Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease
2022; Wiley; Volume: 27; Issue: 6 Linguagem: Inglês
10.1111/nep.14025
ISSN1440-1797
AutoresKelly Lambert, Su Bahceci, Harriet Harrison, Maria Chan, Nicole Scholes‐Robertson, David W Johnson, Adela Yip, Andrea K. Viecelli,
Tópico(s)Palliative Care and End-of-Life Issues
ResumoNephrologyVolume 27, Issue 6 p. 537-540 COMMENTARYOpen Access Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease Kelly Lambert, Corresponding Author Kelly Lambert klambert@uow.edu.au orcid.org/0000-0001-5935-7328 Discipline of Nutrition and Dietetics, School of Medicine, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia Correspondence Kelly Lambert, Discipline of Nutrition and Dietetics, School of Medicine, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, New South Wales, 2522, Australia. Email: klambert@uow.edu.auSearch for more papers by this authorSu Bahceci, Su Bahceci Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, AustraliaSearch for more papers by this authorHarriet Harrison, Harriet Harrison Flinders Medical Centre, Bedford Park, South Australia, AustraliaSearch for more papers by this authorMaria Chan, Maria Chan Departments of Renal Medicine and Nutrition and Dietetics, The St. George Hospital, Kogarah, New South Wales, AustraliaSearch for more papers by this authorNicole Scholes-Robertson, Nicole Scholes-Robertson orcid.org/0000-0001-8260-0453 Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorDavid W. Johnson, David W. Johnson Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia Translational Research Institute, Brisbane, Queensland, AustraliaSearch for more papers by this authorAdela Yip, Adela Yip CARI (Caring for Australians and New ZealandeRs with Kidney Impairment) Guidelines Office, Centre for Kidney Research, Westmead, New South Wales, AustraliaSearch for more papers by this authorAndrea K. Viecelli, Andrea K. Viecelli Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia Translational Research Institute, Brisbane, Queensland, AustraliaSearch for more papers by this authorThe Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guideline Group, The Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guideline GroupSearch for more papers by this author Kelly Lambert, Corresponding Author Kelly Lambert klambert@uow.edu.au orcid.org/0000-0001-5935-7328 Discipline of Nutrition and Dietetics, School of Medicine, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia Correspondence Kelly Lambert, Discipline of Nutrition and Dietetics, School of Medicine, Indigenous and Health Sciences, Faculty of Science, Medicine and Health, University of Wollongong, Northfields Ave, Wollongong, New South Wales, 2522, Australia. Email: klambert@uow.edu.auSearch for more papers by this authorSu Bahceci, Su Bahceci Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, AustraliaSearch for more papers by this authorHarriet Harrison, Harriet Harrison Flinders Medical Centre, Bedford Park, South Australia, AustraliaSearch for more papers by this authorMaria Chan, Maria Chan Departments of Renal Medicine and Nutrition and Dietetics, The St. George Hospital, Kogarah, New South Wales, AustraliaSearch for more papers by this authorNicole Scholes-Robertson, Nicole Scholes-Robertson orcid.org/0000-0001-8260-0453 Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorDavid W. Johnson, David W. Johnson Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia Translational Research Institute, Brisbane, Queensland, AustraliaSearch for more papers by this authorAdela Yip, Adela Yip CARI (Caring for Australians and New ZealandeRs with Kidney Impairment) Guidelines Office, Centre for Kidney Research, Westmead, New South Wales, AustraliaSearch for more papers by this authorAndrea K. Viecelli, Andrea K. Viecelli Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia Translational Research Institute, Brisbane, Queensland, AustraliaSearch for more papers by this authorThe Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guideline Group, The Caring for Australians and New Zealanders with Kidney Impairment (CARI) Guideline GroupSearch for more papers by this author First published: 03 February 2022 https://doi.org/10.1111/nep.14025 List of CARI Guideline Group Investigators is provided in the Acknowledgements section. 