ckd guidelines 2005

7/23/2019 CKD Guidelines 2005

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Evidence Based Practice Guidelines for Nutritional

Management of Chronic Kidney Disease

Developed by the Australia and New Zealand Renal Guidelines Taskforce

(ANZRGT)

Revised May, 2005


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Evidence Based Practice Guidelines for the Nutritional Management of Chronic Kidney Disease

Table of Contents

INTRODUCTION 3

AIM 3

GUIDELINE DEVELOPMENT PROCESS 3

CONSULTATION PROCESS 3

USE OF GUIDELINES 4

REVIEW PROCESS 4

TASKFORCEMEMBERS 5

EVIDENCE BASED PRACTICE GUIDELINE FRAMEWORK 6

CHRONIC KIDNEY DISEASE STAGE 3 (GFR 30-59) 7

1 SCOPE 7

2 EVIDENCE BASED RECOMMENDATIONS 7

3 SUMMARY OF RECOMMENDATIONS 10

CHRONIC KIDNEY DISEASE STAGE 4 (GFR 15- 29) 11

1 SCOPE 11



CHRONIC KIDNEY DISEASE STAGE 5

-

HAEMODIALYSIS 15

1 SCOPE 15



CHRONIC KIDNEY DISEASE STAGE 5 - PERITONEAL DIALYSIS 18

1 SCOPE 18



REFERENCES 22

APPENDIX 1: SUMMARY OF RECOMMENDATIONS FOR MANAGEMENT OF CHRONIC KIDNEY DISEASE 23

APPENDIX 2: SUMMARY OF RECOMMENDATIONS FOR NUTRITION PRESCRIPTION IN CHRONIC KIDNEY

DISEASE 24

APPENDIX 3: DESCRIPTIONS OF LEVELS OF EVIDENCE CITED FROM ORIGINAL SOURCES 25

APPENDIX 4: STAGES OF CHRONIC KIDNEY DISEASE 25

APPENDIX 5: CALCULATIONS 26

APPENDIX 6: BMI RANGES 28

APPENDIX 7: MALNUTRITION SCREENING TOOL 29

APPENDIX 8: SUBJECTIVE GLOBAL ASSESSMENT 30

APPENDIX9: GLOSSARY 32

Australia & New Zealand Renal Guidelines Taskforce 2


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Introduction

Aim

A working party of Dietitians from Australia and New Zealand has developed evidence based practice guidelines for thedietetic management of chronic kidney disease. The purpose of these guidelines is to provide dietitians in Australia and

New Zealand with a user-friendly summary of evidence based clinical guidelines related to the dietetic management of

adult patients with chronic kidney disease.

Guideline Development Process

The evidence based practice guidelines for the dietetic management of chronic kidney disease were developed by

summarising the nutrition components of the following published guidelines:

Caring for Australians with Renal Impairment (CARI) Guidelines

Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines

American Dietetic Association (ADA) Medical Nutrition Therapy Evidence-Based Guides for Practice:Chronic Kidney Disease (non-dialysis) Medical Nutrition Therapy Protocol

ADA Guidelines for Nutritional Care of Renal Patients (3rded)

European Dialysis and Transplant Nurses Association and European Renal Care Association (EDTNA/ERCA)

Guidelines for the Nutritional Care of Adult Renal Patients.Levels of evidence or opinion have been cited from the above documents and referenced in each guideline. Descriptionsof the levels of evidence are listed in Appendix 3. The relevant guidelines and articles were identified by Medlinedatabase and Internet key word searches between April 2002 and October 2003.

Where conflicting guidelines answering the same clinical question existed, the guideline with the strongest level of

evidence was included. When conflicting supporting evidence was equal in quality and depth, CARI guidelines wereselected preferentially as more relevant to the local environment. If similar information was proposed from more thanone set of guidelines, all sources were acknowledged. Aspects of nutritional management not included in any of theguidelines were omitted, however some aspects deemed important by the taskforce have been included as practice tips.

Due to the difficulties associated with research into nutritional management of kidney disease, an evidence-basedapproach could not be adopted for all aspects. For published guidelines based on opinion or agreed best practice withoutsupporting research, recommendations have still been included to complete the document but are acknowledged as

being open for wider variance in practice. In particular, adherence to process type guidelines may be strictly resourcedependant.

The selected guidelines were reformatted into the following components: definition of disease, diagnostic criteria,clinical questions to be addressed, referral criteria, nutrition assessment, nutrition prescription and outcome measures, in

line with established nutritional management process. Dietetic management of acute renal failure, transplantation,nephrotic syndrome or kidney disease in paediatrics is not included.

These guidelines include information taken from existing sets of guidelines based on scientific evidence, and where noevidence exists, published guidelines stating consensus opinion from experienced practitioners including dietitians havebeen included. These guidelines do not address many issues concerning the implementation of dietetic practice, such as

using groups or individual consultations, educational strategies or counselling techniques. This is beyond the scope ofthese guidelines and neither the evidence nor consensus opinion currently exists to promote one form of practice over

another.

The practice tips sections were added to provide further assistance to Dietitians and go beyond the scope of theguidelines themselves. These sections are not evidence based but are included as a guide only, and are intended to

provide extra information about patient management.

These guidelines have been developed as a quality activity without funding, therefore there is no external influence onthe content of the guidelines. No member of the guideline taskforce has any conflict of interest to declare relating to thedevelopment of these guidelines.

Consultation Process

These practice guidelines have undergone several stages of peer and expert review using the Appraisal of Guidelines for

Research and Evaluation (AGREE) instrument (The AGREE Collaboration). The rigour of scientific process variesbetween guidelines. The K/DOQI and CARI guidelines have documented systematic search and review processes in

place, which meet the NH&MRC and AGREE criteria for quality. The ADA and EDTNA/ERCA guidelines are lessrigorous, but the information extracted from these documents is based on expert opinion and is unable to be assessed

using an evidence based practice tool.



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The first draft of these guidelines was presented at the Dietitians Association of Australia (DAA) 21stNationalConference in Cairns in May 2003 and achieved support in principle. A national panel of experts was defined at theconference, the Australia and New Zealand Renal Guidelines Taskforce (ANZRGT) to oversee further development and

formulation of the final document. Consultation with nephrologists and renal nurses was undertaken when theguidelines were presented at the 31

stAnnual Renal Society of Australasia Conference in Brisbane, also in May 2003.

The second draft was reviewed by the ANZRGT in August 2003 with comments incorporated into the final document.ANZRGT launched the guidelines in Queensland on October 30, 2003 with the assistance of the Queensland Health

Core Practice Group. Following the launch of the 2003 Guidelines, a workshop was conducted at the DAA 22

ndNational Conference in Melbourne in May 2004, on implementing the guidelines, and the taskforce gathered feedback

from the 6 month pilot period since launching the guidelines. Currently, the guidelines are published on the QueenslandHealth Electronic Publishing Service (QHEPS) Internet site and are undergoing the endorsement process by DAA..

