who received Web-based SGA training and reported moderate validity, with a 54% interrater reliability and a 68% intrarater reliability.11 Intrarater reliability is the reliability of a test producing the same result multiple times by the same researcher. Interrater reliability is the reliability of the test producing the same result among more than one researcher. Lower scores of interrater reliability may be attributable to the differences in training among dietitians. Web-based training does not allow for actual hands-on experience, which can decrease the SGA’s reliability if RDs are not trained properly. Many dietetic programs now are having students and interns take hands-on approaches to learning SGAs or nutrition-focused physical exams, which are improving the reliability of RD assessments. Some institutions have coach/mentors who accept visiting RDs for brief training periods to learn this technique. It is the RD’s responsibility to find local facilities in which to hold a physical training session. Also, a speaker could attend a local dietetic association or staff meeting to educate members on the use of patient-generated SGAs or have nutrition-focused physical exams with interactive participation to increase learning. Another study looked at the specificity (malnutrition) and sensitivity (malnourished) of SGAs and determined that while they were only 32% specific in identifying patients with malnutrition, they were 100% sensitive in identifying those patients.12 For example, out of 100 patients, SGAs identified 16 patients as having malnutrition even though there might have been 50 patients. However, of the 16 patients identified as having malnutrition, SGAs were 100% accurate in defining these patients as malnourished. This same study determined that by screening all dialysis patients for malnutrition on the basis of low serum albumin scores, a BMI of less than 18.5 and a greater-than-10% weight loss over six months followed by an SGA, all patients with malnutrition would be identified.12 By using the SGA, many studies reported that CKD patients, whether or not on dialysis, met only 50% to 70% of their energy needs and only about 50% of their protein needs.13-15 These numbers and SGA scores improved if RDs followed their patients monthly. The main causes of malnutrition in these patients were poor nutrition statuses (both energy and protein intakes), inflammation, age, and comorbidities leading to loss of lean body mass.14,16 Current Research on Why Nutrition Is Critical for CKD Patients There have been several studies analyzing the importance of good nutrition for CKD patients. As indicated in the preceding section, depending on what stage of CKD the patient is in, increasing energy intake and varying amounts of protein intake are important ways of decreasing malnutrition because decreased protein intake can lead to hypoalbuminemia, malnutrition, loss of lean body mass and weight, and poor appetite secondary to uremia.17 In addition, higher levels of serum albumin markers, which indicate excellent protein intake, were correlated with decreased complications from CKD, improved energy levels, and improved mental well-being.18 One study showed that CKD patients’ appetites improved by 40.7% after the patients received nutritional supplements and RD intervention for three months.19 One of the protein indicators (normalized protein catabolic rate) improved above 1 g/kg/day in patients receiving the nutritional supplement, while the rate in the control group decreased, although this difference was not significant.19 This is important since a normal protein catabolic rate of 1 to 1.2 g/kg/day indicates optimal nutritional intake in dialysis patients, while rates below 0.8 g/kg/day indicate possible malnutrition.20 Another study looked at the impact of nutrition counseling on protein and energy intake. Both the control and intervention groups were given initial RD education; however, the intervention group was allowed additional nutrition education as requested (not required by the trial). The results found only slight improvements in the intervention group, though not significant, in protein or energy intake with RD follow-up.20 The study’s authors recommended that “dietetic resources may be used to greater effect if concentrated on ensuring a nutrient-rich diet, optimizing vitamin and iron intake, and promoting good potassium and phosphorus control” instead of focusing on energy and protein intake alone. However, it should be noted that during this study, few participants in the intervention group actually opted for the additional education. This lack of controlled intervention, coupled with the control group receiving identical instructions in the beginning and at month 4, could be the reason no significance was found.20 It’s important for RDs to consider optimizing nutrition by using individualized specific nutrition therapy, especially when evaluating potassium and phosphorus effects on the body. One study determined that dialysis patients could safely be given protein supplements three times per week without affecting phosphorus levels or binder needs.21 This supplement led to increased protein and energy intake as well as improved quality of life and SGA scores. Another study looked at the effect of calcium dialysate baths on inflammation and mortality in hemodialysis patients.22 The study found that patients who received