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Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Dietary modification is an important component in the management of Chronic Kidney Disease (CKD).1 An appropriate diet can slow disease progression,2, 3 reduce CKD complications,4 and increase survival.5, 6 The release of new guidance has been eagerly awaited by many clinicians as the previous versions had not been updated since 2000.7 The intent of this commentary is to consider some of the key recommendations in the Australian and New Zealand context and to highlight areas for potential local adaptation. 1 GUIDELINE SUMMARY The 2020 update consists of six chapters with 75 recommendations.8 These guidelines cover nutrition assessment, medical nutrition therapy, dietary protein and energy intake, nutritional supplementation and micronutrients. Importantly, the guidelines cover management across stages of CKD as well as specific recommendations for those undertaking maintenance haemodialysis or peritoneal dialysis, and those post-transplant. The guidelines are based on the best available evidence to April 2017 and for those recommendations based on consensus, evidence was reviewed until August 2018. This represents critical review of more than 11 000 individual studies. A summary of the nutrient recommendations for the Australian and New Zealand (ANZ) context is provided in Table S1. Assessment of the methodological rigour and transparency of the guideline using the AGREE II tool9 are shown in Supporting information. The overall score was rated at 69%, with reduced scores due to lack of stakeholder engagement and minimal discussion regarding implementation. 2 COMMENTARY 2.1 Protein intake The new recommendations for protein intake contain a major departure from previous advice. The recommendations are summarized in Table 1. For adults with CKD stage 3–5 who are metabolically stable, protein should be restricted to 0.55–0.60 g/kg ideal body weight per day. It is slightly higher for those with diabetes (0.6–0.8 g/kg ideal body weight). Reduction of intake to these levels is recommended due to the negative side effects on kidney health (accumulation of urea and other uremic toxins and increased kidney hyperfiltration). Additional benefits to kidney health can be achieved using ketoacid analogue supplements but these are not available readily or registered with the Therapeutic Goods Administration10 in Australia or the Pharmaceutical Management Agency (Pharmac) in New Zealand. TABLE 1. Protein recommendations in the KDOQI 2020 guideline for nutrition in CKD with level of evidence grading11 CKD stage 3–5 (metabolically stable) CKD stage 3–5 and diabetes (metabolically stable) Dialysis (metabolically stable) 0.55–0.60 g/kg/day ideal body weight 0.6–0.8 g/kg/day ideal body weight 1–1.2 g/kg/day ideal body weight Evidence level: 1A to reduce risk of ESKD/death; 2C to improve quality of life Evidence level: OPINION HD no diabetes: Evidence level 1C PD no diabetes: OPINION Dialysis with diabetes: OPINION These recommendations are controversial and are in contrast to a 2020 Cochrane review12 which found that, in non-diabetic adults, a low protein intake (0.5–0.6 g/kg) may make little difference to the number of people who reached kidney failure compared to a normal protein intake (≥0.8 g/kg). The 2013 CARI Guidelines for Early CKD recommend 0.75–1.0 g/kg/day with adequate energy13 and the 2020 KDIGO guidelines for diabetes in CKD suggest 0.8 g/kg.14 The challenge for Australasian clinicians is that any changes to protein intake must be carefully managed to meet overall energy needs. Conveying the message to patients to significantly reduce protein intake without attention to adequate calories may result in unintentional weight loss, malnutrition and hyperkalaemia. In accordance with recent Cochrane guidance on low protein diets for those with CKD,12 we suggest consideration also be given to the potentially negative impacts of intensive protein restrictions on patient quality of life. In the absence of high-certainty evidence to support intensive protein restrictions in patients with CKD 3–5 not requiring dialysis and considering the potential harms, we recommend taking an individualized approach to protein restriction taking into account the potential impact on quality of life and nutritional needs. 