendation classifiedas Consensus, although they may setboundaries on alternatives. Patient preferenceshould have a substantial influencing role.

Insufficient

Evidence

An Insufficient Evidence recommendation means that there is both a lack ofpertinent evidence (grade V)* and/or an unclear balance between benefitsand harms.

Practitioners should feel little constraint indeciding whether to follow a recommendationlabeled as Insufficient Evidence and should

exercise judgment and be alert to emergingpublications that report evidence that clarifiesthe balance of benefit versus harm. Patientpreference should have a substantialinfluencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifiesexpert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence

Back to topRecommendations

expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidenceand these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline,Pediatrics. 2004;114;874-877.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer ReviewInternal Peer Review

Description of Method of Guideline Validation

Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument asthe evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include dietitians, doctors, psychologists,nurses, etc.). The guideline is adjusted by consensus of the expert panel and approved by American Dietetic Association's Evidence-BasedPractice Committee prior to publication on the Evidence Analysis Library (EAL).

Major Recommendations

Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), andstatement labels (Conditional versus Imperative) are defined at the end of the "Major Recommendations" field.

Chronic Kidney Disease (CKD) Medical Nutrition Therapy (Non-Dialysis)

CKD: Medical Nutrition Therapy

Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with chronic kidney disease (CKD,Stages One to Five including post-kidney transplant). MNT prevents and treats protein-energy malnutrition and mineral and electrolytedisorders and minimizes the impact of other comorbidities on the progression of kidney disease (e.g., diabetes, obesity, hypertension anddisorders of lipid metabolism). Studies regarding effectiveness of MNT report significant improvements in anthropometric and biochemicalmeasurements sustained for at least one year.

Strong, Imperative

CKD: Initiation of Medical Nutrition Therapy

Referral for MNT per federal or state guidelines should be initiated at diagnosis of CKD, in order to maintain adequate nutritional status,prevent disease progression and delay renal replacement therapy (RRT). MNT should be initiated at least 12 months prior to theanticipation of RRT (dialysis or transplant).

Strong, Imperative

CKD: Frequency of Medical Nutrition Therapy

Depending on the care setting and the initiation of MNT, the RD should monitor the nutritional status of individuals with CKD every one tothree months and more frequently if there is inadequate nutrient intake, protein-energy malnutrition, mineral and electrolyte disorders orthe presence of an illness that may worsen nutritional status, as these are predictive of increased mortality risk. Research related to the

time requirements for MNT provided by an RD indicate that approximately two hours per month for up to one year may be required toprovide an effective intervention for adults with CKD.

Strong, Conditional

Recommendation Strength Rationale

Conclusion statements were Grade I.The American Dietetic Association (ADA) CKD Expert Work Group concurs with the National Kidney Foundation Kidney DiseaseOutcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. KDOQI group membersaccepted the guideline statements as valid if the median panel rating was seven or greater on a scale of one to nine.

CKD Assessment of Food/Nutrition-Related History

CKD: Initial Assessment of Food/Nutrition-Related History

The registered dietitian should assess the food- and nutrition-related history of adults with chronic kidney disease (including post kidneytransplant), including but not limited to the following:

Food and nutrient intake (e.g., diet history, diet experience and intake of macronutrients [and micronutrients, such as energy,protein, sodium, potassium, calcium, phosphorus, and others], as appropriate)Medication (prescription and over-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or botanicalsupplement useKnowledge, beliefs or attitudes (e.g., readiness to change nutrition and lifestyle behaviors)BehaviorFactors affecting access to food and food and nutrition-related supplies (e.g., safe food and meal availability)

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability toachieve optimal nutrient intake may contribute to poor outcomes.

Consensus, Imperative

CKD: Reassessment of Food/Nutrition-Related History

On subsequent visits, the RD should reassess the food- or nutrition-related history of adults with CKD (including post kidney transplant),

related to changes in other assessment parameters (laboratory and anthropometric changes), including but not limited to the following:

Food and nutrient intake, targeted to changes in biochemical parametersMedication, dietary supplements, herbal or botanical supplement useKnowledge, beliefs or attitudesBehaviorFactors affecting access to food and food and nutrition-related supplies

Assessment of the above factors is needed to explain changes in the other assessment parameters and plan additional nutritioninterventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.



The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in ChronicRenal Failure.

CKD Anthropometric Assessment Options

CKD: Use Clinical Judgment in Assessing Body Weight

Due to the absence of standard reference norms in the chronic kidney disease population (CKD, including post kidney transplant), theregistered dietitian should use clinical judgment to determine which data to include in estimations of body weight:

Actual measured weightHistory of weight changes (both long-term and recent)Serial weight measurements, monitored longitudinallyAdjustments for suspected impact of edema, ascites and polycystic organs

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body weight can be difficultto determine because as kidney function declines, the ability to regulate fluid balance may be compromised and multiple factors must beconsidered.


