to track disease progression. It is at this point that they start receiving information about dialysis or transplant.6 Stage 5: In stage 5, the patient has reached full kidney failure. Together with the metabolic and endocrine disorders seen in stage 4, the patient will have little to no urine output and can experience itching, muscle cramping, changes in skin color, and increased skin pigmentation. Patients might have weakness, malaise, poor sleeping habits, fatigue, and loss of appetite because of increased waste products in the blood, which can result in gastrointestinal problems, weight loss, and symptoms seen in other stages.3 Unless patients undergo a kidney transplant, they are given options for different types of dialysis treatment or hospice/palliative care. 6 GFR’s Role The presence of kidney disease is measured through the GFR, which gauges the patient’s level of kidney function. CKD is defined by a GFR below 60 mL/min/1.73 m2 with or without the evidence of kidney damage. This damage can be seen as albuminuria with levels greater than 30 mg of albumin on a urinalysis. Kidney failure is defined by a GFR below 15 mL/min/1.73m2 . Table 1, below, shows the different stages of CKD based on the various GFR values. Table 1: CKD Stages and Associated GFR3 CKD Stage GFR Level 1 (normal) ≥ 90 2 (mild) 60 to 89 3 (moderate) 30 to 59 4 (severe) 15 to 29 5 (failure) < 15 Causes of Kidney Disease Kidney disease can be attributed to several underlying causes, some of the most common being nephrotic syndrome, glomerularnephritis, acute renal failure, diabetes, hypertension, and HIV. When aware of these conditions, RDs are better equipped to provide individual, evidencebased nutritional guidance for their patients. Nephrotic syndrome: This is a loss of protein through the glomerular lumen, which can lead to proteinuria, hypoalbuminemia, edema, increased cholesterol, poor bleeding times, and alterations in bone metabolism. Most cases of nephrotic syndrome result from diabetes, lupus, amyloidosis, minimal change disease, membraneous nephropathy, focal glomerulosclerosis, and membranoproliferative glomerulonephritis.5 Glomerularnephritis (nephritic syndrome): This is an inflammatory response in the glomerulus capillary loop. It normally occurs only after streptococcal infections, and can cause hypertension and blood in the urine along with decreased renal function. The main side effect of this disease is hematuria.5 Acute renal failure: This develops when filtration rate and urea production suddenly drop, a process that can be reversed if caught in time. It usually occurs because of inadequate renal cell perfusion, a disease of the parenchyma cells in the kidney, or an obstruction of the urinary tract often seen with kidney stones.5 Diabetes: People with poor glycemic control from diabetes often experience increased thirst and will drink more fluids. As blood sugars continue to rise, the damage to the small blood vessels in the kidney increase with time. 5 Hypertension: Poor blood pressure control places continued high pressure on the kidneys’ arteries and weakens them.5 HIV: Patients with HIV may be taking nephrotoxic drugs to help combat the infection.5 This can lead to lactic acidosis, crystal-induced obstruction, interstitial nephritis, and electrolyte abnormalities. The HIV infection can affect the cells in the kidney and also can attack the nephrons within the kidneys that help filter the by-products.6 How Subjective Global Assessments Determine a Patient’s Nutrition Status Malnutrition is a common problem in most late-stage CKD patients because of the metabolic and endocrine disturbances that lead to poor appetite and weight loss. Thus, the Academy recommends that RDs perform subjective global assessments (SGAs) of their CKD patients at the initial visit and again quarterly to determine the patients’ nutrition status. SGA evaluations, which show whether any changes in nutritional status have occurred throughout the course of the disease, are critical for identifying patients who are nutritionally compromised in any stage of CKD or in danger of becoming malnourished. SGAs merge both historical and physical data. The historical data can be gleaned from the past six months or even the past week and include weight and appetite changes, gastrointestinal alterations, ability to complete activities of daily living (functional status), and medical history (in particular, signs of fever, steroid use, and hypermetabolic diseases). The physical aspects of SGA assess the loss of subcutaneous fat, muscle wasting, and edema on a four-point scale. The higher the SGA score, the more nutritionally compromised the patient is, with nutrition education being advised for scores of 2 or 3, and RD intervention for scores greater than 4. An example of the patient-generated SGA form can be found here. Research during the past decade has supported the use of SGAs. Specifically, several articles that looked at malnutrition and mortality in patients with ESRD reported correlations with low SGA scores, which indicated malnutrition, and mortality rates increasing by as much as 500% based on the following factors: severity of malnutrition, an age greater than 55, dialysis treatment of fewer than two years, and the presence of diabetes.7-10 While this increase seems excessive, one study examined the interrater and intrarater reliability of RDs