RBT Roundtable: The Renal Diet

LATE LAST YEAR, the Medicare Payment Advisory Committee met to discuss how to improve efficiency and quality of care for end-stage renal disease, and one of the topics discussed was patient nutrition. In her presentation to the commissioners on Nov. 8, 2007, Nancy Ray, a MedPAC analyst, said the proportion of malnourished dialysis patients is substantial, and that these patients have a higher risk of hospitalization and death.

It’s clear nutrition for dialysis patients is on the national radar, so Renal Business Today wanted to ask leaders in the renal community their thoughts about the current state of renal nutrition care and what their respective organizations are doing on a daily basis to improve the lives of dialysis patients. Below is the resulting roundtable discussion, which includes Jennifer Hawkins, RD, renal clinical consultant manager for Genzyme Renal; Debbie Benner, MA, RD, CSR, national director nutrition services, DaVita Inc.; Roberta Wager, RN, MSN, president, American Association of Kidney Patients, and two-time kidney transplant recipient; J. Kelley Trahan, RD, LD, Quality Dialysis, renal dietitian; Maria Karalis, MBA, RD, LDN, National Kidney Foundation, Council on Renal Nutrition chairperson; and Phaneth Keto, PharmD, Fresenius Medical Care, director, scientific affairs.

Do you feel there is enough being done to improve the nutritional status of renal patients?

Hawkins: I do indeed. I began working with renal patients in 1980, and I feel that we have come such a long way to help maintain the optimal nutritional status so that we can improve both the outcomes and quality of life of our patients. The most important consideration is quality of life. The critical question is how can we best maintain that quality of life for patients with a chronic illness like chronic kidney disease? We have really learned a tremendous amount of how we can foster better nutrition and also achieve those optimal lab reports that are so important.

Benner: The nutritional challenge facing renal patients is significant. There are many aspects of care that could be improved if there were increased resources and funding available. The nutritional needs vary greatly for individual patients. The dietitian leads in identifying and developing treatment plans related to nutritional status, but it takes the entire team to constantly address individual patient needs and reinforce diet, optimal nutrition intake and adherence to physician-prescribed medications and treatment plans—all the aspects that make a difference. Empowering patients with education and management skills that they are willing and able to implement within their own lives is an ongoing challenge.

Wager: The renal community addresses many patient issues regarding kidney disease. However, I feel renal professionals are so focused on the disease process of patients and the medication we prescribe for patients that we sometimes forget the simpler things, like diet and what effect it has on patients. The medical community has dropped the ball when it comes to addressing renal patients’ nutritional needs. Dialysis patients work with a renal dietitian who helps patients map out a healthy eating plan. However, CKD patients in stages 1 through 4 have no one to help them address their nutritional needs. Nutritional education needs to start much earlier. The majority of the patients arriving at dialysis clinics are already malnourished—low albumins levels, high phosphorus levels. From the beginning, renal professionals are trying to play catch-up with these patients in regards to getting the patients well-nourished. In fact, some patients never are able to catch up nutritionally.

Trahan: All of the dietitians I know are passionately committed to improving their patients’ nutritional status and make every effort to offer all that is available to their patients. Much research has been shown that inflammation coexisting with malnutrition becomes a vicious cycle. More doctors are checking C-reactive protein levels and treating inflammation to enhance the patient’s nutritional status. It’s a great feeling when we all work as a team to enhance the patients’ well-being and not chastise them for what they may or may not be doing.

Karalis: Nutrition intervention by a registered dietitian (RD) is part of a successful program to prevent inadequate calorie and protein intake in patients with CKD. As such, to the extent that RDs are involved in CKD teams, nutrition counseling and other intervention to improve outcomes is an effective strategy in delaying the progression of CKD and other related co-morbidities.

Keo: The nutritional status of patients is an issue that will be addressed forever. It takes the patient and the renal dietitian working in concert to try and achieve optimal nutrition for each patient. The kidney patient diet is challenging, there is no “one size fits all” solution. The continuing changes to guidelines make controlling lab values difficult. At Fresenius Medical Care, the education of patients is paramount so that they can drive their own health status. Our web site www.kidneyoptions.com has been a tool used by patients and healthcare providers alike. This Web site touches on kidney disease, treatment options, diet and nutrition and social services. It also contains a resource library, dialysis unit locator and bulletin board. Our Kidney Options seminars are also beneficial due to the one-on-one approach of communicating the appropriate information and answering the questions of our patients.