CKD: Use Published Weight Norms with Caution

The RD may use other published weight norms in the anthropometric assessment of individuals with CKD (including post kidneytransplant), but each norm has significant drawbacks and must be used with caution:

Ideal body weight (IBW) is the body weight associated with the lowest mortality for a given height, age, sex and frame size and isbased on the Metropolitan Life Insurance Height and Weight Tables. (Caution: Not generalizable to the CKD population and data-gathering methods were not standardized.)Hamwi Method determines the optimal body weight. (Caution: A quick and easy method for determining optimal body weight, buthas no scientific data to support its use.)Standard Body Weight, National Health and Nutrition Examination Survey (NHANES II) (SBW as per KDOQI Nutrition PracticeGuidelines) describes the median body weight of average Americans from 1976 to 1980 for height, age, sex and frame size.(Caution: Although data is validated and standardized and uses a large database of ethnically-diverse groups, data is provided onlyon what individuals weigh, not what they should weigh in order to reduce morbidity and mortality.)Body Mass Index (BMI) often defines generalized obesity and CKD research, specific to dialysis patients, has identified that patientsat higher BMIs have a lower mortality risk. (Caution: The researchers may not have statistically adjusted for all confounders relatedto comorbid conditions occurring in CKD on dialysis [diabetes, malignancy, etc.] and it is unclear how it may relate to CKD patientsnot on dialysis.)Adjusted Body Weight (ABW) is based on the theory that 25% of the excess body weight (adipose tissue) in obese patients ismetabolically active tissue. KDOQI supports the concept of subtracting 25% for obese patients and adding 25% for underweightpatients. (Caution: This has not been validated for use in CKD and may either overestimate or underestimate energy and proteinrequirements.)

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body weight can be difficultto determine because as kidney function declines, the ability to regulate fluid balance may be compromised and multiple factors must beconsidered.

Consensus, Conditional

CKD: Assessment of Body Composition

The RD should assess the body composition of individuals with CKD (including post kidney transplant). Studies suggest that CKD patientsexhibit altered body composition, as compared to healthy individuals.

Fair, Imperative

CKD: Methodologies for Body Composition Assessment

When assessing the body composition of individuals with CKD (including post kidney transplant), the RD may use any valid measurementmethodology, such as anthropometrics (including waist circumference and body mass index) and body compartment estimates. Currently,there is no reference standard for assessing body composition in CKD patients and studies do not show that any one test is superior toanother in assessing body composition among CKD patients.

Fair, Imperative


Conclusion statement was Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition inChronic Renal Failure.

CKD Assessment of Biochemical Parameters

CKD: Assess Biochemical Parameters

The RD should assess various biochemical parameters in adults with chronic kidney disease (including post-kidney transplant), related to:

Glycemic controlProtein-energy malnutritionInflammationKidney functionMineral and bone disordersAnemiaDyslipidemiaElectrolyte disordersOthers as appropriate

Assessment of the above factors is needed to effectively determine the nutrition diagnoses and nutrition prescription in adults with CKD andpost-kidney transplant.



The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:

Nutrition in Chronic Renal FailureBone Metabolism and Disease in Chronic Kidney DiseaseAnemia in Chronic Kidney Disease

CKD Assess CKD-Mineral and Bone Disorders

CKD: Assess CKD-Mineral and Bone Disorders

The RD should assess measurements of mineral and bone disorders (MBD) in adults with chronic kidney disease (including post kidneytransplant) for prevention and treatment. Adults with CKD have altered mineral-bone metabolism and increased risk of vascular disease.



The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism andDisease in Chronic Kidney Disease.

CKD Assessment of Medical/Health History

CKD: Assessment of Medical/Health History

When implementing MNT, the RD should assess the medical and health history of individuals with CKD (including post kidney transplant) forthe presence of other disease states and conditions, such as diabetes, hypertension, obesity and disorders of lipid metabolism. Adults withCKD, including post kidney transplant, have a higher prevalence of comorbidities, which are risk factors for the progression of kidneydisease.

