Nutritional treatment of advanced CKD: twenty consensus statements

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Abstract

The Italian nephrology has a long tradition and experience in the field of dietetic-nutritional therapy (DNT), which is an important component in the conservative management of the patient suffering from a chronic kidney disease, which precedes and integrates the pharmacological therapies. The objectives of DNT include the maintenance of an optimal nutritional status, the prevention and/or correction of signs, symptoms and complications of chronic renal failure and, possibly, the delay in starting of dialysis. The DNT includes modulation of protein intake, adequacy of caloric intake, control of sodium and potassium intake, and reduction of phosphorus intake. For all dietary-nutritional therapies, and in particular those aimed at the patient with chronic renal failure, the problem of patient adherence to the dietetic-nutritional scheme is a key element for the success and safety of the DNT and it can be favored by an interdisciplinary and multi-professional approach of information, education, dietary prescription and follow-up. This consensus document, which defines twenty essential points of the nutritional approach to patients with advanced chronic renal failure, has been written, discussed and shared by the Italian nephrologists together with representatives of dietitians (ANDID) and patients (ANED).

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Most cited references 124

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A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients.

K. Kalantar-Zadeh, J Kopple, G Block … (2001)

Malnutrition inflammation complex syndrome (MICS) occurs commonly in maintenance hemodialysis (MHD) patients and may correlate with increased morbidity and mortality. An optimal, comprehensive, quantitative system that assesses MICS could be a useful measure of clinical status and may be a predictor of outcome in MHD patients. We therefore attempted to develop and validate such an instrument, comparing it with conventional measures of nutrition and inflammation, as well as prospective hospitalization and mortality. Using components of the conventional Subjective Global Assessment (SGA), a semiquantitative scale with three severity levels, the Dialysis Malnutrition Score (DMS), a fully quantitative scoring system consisting of 7 SGA components, with total score ranging between 7 (normal) and 35 (severely malnourished), was recently developed. To improve the DMS, we added three new elements to the 7 DMS components: body mass index, serum albumin level, and total iron-binding capacity to represent serum transferrin level. This new comprehensive Malnutrition-Inflammation Score (MIS) has 10 components, each with four levels of severity, from 0 (normal) to 3 (very severe). The sum of all 10 MIS components ranges from 0 to 30, denoting increasing degree of severity. These scores were compared with anthropometric measurements, near-infrared-measured body fat percentage, laboratory measures that included serum C-reactive protein (CRP), and 12-month prospective hospitalization and mortality rates. Eighty-three outpatients (44 men, 39 women; age, 59 +/- 15 years) on MHD therapy for at least 3 months (43 +/- 33 months) were evaluated at the beginning of this study and followed up for 1 year. The SGA, DMS, and MIS were assessed simultaneously on all patients by a trained physician. Case-mix-adjusted correlation coefficients for the MIS were significant for hospitalization days (r = 0.45; P < 0.001) and frequency of hospitalization (r = 0.46; P < 0.001). Compared with the SGA and DMS, most pertinent correlation coefficients were stronger with the MIS. The MIS, but not the SGA or DMS, correlated significantly with creatinine level, hematocrit, and CRP level. During the 12-month follow-up, 9 patients died and 6 patients left the cohort. The Cox proportional hazard-calculated relative risk for death for each 10-unit increase in the MIS was 10.43 (95% confidence interval, 2.28 to 47.64; P = 0.002). The MIS was superior to its components or different subversions for predicting mortality. The MIS appears to be a comprehensive scoring system with significant associations with prospective hospitalization and mortality, as well as measures of nutrition, inflammation, and anemia in MHD patients. The MIS may be superior to the conventional SGA and the DMS, as well as to individual laboratory values, as a predictor of dialysis outcome and an indicator of MICS.

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A randomized, controlled trial of early versus late initiation of dialysis.

Bruce A Cooper, Pauline Branley, Liliana Bulfone … (2010)

In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause. Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis). In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)

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Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.

Sara N Davison, Adeera Levin, Alvin H Moss … (2015)

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.