As part of the DAA endorsement process, consumer input was sourced from Kidney Health Australias regionalAdvocacy Committees, which are comprised of CKD patients. A standardised feedback form was developed based onrecommendations from the Charter of Patient Rights. Feedback from consultation in two states has indicated that overall

consumers felt the guidelines provided a standardised approach to care, however were concerned that in their currentformat were too technical to be understood by consumers. Consumers would have liked to have been involved from theoutset and were particularly interested that minority groups such as Indigenous people and those from non Englishspeaking backgrounds be considered in any educational material and that those in rural and remote areas receive thesame access to dietetic care as people in metropolitan areas. Discussion at both the National DAA workshops in 2003

and 2004 recognised the importance of involving consumers particularly from Indigenous backgrounds in thedevelopment of education materials.

Use of Guidelines

These guidelines are meant to serve as a general framework for handling patients with particular health problems. Itmay not always be appropriate to use these guidelines to manage clients because individual circumstances may vary.

The independent skill and judgement of the health care provider must always dictate treatment decisions. Theseguidelines for practice are provided with the express understanding that they do not establish or specify particularstandards of care, whether legal, medical or other. (Adapted from Splett, 2000)

Review ProcessThese guidelines are based on other published guidelines and should be reviewed annually to ensure they remain

current. Responsibility for review lies with Royal Brisbane and Womens Hospital in conjunction with the Australiaand New Zealand Renal Guidelines Taskforce.Next Review Date: October 2005

References

The AGREE Collaboration. 2001. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument.

www.agreecollaboration.org(accessed 31/03/2003)

Splett, P.L. 2000. Developing and Validating Evidence Based Guides for Practice: A Tool Kit for DieteticsProfessionals, American Dietetic Association: United States of America.

http://www.agreecollaboration.org/http://www.agreecollaboration.org/


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Australia and New Zealand Renal Guidelines Taskforce (ANZRGT)

NAME POSITION LOCATION STATE PHONE EMAILSusan Ash Associate Professor,

Dietitian

Queeensland University of

Technology

Qld (07) 3864 3524 [email protected]

Kathryn Anderson Renal Dietitian Greenslopes Private Hospital Qld (07) 3394 7363 [email protected]

Katrina Campbell PhD Student, Dietitian RBWH Qld (07) 3636 7997 [email protected]

Maria Chan Renal Dietitian St George Hospital NSW [email protected]

Suzie Chesterfield Renal Dietitian RBWH Qld (07) 3636 7997 [email protected]

Karen Corke Renal Dietitian Canberra Hospital ACT (02) 6244 2211 [email protected]

Ruth Dumont Renal Dietitian Royal Perth Hospital WA (08) 9224 3203 [email protected]

Kristin Gay Renal Dietitian Monash Medical Centre Vic (03) 9594 6666 [email protected]

Lyn Lloyd Renal Dietitian Auckland City Hospital NZ 64 9 5357 137 [email protected]

Helen MacLaughlin Renal Dietitian Abbey Community UK (07) 3636 7997 [email protected]

Ellen McCoy Renal Dietitian RBWH Qld (07) 3636 7997 [email protected]

Anthony Meade Renal Dietitian Queen Elizabeth Hospital SA (08) 8222 6000 [email protected]

Robyn Montgomery Renal Dietitian Townsville Hospital Qld (07) 4796 2950 robyn.montgomery-

[email protected]

Tracey Tasker Renal Dietitian Royal Hobart Hospital Tas (03) 6222 8503 [email protected]

Paulett Thrift Renal Dietitian Area Renal, Tamworth NSW (02) 6767 8448 [email protected]

Bernadeen Trotter Renal Dietitian Top End Renal Service NT (08) 8948 9000 [email protected]

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Evidence Based Practice Guideline Framework

Nutrition Care Process Clinical Questions Related to Stage of Care Process

6

Criteria for referral to Dietitian Objectives

Achieve and

maintain

desirable

weight and

adequatenutritional

status

Optimise

status of co-

morbidities

Normalise or

stabilise

biochemical

markers

Maintain

skeletal

muscle stores

and strength

Patients to

achieve

individual

goals

At what level of GFR should

patients be referred to the dietitian

in order to maximise nutritional

intervention opportunities?

Nutrition Assessment

Which specific measures best

reflect nutritional status or change

in nutritional status in Chronic

Kidney Disease?

Nutrition

Prescription/Intervention

What is (are) the appropriate

nutritional intervention(s) to

optimise nutritional status in

Chronic Kidney Disease and

prevent malnutrition?

Implementation and

Management

What is the optimal method of

implementation and follow up to

ensure nutritional status ismaintained or improved?

Australia & New Zealand Renal Guidelines Taskforce


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Chronic Kidney Disease Stage 3 (GFR 30-59)

1 Scope

1.1 Definition

Chronic Kidney Disease (CKD) is defined as the presence of kidney damage for 3 months or more, as defined bystructural or functional abnormalities, with or without decreased glomerular filtration rate (GFR), OR, GFR less

than 60ml/min for more than 3 months with or without kidney damage. (3)

1.2 Diagnostic CriteriaChronic Kidney Disease stages are defined by level of kidney function, irrespective of diagnosis. Stage 3 Chronic Renal Insufficiency (CRI) is described as moderate decrease in GFR, defined as GFR < 60 ml/min,irrespective of the presence or absence of kidney damage. (3 - (R) & (O))

1.3 Patient Target GroupAny adult patient fulfilling the definition and diagnostic criteria, excluding those with nephrotic syndrome. Theseguidelines by definition also exclude acute renal failure and transplantation.

2 Evidence Based Recommendations

2.1 Criteria for referral to Dietitian

GFR < 60ml/min(1 - level C evidence; 3 - (C) and (S))Protein energy malnutrition develops during the course of chronic kidney disease and is associated with adverseoutcomes. Low protein and calorie intake is an important cause of malnutrition in chronic kidney disease. (3 - (C) and

(S))

PRACTICE TIPS:1. Dietetic Management of Stage 3 CKD is focused on prevention of malnutrition and co-morbidity

management.

2. Prioritise patients who are malnourished or at risk of malnutrition. Use the Malnutrition Screening Tool(Appendix 7) to determine who is at risk.

3. Manage co-morbidities or refer on to those who specialise in Overweight/Obesity, Diabetes or Coronary

Heart Disease Management.