Strong, Imperative



Hypertension and Antihypertensive Agents in Chronic Kidney DiseaseManaging Dyslipidemias in Chronic Kidney DiseaseDiabetes and Chronic Kidney Disease

CKD Protein Intake

CKD: Protein Intake for Estimated Glomerular Filtration Rate (eGFR) <50 ml per minute per 1.73m2

For adults with CKD without diabetes, not on dialysis, with eGFR below 50ml per minute per 1.73m2, the RD should recommend orprescribe a protein-controlled diet providing 0.6 g to 0.8 g dietary protein per kg of body weight per day. Clinical judgment should be usedwhen recommending lower protein intakes, considering the client's level of motivation, willingness to participate in frequent follow-up and

risk for protein-energy malnutrition. Research reports that protein-restricted diets (0.7 g dietary protein per kg of body weight per day,ensuring adequate caloric intake) can slow GFR decline and maintain stable nutrition status in adult non-diabetic patients with CKD.

Strong, Conditional

CKD: Very-Low-Protein Intake for eGFR <20 ml per minute per 1.73m2

In international settings where keto acid analogs are available, a very-low protein-controlled diet may be considered. For adults with CKD

without diabetes, not on dialysis, with an eGFR below 20 ml per minute per 1.73m2, a very-low protein-controlled diet providing 0.3 g to0.5 g dietary protein per kg of body weight per day with addition of keto acid analogs to meet protein requirements may be recommended.International studies report that additional keto acid analogs and vitamin or mineral supplementation are needed to maintain adequatenutrition status for patients with CKD who consume a very-low-protein controlled diet (0.3 g to 0.5 g per kg per day).

Strong, Conditional

CKD: Protein Intake for Diabetic Nephropathy

For adults with diabetic nephropathy, the RD should recommend or prescribe a protein-controlled diet providing 0.8 g to 0.9 g of proteinper kg of body weight per day. Providing dietary protein at a level of 0.7 g per kg of body weight per day may result in hypoalbuminemia.Research reports that protein-restricted diets improved microalbuminuria.

Fair, Conditional

CKD: Protein Intake for Kidney Transplant

For adult kidney transplant recipients (after surgical recovery, with an adequately functioning allograft), the RD should recommend 0.8 g to1.0 g per kg of body weight per day for protein intake, addressing specific issues as needed. Adequate, but not excessive, protein intakesupports allograft survival and minimizes impact on comorbid conditions.



For the CKD: Protein Intake (Non-dialysis) for eGFR <50 ml per minute per 1.73m2 recommendation, the conclusion statement wasGrade I.

For the CKD: Very-Low-Protein Intake (Non-dialysis) for eGFR <20 ml per minute per 1.73m2 recommendation, the conclusionstatement was Grade I.For the CKD: Protein Intake for Diabetic Nephropathy recommendation, the conclusion statement was Grade II.For the CKD: Protein Intake for Kidney Transplant recommendation, the conclusion statement was Grade III.

CKD Energy Intake

CKD: Energy Intake

For adults with CKD (including post kidney transplant after surgical recovery), the RD should recommend or prescribe an energy intakebetween 23 kcal to 35 kcal per kg of body weight per day, based on the following factors:

Weight status and goalsAge and genderLevel of physical activityMetabolic stressors

Research reports that energy intakes between 23 kcal to 35 kcal per kg body weight per day are adequate to prevent signs of malnutrition.

Fair, Imperative


Conclusion statement in support of this recommendation was Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition inChronic Renal Failure.

CKD Phosphorus

CKD: Phosphorus

For adults with CKD (Stages Three to Five), the RD should recommend or prescribe a low-phosphorus diet providing 800 mg to 1,000 mgper day or 10 mg to 12 mg phosphorus per gram of protein. CKD patients have a predisposition for mineral and bone disorders. Phosphoruscontrol is the cornerstone for the treatment and prevention of secondary hyperparathyroidism, renal bone disease and soft tissuecalcification.

Strong, Conditional

CKD: Adjust Phosphate Binders

For adults with CKD (Stages Three to Five), the dose and timing of phosphate binders should be individually adjusted to the phosphatecontent of meals and snacks to achieve desired serum phosphorus levels. Serum phosphorus levels are difficult to control with dietaryrestrictions alone.

Strong, Conditional

CKD: Phosphorus Management for Kidney Transplant

For adult kidney transplant recipients exhibiting hypophosphatemia, the RD should recommend or prescribe a high-phosphorus intake (dietor supplements) to replete serum phosphorus as needed. Hypophosphatemia is common post kidney transplant.



Conclusion statement was Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for BoneMetabolism and Disease in Chronic Kidney Disease.

CKD Calcium

CKD: Calcium

For adults with CKD (Stages Three to Five, including post kidney transplant), the RD should recommend a total elemental calcium intake(including dietary calcium, calcium supplementation and calcium-based phosphate binders) not exceeding 2, 000 mg per day. CKD patientshave a predisposition for mineral and bone disorders. Serum calcium concentration is the most important factor regulating parathyroidhormone (PTH) secretion affecting bone integrity and soft tissue calcification.




