RBT Roundtable: The Renal Diet

Is there room for improvement in nutrition? If so, what can be done?

Benner: The kidney diet is one of the most difficult diets to follow due to the multiple components to balance—fluid, sodium, protein, potassium, phosphorus and calcium. It’s often complicated by other health issues such as diabetes and heart disease along with changes in appetite and intake. This makes diet a huge task for patients and a constant challenge for those helping educate and care for the patient. We must continue to advance the focus on individualized nutrition care. Patients need to be considered as individuals with their own unique set of nutrition challenges with consideration of intake, dietary habits, co-morbid conditions, current health status, lifestyle, access to food, education, understanding and ability to implement dietary modifications based on their individual situations. There is need to continue to improve educational tools and resources that patients are able to utilize to enhance their overall nutritional intake and status on a daily basis.

Wager: Yes, there is room for improvement in nutrition education. Patients crave the information. One of the No. 1 requests the AAKP office receives is for information on diet and nutrition. There is basic information every patient should know after a diagnosis of CKD. For example, patients should understand how hypertension can be treated with a low-sodium diet. Patients should also understand the difference between high biological proteins versus low biological proteins. Providing patients with access to a renal dietitian in the early stages of the disease can also help slow the progression of the disease. Patients have different dietary needs, and working with a renal dietitian will help patients make the right food choices. Many patients feel nutrition is the one thing they can really take control of when trying to manage their kidney disease. We as renal professionals need to give them the tools necessary to make good choices at the beginning of their diagnosis.

Trahan: I will confess sometimes we get so focused on phosphorus and albumin levels that we forget it’s important to make sure the patient is receiving enough overall calories from different sources to improve their nutritional status or albumin levels. Once again, I think as more research emerges, inflammation will be more aggressively treated and will affect positive nutritional outcomes.

Karalis: More randomized, controlled trials in linking nutrition intervention to patient level outcomes are needed. Studies are needed to characterize the optimal level of protein restriction and duration of intervention. Additional studies should explore a potential additive effect of a low protein diet in combination with angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists or other anti-proteinuric medications.

The Council on Renal Nutrition (CRN) has been focused on stimulating, supporting and encouraging nutrition-related research. Areas requiring additional research will be prioritized and a movement towards a “call for proposals” has been initiated. Just recently a call for proposals in determination of a predictive equation to estimate energy requirements in the hemodialysis population was released.

Keo: There can always be room for improvement. Along with disease state knowledge, i.e., knowing the type of kidney disease, stage of kidney disease, type of dialysis chosen, diabetic status and activity level of our patients. Labeling of food items is a concern, particularly knowing the phosphorus content of foods. As every renal healthcare provider knows, phosphorus control is tied to survival for the patient. The control of phosphorus is largely dependent on the patient through smart nutritional choices and taking the prescribed phosphorus binders with their meals. By food manufacturers clearly identifying the phosphorus/phosphate content and allowing the patient to know how many different ways phosphorus is delivered in food, we have a better chance of controlling this mineral.

Hawkins: There is always room for improvement. We have so many variables with the renal diet that the best approach is to individualize the diet of each dialysis patient so as to provide optimal outcomes, thus improving overall care for the entire renal community. With our patients, we often say to them the only thing they have in common with the person in the dialysis chair next to them is that they both have no renal function. One may be diabetic, one may have come to us with a long-term history of hypertension, and yet another may have had kidney cancer. Their comorbidities are so different, which dictates their subsequent nutritional and medical care. We can’t give a diet to 100 people and say, “Just follow the low phosphorus, low potassium, adequate high-biological-value protein diet and stay away from all salt and all fluid.” We really need to look at every patient as an individual. We need to look at them as a favorite aunt, or a favorite uncle, or a parent and say, “What is your lifestyle? Talk to me about what you have normally eaten in the past.” We each tend to order about the same 100 foods out of a supermarket every week. If we zero in on the patient’s lifestyle and simply tweak it, the patient will truly have better nutritional outcomes.