2.2 Nutrition Assessment CKD Stage 3

Measure OutcomeOedema-free (dry) actual body weight andbody mass index (BMI)(1 evidence, 3 -evidence & opinion)and/or

BMI 18.5-25 (1) or as appropriate forcultural group (see appendix 6)

Subjective global assessment(SGA) and/or% ideal body weight (IBW)(3 - evidence &

opinion)

SGA optimise weight, muscle and fatstores (4 opinion)

IBW within healthy weight range(appendix 6)

Anthropometry

Use total body nitrogen, dual x-ray

absorptiometry (DEXA) or bioelectrical

impedance (BIA) to measure long termnutritional adequacy (1 - evidence & opinion) ifavailable and/or appropriate

Within the normal ranges for thepopulation



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Measure OutcomeSerum albumin (3 evidence) Within the normal range at individual

facilities (ANZRGT - opinion)

Creatinine and thus GFR (4 opinion) Monitor rate of declineAddress modifiable factors (BP control;

glucose control in DM) (3 - R)

Haemoglobin(4 grade II evidence) >120mg/L (males)>110mg/L (females)

K+and PO4(4 - grade II evidence) Maintained within or progressed towardsnormal range at individual facilities

Plasma PTH (12 evidence) 3.85-7.7 pmol/L (12 Opinion)Blood glucose (with Diabetes) (1- level Aevidence

4.4-6.7 (pre-prandial)

HbA1c (with Diabetes) (1 -level A evidence)


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2.3 Nutrition Prescription/Intervention CKD Stage 3

Energy Ideal kilojoule/calorie energy intake determined for their age, gender, BMI and level ofphysical activity

A nutritionally balanced diet with adequate energy intake to maintain a healthy weightshould be prescribed. (1 - level C evidence)

Protein A normal protein diet, consisting of 0.75-1.0g/kg IBW/day, is recommended. Theclinically unimportant benefit of low protein diets (7.7pmol/L on more than 2 consecutivemeasurements (12 evidence).

Fluid Intake should be adjusted to the degree of CKD, and prevention of renal disease, oedemaand hypertension management. Once fluid management requires diuretics a liberal fluid

intake should be curbed. Management of hypertension includes limiting fluid intake. (1level C evidence)

Supplementation Patients with chronic kidney disease with GFR < 50ml/min, and an elevated parathyroidhormone (PTH) level or histological evidence of osteodystrophy, should receive

supplementation with vitamin D (calcitriol). (1 level A evidence)

Lifestyle Dietitian to encourage physical activity as outlined in the National Physical ActivityGuidelines for Australians (5). Refer patient to medical team and exercise physiologist /physiotherapist as appropriate

PRACTICE TIPS:1. for IBW ranges see appendix 62. Energy: Weight loss is appropriate if BMI > 30 in order to manage co-morbidities (3 - opinion)3. Protein: focus on achieving ideal intake and avoid the terms restriction or low protein4. Fat: On occasions the fat intake may need to be increased to above 30% to prevent undesired weight loss.

Unsaturated fats are to be used in preference to saturated fat sources. (ANZRGT - opinion)5. Potassium: A reduced potassium diet limits K

+intake to 1mmol/kg IBW/day. (ANZRGT opinion). Before

commencing this diet, ensure that hyperkalaemia is not a result of an acute response to conditions such asuncorrected acidosis or raised haematocrit (ANZRGT opinion).

6. Phosphate: If PO4>1.49mmol/L and/or PTH >7.7pmol/L, phosphate intake should be maintained between


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2.4 Implementation and Management CKD Stage 3

Patients with decreased dietary intake or malnutrition should undergo dietarymodification, counselling and education or specialised nutrition therapy(3-R)

Education

Nutrition counselling should encompass adequate protein and energy intake, bloodglucose control in DM, fluid and sodium control in hypertension (3 - evidence),

phosphate control in hyperparathyroidism (12 evidence), lipid control if indicated (1 level C evidence),weight management if indicated (3 - opinion), meal plans, recipemodification, self monitoring and reading food labels(4 opinion).

Recommended time for the initial consultation is 45-60 minutes (4 opinion)Recommended time for review consultations is 20-30 minutes (4 opinion)

Monthly Oedema-free (dry) body weight & BMI calculated (1 evidence)

Management

6-12

monthly

For patients with GFR 30-60 ml/min (CKD stage 3) nutritional status

should be monitored every 6-12 months if there is no evidence ofmalnutrition(3 opinion) and more frequently if malnourished

3 Summary of Recommendations

- See Appendix 1 and 2

PRACTICE TIPS:1. For patients with poorly controlled co-morbidities (hyperglycaemia, hypertension & hyperlipidaemia) refer to

the appropriate medical specialist for management of co-morbidities. (ANZRGT - opinion)2. It is important to recognise this stage of CKD requires nutritional management to maximise health and

prevent nutritional deterioration. Individualised management with 6-12 monthly reviews is recommended. Ifresources are not available to see patients, then documentation of referrals is advised, for future lobbying forresources. (ANZRGT - opinion)

3. Consultation times account for patient contact time only and do not include additional time spent in associatedadministrative tasks such as making patient-associated telephone calls, obtaining biochemistry results or

writing letters. (ANZRGT opinion)



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Chronic Kidney Disease Stage 4 (GFR 15- 29)

1 Scope

1.1 Definition

Chronic Kidney Disease (CKD) is defined as the presence of kidney damage for 3 months or more, as defined bystructural or functional abnormalities, with or without decreased glomerular filtration rate (GFR), OR, GFR lessthan 30ml/min for more than 3 months with or without kidney damage. (3)

1.2. Diagnostic CriteriaChronic Kidney Disease stages are defined by level of kidney function. Stage 4 is described as a severe decrease

in GFR, defined as GFR 15-29 ml/min, with or without kidney damage. (3)

1.3 Patient Target Group

Any adult patient fulfilling the definition and diagnostic criteria, excluding those with nephrotic syndrome. Theseguidelines by definition also exclude acute renal failure and transplantation.



GFR < 30ml/min(1 - level C evidence; 3 - (C) and (S))

PRACTICE TIPS:1. Dietetic Management of Stage 4 CKD is focused on optimisation of protein and energy intake to reduce

symptoms of uremia and malnutrition.2. Prioritise those patients who are malnourished or at risk of malnutrition.3. These guidelines also apply to patients with GFR < 15 ml/min who are not undergoing dialysis treatment.

2.2 Nutrition Assessment CKD Stage 4

Measure OutcomeOedema-free (dry) actual body weight andbody mass index (BMI) (1 evidence, 2 -evidence & opinion)

BMI 18.5-25 (1) or as appropriate forcultural group (see appendix 6)

Subjective global assessment(SGA) and/or% ideal body weight (IBW)(2- evidence &

opinion)

SGA optimise muscle stores, weight andfat stores (4 opinion)IBW within healthy weight range(appendix 6)

Anthropometry



impedance (BIA) to measure long termnutritional adequacy (1 - evidence & opinion) ifavailable and/or appropriate

Within the normal ranges for the

population

Serum albumin (2 evidence) Within the normal range at individualfacilities (ANZRGT - opinion)

Creatinine and thus GFR (4 opinion) Monitor rate of declineAddress modifiable factors (BP control;

glucose control in DM) (3 - R)

Biochemistryand Clinical

Haemoglobin(4 grade II evidence) >120mg/L (males)>110mg/L (females)



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Measure OutcomeK+and PO4 (4 - grade II evidence) K

+< 6.0mmol/L (1 level C evidence)

PO40.87 1.49 mmol/L (12 evidenceand opinion)

Plasma PTH (12 evidence) 7.7 12.1 pmol/L (12 opinion)Blood glucose (with Diabetes) (1 - level A

evidence)

4.4-6.7 (pre-prandial)

HbA1c (with Diabetes) (1 -level A evidence)


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2.3 Nutrition Prescription/Intervention CKD Stage 4

Energy An energy intake of at least 146kJ (35kcal)/kg IBW/day must accompany a moderateprotein restriction to minimise protein energy malnutrition.(1 - level A evidence)