2.2 Potassium, phosphorus and sodium intake It is now recommended that dietary potassium and phosphorus intake should be individualized in adults with CKD3-5D and post-transplant with hyperkalaemia. This is far less prescriptive than previous dietary guidelines.15 The bioavailability of potassium and phosphorus in fruits, vegetables, wholegrain breads and cereals, legumes and nuts is substantially lower than previously thought,16-18 and these foods need not be restricted as they offer other benefits that are beneficial to people with CKD. Clinicians should actively investigate other factors that contribute to hyperkalaemia before reducing dietary potassium intake. These factors include constipation, inadequate insulin, untreated metabolic acidosis, inadequate dialysis, and medications.19, 20 If hyperkalaemia cannot be reversed, then sensible dietary restriction is encouraged. Regarding phosphorus intake, the new guideline also recommends reducing intake of phosphorus containing additives from processed foods. In the ANZ context, like potassium, phosphorus does not need to be declared on food labels and contributes significantly to overall dietary phosphorus intake.21 Given the increasing popularity of plant-based diets, emphasis on low-bioavailable sources of phosphate, such as those from plant foods, would result in reduced bioavailable phosphate compared to animal-based protein sources. Additional suggested strategies, such as boiling meat prior to eating, can result in an approximate 50% reduction of phosphorus content.22 This practice is common in New Zealand ('boil ups') and should be encouraged to support those with CKD. Recommendations for sodium intake remain unchanged, and less than 2300 mg (100 mmol) of sodium per day is advised for all with CKD. 2.3 Dietary patterns The new guideline recommends a Mediterranean diet and high fruit and vegetable diet for those with CKD to improve lipid profile, decrease body weight and blood pressure, and reduce net acid production. Patients will benefit from individualized advice to adopt this dietary pattern and accommodate serum potassium and protein needs. Dietary education resources for patients should be updated to reflect these new recommendations and counter misinformation. 2.4 Identifying patients who need nutritional intervention The new guidelines recommend nutrition screening occur at least biannually for adults with CKD3-5D or post-transplantation8 to identify risk of Protein Energy Wasting (PEW). However, no gold standard screening tool is available. Clinicians may wish to consider use of the Renal Nutrition Screening Tool (R-NST).23 This tool has good sensitivity (97%) and specificity (74%) to detect risk of undernutrition and was developed in New Zealand. 2.5 Nutrition assessment A comprehensive nutrition assessment is also encouraged in adults with CKD3-5D within 90 days of commencing dialysis, annually or when indicated following screening or provider referral. These recommendations will be challenging for many units in ANZ as dietetic staffing is inadequate or absent.24-26 The 7-point Subjective Global Assessment is now recommended as the preferred tool for nutrition assessment due to the robust evidence base, particularly for assessment of body composition in dialysis cohorts.27 The 7-point SGA does not include an extensive list of symptoms that are known to impact patients with CKD at the later stages. As a result, clinicians may still wish to utilize tools, such as the IPOS-renal,28 to establish the degree and severity of symptom burden. 3 FUTURE DIRECTIONS AND CONCLUSION There is a notable absence of information for clinicians on the dietary management of patients undertaking conservative management (also referred to as supportive care29). We suggest that health professionals working with these patients refer to important guidance published to assist with diet and symptom management.30-32 To conclude this commentary, the KDOQI nutrition guidelines represent an important discussion of nutrient based guidance as well as food-based recommendations. While input from consumers into these guidelines is lacking, these guidelines are an important step forward and may reduce the challenge and complexity for patients of adhering to the diet for kidney disease.33, 34 Future guidelines are likely to include recommendations regarding plant-based protein35 and eating patterns36, 37 but these studies were published after the guidelines evidence review process. Based on these guidelines, it would be reasonable for ANZ health professionals to encourage all patients with CKD to improve fruit and vegetable intake, focus on plant-based proteins, reduce added