The 2020 Updated KDOQI Clinical Practice Guidelines for ...

The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD provides a comprehensive up-to-date information on the understanding and care ... × Title (Title) Mr Ms Dr. Professor FirstName* LastName* Company/Institution E-Mail* Message *indicatesrequiredfields ThissiteisprotectedbyreCAPTCHAandtheGooglePrivacyPolicyandTermsofServiceapply. 0 0 × OurServices OurContent PublishWithUs AboutUs Login 0 0 JournalMenu JournalHome AboutThisJournal Guidelines JournalContact SubscriptionRates RelatedArticles Contents:allyears × BloodPurification DownloadFulltextPDF Review-AdvancesinCKD2021 FreeAccess The2020UpdatedKDOQIClinicalPracticeGuidelinesforNutritioninChronicKidneyDisease IkizlerT.A.a·CuppariL.b Authoraffiliations aDivisionofNephrologyandHypertension,DepartmentofMedicine,VanderbiltUniversitySchoolofMedicine,Nashville,TN,USAbOswaldoRamosFoundation-Hrim,FederalUniversityofSãoPaulo,SãoPaulo,Brazil CorrespondingAuthor TalatAlpIkizlerDivisionofNephrology,VanderbiltUniversityMedicalCenterS-3223MedicalCenterNorth,116121stAvenueSouthNashville,TN37232-2372(USA)[email protected] Keywords:NutritionDialysisMetabolismWastingTransplantation RelatedArticlesfor"" BloodPurif2021;50:667–671 https://doi.org/10.1159/000513698 Abstract FullText PDF References Extras:1 Abstract Overthelast2decades,therehasbeenagreataccumulationofnewevidenceregardingthemanagementofnutritionalandmetabolicaspectsofkidneydisease.The2020updatetotheKDOQIClinicalPracticeGuidelineforNutritioninCKDprovidesacomprehensiveup-to-dateinformationontheunderstandingandcareofpatientswithCKD.Itprovidesupdatedinformationonnutritionalaspectsofkidneydiseaseforthepracticingclinicianandalliedhealth-careworkers.Thecurrentmanuscriptprovidesanoverviewoftheupdatedguidelinestatementsonmajorsubjectsincludingnutritionalassessment,dietaryproteinandenergyintake,nutritionalsupplementation,micronutrients,andelectrolytes.Theguidelinesarefocusedondietarymanagementratherthanallpossiblenutritionalinterventions. ©2021S.KargerAG,Basel IntroductionPatientswithCKDareatriskformultiplenutritionalandmetabolicabnormalities.Theseincludeprotein-energywasting(PEW),obesity,nutrientdeficiencies,undesirableaccumulationofelectrolytes,andmetabolicwasteproducts.ProvisionofoptimalnutritionalcareforCKDpatientsisessentialtopreventand/ortominimizethecomplicationsandultimatelytoreducetheriskofunfavorableoutcomes.Clinicalpracticeguidelinesareofparamountimportancetoassistclinicianswithevidence-basedrecommendationsintendedtooptimizepatientcare.TheoriginalClinicalPracticeGuidelinesforNutritioninChronicRenalFailurebytheNationalKidneyFoundationDiseaseOutcomesQualityInitiative(KDOQI)waspublishedin2000.Sincethen,therehasbeenaremarkableaccumulationofnewevidenceontheassessmentandmanagementofnutritionaspectsinCKD.Newmethodologyandprocessesforthedevelopmentofclinicalguidelineshavealsobeenintroduced[1].TheKDOQIClinicalPracticeGuidelineforNutritioninCKD:2020UpdatewasdevelopedasajointeffortbyNationalKidneyFoundationandtheAcademyofNutritionandDietetics.Thecompleteguidelinedevelopmentprocessisdescribedindetailintheguidelinedocument[2].Inbrief,aworkgroupcomposedof15membersincludingphysicians,registereddietitiansornutritionists,researchers,andmethodologicalexpertswasformed.Thefocusoftheupdatedguidelinewasdefinedasadults’aged19yearsandolder,CKDstages1through5,includingpatientsonmaintenancedialysisandpatientswithkidneytransplant.The3mainareascoveredweremacronutrients,micronutrients,andelectrolytes.Keyquestionsofassessmentandinterventionwereusedforevidencereviewwhichcoveredstudiespublishedbetween1985and2016.Forassessmentquestions,studiesonvalidity,reliability,orrelationshipofanassessmenttoolagainstacomparativetoolormortalitywereincludedinthereview.Forinterventionquestions,onlyrandomizedcontrolledtrialswithatleast6individualsperarmwereincluded.Themainoutcomesdefinedweremortality,comorbidconditions,CKDprogression,qualityoflife,nutritionalparameters,andnutrientbiomarkers.Aftercompletionofdataextractionanddatasynthesis,theworkgrouptranslatedtheavailableevidenceintoactionstatements.TheGradingofRecommendations,Assessment,Development,andEvaluation(GRADE)methodwasusedfordevelopmentofrecommendation.TheGRADEmethodinvolves2majorcomponents:aratingforthequalityofevidenceandaratingofthestrengthofrecommendations.Theevidencegradesarereportedattheendoftherecommendationstatements(A,B,C,orD)andreflecttheconfidenceintheestimatedeffects.Thesecondcomponentisratingthestrengthoftherecommendationstatement.Thisratingreflectstheextenttowhichoneisconfidentthatdesirableeffectsofaninterventionoutweighundesirableeffects.ThegradeforstrengthoftherecommendationcanbeassignedLevel1orLevel2.Incertainscenarioswhentherewasnotenoughevidence,ortheevidencewasoftoolow,“Opinion”statementsweredeveloped.WhatIsDifferentintheUpdatedGuideline?ThepopulationcoveredintheupdatedguidelineswasexpandedtoincludeadultswithCKDstages1–5,onmaintenancedialysis(HDandPD)andindividualswithkidneytransplant.Theextentofcertainareascoveredinthepreviousguidelinessuchasnutritionalassessment,protein,andenergyintakewereexpandedwithmorecomprehensivedatacapture.Thisledtothedevelopmentofadditionalstatementswithevidence-basedinformation.Inadditiontopreviouslycoveredtopics,4newareaswerereported:medicalnutritiontherapy,nutritionalsupplementation,micronutrients,andelectrolytes.Whilesomeoftheaspectsofthesesubjectareaswerereportedintheoriginalguidelinespublishedin2000,thenewlyupdatedguidelinesincorporatedtheseasstandalonesections.Table 1providesasummaryofthestatementscoveredintheKDOQIClinicalPracticeGuidelineforNutritioninCKD:2020Update.Table 1.SummaryandupdatesofthestatementscoveredintheKDOQIclinicalpracticeguidelinefornutritioninCKD:2020updateNutritionalAssessmentRecommendationsTherewasasubstantialexpansionandupdateintherecommendationsregardingmethodstoassessnutritionstatusinpatientswithCKD.OneoftheimportanthighlightsofthenewguidelinesistherecognitionofpoorlevelofevidencetouseonetooloverotherstodiagnosePEW.Acomprehensivedescriptiononthepotentialapplicabilityoftechnicaldevicesandanthropometricmethodstoassessnutritionalstatusisprovidedbuttheevidencewasstrongerforrecommendationofcertainestablishedcomprehensivemethodssuchassubjectiveglobalassessment(SGA)andmalnutritioninflammationscore(MIS).ItisalsoemphasizedthatbiochemicalmarkersshouldnotbeinterpretedinisolationtoassessnutritionalstatussincetheyareinfluencedbyotherfactorsinpatientswithCKD,especiallyinonesonmaintenancedialysis.Forexample,whileserumalbuminhasbeentraditionallyusedasamarkerofnutritionalstatus,thepredictivevalueoflowserumalbuminasariskforhospitalizationandmortalityinpatientsonmaintenancedialysiswasrecognizedwiththehighestlevelofevidenceratherthanitsuseasadiagnosticmarkerforpresenceorabsenceofPEW.Inassessingenergyrequirementstoguidedietaryenergyintake,indirectcalorimetryremainsthegoldstandardformeasuringrestingenergyexpenditure.However,sinceitisnotreadilyavailable,useofdisease-specificpredictiverestingenergyexpenditureequationsforpatientsonmaintenancedialysisisencouragedalthoughfurtherresearchisnecessaryforthisarea.Whenassessingdietaryintakeneeds,anewstatementpointsoutthatfactorsbeyondfoodintakesuchasknowledge,beliefs,attitudes,behavior,andaccesstofoodaswellaspsychologicalandcognitiveaspectsshouldbetakenintoconsiderationtoeffectivelyplannutritioninterventionsinpatientswithCKD.Additionalsuggestionsareprovidedforfurtherresearchinthisarea,especiallyintermsofdevelopmentofriskpredictionmodelsusingmultiplenutritionalmarkers,determiningtheeffectsofvariousnutritionalinterventionsonnutritionalmarkersandwhetherchangesinvaluesofanutritionalmarkercorrelatewithoutcomesasamarkerofefficacy.InterventionRecommendationsMedicalNutritionTherapyandEnergyandProteinRecommendationsAnewtopicaddedintheupdatedguidelineistherecommendationforMedicalNutritionTherapy(MNT).Therecommendationemphasizestheimportanceofprovidingthiscollaborativeapproachbythehealth-careteamtooptimizethenutritionalcarebytailoringittotheindividuals’needs,nutritionalstatus,andcomorbidconditions.DuetothedynamicnutritionalchangesthatoccurduringCKD,theimportanceofmonitoringandevaluationasetofnutrition-relatedmarkerstoachievethebenefitsofMNTispointedoutinthisnewguidelinestatement.Inthenewguidelinedocument,proteinandenergyintakerecommendationswereupdated,andnewstatementswereadded.Therecommendationforproteinintakefornon-dialysispatientshaschangedconsiderablyinthisupdatedguideline.Overthelast2decades,substantialanumberofwell-designedstudieswerepublishedallowingamorecomprehensiveanalysisoftheeffectivenessofproteinrestrictionwithorwithoutketo-acidanalogssupplementationonseveralrelevantoutcomes[3].Intheupdatedstatements,itishighlightedthatthelow-proteindiet(0.55–0.6or0.28–0.43g/kg/daywithketo-acidanalogs)shouldbedeliveredfornondiabeticandmetabolicallystablepatientswithstages3and4CKD.Thisshouldbedoneundercloseclinicalsupervision,preferentiallybyadieticiantoreduceanyriskthatmightbeassociatedwithdecreasednutrientintake.Ontheotherhand,forpatientswithdiabetickidneydisease,amoremodestdietaryproteinrestrictionisrecommended(0.6–0.8g/kg/day).Thisisbasedonexpertopinionandwithlimitedhigh-qualitystudiesinthispatientpopulation.Numberofpatient-specificfactorsandclinicalconditionsaffecttheenergyneedsofpatientswithCKD.Therefore,awiderrangeintheprescriptionofenergyintake(25–35kcal/kg/day)wasrecommendedbasedonage,sex,levelofphysicalactivitybodycomposition,weightstatusgoals,andconcurrentillnesses.Therearemultipleepidemiologicalstudiesinthegeneralpopulationindicatingbenefitsorrisksofdifferentproteintypes(plantvs.animal)onmultipleclinicaloutcomes.However,despitenotablenumberofobservationalstudiessuggestingbenefitsofplant-baseddietsinCKD,thelackofrandomizedclinicaltrialshaspreventedtheworkgrouptorecommendonetypeofproteinoveranotherinpatientswithkidneydisease.Similarly,apromisingdietaryapproachisthepotentialbenefitsoffollowinghealthydietarypatternsinpatientswithCKD.Despitethelevelofevidence,theworkgrouprecommendedprescriptionofMediterraneandietandadietarypatternwithincreasedintakeoffruitsandvegetablesinpatientswithCKDwiththepotentialbenefitsonlipidprofile,bloodpressure,andnetacidproduction.NutritionSupplementationTheguidelinessetonrecommendationsfornutritionsupplementationweregreatlyexpandedaddressingdifferenttypesandroutsofnutritionalsupplementation.Notably,strategiestopreventdialysisinducedcatabolismandinterventionstotreatPEWinpatientswithCKDstages3–5andmaintenancedialysispatientsareupdatedandpresentedindetail.TheconsecutivestepstobetakeninCKDpatientswithPEWoratriskofPEWincludedietarycounseling,a3-monthtrialoralnutritionalsupplementsandenteraltubefeeding,ifpatientssufferfromchronicallyinadequateintakeandwhentheproteinandenergyrequirementcannotbeattainedbycounselingandoralnutritionalsupplement.Feedingthroughthegastrointestinalrouteshouldbepreferredaslongaspossibleandtotalparenteralnutritionorintradialyticparenteralnutritionmaybeconsideredasanoptiontoadministernutrientsiftheenteralroutefails.SeveralimportantconsiderationsregardingpreventionandtreatmentofPEW,suchaswhototreat(allpatientsvs.thehigherriskindividuals),whentoadministersupplements(e.g.,immediatelybeforeorduringdialysistreatmentsvs.duringtheinterdialyticinterval),howmuchandforhowlongtoadminister,andhowtomonitortheresponsearenotcoveredbythecurrentguidelinesduetolackofsoliddataandrecommendedasfurtherresearchareas.MicronutrientsandElectrolytesAnimportantadditiontotheupdatedguidelinesistheinclusionofvitaminsandtraceelementsrecommendations,animportantareathatwasnotcoveredin-depthintheoriginalguidelines.Itisnotedintheupdatedguidelinesthatprovisionofaccurateandreliableevidence-basedstatementsforassessmentandadministrationofmicronutrientsinpatientswithCKDremainschallenging.Despitethelargenumberoftrialsontheeffectsofmicronutrientsupplementation,mostofthemdonotreportthebaselinestatusofthemicronutrientsexaminedorthedietaryintakeduringthestudies;thishasledtosignificantlimitationsintheevidence-basedrecommendations.Furthermore,differencesinpublishedstudiesregardingthedosesofthesupplements,durationoftheintervention,andtheoutcomesanalyzed,amongseveralotherissues,makeitdifficulttoproviderecommendationsontheamountsofmicronutrientstobegivenandthetypesofCKDpatientswhoshouldreceivethesesupplements.Takingalltheseissuesintoconsideration,theworkgroupagreedtodevelopopinion-basedrecommendationtoguidepractitionersandtoemphasizetheneedtoindividualizemicronutrientsupplementation.Asetofrecommendationsonelectrolytesisanothernewareaincludedintheupdatedguidelines.Disturbancesinmineralmetabolismandacid-basehomeostasisoccurearlyinthecourseofCKDandareassociatedwithanumberofcomplicationsofthedisease[4].Managementofdietarycomponentsisofgreatimportanceforthepreventionandtreatmentofelectrolyteandacid-basedisorders.Despitethemoreconsistentevidencetoreducenetacidproductionthroughsodiumbicarbonateorsodiumcitratesupplementationwithbeneficialeffectinthedeclineofresidualkidneyfunction,recentevidencehasemergedthatincreaseddietaryintakeoffruitsandvegetablesmayhavesimilareffects.StatementsofbothapproachesareprovidedinthenewguidelinesforCKD1–5.Regardingdietaryphosphorusandpotassium,althoughsometraditionaldietaryrecommendationshaveproposedacertainamountofintakeforbothnutrients,theefficacyofthisrecommendationhasnotbeenestablished.Therefore,therecommendationintheupdatedguidelineisthatdietshouldbeadjustedtomaintainserumphosphorusandpotassiuminthenormalrange.Individualizationmustbeconsideredinconjunctionwithseveralotherfactorsandconditionsthatinfluenceserumconcentrationofbothelectrolytes.Itwasalsorecognizedthatbioavailabilityofdietaryphosphorussourcesshouldbeconsideredinthedietplanning,andforbothphosphorusandpotassium,emphasisonfoodadditivesisaddressed.Regardingsodium,theevidenceismoreconsistentthatlimitingtheintaketolessthan2.3g/daymayreducebloodpressureandimprovevolumecontrolinpatientswithCKD3–5D.ConclusionTheupdatednutritionguidelinesinCKDtooksubstantialamountofworkbymultipleindividualsandprovidesextensiveinformationbasedonrecentadvancementsinthecareofpatientswithCKD.Despiteitsextensivecontent,theguidelinestatementsdonotcovercertainpatientpopulationssuchasthosewhoareobese,elderly,whohaveacutekidneyinjury.Theupdatedguidelinesalsodonotaddressspecificnutritionalinterventionslikeexerciseoranypharmacotherapiestopreventortreatnutritionalabnormalities.Sincetheguidelineupdatesareacontinuousanddynamicprocess,theseadditionalareasalongwiththebasiccomponentsoftheguidelinesmustbereassessedonarecurringbasisinthefuture.Finally,implementationoftheupdatedguidelinesintotheclinicalpracticemustbeassessedinordertodefineitsrealimpactonpatientcare[5].AcknowledgementsTheauthorswouldliketoacknowledgethesupportfromtheKidneyDiseaseOutcomesQualityInitiative(KDOQI)andTheAcademyofNutritionandDietetics(Academy)fordevelopmentoftheguidelines.Theyalsowouldliketoacknowledgealltheworkgroupandevidencereviewteammemberswhoparticipatedintheguidelinedevelopment.ConflictofInterestStatementDr.IkizlerisaconsultantandreceivedhonorariaforhisconsultingworkfromAbbottRenalCare,FreseniusKabi,Nestle,andReata.Dr.Cupparireportsnorelevantfinancialrelationships.FundingSourcesTheauthorsdidnotreceiveanyfunding.AuthorContributionsDr.Ikizlerdevelopedtheconceptandeditedthemanuscriptforfinalsubmission.Dr.Cupparidraftedthefirstdraftandcontributedtofurthereditingforfinalversion. References InstituteofMedicine.Clinicalpracticeguidelineswecantrust.In:GrahamR,MancherM,WolmanDM,GreenfieldS,SteinbergE,editors.Washington,DC:TheNationalAcademiesPress;2011.p.290. IkizlerTA,BurrowesJD,Byham-GrayLD,CampbellKL,CarreroJJ,ChanW,etal.KDOQIclinicalpracticeguidelinefornutritioninCKD:2020update.AmJKidneyDis.2020;76(3Suppl1):S1–S107. ExternalResources Crossref(DOI) HahnD,HodsonEM,FouqueD.Lowproteindietsfornon-diabeticadultswithchronickidneydisease.CochraneDatabaseSystRev.2018;10(10):CD001892. KettelerM,BlockGA,EvenepoelP,FukagawaM,HerzogCA,McCannL,etal.Executivesummaryofthe2017KDIGOchronickidneydisease-mineralandbonedisorder(CKD-MBD)guidelineupdate:what’schangedandwhyitmatters.KidneyInt.2017;92(1):26–36. FouqueD,IkizlerTA.Editorial:implementinglowproteindietsinclinicalpracticeinpatientswithchronickidneydisease.NephrolDialTransplant.2020;35(10):1643–5. ExternalResources Crossref(DOI) AuthorContacts TalatAlpIkizlerDivisionofNephrology,VanderbiltUniversityMedicalCenterS-3223MedicalCenterNorth,116121stAvenueSouthNashville,TN37232-2372(USA)[email protected] Article/PublicationDetails First-PagePreview Received:November09,2020Accepted:December08,2020Publishedonline:March02,2021 Issuereleasedate:July2021 