For patients > 60 years, with a moderate protein restriction, an energy intake of 125-146kJ (30-35kcal)/kg IBW is recommended.(2 evidence and opinion)

Protein For patients with progressive chronic kidney disease (GFR < 25ml/min), the proteincontent of the diet should not be less than 0.75g/kg IBW/day. (1 - level A evidence)

At least 50% of the protein should be of high biological value. (1 - level A evidence)

Fat and

Carbohydrate

Priority should be given to a diet aimed at avoidance of protein-energy malnutrition, and

reducing fat intake to 1.49mmol/L (12 opinion) and/or PTH > 12.1 pmol/L on more than 2 consecutivemeasurements (12 evidence)

Fluid Fluid intake should be adjusted to the degree of CKD, oedema and hypertension

management.Once fluid management requires diuretics a liberal fluid intake should becurbed. Management of hypertension includes limiting fluid intake. (1 level C

evidence)

Patients with chronic kidney disease following a protein restricted diet (1mg/day), B2 (1-2mg/day)and B6 (1.5-2mg/day). (1 level B evidence)

Supplementation

Patients with chronic kidney disease with GFR < 50ml/min, and an elevated parathyroid

hormone (PTH) level or histological evidence of osteodystrophy, should receive

supplementation with vitamin D (calcitriol).(1 - level A evidence)

Dietitian to encourage physical activity as outlined in the National Physical ActivityGuidelines for Australians (5). Refer patient to medical team and exercisephysiologist/physiotherapist as appropriate.

Lifestyle

PRACTICE TIPS:

1. for IBW ranges see appendix 62. Energy: maximise unsaturated fats and sugars or modular supplements to achieve energy intake of 125-

146kJ/kg IBW/day if in HWR. Weight loss is appropriate if BMI > 30 in order to manage co-morbidities (3 -

opinion).3. Protein: The protein content should also not be greater than 1.0g/kg IBW/day. (ANZRGT opinion)4. Fat: On occasions the fat intake may need to be increased to above 30% to prevent undesired weight loss.

Unsaturated fats are to be used in preference to saturated fat sources. (ANZRGT - opinion)5. Potassium: A reduced potassium diet limits K

+intake to 1mmol/kg IBW/day. (ANZRGT opinion)

6. Phosphate: try to optimise compliance with PO4binder medication in conjunction with maintaining phosphateintake between 800mg and 1000mg/day, (12 evidence and opinion)

7. The medical team should prescribe supplementation of vitamins. The guidelines on supplementation areincluded for information purposes and the Dietitian may recommend supplementation.



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2.4 Implementation and Management CKD Stage 4

Education Pre end stage kidney disease education forms an important part of the management

strategy to slow the progression of renal disease and may have an independent beneficial

effect. (1 level A evidence)

Nutrition counselling should encompass appropriate protein and energy intake (2

evidence and opinion), fluid, sodium and potassium intake

(1 level C evidence), weightmanagement if indicated (1 & 3 - opinion), meal plans, recipe modification, selfmonitoring and reading food labels(4 opinion).

Recommended time for the initial consultation is 45-60 minutes(4 opinion)Management

Recommended time for review consultations is 20-30 minutes(4 opinion)

Oedema-free (dry) body weight measured and BMI calculated (1 -evidence)

Monthly

Recent nutrient intake assessment (diet evaluation or nPNA) (1 evidenceand opinion)

3 monthly

especially if GFR < 15ml/min, concomitant illness, inadequate nutrient

intake or malnutrition(2 evidence & opinion)

SGA (1 - opinion)6-12 monthly

Assessment of long term nutritional adequacy with total body nitrogen,DEXA or BIA (1 evidence and opinion)if available or appropriate


- see Appendix 1 and 2

PRACTICE TIPS:1. It is important to recognise this stage of CKD requires nutritional management to prevent malnutrition by

optimising protein, energy and fluid intake. Individualised management with 3 monthly reviews is

recommended. If resources are not available to see patients, then documentation of referrals is advised, forfuture lobbying for resources. (ANZRGT - opinion)

2. ForPatients with poorly controlled co-morbidities (hyperglycaemia, hypertension & hyperlipidaemia)education should also address improving blood glucose control, weight management and blood lipids.(ANZRGT - opinion)

3. Consultation times account for patient contact time only and do not include additional time spent in associatedadministrative tasks such as making patient-associated telephone calls, obtaining biochemistry results or

writing letters (ANZRGT opinion)



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Chronic Kidney Disease Stage 5-

Haemodialysis

1 Scope

1.1 Definition

Chronic Kidney Disease (CKD) is defined as the presence of kidney damage for 3 months or more, as defined by

structural or functional abnormalities, with or without decreased glomerular filtration rate (GFR), OR, GFR lessthan 60ml/min for more than 3 months with or without kidney damage. (3)

1.2 Diagnostic CriteriaChronic Kidney Disease stages are defined by level of kidney function. Stage 5 is described as kidney failure,with renal replacement therapy such as haemodialysis. (3)

1.3 Patient Target GroupAny adult patient fulfilling the definition and diagnostic criteria. These guidelines by definition also exclude acuterenal failure and transplantation, unless the transplant has failed and the patient is undergoing dialysis treatment.



For haemodialysis patients, nutritional status should be routinely assessed at commencement of haemodialysis

and at regular intervals thereafter.(1 evidence; 2 evidence)

PRACTICE TIP:1. Prioritise those patients with poorly controlled co-morbidities or malnutrition. (ANZRGT - opinion)

2.2 Nutrition Assessment CKD Stage 5 - Haemodialysis

Measure Outcome

% Ideal oedema free (dry) body weight(2 opinion) and body mass index (BMI) (1 evidence)

IBW within range BMI 23-26(ANZRGT - opinion) or as appropriate forcultural group (see appendix 6)

Anthropometry

Subjective global assessment (SGA) (1&2 -opinion)

SGA maintained or improved (8 - no levelcited)



impedance (BIA) to measure long termnutritional adequacy (1 - evidence & opinion) if

available &/or appropriate

Within range for normal population

Pre dialysis serum albumin (1 evidence; 2 -

evidence)

Within the normal range at individual

facilities (ANZRGT - opinion)

Biochemistry

and Clinical

Pre dialysis serum potassium (8 - no level cited) < 5.5mmol/L

Pre dialysis serum urea (7 level B evidence) 21-39mmol/L correlates with reducedrelative risk of morbidity

Pre dialysis serum phosphate(12 evidence) 1.13-1.78 mmol/L target range (12

evidence)Pre dialysis PTH (12 evidence) 16.5-33.0 pmol/L (12 evidence)

2Pre dialysis corrected calcium x phosphateproduct (1 - level B evidence)


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Measure OutcomePost dialysis serum urea (8 - no level cited) 65% reduction from pre dialysis value

indicates adequate haemodialysis (1 - levelB evidence)

Biochemistry

and Clinical

(cont)

Ascertain dialysis adequacy (1 - level Bevidence)

Target Kt/V should be 1.2 (9 evidence)

Ascertain dialysis frequency and fluid gains(8- no level cited) Achieve interdialytic fluid gains 2-5%IBW

HbA1c (for persons with diabetes) (8 -no levelcited)


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80 110 mmol/day (6 evidence and agreed best practice)Sodium

1mmol/kg IBW/day(8 no level cited)

Potassium

Dietary phosphate restriction (800-1000 mg/d) and/or use of phosphate binders, if POPhosphate 4

>1.8mmol/L (12 opinion) and/or PTH >33.3pmol/L (12 evidence).