CKD Vitamin D Therapy

CKD: Vitamin D Supplementation

In adults with CKD (including post kidney transplant), the RD should recommend vitamin D supplementation to maintain adequate levels ofvitamin D if the serum level of 25-hydroxyvitamin D is less than 30 ng per ml (75 nmol per L). CKD patients have a predisposition formineral and bone disorders, as well as other conditions that may be affected by insufficient vitamin D. Sufficient vitamin D should be

mineral and bone disorders, as well as other conditions that may be affected by insufficient vitamin D. Sufficient vitamin D should berecommended to maintain adequate levels of serum vitamin D.




CKD Anemia

CKD: Iron Supplementation

In adults with CKD (including post kidney transplant), the RD should recommend oral or intravenous (IV) iron administration if serumferritin is below 100 ng per ml and transferrin saturation (TSAT) is below 20%. CKD patients have a predisposition for anemia. Sufficientiron should be recommended to maintain adequate levels of serum iron to support erythropoiesis.


CKD: Vitamin B12 and Folic Acid for Anemia

In adults with CKD (including post kidney transplant), the RD should recommend vitamin B12 and folic acid supplementation if the meancorpuscular volume (MCV) is over 100 ng per ml and serum levels of these nutrients are below normal values. CKD patients have apredisposition for anemia and all potential causes should be investigated.


CKD: Vitamin C for Treatment of Anemia

If the use of vitamin C supplementation is proposed as a method to improve iron absorption for adults with CKD (including post kidneytransplant) who are anemic, the RD should recommend the dietary reference intakes (DRI) for vitamin C. There is insufficient evidence torecommend the use of vitamin C supplementation above the DRI in the management of anemia in patients with CKD, due to risk ofhyperoxalosis.


CKD: L-Carnitine for Treatment of Anemia

For adults with CKD (including post kidney transplant) who are anemic, the RD should not recommend L-carnitine supplementation. Thereis insufficient evidence to recommend the use of L-carnitine in the management of anemia in adults with CKD including post kidneytransplant.



Conclusion statement was Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Anemia inChronic Kidney Disease.

CKD Management of Hyperglycemia in Diabetes and CKD

CKD: Management of Hyperglycemia in Diabetes and CKD

For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT for diabetes care to managehyperglycemia to achieve a target A1C of approximately 7%. Intensive treatment of hyperglycemia, while avoiding hypoglycemia, preventsdiabetic kidney disease (DKD) and may slow progression of established kidney disease.

Strong, Conditional


The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical PracticeRecommendations for Diabetes and Chronic Kidney Disease.

CKD Multi-Faceted Approach to Intervention in Diabetes and CKD

CKD: Multi-Faceted Approach to Intervention in Diabetes and CKD

For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT using a multi-faceted approach,including education and counseling in healthy behaviors, treatment to reduce risk factors and self-management strategies. Multiple riskfactors are managed concurrently in adults with diabetes and CKD and the incremental effects of treating each of these risk factors resultsin substantial clinical benefits.



The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical PracticeRecommendations for Diabetes and Chronic Kidney Disease.

CKD Multi-Faceted Approach to Intervention in Dyslipidemias and CKD

CKD: Multi-Faceted Approach to Intervention in Dyslipidemias and CKD

For adults with dyslipidemia and CKD (including post kidney transplant), the RD should implement MNT, using a multi-faceted approach,including education and counseling in therapeutic lifestyle changes (TLC), treatment to reduce risk factors and self-management strategies.Multiple risk factors are managed concurrently in adults with dyslipidemia and CKD and the incremental effects of treating each of theserisk factors results in substantial clinical benefits.

Fair, Conditional



Managing Dyslipidemias in Chronic Kidney DiseaseDiabetes and Chronic Kidney Disease

CKD Education on Self-Management Behaviors

CKD: Education on Self-Management Behaviors

For individuals with CKD (including post kidney transplant), the RD should provide education and counseling regarding self-managementbehaviors. Therapy must take into consideration the patient's perception of the health-care provider's advice and prescriptions, factors thatmay influence self-management behaviors and the likelihood that the patient will adhere to recommendations.

Fair, Imperative


The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertension andAntihypertensive Agents in Chronic Kidney Disease.

CKD Sodium

CKD: Control Sodium Intake in CKD

For adults with CKD (including post-kidney transplant) the RD should recommend/prescribe a sodium intake of less than 2.4 g (Stages Oneto Five), with adjustments based on the following:

Blood pressureMedicationsKidney functionHydration statusAcidosisGlycemic controlCatabolismGastrointestinal issues, including vomiting, diarrhea and constipation

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce cardiovasculardisease risk in adults with CKD.