salt and processed foods. Based on recent evidence,12 we recommend an individualized, less stringent approach to protein restriction for non-diabetic patients with CKD 3–5. ACKNOWLEDGEMENTS We wish to thank the CARI Guideline group for their support. CARI Guideline Group Investigators: Rathika Krishnasamy, Jane Boag, Helen Coolican, Jonathan Craig, Min Jun, Vincent Lee, Thu Nguyen, Carla Scuderi, Emily See, Rachael Walker, Debbie Fortnum, Vanessa Cullen, Martin Howell, Chandana Guha, David Tunnicliffe, Brydee Johnston, Andrea Viecelli, Kelly Lambert. Open access publishing facilitated by University of Wollongong, as part of the Wiley - University of Wollongong agreement via the Council of Australian University Librarians. Supporting Information Filename Description nep14025-sup-0001-Supinfo.pdfPDF document, 428.8 KB Appendix S1: Supporting information. nep14025-sup-0002-TableS1.docxWord 2007 document , 35.4 KB TABLE S1: Summary of nutrient recommendations from the 2020 guidelines on dietary management of Chronic Kidney Disease1 and the level of evidence. If no recommendation is made in the 2020 guidelines then previous recommendations are included in italics, with citation where appropriate. nep14025-sup-0003-TableS2.docxWord 2007 document , 25.4 KB TABLE S2: Guideline assessment according to the Appraisal of Guidelines for Research and Evaluation (Agree II) instrument. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. REFERENCES 1Mitch WE, Remuzzi G. Diets for patients with chronic kidney disease, should we reconsider? BMC Nephrol. 2016; 17(1): 80. CrossrefPubMedWeb of Science®Google Scholar 2Picard K, Barreto Silva MI, Mager D, Richard C. Dietary potassium intake and risk of chronic kidney disease progression in Predialysis patients with chronic kidney disease: a systematic review. Adv Nutr. 2020; 11(4): 1002- 1015. CrossrefPubMedWeb of Science®Google Scholar 3Kramers BJ, Koorevaar IW, Drenth JP, et al. Salt, but not protein intake, is associated with accelerated disease progression in autosomal dominant polycystic kidney disease. Kidney Int. 2020; 98(4): 989- 998. CrossrefCASPubMedWeb of Science®Google Scholar 4Kalantar-Zadeh K, Fouque D. Nutritional Management of Chronic Kidney Disease. N Engl J Med. 2017; 377(18): 1765- 1776. CrossrefCASPubMedWeb of Science®Google Scholar 5Kang S, Chang J, Park Y. Nutritional status predicts 10-year mortality in patients with end-stage renal disease on hemodialysis. Nutrients. 2017; 9(4): 399. CrossrefWeb of Science®Google Scholar 6Ortiz A, Covic A, Fliser D, et al. Epidemiology, contributors to, and clinical trials of mortality risk in chronic kidney failure. The Lancet. 2014; 383(9931): 1831- 1843. CrossrefPubMedWeb of Science®Google Scholar 7 KDOQI. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. Am J Kidney Dis. 2000; 35(6 Suppl 2): S1- S140. PubMedWeb of Science®Google Scholar 8Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020; 76(3, Supplement 1): S1- S107. CrossrefCASPubMedWeb of Science®Google Scholar 9Hoffmann-Eßer W, Siering U, Neugebauer EAM, Brockhaus AC, Lampert U, Eikermann M. Guideline appraisal with AGREE II: systematic review of the current evidence on how users handle the 2 overall assessments. PLoS One. 2017; 12(3):e0174831. CrossrefPubMedWeb of Science®Google Scholar 10Van Der Veer SN, Van De Luijtgaarden MW, Brown EA, Jager KJ, Van Biesen W. The decision to withdrawdialysis: European nephrologists' perceptions of associated factors. Nephrol Dialysis Transplant. 2014; 29(Suppl 3): MO023Google Scholar 11 GRADE Working Group. GRADE handbook. In: H Schunemann, J Brozek, G Guyatt, A Oxman, eds. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. GRADE Working Group; 2013. https://gdt.gradepro.org/app/handbook/handbook.htmlGoogle Scholar 12Hahn D, Hodson EM, Fouque D. Low protein diets for non-diabetic adults with chronic kidney disease. Cochrane Database Syst Rev. 2020; 10(10): CD001892. PubMedWeb of Science®Google Scholar 13Johnson DW, Atai E, Chan M, et al. KHA-CARI guideline: early chronic kidney disease: detection, prevention and management. Nephrology. 