500ml + previous days urine output (PDUO). (6 evidence and agreed best practice)Fluid

Supplementation not specifically addressed by any guidelines for haemodialysis

Dietitian to encourage physical activity as outlined in theNational Physical ActivityGuidelines for Australians (5). Refer patient to medical team and exercise

physiologist/physiotherapist as appropriate.

Lifestyle

PRACTICE TIPS:

1. Energy and Protein: IBW range for HD is BMI 22-25 (1 - opinion, ethnic group or age not specified), forIBW ranges see Appendix 6; aim to achieve weight in IBW range

2. Phosphate: Care must be taken to make the diet as low as possible inphosphate whilst maintaining adequate

protein. To ensure a reasonable level, calculate 10-12mg phosphate per gram of recommended protein. (12 opinion).

3. Supplementation: The medical team manages prescription of vitamins and minerals. Supplementation as in

CKD stages 3 and 4 is still applicable. (ANZRGT - opinion)4. Fibre intake should be encoura ed as consti ation can be common in haemodial sis. ANZRGT - o inion

2.4 Implementation and Management CKD Stage 5 - Haemodialysis

Education Every haemodialysis patient should receive intensive nutritional counselling based on anindividualised care plan (2 opinion), focusing on adequate protein and energy intake(1 level C evidence), fluid and electrolyte management(8 no level cited), self monitoring and

meal plans(8 no level cited).

Recommended time for initial consultation is 45-60 mins (8 - no level cited)Management

Recommended time for review sessions is 30-45 minutes for initial review and then 45-60minutes every 6 months(8 no level cited)

Oedema-free (dry body weight) and BMI (1 - evidence)MonthlySerum albumin (1 opinion)

Dialysis adequacy(Kt/V) (1 - Level C evidence)3 6 monthlynPNA(1 evidence and opinion)Dietary interviews (more frequently if clinically indicated) (1 opinion)SGA (1&2- opinion)

6-12 monthly Assessment of long term nutritional adequacy with total body nitrogen,DEXA or BIA (1 opinion) if available or appropriate

PRACTICE TIPS:1. Consultation times account for patient contact time only and do not include additional time spent in associated

administrative tasks such as making patient-associated telephone calls, obtaining biochemistry results orwriting letters (ANZRGT opinion)

2. If resources are not available to see patients as frequently as recommended, then documentation is advised,

for future lobbying for resources. (ANZRGT - opinion)





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Chronic Kidney Disease Stage 5 - Peritoneal Dialysis

1 Scope

1.1 Definition

Chronic Kidney Disease (CKD) is defined as the presence of kidney damage for 3 months or more, as defined bystructural or functional abnormalities, with or without decreased glomerular filtration rate (GFR), OR, GFR less

than 60ml/min for more than 3 months with or without kidney damage (3).

1.2 Diagnostic CriteriaChronic Kidney Disease stages are defined by level of kidney function. Stage 5 is described as kidney failure,with renal replacement therapy such as peritoneal dialysis (3).

1.3 Patient Target Group

Any adult patient fulfilling the definition and diagnostic criteria. These guidelines by definition also exclude acuterenal failure and transplantation, unless the transplant has failed and the patient is undergoing dialysis treatment.



For peritoneal dialysis patients, nutritional status should be routinely assessed at commencement of peritonealdialysis and at regular intervals thereafter. (1 & 2 evidence)

PRACTICE TIP:

1. Prioritise those patients with poorly controlled co-morbidities or malnutrition. (ANZRGT - opinion)

2.2 Nutrition Assessment CKD Stage 5 Peritoneal Dialysis

Measure OutcomeThe nutritional status of peritoneal dialysis

patients should be monitored by methods

appropriate to assess total body stores and

detect early changes of malnutrition.

Methods such as nPNA (1 - level C evidence; 2 evidence & opinion), total body nitrogen (1 -level C evidence), DEXA (1&2 evidence &opinion)or SGA (1 level C evidence; 2 evidence and opinion)should be used.

nPNA >0.9 (10 - opinion)Anthropometrytotal body nitrogen & DEXA within therange for normal populationSGA maintained or improved (8 no level

cited)

% Ideal dry body weight (2 opinion) and

body mass index (BMI)(1 evidence)

IBW within range BMI 23-26

(ANZRGT opinion) or as appropriate forcultural group (see appendix 6)

Serum Albumin(1 evidence; 2 - evidence). Within the normal range at individualfacilities (ANZRGT - opinion)

Biochemistry

and Clinical

Serum urea and/or creatinine (1 - evidence) Stabilise

If urea and /or creatinine are low patientshould be further evaluated for

malnutrition. (1 evidence)

Serum K K: 3.5 5.5 mmol/L

HbA1c (for persons with diabetes)(8 -no levelcited


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Measure OutcomeSerum lipids (11 - evidence) TC


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For peritoneal dialysis patients, recommendation of 1.2-1.4g protein/kg IBW /day. (1 level C evidence)

Protein

At least 50% of the dietary protein should be of high biological value(2 evidence andopinion)

Recommended protein intake for a peritoneal dialysis patient who is acutely ill is at least1.3g/kg IBW/day. (2 opinion)

A higher intake of 1.5g/kg IBW/day is recommended for patients with peritonitis.(6

evidence and agreed best practice)

Saturated fat 1.8mmol/L (K/DOQI bone, opinion) and/or PTH >33.3pmol/L (12 evidence).Phosphate

Fluid Individualised treatment recommended based on oedema and hypertension

If fluid overloaded: limit fluid intake to 800ml + previous days urine output (PDUO). (6 evidence and agreed best practice)

Supplementation not specifically addressed by any guidelines for peritoneal dialysis

Dietitian to encourage physical activity as outlined in theNational Physical ActivityGuidelines for Australians (5). Refer patient to medical team and exercisephysiologist/physiotherapist as appropriate.

Lifestyle

PRACTICE TIPS:1. Energy & Protein: IBW range for PD is BMI 23-26 (opinion, ethnic group or age not specified), for IBW

ranges see Appendix 6; aim to achieve weight in IBW range

2. Energy: To calculate the energy from a peritoneal dialysis bag based on dextrose, estimate 60-100%absorption of dextrose. For example for a 1500mL bag, 15% dextrose, will give 250-420kJ. Commonpractise is to estimate absorption of up to 2000kJ/day from the diasylate, if a patient is on 4 bags per day.(ANZRGT opinion).

3. Potassium: If restriction required, suggested level is 1mmol/kg IBW/day. (ANZRGT - opinion)4. Phosphate: Care must be taken to make the diet as low as possible inphosphate whilst maintaining adequate

protein. To ensure a reasonable level, calculate 10-12mg phosphate per gram of recommended protein. (12 opinion).