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Author and article information

Contributors

Adamasco Cupisti: 0039.050.997291 , adamasco.cupisti@med.unipi.it

Journal

Journal ID (nlm-ta): J Nephrol

Journal ID (iso-abbrev): J. Nephrol

Title: Journal of Nephrology

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1121-8428

ISSN (Electronic): 1724-6059

Publication date (Electronic): 24 May 2018

Publication date PMC-release: 24 May 2018

Publication date (Print): 2018

Volume: 31

Issue: 4

Pages: 457-473

Affiliations

[1 ]ISNI 0000 0004 1757 3729, GRID grid.5395.a, Dipartimento di Medicina Clinica e Sperimentale, , Università di Pisa, ; Via Roma 67, 56126 Pisa, Italy

[2 ]SC Multizonale di Nefrologia e Dialisi, APSS, Trento, Italy

[3 ]UOC di Nefrologia, PO “A. Landolfi”, Solofra, AV Italy

[4 ]ANDID Associazione Nazionale Dietisti, Verona, Italy

[5 ]Dipartimento di Medicina, USL Umbria 1, Perugia, Italy

[6 ]ISNI 0000 0001 0120 3326, GRID grid.7644.1, Dipartimento dell’Emergenza e dei Trapianti di Organi D.E.T.O. - Sezione di Nefrologia, Dialisi e Trapianti, , Università degli Studi di Bari Aldo Moro, ; Bari, Italy

[7 ]Divisione di Nefrologia, Dialisi e Trapianto Azienda Ospedaliera Universitaria “San Giovanni di Dio e Ruggi d’Aragona” Salerno, Salerno, Italy

[8 ]Nefrologia e Dialisi, ASL Cagliari Consultant, Cagliari, Italy

[9 ]SOS Nefrologia Pistoia, ASL Toscana Centro, Florence, Italy

[10 ]ISNI 0000 0004 1756 2640, GRID grid.476047.6, Nutrizione e Dietetica Aziendale, AUSL Modena, ; Modena, Italy

[11 ]ISNI 0000000417571846, GRID grid.7637.5, UO Nefrologia, ASST Spedali Civili e Università di Brescia, ; Brescia, Italy

[12 ]ISNI 0000 0001 2336 6580, GRID grid.7605.4, Dipartimento di Scienze Cliniche e Biologiche, , Università di Torino, ; Turin, Italy

[13 ]ISNI 0000 0004 1771 4456, GRID grid.418061.a, Centre Hospitalier Le Mans, ; Le Mans, France

[14 ]ISNI 0000 0004 1760 3158, GRID grid.417287.f, Nefrologia e Dialisi, Azienda Ospedaliera di Perugia, ; Perugia, Italy

[15 ]Nefrologia e Dialisi, ASL TO5, Chieri, TO Italy

[16 ]ISNI 0000 0001 2178 8421, GRID grid.10438.3e, Dipartimento di Medicina Clinica e Sperimentale-UOC di Nefrologia e Dialisi, , Università di Messina, ; Messina, Italy

[17 ]ANED Onlus, Milan, Italy

[18 ]ISNI 0000 0004 1758 0937, GRID grid.10383.39, Unità di Fisiopatologia Insufficienza Renale, , Università di Parma, ; Parma, Italy

[19 ]ISNI 0000 0001 0941 3192, GRID grid.8142.f, Dipartimento di Medicina, , Università Cattolica del Sacro Cuore, ; Rome, Italy

[20 ]ISNI 0000 0001 2151 3065, GRID grid.5606.5, Università degli Studi di Genova, DIMI and IRCCS AOU San Martino IST, ; Genoa, Italy

[21 ]SC Nefrologia e Dialisi Arcispedale S. Maria Nuova Azienda USL Reggio Emilia, Reggio Emilia, Italy

[22 ]Nefrologia e Dialisi, Ospedale S. Maria Scaletta, Azienda USL Imola, Imola, Italy

[23 ]ISNI 0000 0001 2200 8888, GRID grid.9841.4, Divisione di Nefrologia, , Università della Campania “Luigi Vanvitelli”, ; Naples, Italy

[24 ]ISNI 0000 0004 0493 6789, GRID grid.413175.5, SC Nefrologia e Dialisi, Ospedale Manzoni, ASST, ; Lecco, Italy

Article

Publisher ID: 497

DOI: 10.1007/s40620-018-0497-z

PMC ID: 6061255

PubMed ID: 29797247

SO-VID: 1d7ac197-7767-4709-a067-19aa7abf9859

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 5 March 2018

Date accepted : 4 May 2018

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Keywords: ckd,nutritional treatment,diet,dialysis,kidney transplant,chronic renal failure

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Keywords: ckd, nutritional treatment, diet, dialysis, kidney transplant, chronic renal failure

Nutritional treatment of advanced CKD: twenty consensus statements

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Abstract

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Karger: Nephrology

Most cited references 124

A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients.

A randomized, controlled trial of early versus late initiation of dialysis.

Executive summary of the KDIGO Controversies Conference on Supportive Care in Chronic Kidney Disease: developing a roadmap to improving quality care.

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