2013; 18: 340- 350. Wiley Online LibraryPubMedWeb of Science®Google Scholar 14de Boer IH, Caramori ML, Chan JC, et al. KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2020; 98(4): S1- S115. CrossrefPubMedWeb of Science®Google Scholar 15Ash S, Campbell K, MacLaughlin H, et al. Evidence based practice guidelines for the nutritional management of chronic kidney disease. Nutr Diet. 2006; 63: S33- S45. Wiley Online LibraryGoogle Scholar 16Picard K. Potassium additives and bioavailability: are we missing something in hyperkalemia management? J Ren Nutr. 2018; 29: 350- 353. CrossrefPubMedWeb of Science®Google Scholar 17Naismith DJ, Braschi A. An investigation into the bioaccessibility of potassium in unprocessed fruits and vegetables. Int J Food Sci Nutr. 2008; 59(5): 438- 450. CrossrefCASPubMedWeb of Science®Google Scholar 18Rastogi A, Bhatt N, Rossetti S, Beto J. Management of Hyperphosphatemia in end-stage renal disease: a new paradigm. J Ren Nutr. 2021; 31(1): 21- 34. CrossrefCASPubMedWeb of Science®Google Scholar 19Stover J. Non-dietary causes of hyperkalemia. Nephrol Nurs J. 2006; 33(2): 221- 222. PubMedWeb of Science®Google Scholar 20St-Jules DE, Goldfarb DS, Sevick MA. Nutrient non-equivalence: does restricting high-potassium plant foods help to prevent hyperkalemia in hemodialysis patients? J Ren Nutr. 2016; 26(5): 282- 287. CrossrefCASPubMedWeb of Science®Google Scholar 21Conley M, Lioufas N, Toussaint ND, et al. Dietary phosphate consumption in Australians with stages 3b and 4 chronic kidney disease. J Ren Nutr. 2020; 31: 155- 163. CrossrefPubMedWeb of Science®Google Scholar 22Ando S, Sakuma M, Morimoto Y, Arai H. The effect of various boiling conditions on reduction of phosphorus and protein in meat. J Ren Nutr. 2015; 25(6): 504- 509. CrossrefCASPubMedWeb of Science®Google Scholar 23Xia YA, Healy A, Kruger R. Developing and validating a renal nutrition screening tool to effectively identify undernutrition risk among renal inpatients. J Ren Nutr. 2016; 26(5): 299- 307. CrossrefPubMedWeb of Science®Google Scholar 24Patwardhan ABL, Chan M, Ryan C. A survey of renal dietitian staffing in New South Wales. Nephrology. 2004; 9(S1): 147. Google Scholar 25Crosby C, Barnes P, Lambert K, Rounsley K. A survey of renal dietitian staffing in New South Wales. Nephrology. 2010; 15(Supplement 4): 44– 45. Google Scholar 26Campbell KL, Murray EM. Allied health services to nephrology: an audit of current workforce and meeting future challenges. J Ren Care. 2013; 39(1): 52- 61. Wiley Online LibraryPubMedGoogle Scholar 27 CANUSA Peritoneal Dialysis Study Group. Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol. 1996; 7(2): 198- 207. CrossrefPubMedWeb of Science®Google Scholar 28Cicely Saunders Institute. IPOS-Renal; 2016. https://pos-pal.org/maix/ipos-renal-in-english.php. Google Scholar 29Davison SN, Levin A, Moss AH, et al. Executive summary of the KDIGO controversies conference on supportive care in Chronic Kidney Disease: developing a roadmap to improving quality care. Kidney Int. 2015; 88(3): 447- 459. CrossrefPubMedWeb of Science®Google Scholar 30Stevenson J, Meade A, Randall AM, et al. Nutrition in renal supportive care: patient-driven and flexible. Nephrol Ther. 2017; 22(10): 739- 747. Wiley Online LibraryGoogle Scholar 31Meade A, Stevenson J, Notaras S. Nutrition in renal supportive care: is it time to bend the rules? Nephrol Ther. 2017; 22(5): 341- 342. Wiley Online LibraryGoogle Scholar 32Dawson J, Brennan FP, Hoffman A, et al. Prevalence of taste changes and association with other nutrition-related symptoms in end-stage kidney disease patients. J Ren Nutr. 2021; 31(1): 80- 84. CrossrefPubMedWeb of Science®Google Scholar 33Palmer SC, Hanson CS, Craig JC, et al. Dietary and fluid restrictions in CKD: a thematic synthesis of patient views from qualitative studies. Am J Kidney Dis. 2015; 65: 559- 573. CrossrefPubMedWeb of Science®Google Scholar 34Lambert K, Mansfield K, Mullan J. How do patients and carers make sense of renal dietary advice? A qualitative exploration. J Ren Care. 2018; 44(4): 238- 250. Wiley Online LibraryPubMedWeb of Science®Google Scholar 35Kim H, Caulfield LE, Garcia-Larsen V, et al. Plant-based diets and incident CKD and kidney function. Clin J Am Soc Nephrol. 2019; 14(5): 682- 691. CrossrefCASPubMedWeb of Science®Google Scholar 36Liu H-W, Tsai W-H, Liu J-S, Kuo K-L. Association of Vegetarian Diet with chronic kidney disease. Nutrients. 2019; 11(2): 279. CrossrefWeb of Science®Google Scholar 37Ko G-J, Rhee CM, Kalantar-Zadeh K, Joshi S. The effects of high-protein diets on kidney health and longevity. J Am Soc Nephrol. 2020; 31(8): 1667- 1679. CrossrefCASPubMedWeb of Science®Google Scholar Volume27, Issue6June 2022Pages 537-540 ReferencesRelatedInformation
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