Q&A
Clinicians Are Asking: Dialysis Patients Requiring Surgery
Renal practitioners tackle three common questions from their primary care colleagues, including input on the renal diet.
Your renal practitioners/department editors have chosen three typical situations you might encounter in practice.
• Nutrition and diet help control kidney disease, but also heart disease, diabetes, and other comorbid states.
• Renal patients, like many others, often require surgeries; what specific concerns exist for surgical patients requiring dialysis?
• The Medicare education benefit has been a particular bonus for advanced practitioners, as we teach many of the classes.
We welcome your questions and comments.
Q: What is the renal diet? Should my patients with chronic kidney disease (CKD) restrict their protein consumption?
The CKD nondialysis diet aims to preserve remaining kidney function. A person living with kidney disease can continue to enjoy a variety of foods, including whole grains, fruits, and vegetables. These foods must be restricted only when phosphorus, parathyroid hormone, and/or potassium levels become elevated. However, many advanced practitioners recommend avoiding dark sodas because of their high phosphorus content. Sodium is limited to help maintain blood pressure control and decrease fluid buildup.
Fluid intake is not restricted unless fluid retention becomes an issue. Adequate caloric intake from carbohydrates and healthy fats is essential so as to spare protein for growth and repair. Aiming for a healthy weight through appropriate caloric intake and regular physical activity is important. A water-soluble vitamin B complex and a vitamin C supplement may be recommended as the diet becomes more restrictive. Supplemental vitamin D requirements and iron needs are based on findings from laboratory studies.
As is always the case when advising patients on food choices, the emphasis should be on optimizing nutrition and avoiding empty calories. A review of how to interpret a food label is often helpful to patients and their families.
Dietary protein recommendations continue to be controversial in CKD stages 1 through 4 (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2). The renal diet emphasizes high-quality proteins but limits protein intake to approximately 0.6 to 0.8 g/kg/d so as to decrease the workload on the kidneys and reduce urea waste production. The National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-K/DOQI) Clinical Practice Guidelines for nutrition in patients with CKD1 recommend that patients who have an eGFR between 25 and 55 mL/min/1.73 m2 should eat at least 0.8 g/kg/d of protein; and that those whose eGFR is less than 25 mL/min/1.73 m2 and who are not receiving dialysis consume 0.6 g/kg/d. If a patient cannot tolerate the diet or is unable to maintain an adequate caloric intake, then protein intake can be 0.75 g/kg/d.
Once a patient is undergoing dialysis, the protein requirements may change, depending on the patient’s needs and type of dialysis. Fortunately, the renal dietician, an essential member of the interdisciplinary dialysis team, offers great assistance to the advanced practitioner in addressing the patient’s nutritional needs.
However, referral to a renal dietitian is recommended before dialysis, as diet is an important part of CKD treatment. A Medicare recipient with stage 3 or 4 CKD can see a registered dietitian through the Medical Nutrition Therapy benefit.2
Individualizing nutritional therapy is essential to optimize health in people living with the complexities of CKD. It is also very important, when assessing, monitoring, and intervening to avoid or treat malnutrition in these patients, to provide care as an interprofessional team that includes a renal dietician. (To provide the best evidence available, an experienced renal dietician was asked to contribute to this response.)
Debra Hain, PhD, APRN, GNP-BC
Assistant Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton; Nurse Practitioner, Cleveland Clinic Florida, Weston
Susan Meese-Morris, RD, LD/N
Renal Dietitian, Pine Island, Weston, and Miramar, Florida
REFERENCES
1. National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-K/DOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure (2000). www.kidney.org/professionals/kdoqi/guidelines_updates/doqi_nut.html. Accessed February 16, 2012.
2. Medicare.gov. Medical nutrition therapy. www.medicare.gov/navigation/manage-your-health/preventive-services/medical-nutrition-therapy.aspx?AspxAutoDetectCookieSupport=1. Accessed February 16, 2012.
3. Soundararajan R, Golper T. Medical management of the dialysis patient undergoing surgery. www.uptodate.com/contents/medical-management-of-the-dialysis-patient-undergoing-surgery. Accessed February 16, 2012.
4. Young HN, Chan MR, Yevzlin AS, Becker BN. The rationale, implementation and effects of the Medicare CKD education benefit. Am J Kidney Dis. 2011;57(3):381-386.
5. H. R. 6331: Medicare Improvements for Patients and Providers Act of 2008. www.govtrack.us/congress/bill.xpd?bill=h110-6331. Accessed February 16, 2012.
6. §410.48. Kidney disease education services. Federal Register. 2009;74(226):62003.
7. Lazarus JM. National health care policy and its effect on renal care. Presented at: NKFI Multi-Disciplinary Conference; September 24, 2009; Chicago, IL.
8. National Kidney Foundation. MIPPA Kidney Disease Education Benefit. Your Treatment, Your Choice (2010). www.kidney.org/professionals/KLS/YTYC.cfm. Accessed February 16, 2012.