Fair, Imperative


Conclusion statement received Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertensionand Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for Diabetes and Chronic Kidney

Disease.

CKD Fish Oil/Omega-3 Fatty Acids

CKD: Fish Oil/Omega-3 Fatty Acids

If the use of fish oil or omega-3 fatty acid supplementation is proposed as a method to improve renal function, the RD should advise on theconflicting evidence regarding effectiveness of this strategy. Research reports that renal outcomes were inconsistent among patients withimmunoglobulin A (IgA) nephropathy who received fish oil supplementation. There is insufficient evidence to support fish oil therapy toimprove renal function and patient or graft survival for kidney transplant patients. However, evidence does support a benefit of fish oilsupplementation in reducing oxidative stress and improving lipid profile in adults with CKD (including post kidney transplant).

Fair, Conditional


Conclusion statements were Grades II and III.

CKD Physical Activity

CKD: Physical Activity

If not contraindicated, the RD should encourage adults with CKD (including post kidney transplant), to increase frequency or duration ofphysical activity as tolerated. Studies report that physical activity may minimize the catabolic effects of protein restriction and improvequality of life.

Fair, Conditional


Conclusion statements were Grade III.

CKD Coordination of Care

CKD: Coordination of Care

For adults with CKD (including post kidney transplant), the RD should implement MNT and coordinate care with an interdisciplinary team,through:

Requesting appropriate data (biochemical and other)Communicating with referring providerIndicating specific areas of concern or needed reinforcement.

This approach is necessary to effectively integrate MNT into overall management for patients with CKD.

This approach is necessary to effectively integrate MNT into overall management for patients with CKD.




CKD Multivitamin Supplementation

CKD: Multivitamin Supplementation

In adults with CKD (including post kidney transplant), with no known nutrient deficiency (biochemical or physical) and who may be athigher nutritional risk due to poor dietary intake and decreasing GFR, the RD should recommend or prescribe a multivitamin preparation.Sufficient vitamin supplementation should be recommended to maintain indices of adequate nutritional status.



Conclusion statement was Grade III.

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for BoneMetabolism and Disease in Chronic Kidney Disease.

CKD Potassium

CKD: Control Potassium Intake in CKD

For adults with CKD (including post kidney transplant) who exhibit hyperkalemia, the RD should recommend or prescribe a potassiumintake of less than 2.4 g (Stages Three to Five), with adjustments based on the following:

Serum potassium levelBlood pressureMedicationsKidney functionHydration statusAcidosisGlycemic controlCatabolismGastrointestinal (GI) issues, including vomiting, diarrhea, constipation and GI bleed

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce cardiovasculardisease risk in adults with CKD. The degree of hypokalemia or hyperkalemia can have a direct effect on cardiac function, with potential forcardiac arrhythmia and sudden death.

Fair, Conditional


Conclusion statement was Grade II.The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertensionand Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for Diabetes and Chronic KidneyDisease.

CKD Monitor and Evaluate Biochemical Parameters

CKD: Monitor and Evaluate Biochemical Parameters

The RD should monitor and evaluate various biochemical parameters in adults with CKD (including post kidney transplant), related to:

Glycemic controlProtein-energy malnutritionInflammationKidney functionMineral and bone disordersAnemiaDyslipidemiaElectrolyte disordersOthers as appropriate

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and post kidneytransplant.




Nutrition in Chronic Renal FailureBone Metabolism and Disease in Chronic Kidney DiseaseAnemia in Chronic Kidney Disease

CKD Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations

CKD: Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations

The RD should monitor the following in adults with CKD (including post kidney transplant):

Food and nutrient intake (e.g., diet history, diet experience and intake of macronutrients and micronutrients, such as energy,protein, sodium, potassium, calcium, phosphorus and others, as appropriate)

Medication (prescription and over-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or botanicalsupplement useKnowledge, beliefs or attitudes (e.g., readiness to change nutrition and lifestyle behaviors)BehaviorFactors affecting access to food and food- and nutrition-related supplies (e.g., safe food and meal availability)

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and post kidneytransplant.




Definitions:

Conditional versus Imperative Recommendations

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation,while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, aconditional recommendation can be stated in if/then terminology (e.g., If an individual does not eat food sources of omega-3 fatty acids,then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).

In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text thatwould limit their applicability to specified circumstances. (e.g., Portion control should be included as part of a comprehensive weightmanagement program. Portion control at meals and snacks results in reduced energy intake and weight loss).