5. Supplementation: The medical team manages prescription of vitamins and minerals. Multivitaminsupplementation may be required, and supplementation as in CKD stages 3 and 4 is still applicable.(ANZRGT - opinion)

6. Encourage fibre intake. Constipation in PD can affect catheter position and increase risk of peritonitis.

(ANZRGT - opinion)



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2.4 Implementation and Management CKD Stage 5 Peritoneal Dialysis

Education Every peritoneal dialysis patient should receive intensive nutritional counselling based on

an individualised care plan (2 opinion) focusing on adequate protein intake andappropriate energy intake(1 level C evidence), maintenance of muscle stores(1 level Cevidence), self monitoring and meal plans(8 no level cited).

Recommended time for initial consultation is 45-60 mins (8 - no level cited)Management

Recommended time for review sessions is 30-45 minutes for initial review and then 45-60minutes every 6 months(8 no level cited).

Oedema-free (dry body weight) and BMI (1 - evidence)MonthlySerum albumin (1 opinion)

SGA (1 level C evidence)6 monthlynPNA (1 level C evidence)Dietary interviews (more frequently if clinically indicated) (1 opinion)weekly Kt/V (1 level C evidence)

total body nitrogen or DEXA (1 opinion) if available



PRACTICE TIPS:1. Consultation times account for patient contact time only and do not include additional time spent in associated

administrative tasks such as making patient-associated telephone calls, obtaining biochemistry results orwriting letters (ANZRGT opinion)

2. If resources are not available to see patients as frequently as recommended, then documentation is advised,for future lobbying for resources. (ANZRGT - opinion)



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References

1. The CARI Guidelines(Caring for Australians with Renal Impairment). 2003. Australian

Kidney Foundation & Australia New Zealand Society of Nephrology.

2. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney

Foundation. 2000. American Journal of Kidney Diseases, 35 (supp 2), s1-s140.

3. National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) AdvisoryBoard.2002. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation,

classification and stratification.American Journal of Kidney Diseases, 39 (supp 2), s1-s246.

4. American Dietetic Association. 2002. Medical Nutrition Therapy Evidence-Based Guides for

Practice: Chronic Kidney Disease (non-dialysis) Medical Nutrition Therapy Protocol.

Chicago: American Dietetic Association.

5. National Physical Activity Guidelines for Australians. 1999. Canberra: Australian Department

of Health and Ageing.

6. European Guidelines for the Nutritional Care of Adult Renal Patients. 2003. European

Dialysis and Transplantation Nurses Association/European Renal Care Association (Edtna-Erca) Journal, 29(1), s1-s23.

7. Lowrie, EG & Lew, NL. 1990. Death risk in haemodialysis patients: the predictive value of

commonly measured variables and an evaluation of death rate differences between facilities.

American Journal of Kidney Diseases, 15, 458-482.

8. Wiggins, K.L. 2002.Guidelines for Nutritional Care of Renal Patients (3rd

ed). Renal

Dietitians Dietetic Practice Group, American Dietetic Association. Chicago: American Dietetic

Association.

9. NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. 2001.

AmericanJournalof KidneyDiseases,37(supp 1), s7-s64.

10.NKF-K/DOQI clinical practice guidelines for peritoneal dialysis adequacy: update 2000. 2001.

AmericanJournalofKidneyDiseases. 37 (supp 1), s65-s136.

11. K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease.2003. AmericanJournalofKidneyDiseases, 41(supp 3), s1 s79.

12. K/DOQI Clinical Practice Guidelines for bone metabolism and disease in chronic kidney

disease.American Journal of Kidney Disease,42(4), S7 S169.



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Appendix 1: Summary of Recommendations for Management of Chronic KidneyDisease

Chronic Kidney

Disease Stage 3

(GFR 30-59)3

Chronic Kidney

Disease Stage 4

(GFR 15-29)3

Chronic Kidney

Disease Stage 53

Haemodialysis

Chronic Kidney

Disease Stage 53

Peritoneal Dialysis

Point of

referral

GFR


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Appendix 2: Summary of Recommendations for Nutrition Prescription in ChronicKidney Disease

CKD Stage 3 CKD Stage 4 CKD Stage 5 CKD Stage 5

Peritoneal DialysisGFR 59-30ml/min GFR 50% HBV1

1.2-1.4g/kg IBW1

>50% HBV

min 1.2g/kg IBW1

;>50% HBV2 2

acute illness: > 1.2 g/kg IBW

acute illness: >1.3g/kgIBW2 2; peritonitis:

1.5g/kg IBW6

Sodium 6.0limitintake1to 1mmol/ kgIBW/day(ANZRGT)

1mmol/kg IBW/day8 Indiv treatmentrecommended, ifrestricted 1mmol/ kg

IBW/day (ANZRGT)

Phosphate if >1.49 mmol/L, (or>target PTH) restrictto 800-1000mg/day(adj for protein) &/or

binders

if >1.49 mmol/L, (or>target PTH) restrictto 800-1000mg/day(adj for protein) &/or

binders

if >1.78 mmol/L, (or>target PTH) restrictto 800-1000mg/day(adj protein) &/or

binders

if >1.78 mmol/L, (or>target PTH) restrictto 800-1000mg/day(adj for protein) &/or

binders12 12 12 12

Fluid Individualised basedon CKD, oedema andhypertension

1

Individualised basedon CKD, oedema andhypertension

500ml + PDUO6

Indiv treatmentrecommended, iffluid overloaded orhypertensive: 800ml+ PDUO

1

6

References

1. The CARI Guidelines(Caring for Australians with Renal Impairment). 2003. Australian Kidney Foundation & Australia New Zealand Society

of Nephrology.

2. Clinical practice guidelines for nutrition in chronic renal failure. K/DOQI, National Kidney Foundation. 2000. American Journal of KidneyDiseases, 35 (supp 2), s1-s140.

3. National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) Advisory Board.2002. K/DOQI clinical practice guidelines

for chronic kidney disease: evaluation, classification and stratification. American Journal of Kidney Diseases, 39 (supp 2), s1-s246.4. American Dietetic Association. 2002. Medical Nutrition Therapy Evidence-Based Guides for Practice: Chronic Kidney Disease (non-

dialysis) Medical Nutrition Therapy Protocol. Chicago: American Dietetic Association.5. National Physical Activity Guidelines for Australians. 1999. Canberra: Australian Department of Health and Ageing.

6. European Guidelines for the Nutritional Care of Adult Renal Patients. 2003. European Dialysis and Transplantation Nurses Association/European Renal Care Association (Edtna/Erca) Journal, 29(1), s1-s23.

7. Lowrie, EG & Lew, NL. 1990. Death risk in haemodialysis patients: the predictive value of commonly measured variables and an evaluation of

death rate differences between facilities. American Journal of Kidney Diseases, 15, 458-482.rd8. Wiggins, K.L. 2002.Guidelines for Nutritional Care of Renal Patients (3 ed). Renal Dietitians Dietetic Practice Group, American Dietetic

Association. Chicago: American Dietetic Association.9. NKF-K/DOQI clinical practice guidelines for hemodialysis adequacy: update 2000. 2001. AmericanJournalof KidneyDiseases,37(supp

1), s7-s64.

