KDOQI CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN CKD:
Since 1999, the Kidney Disease Outcomes Quality Initiative (KDOQI) of the American National Kidney Foundation has given evidence-based nutrition guidelines for kidney disease patients. There has been a significant accumulation of new knowledge addressing the management of dietary aspects of kidney disease and sophistication in the guidelines process since the publication of the first KDOQI nutrition guideline. The Academy of Nutrition and Dietetics collaborated on the most recent version to the KDOQI Clinical Practice Guideline for Nutrition in CKD (Academy). It provides practicing clinicians and allied health care workers with comprehensive up-to-date knowledge on the understanding and care of patients with chronic kidney disease (CKD), particularly in terms of their metabolic and nutritional environment. Patients with end-stage renal disease or advanced CKD, as well as patients with stages 1 to 5 CKD who are not on dialysis and those who have had a functional kidney transplant, are now included in the recommendation. Nutritional evaluation, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplements, micronutrients, and electrolytes are all covered in the new guideline statements. Dietary management is the focus of the guidelines, rather than all conceivable nutritional interventions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) standards were used to assess the evidence data and guideline statements. Each guideline statement includes a rationale/background statement, a full justification, monitoring and evaluation instructions, implementation considerations, special talks, and recommendations for future study.
Summary of Guideline Statements
Medical Nutrition Therapy
Statements on Medical Nutrition Therapy (MNT):
MNT(Medical Nutrition Therapy) to Improve Outcomes
In adults with CKD 1-5D, we recommend that a registered dietitian nutritionist (RDN) or an international equivalent, in close collaboration with a physician or other provider (nurse practitioner or physician assistant), provide MNT. Goals are to optimize nutritional status, and to minimize risks imposed by comorbid conditions and alterations in metabolism on the progression of kidney disease and on adverse clinical outcomes (OPINION).
MNT Content
In adults with CKD 1-5D or posttransplantation, it is reasonable to prescribe MNT that is tailored to the individuals’ needs, nutritional status, and comorbid conditions (OPINION).
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MNT Monitoring and Evaluation
In adults with CKD 3-5D or posttransplantation, it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent to monitor and evaluate appetite, dietary intake, body weight changes, biochemical data, anthropometric measurements, and nutrition-focused physical findings to assess the effectiveness of MNT (OPINION).
Protein and Energy Intake
Statements on Protein Amount
In adults with CKD 3-5 who are metabolically stable, we recommend, under close clinical supervision, protein restriction with or without keto acid analogs, to reduce risk for end-stage kidney disease (ESKD)/death (1A) and improve quality of life (QoL) (2C):
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a low-protein diet providing 0.55–0.60 g dietary protein/kg body weight/day, or
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a very low-protein diet providing 0.28–0.43 g dietary protein/kg body weight/day with additional keto acid/amino acid analogs to meet protein requirements (0.55–0.60 g/kg body weight/day)
In the adult with CKD 3-5 and who has diabetes, it is reasonable to prescribe, under close clinical supervision, a dietary protein intake of 0.6-0.8 g/kg body weight per day to maintain a stable nutritional status and optimize glycemic control (OPINION).
In adults with CKD 5D on MHD (1C) or PD (OPINION) who are metabolically stable, we recommend prescribing a dietary protein intake of 1.0-1.2 g/kg body weight per day to maintain a stable nutritional status.
In adults with CKD 5D and who have diabetes, it is reasonable to prescribe a dietary protein intake of 1.0-1.2 g/kg body weight per day to maintain a stable nutritional status. For patients at risk of hyper- and/or hypoglycemia, higher levels of dietary protein intake may need to be considered to maintain glycemic control (OPINION).
Statement on Energy Intake
In adults with CKD 1-5D (1C) or posttransplantation (OPINION) who are metabolically stable, we recommend prescribing an energy intake of 25-35 kcal/kg body weight per day based on age, sex, level of physical activity, body composition, weight status goals, CKD stage, and concurrent illness or presence of inflammation to maintain normal nutritional status.
In adults with CKD 1-5D (1B) or posttransplantation (OPINION), there is insufficient evidence to recommend a particular protein type (plant vs animal) in terms of the effects on nutritional status, calcium or phosphorus levels, or the blood lipid profile.