Conclusion Grading Table

Strength of

Evidence

Elements

Grade I

Good/Strong

Grade II

Fair

Grade III

Limited/Weak

Grade IV

Expert Opinion Only

Grade V

Grade Not

Assignable

Quality

Scientificrigor/validityConsidersdesign andexecution

Studies of strong design forquestion

Free from design flaws, biasand execution problems

Studies ofstrong designfor question withminormethodologicalconcerns

OR

Only studies ofweaker studydesign forquestion

Studies of weak design foranswering the question

OR

Inconclusive findings dueto design flaws, bias orexecution problems

No studies available

Conclusion based on usualpractice, expert consensus,clinical experience, opinion,or extrapolation from basicresearch

No evidencethatpertains toquestionbeingaddressed

Consistency

Of findings acrossstudies

Findings generally consistent indirection and size of effect ordegree of association, andstatistical significance withminor exceptions at most

Inconsistencyamong results ofstudies withstrong design

OR

Consistency withminorexceptionsacross studies ofweaker designs

Unexplained inconsistencyamong results fromdifferent studies

OR

Single study unconfirmedby other studies

Conclusion supportedsolely by statements ofinformed nutrition ormedical commentators

NA

Quantity

Number ofstudiesNumber ofsubjects instudies

One to several good qualitystudies

Large number of subjectsstudied

Studies with negative resultshaving sufficiently large samplesize for adequate statisticalpower

Several studiesby independentinvestigators

Doubts aboutadequacy ofsample size toavoid Type I andType II error

Limited number of studies

Low number of subjectsstudied and/or inadequatesample size within studies

Unsubstantiated bypublished studies

Relevantstudieshave notbeen done

Clinical Impact

Importanceof studiesoutcomesMagnitudeof effect

Studied outcome relates directlyto the question

Size of effect is clinicallymeaningful

Significant (statistical)difference is large

Some doubtabout thestatistical orclinicalsignificance ofeffect

Studied outcome is anintermediate outcome orsurrogate for the trueoutcome of interest

OR

Size of effect is small orlacks statistical and/orclinical significance

Objective data unavailable Indicatesarea forfutureresearch

Generalizability

To population of

Studied population, interventionand outcomes are free fromserious doubts about

Minor doubtsaboutgeneralizability

Serious doubts aboutgeneralizability due tonarrow or different study

Generalizability limited toscope of experience

NA

Back to topEvidence Supporting the Recommendations

Back to topBenefits/Harms of Implementing the Guideline Recommendations

interest generalizability population, interventionor outcomes studied

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading.Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Criteria for Recommendation Rating

Statement

Rating

Definition Implication for Practice

Strong A Strong recommendation means that the workgroup believes that thebenefits of the recommended approach clearly exceed the harms (or thatthe harms clearly exceed the benefits in the case of a strong negativerecommendation), and that the quality of the supporting evidence isexcellent/good (grade I or II).* In some clearly identified circumstances,strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits stronglyoutweigh the harms.

Practitioners should follow a Strong

recommendation unless a clear andcompelling rationale for an alternativeapproach is present.

Fair A Fair recommendation means that the workgroup believes that thebenefits exceed the harms (or that the harms clearly exceed the benefits inthe case of a negative recommendation), but the quality of evidence is notas strong (grade II or III).* In some clearly identified circumstances,recommendations may be made based on lesser evidence when high-qualityevidence is impossible to obtain and the anticipated benefits outweigh theharms.

Practitioners should generally follow a Fair

recommendation but remain alert to newinformation and be sensitive to patientpreferences.

Weak A Weak recommendation means that the quality of evidence that exists issuspect or that well-done studies (grade I, II, or III)* show little clear

advantage to one approach versus another.

Practitioners should be cautious in decidingwhether to follow a recommendation classified

as Weak, and should exercise judgment andbe alert to emerging publications that reportevidence. Patient preference should have asubstantial influencing role.

Consensus A Consensus recommendation means that Expert opinion (grade IV)*supports the guideline recommendation even though the available scientificevidence did not present consistent results, or controlled trials were lacking.

Practitioners should be flexible in decidingwhether to follow a recommendation classifiedas Consensus, although they may setboundaries on alternatives. Patient preferenceshould have a substantial influencing role.

Insufficient

Evidence

An Insufficient Evidence recommendation means that there is both a lack ofpertinent evidence (grade V)* and/or an unclear balance between benefitsand harms.

Practitioners should feel little constraint indeciding whether to follow a recommendationlabeled as Insufficient Evidence and shouldexercise judgment and be alert to emergingpublications that report evidence that clarifiesthe balance of benefit versus harm. Patientpreference should have a substantialinfluencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifiesexpert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidenceand these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline,Pediatrics. 2004;114;874-877.

Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

Chronic Kidney Disease (CKD) Nutrition GuidelineCKD Nutrition AssessmentCKD Nutrition DiagnosisCKD Nutrition InterventionCKD Nutrition Monitoring and Evaluation

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These resourcessummarize the important studies (randomized controlled trials [RCTs], clinical trials, observational studies, cohort and case-control studies)pertaining to the conclusion statement and provide the study details.

Potential Benefits

A primary goal of implementing these recommendations includes improving a person's ability to achieve optimal nutrition throughhealthful food choices and physically active lifestyle.Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT is essential for improved outcomes. MNTeducation can be considered cost effective when considering the benefits of nutrition interventions on the onset and progression ofcomorbidities versus the cost of the intervention.

Potential Harms

Back to topContraindications

Back to topQualifying Statements

Back to topImplementation of the Guideline

Potential Harms

Risk/Harm Considerations

When using these recommendations:

Review the patient's age, socioeconomic status, cultural issues, health history, and other health conditions.Consider referral to a behavioral specialist if psychosocial issues are a concern.Consider a referral to social services to assist patients with financial arrangements if economic issues are a concern.Use clinical judgment in applying the guidelines when evaluating adults with chronic kidney disease.

In addition to the above, a variety of barriers may hinder the application of these recommendations:

Lower protein and energy intakes can lead to hypoalbuminemia, malnutrition, loss of lean body mass and unintentional weight loss.For chronic kidney disease (CKD) patients with hypophosphatemia or hyperphosphatemia, the registered dietitian (RD) should beaware that protein-controlled diets are typically lower in phosphorus content and therefore protein intake may affect phosphorusmanagement. Hypophosphatemia and hyperphosphatemia are associated with increased morbidity and mortality.The RD should be aware of the risks of hypercalcemia, such as soft tissue calcification, altered mental status, tetany, cardiac eventsand other adverse effects.Oral iron supplementation may result in gastrointestinal distress and lack of adherence to regime. Iron absorption may be impairedby other medications, including phosphate binders, other iron and supplements.Excessive intake of vitamin C may result in hyperoxalosis and contribute to the formation of calcium oxalate kidney stones.Intensive treatment of hyperglycemia may result in more frequent episodes of hypoglycemia.A nutrition prescription that is too high or too low in sodium may result in adverse outcomes.The dietitian should be aware that fish oil therapy provided at the levels given in the studies can affect the ability of the blood tocoagulate and may be additive to the effects of anticoagulant therapy. Patient tolerance, adherence or allergies may be factors inmaintaining a fish oil supplementation regimen.Before beginning a program of physical activity more vigorous than brisk walking, individuals with CKD should be assessed forconditions that might be associated with an increased risk of cardiovascular disease and other physical conditions that may beadversely affected. Intense physical activity in adults with CKD may contribute to disability or death, thus consultation with aphysician prior to beginning an exercise program should be recommended.Intakes of multivitamin supplementation above 100% of the dietary reference intakes (DRI) for an individual may result in adverseeffects.A nutrition prescription that is too high or too low in potassium may result in adverse outcomes.

Contraindications

Bone density assessment may be contraindicated in pregnancy.

Qualifying Statements

This American Dietetic Association Evidence-Based Nutrition Practice Guideline is meant to serve as a general framework for handlingclients with particular health problems. It may not always be appropriate to use these nutrition practice guidelines to manage clientsbecause individual circumstances may vary. For example, different treatments may be appropriate for clients who are severely ill orwho have co-morbid, socioeconomic, or other complicating conditions. The independent skill and judgment of the health care providermust always dictate treatment decisions. These nutrition practice guidelines are provided with the express understanding that they donot establish or specify particular standards of care, whether legal, medical, or other.Evidence-based nutrition practice guidelines are developed to help registered dietitans, practitioners, patients, families, andconsumers make shared decisions about health care choices in specific clinical circumstances. If properly developed, communicatedand implemented, guidelines can improve care. While they represent a statement of promising practice based on the latest availableevidence at the time of publishing, they are not intended to overrule professional judgment. Rather, they may be viewed as a relativeconstraint on individual clinician discretion in a particular clinical circumstance.This guideline recognizes the role of patient and family preferences for possible outcomes of care, when the appropriateness of aclinical intervention involves a substantial element of personal choice or values.Clinical judgment is crucial in the application of these guidelines. Careful consideration should be given to the application of theseguidelines for patients with significant medical co-morbidities.

Description of Implementation Strategy

Description of Implementation Strategy

The publication of this guideline is an integral part of the plans for getting the American Dietetic Association Medical Nutrition Therapy (ADAMNT) evidence-based recommendations on chronic kidney disease (CKD) to all dietetics practitioners engaged in teaching about orresearching this topic. National implementation workshops at various sites around the country and during the ADA Food NutritionConference Expo (FNCE) are planned. Additionally, there are recommended dissemination and adoption strategies for local use of the ADACKD Evidence-Based Nutrition Practice Guideline.