10. NKF-K/DOQI clinical practice guidelines for peritoneal dialysis adequacy: update 2000. 2001. AmericanJournalofKidneyDiseases,37(sup 1), s65-s136.

11. K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease. 2003. American Journal of Kidney Diseases,

41 (supp 3), s1 s79.

12. K/DOQI Clinical Practice Guidelines for bone metabolism and disease in chronic kidney disease.American Journal of Kidney Disease,42(4),S7 S169.



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Appendix 3: Descriptions of levels of evidence cited from original sources

Source Description

Grade IThe evidence consists of results from studies of strong designfor answering the questions addressed. The results are both clinicallyimportant and consistent with minor exceptions at most. The results

are free of serious doubts about generalisability, bias, and flaws in

research design. Studies with negative results have sufficiently largesamples to adequate statistical power.

American Dietetic Association

Medical Nutrition TherapyEvidence-Based Guides forPractice: Chronic Kidney Disease

(non-dialysis) Medical NutritionTherapy Protocol

Grade IIThe evidence consists of results from studies of strongdesign for answering the questions addressed, but there is uncertaintyattached to the conclusion because of inconsistencies among the

results for different studies or because of doubts aboutgeneralisability, bias, research design flaws or adequacy of sample

size. Alternatively, the evidence consists solely of studies fromweaker designs for the questions addressed, but the results have beenconfirmed in separate studies and are consistent with minorexceptions at most.Grade IIIThe evidence consists of results from limited studies ofweak design for answering the questions addressed. Evidence from

studies of strong design is either unavailable because no studies ofstrong design have been done or because the studies that have beendone are inconclusive due to lack of generalisability, bias, designflaws or inadequate sample sizes.Grade IVThe support of the conclusion consists solely of thestatements of informed medical commentators based on their clinical

experience, unsubstantiated by the results of any research studies.

Level ARandomised controlled trials and meta analysesThe CARI GuidelinesLevel BDescriptive StudiesLevel CConsensus or opinion

A rating of "evidence" was defined as "mainly convincing scientificevidence, limited added opinion";

K/DOQI Clinical practice

guidelines for chronic kidneydisease 2000, 2001, 2003 "Opinion" was defined as "mainly opinion, limited scientific

evidence";"Evidence and Opinion" was defined as "about equal mixtures ofscientific evidence and opinion."

SAnalysis of individual patient data from a single large, generalisable

study of high methodological quality (for example NHANES III)K/DOQI Clinical practiceguidelines for chronic kidney

disease: evaluation, classificationand stratification 2002

CCompilation of original articles into evidence tablesRReview of reviews and selected original articlesOOpinion

Guidelines for Nutritional Care ofRenal Patients (3

No levels of evidence or opinion providedrd

ed)

Examination of the scientific literature shows a paucity of evidenceon dietary advice in renal failure. Therefore the guidelines are based

on scientific evidence, where available, and on a consensus of whatconstitutes best practice where not.

European Guidelines for theNutritional Care of Adult Renal

Patients

Appendix 4: Stages of Chronic Kidney Disease

Stage Description GFR (mL/min/1.73m2)

1 Kidney damage with normal or GFR 90

2 60-89Kidney damage with mild GFR

3 30-59Moderate GFR

4 15-29Severe GFR

5 Kidney failure < 15 (or dialysis)

Chronic kidney disease is defined as either kidney damage or GFR 60 mL/min/1.73m2

for 3 months. Kidneydamage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests orimaging studies (K/DOQI 2002).



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Appendix 5: Calculations

1. GFR

Cockcroft-Gralt Formula for estimating creatinine clearance / GFR

GFR (ml/min) = (140 - age in years) x weight in kg814 x serum creatinine in mmol/L

Multiply by 0.85 for women

GFR should be corrected for body surface area (BSA).BSA may be calculated by the Du Bois formula

0.725BSA = 0.007184 x [height (cm)] x [weight (kg)]

0.425(Du Bois and Du Bois 1916).

Use GFR rather than creatinine levels or other measures of renal impairment in referral criteria and assessment ofpatients for the following reasons:

this is the measure used to define the stages of kidney disease

this is used by all nephrologists

it is the measure used in all referenced guidelines

it does account for age, weight and renal function

2. Prediction Equations for BIA and DEXA

BIAUseKushner formula for calculation of total body water (TBW)Males:TBW=8.399+0.396(H2/R) + (0.143W)Females:TBW=8.315+0.382(H2/R) +(0.105W)

R is resistance in ohmsH is the Height in cmW is the weight in kgKushner, R.F. & Schoeller, D.A. 1986. Estimation of total body water by bioelectrical impedance analysis.Am J Clin Nutr44:417-424.

DEXAUse Lukaski formula for fat free mass (FFM) which is roughly equivalent to lean body mass (LBM)

FFM = -4.03+(0.734H2/R) +(0.116W) +(0.096Xc) +(0.878 x 1 for males or 0 for females)

Xc= compacitentsLukaski, H. C., Bolonchuk, W. W., Hall, C. B. & Siders, W.A. 1986. Validation of tetrapolar bioelectrical impedance method to assess human body

composition.J Appl Physiol60:1327-1332.

3. Calculation of normalised protein nitrogen appearance (nPNA) (adapted from The CARI Guidelines)

Chronic renal failurenPNA may be approximated by the Randerson formula

nPNA (g/kg/day) = [[urea excretion (mmol/day) x 0.209] + 15.71] weight (kg) (Kopple et al 1993 in CARI).

Peritoneal dialysisGiven that daily changes in body nitrogen are usually negligible in stable patients on peritoneal dialysis, the UNA isusually represented as the sum of dialysate and urinary losses. The protein equivalent of total nitrogen appearance(PNA) expresses the nitrogen appearance in terms of protein.

PNA (grams of protein/24hrs) = TNA (grams of nitrogen/24 hrs) x 6.25.

Because of the constant relationship between the measured UNA and the total nitrogen appearance, the proteinequivalent of total nitrogen appearance (PNA) is determined from the UNA, or from the urea appearance (UA) by the

following formulae [13 in 1].PNA (g/day) = 20.1 + 7.5 x UNA (g/24 hrs)

or

PNA (g/day) = 20.1 + 0.209 x UA (mmol/24 hrs)Several alternative equations have been derived to calculate the PNA in CAPD patients. Comparisons performed by

Keshaviah and Nolph [14 in 1] have shown that all equations correlate closely with each other and do not show any



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significant difference to the measured protein intake. However, if dialysate protein loss is excessive (greater than 10-15g protein per day), this needs to be additionally accounted for in making an estimate of protein intake [15 in 1]. In thiscase it is recommended that the protein intake be determined from the UNA by determining the protein equivalent of

nonprotein nitrogen appearance (PNPNA), which in the individual patient, is equal to the PNA minus protein losses.This should reflect the net protein intake under steady state conditions, i.e. the total intake of protein minus dialysateand urinary protein losses [13 in 1]. Thus by determining the PNPNA (see below) and adding dialysate and urinaryprotein loss, a more accurate estimate of the PNA may be made.