NumberofPrintPages:5 NumberofFigures:0 NumberofTables:1 ISSN:0253-5068(Print)eISSN:1421-9735(Online) Foradditionalinformation:https://www.karger.com/BPU Copyright/DrugDosage/Disclaimer Copyright:Allrightsreserved.Nopartofthispublicationmaybetranslatedintootherlanguages,reproducedorutilizedinanyformorbyanymeans,electronicormechanical,includingphotocopying,recording,microcopying,orbyanyinformationstorageandretrievalsystem,withoutpermissioninwritingfromthepublisher. DrugDosage:Theauthorsandthepublisherhaveexertedeveryefforttoensurethatdrugselectionanddosagesetforthinthistextareinaccordwithcurrentrecommendationsandpracticeatthetimeofpublication.However,inviewofongoingresearch,changesingovernmentregulations,andtheconstantflowofinformationrelatingtodrugtherapyanddrugreactions,thereaderisurgedtocheckthepackageinsertforeachdrugforanychangesinindicationsanddosageandforaddedwarningsandprecautions.Thisisparticularlyimportantwhentherecommendedagentisanewand/orinfrequentlyemployeddrug. Disclaimer:Thestatements,opinionsanddatacontainedinthispublicationaresolelythoseoftheindividualauthorsandcontributorsandnotofthepublishersandtheeditor(s).Theappearanceofadvertisementsor/andproductreferencesinthepublicationisnotawarranty,endorsement,orapprovaloftheproductsorservicesadvertisedoroftheireffectiveness,qualityorsafety.Thepublisherandtheeditor(s)disclaimresponsibilityforanyinjurytopersonsorpropertyresultingfromanyideas,methods,instructionsorproductsreferredtointhecontentoradvertisements. References InstituteofMedicine.Clinicalpracticeguidelineswecantrust.In:GrahamR,MancherM,WolmanDM,GreenfieldS,SteinbergE,editors.Washington,DC:TheNationalAcademiesPress;2011.p.290. IkizlerTA,BurrowesJD,Byham-GrayLD,CampbellKL,CarreroJJ,ChanW,etal.KDOQIclinicalpracticeguidelinefornutritioninCKD:2020update.AmJKidneyDis.2020;76(3Suppl1):S1–S107. ExternalResources Crossref(DOI) HahnD,HodsonEM,FouqueD.Lowproteindietsfornon-diabeticadultswithchronickidneydisease.CochraneDatabaseSystRev.2018;10(10):CD001892. KettelerM,BlockGA,EvenepoelP,FukagawaM,HerzogCA,McCannL,etal.Executivesummaryofthe2017KDIGOchronickidneydisease-mineralandbonedisorder(CKD-MBD)guidelineupdate:what’schangedandwhyitmatters.KidneyInt.2017;92(1):26–36. FouqueD,IkizlerTA.Editorial:implementinglowproteindietsinclinicalpracticeinpatientswithchronickidneydisease.NephrolDialTransplant.2020;35(10):1643–5. 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E-mailaddress Next ThissiteisprotectedbyreCAPTCHAandtheGooglePrivacyPolicyandTermsofServiceapply. LogintoMyKarger? WefoundanalreadyexistingMyKargeraccountwiththise-mailaddress: Hidepassword Password Keepmeloggedin Login Forgotpassword CompleteYourName FirstName LastName IhavereadtheKargerTermsandConditionsandagree. createaccount ThankYouforRegistering YourMyKargeraccounthasbeencreated. Checkyoure-mails,aswejustsentyouaverificatione-mail. Setyourpasswordbyclickingthelinkinthee-mail. Thelinkwillleadyoubacktothispagewhereyoucanproceed. done × ResetYourPassword Toresetyourpassword,enteryoure-mailaddressoryouruserIDyouregisteredwith.Youwillbesentane-mailcontainingalinktoresetyourpassword. E-mailaddress/UserID Somethingwentwrong Submit CheckYourE-Mails Alinktoresetyourpasswordhasbeensenttoyoure-mailaddress.Followtheinstructionsandtrytologinagain. Close TOP