The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its implementation.Management support and learning through social influence are likely to be effective in implementing guidelines in dietetic practice.However, additional interventions may be needed to achieve real change in practice routines.

Implementation of the guideline will be achieved by announcement at professional events, presentations and training. Some strategiesinclude:

National and local events: State dietetic association meetings and media coverage will help launch the guideline.Local feedback adaptation: Presentation by members of the work group at peer review meetings and opportunities forcontinuing education units (CEUs) for courses completedEducation initiatives: The guideline and supplementary resources will be freely available for use in the education and training ofdietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE) programs.

Back to topInstitute of Medicine (IOM) National Healthcare Quality Report Categories

Back to topIdentifying Information and Availability

Champions: Local champions will be identified and expert members of the guideline team will prepare articles for publications.Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case studies.Practical Tools: Some of the tools that will be developed to help implement the guideline include specially-designed resources,such as clinical algorithms, slide presentations, training and toolkits.

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library website (www.adaevidencelibrary.com )and announced to all ADA Dietetic Practice Groups. The ADA Evidence Analysis Library will also provide downloadable supportinginformation and links to relevant position papers.

Implementation Tools

Clinical AlgorithmQuick Reference Guides/Physician GuidesSlide Presentation

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Living with Illness

IOM Domain

EffectivenessPatient-centeredness

Bibliographic Source(s)

American Dietetic Association. Chronic kidney disease evidence-based nutrition practice guideline. Chicago (IL): American DieteticAssociation; 2010 Jun. Various p. [205 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2002 May (revised 2010 Jun)

Guideline Developer(s)

American Dietetic Association - Professional Association

Source(s) of Funding

American Dietetic Association

Guideline Committee

American Dietetic Association Chronic Kidney Disease (CKD) Expert Work Group

Composition of Group That Authored the Guideline

Work Group Members: Jessie Pavlinac, MS, RD, CSR, LD, Chair; Arianna Aoun, MS, RD, CSR, LD; Laura Byham-Gray, PhD, RD; CarolynCochran, MS, RD, LD, CDE; Barbara Hutson, RD, LD; Joni Pagenkemper, MS, MA, RD, LMNT, CDE

Financial Disclosures/Conflicts of Interest

In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships workgroup membershave with companies that sell products or services that are relevant to this topic. Workgroup members are required to disclose potentialconflicts of interest by completing the ADA Conflict of Interest Form. It should not be assumed that these financial interests will have anadverse impact on the content, but they are noted here to fully inform readers. Users of the evidence analysis library may assume that onlywork group members listed below have potential conflicts of interest to disclose.

None of the work group members disclosed potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical nutrition therapyprotocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.

Guideline Availability

Electronic copies: Available from the American Dietetic Association Web site .

Availability of Companion Documents

The following are available:

American Dietetic Association (ADA) chronic kidney disease (CKD) evidence-based nutrition practice guideline. Executive summary

AHRQ Home | Questions? | Contact AHRQ | Site Map | Accessibility | Privacy Policy | Freedom of Information Act | Disclaimers

U.S. Department of Health & Human Services | The White House | USA.gov: The U.S. Government's Official Web Portal

Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 Telephone: (301) 427-1364

Back to topDisclaimer

American Dietetic Association (ADA) chronic kidney disease (CKD) evidence-based nutrition practice guideline. Executive summaryof recommendations. Chicago (IL): American Dietetic Association. 2010. Electronic copies: Available from the ADA Web site .ADA chronic kidney disease (CKD) evidence-based nutrition practice guideline presentation. Slide set. 2010. 64 p. Chicago (IL):American Dietetic Association. Electronic copies: Available for purchase from the ADA Web site .

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on April 29, 2003. The information was verified by the guideline developer on August 6, 2003.

This summary was updated by ECRI on January 29, 2007, following the U.S. Food and Drug Administration (FDA) advisory onerythropoiesis stimulating agents. This summary was updated by ECRI Institute on July 9, 2007, following the FDA advisory onerythropoiesis stimulating agents. This summary was updated by ECRI Institute on December 16, 2010.

Copyright Statement

The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes the adaptation ofthe guidelines for local conditions. However, please note that guidelines are subject to copyright provisions. To replicate or reproduce thisguideline, in part or in full, please obtain agreement from the American Dietetic Association. Please contact Kari Kren at [email protected] copyright permission.

When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should be fullydocumented and the reasons for the differences explicitly detailed.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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Chronic Kidney Disease Nutrition Guidelines

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