PNPNA (g/day) = 15.1+ 6.95 x UNA (g/24 hrs)or

PNPNA(g/day)=15.1+0.195xUA (mmol/24 hrs)The terminology is often loosely applied, so that the terms used in applying urea kinetic modelling to nutrition in CAPDhave recently been redefined [16 in 1]. For practical purposes the PNA can be substituted for the older terminologyreferring to it as the protein catabolic rate or PCR. Studies assessing the benefits of the kinetically derived protein intakesuggest that relaying the information back to the patient results in an improved compliance with dietaryrecommendations [17 in 1].

HaemodialysisThe methods used to determine the PNA differ in the HD and PD population, The most widely used method calculatesthe urea generation rate from the end of the first dialysis to/the beginning of the second dialysis and reliespredominantly on the difference between the post and pre dialysis urea values .

Several methods are used to calculate the urea generation rate from which the PNA are calculated.

PNA = UGR (g/24 hrs) + 1.7 + Urinary protein losses0.154

UGR (g/24 hrs) = Urea (mmol/24 hrs) x 0.028UGR (mmol/24 hrs) = - V2C2 - V3C3 x 24

interdialytic time (hrs)V2 C2 = Vdurea and concentration of urea post dialysisV3 C3 = Vdurea and concentration of urea pre dialysis.

Note: In all cases urinary urea and protein losses need to be measured and included in the calculations used to

estimate protein intake.



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Appendix 6: BMI Ranges

Suggested table of BMI

ranges

Pre-Dialysis Dialysis (Haemodialysis,

Peritoneal Dialysis)

Underweight 32

The Council for Renal Nutrition (American Kidney Foundation) recommend an ideal body weight of BMI 20-25 forpre-dialysis patients and BMI 23-26 for dialysis patients. They do not address ethnicities or age groups in defining

these levels.

Calculation of Ideal Body Weight (IBW)

Aim for weight to be within BMI of 20-25 if GFR 15-59 and a BMI of 23-26 on a dialysis modality. A patients idealbody weight can be adjusted (as per the equation below), particularly if a patient is obese BMI>30.

Adjusted Body Weight = [(Actual Weight Ideal Weight) x 0.25] + Ideal Body Weight (IBW).

When to use actual or adjusted body weight:1. Use actual body weight (dry weight for dialysis patients) when:

Weight is within reasonable range of ideal or standard body weight (recommended BMI range). Recent weight change has not occurred. The patient is not malnourished. The patient has been slightly overweight or underweight almost all of their lives.

2. Use adjusted body weight when patients are overweight/obese, using clinical judgement.

rdKopple, J.D., 2002, Rocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease 3 Ed, Lippincott Williams & Wikins,

Philadelphia

Koople, J.D., Zhu, X., Lew, N.L., Lowrie, E.G., 1999. Body weight for height relationships predict mortality in maintenance haemodialysis patients

Kidny Int 56:1136-1148.Ed, Lippincott Williams & Wikins, PhiladelphiathMitch, WE., Klahr, S., 2002, Handbook of Nutrition and the Kidney, 4



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Appendix 7: Malnutrition Screening Tool

Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Ferguson

M, Capra S, Bauer J and Banks M. Nutrition 15:458-464. 1999

Have you lost weight recently without trying? No 0

Unsure 2

Yes

see below

If yes, how much weight (kg) have you lost? 1.0 5.0 1

6.0 10.0 2

11.0 15.0 3

> 15.0 4

Have you been eating poorly because of a decreased appetite? No 0

Yes 1

Total Score :

IF THE TOTAL SCORE IS 2 OR MORE, PATIENT IS AT RISK OF MALNUTRITION



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Appendix 8: Subjective Global AssessmentName:Date:

Medical History A B C

WEIGHT Usual weight. Current weight...Wt change past 6 months Amount weight loss.... % weight loss.0-10% loss *

Weight change past 2 weeks Amount.No change; normal weight *Increase to within 5% *Increase (1 level above) * *

No change, but below usual wt *Increase to within 5-10% *

Decrease *

DIETARY INTAKENo change; adequate *

No change; inadequate *

Change Duration of change...Suboptimal diet *Full liquid *Hypocaloric liquid *

Starvation *

Intake borderline; increasing *Intake borderline; decreasing *Intake poor; no change * *Intake poor; increasing *Intake poor decreasing *

GASTROINTESTINAL SYMPTOMS

Frequency (never, daily, no. of times/week) Duration (2wk)Nausea ..Vomiting ..Diarrhoea ...Anorexia ...

None; intermittent *Some (daily >2 week) *All (daily >2 week) *

FUNCTIONAL

CAPACITYNo dysfunction Duration of change .. *Difficulty with ambulation/normal activities *Bed/chair-ridden *

Change past 2 week

Improved *No change *Regressed *


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Physical examination A B C

SUBCUTANEOUS FAT

Under the eyes Slightly bulging area Hollowed look,

depression, dark circlesTriceps Large space between

fingersVery little space

between fingers, orfingers touch

Biceps Large space betweenfingers

Very little spacebetween fingers, or

fingers touch

MUSCLE WASTING

Temple Well-definedmuscle/flat

Slight depression Hollowing, depression

Clavicle Not visible in Males;may be visible but not

prominent in females

Some protrusion; maynot be all the way along

Protruding/prominentbone

Shoulder Rounded No square look;acromion process may

protrude slightly

Square look; bonesprominent

Scapula/ribs Bones not prominent;no significantdepressions

Mild depressions orbone may show

slightly; not all areas

Bones prominent;significant depressions

Quadriceps Well rounded; nodepressions

Mild depression Depression; thin

Calf Well developed Thin; no muscledefinition

Knee Bones not prominent Bones prominent

Interosseous muscle between thumband forefinger

Muscle protrudes;could be flat in females

Flat or depressed area

OEDEMA (related to malnutrition) No sign Mild to moderate Severe

ASCITES(related to malnutrition) No sign Mild to moderate Severe

OVERALL SGA RATING A B C

Adapted from: Detsky et al., 19948; Baxter Healthcare Corporation, 1993; McCann, 1996(Ferguson, Bauer, Banks, Capra, 1996)



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Appendix 9: Glossary

Adult: any person over the age of 18

BIA:Bio-electrical impedance analysis is a method of measuring body composition based on the difference inconductivity of body fat and fat-free tissue.

Body weight: use dry, oedema-free, post dialysis or non-dwelling body weight for all calculations

DEXA: Dual x-ray absorptiometry is a method of measuring body composition using x-ray technology.

Kt/V:Kt/V is a measure of dialysis adequacy. K is the urea clearance of the dialyser, t is the time between drawings ofblood (in minutes) and V is the patients total body water volume. Kt/V is regularly calculated for al dialysis patients.This measure can be adversely affected by many patient related or dialysis associated variables.

nPNA:Normalised Protein equivalent of Total Nitrogen Appearance normalised to ideal body weight. See Appendix 6to calculate nPNA.

Urea Reduction Ratio (URR): A method used to calculate adequacy of haemodialysis is the urea reduction ratio,

where adequate dialysis is a reduction of 65% or more between the pre and post dialysis serum urea values.

ckd guidelines 2005

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