high-calcium dialysate baths during hemodialysis treatment had more inflammation, which led to a 2.765 times higher risk of death than did those who received standard and low-calcium baths.22 Finally, a further study on potassium and mortality found that mortality increased significantly with an increased intake of potassium.23 Dialysis patients who consumed more than 2 g of potassium daily had a 2.5 times higher risk of mortality compared with patients who consumed less than 1 g of potassium daily.23 Thus, because of the small number of patients meeting their nutritional needs,13-15 RDs need to be consulted when patients are found to be at increased risk of malnutrition. The importance of RD involvement is further shown in Figure 1, below, which reveals the average albumin levels in each state.2 Figure 1: Average Nationwide Serum Albumin Levels for 20082 — Source: US Renal Data System, USRDS 2009 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, 2009. The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government. States with patients having albumin levels less than 3.5 g/dL should have nutritional education or direct intervention by an RD to improve these levels and, hopefully, decrease the risk of malnutrition in this population. While these numbers are from 2008 (the most current data available from the US Renal Data System), it’s easy to see which states fell below 2.8 g/dL, on average, for all CKD patients. Evidence-Based Clinical Recommendations The Academy and the KDOQI recommend that during each visit, RDs conduct an SGA and physical measurement of the patient, weigh the patient, check the patient’s recent lab results for protein and calcium, and monitor the patient’s fat, sodium, and fluid intake. RDs can do this by using the following six evidence-based guidelines: 1. Conduct a Nutrition Assessment and Initiate Nutrition Therapy Both the Academy and the KDOQI recommend that when RDs assess CKD patients for malnutrition, they conduct an SGA or nutrition-focused physical exam (as previously mentioned) to determine patients’ nutrition status. Table 2, below, provides a suggested timeline for monitoring patients for nutritional deficiencies. Table 2: Sample Timeline for Monitoring Nutritional Deficiencies3 Measure Time Frame Albumin Monthly % Standard weight Monthly % Postdialysis weight Monthly SGA Every three months Food recall Every six months To prevent the progression of CKD and the onset of kidney failure, the Academy recommends that RDs initiate medical nutrition therapy, on referral from a licensed practitioner, for all patients with a CKD diagnosis because the best outcomes are achieved when RDs begin nutritional therapy as early as possible in the disease course. 17 They should then follow up with the patient every one to three months and for one year if any nutritional deficiency presents itself, if the patient is experiencing malnutrition, and to follow the general course of the disease.17 2. Assess the Patient’s Energy Status and Caloric Intake According to the Academy, energy needs should be based on a patient’s current weight, goals for his or her weight (ie, weight loss, gain, and maintenance), age, gender, level of physical activity, and any metabolic stressors (eg, pressure wounds, HIV infection, decompensated heart failure exacerbation).17 When assessing resting energy expenditure for any CKD patient, RDs should use an actual dry weight—that is, a weight that’s free of edema, ascites, and/or polycystic organs. It is usually the weight taken at the end of dialysis treatments.17 When patients are not on dialysis, the dry weight that should be used is the most current patient weight free of edema, ascites, and/or polycystic organs. Most often this will be the first weight in the morning taken after the patient has used the restroom. Any changes in body weight of 2 lbs in one day or 5 lbs in one week can indicate excessive body fluids. While adjusted body weights are used for patients who are obese, they haven’t been validated for patients with CKD. As a result, RDs should monitor a patient’s lab results and weight on each exam to adjust energy intake if malnutrition begins to appear. For stable CKD patients with a normal BMI, both the Academy and the KDOQI recommend the following guidelines17: · 35 kcals/kg of actual weight for those younger than the age of 60; · 30 to 35 kcals/kg of actual weight for those older than 60; · 23 kcals/kg of actual weight to promote weight loss in patients who are overweight without fear of initiating malnutrition; and · 50 kcals/kg of actual weight to promote weight gain in patients who are underweight or prevent weight loss during times of stress. The KDOQI guidelines do not recommend increasing calories until the GFR is less than 25 or if the patient is in stage 4 CKD. 3. Determine the Patient’s Protein Intake Protein intake can be affected by the type of protein—whether plant or animal—and the amount consumed. High biological value protein that’s found mostly in animal products (such as chicken, beef, pork, and fish), eggs, milk, quinoa,