Statements on Dietary Patterns
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Mediterranean Diet
In adults with CKD 1-5 not on dialysis or posttransplantation, with or without dyslipidemia, we suggest that prescribing a Mediterranean Diet may improve lipid profiles (2C).
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Fruits and Vegetables
In adults with CKD 1-4, we suggest that prescribing increased fruit and vegetable intake may decrease body weight, blood pressure, and net acid production (NEAP) (2C).
Nutritional Supplementation
Statements on Oral, Enteral, and Intradialytic Parenteral Nutrition Supplementation
In adults with CKD 3-5D (2D) or posttransplantation (OPINION) at risk of or with protein-energy wasting, we suggest a minimum of a 3-month trial of oral nutritional supplements to improve nutritional status if dietary counseling alone does not achieve sufficient energy and protein intake to meet nutritional requirements.
In adults with CKD 1-5D, with chronically inadequate intake and whose protein and energy requirements cannot be attained by dietary counseling and oral nutritional supplements, it is reasonable to consider a trial of enteral tube feeding (OPINION).
In adults with CKD with protein-energy wasting, we suggest a trial of TPN for CKD 1-5 patients (2C) and IDPN for CKD 5D on MHD patients (2C), to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake.
Statement on Nutrition Supplementation – Dialysate
In adults with CKD 5D on PD with protein-energy wasting, we suggest not substituting conventional dextrose dialysate with amino acid dialysate as a general strategy to improve nutritional status, although it is reasonable to consider a trial of amino acid dialysate to improve and maintain nutritional status if nutritional requirements cannot be met with existing oral and enteral intake (OPINION).
Statements on Long Chain Omega-3 Polyunsaturated Fatty Acids (LC n-3 PUFA)
In adults with CKD 5D on MHD or posttransplantation, we suggest not routinely prescribing LC n-3 PUFA, including those derived from fish or flaxseed and other oils, to lower risk of mortality (2C) or cardiovascular events (2B).
In adults with CKD 5D on PD, it is reasonable to not routinely prescribe LC n-3 PUFA, including those derived from fish or flaxseed and other oils, to lower risk of mortality or cardiovascular events (OPINION).
In adults with CKD 5D on MHD, we suggest that 1.3-4 g/d LC n-3 PUFA may be prescribed to reduce triglycerides and LDL cholesterol (2C) and raise HDL levels (2D).
In adults with CKD 5D on PD, it is reasonable to consider prescribing 1.3-4 g/d LC n-3 PUFA to improve the lipid profile (OPINION).
In adults with CKD 3-5, we suggest prescribing w2 g/d LC n-3 PUFA to lower serum triglyceride levels (2C).
In adults with CKD 5D on MHD, we suggest not routinely prescribing fish oil to improve primary patency rates in patients with AV grafts (2B) or fistulas (2A).
In adults with CKD posttransplantation, we suggest not routinely prescribing LC n-3 PUFA to reduce the number of rejection episodes or improve graft survival (2D).
Micronutrients
Statements for General Guidance
In adults with CKD 3-5D or posttransplantation, it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent to encourage eating a diet that meets the recommended dietary allowance (RDA) for adequate intake for all vitamins and minerals (OPINION).
In adults with CKD 3-5D or posttransplantation, it is reasonable for the registered dietitian nutritionist (RDN) or an international equivalent, in close collaboration with a physician or physician assistant, to assess dietary vitamin intake periodically and to consider multivitamin supplementation for individuals with inadequate vitamin intake (OPINION).
In adults with CKD 5D who exhibit inadequate dietary intake for sustained periods of time, it is reasonable to consider supplementation with multivitamins, including all the water-soluble vitamins, and essential trace elements to prevent or treat micronutrient deficiencies (OPINION).
Statements on Folic Acid
In adults with CKD 3-5D or posttransplantation who have hyperhomocysteinemia associated with kidney disease, we recommend not to routinely supplement folate with or without B-complex since there is no evidence demonstrating reduction in adverse cardiovascular outcomes (1A).
In adults with CKD 1-5D (2B) or posttransplantation (OPINION), we suggest prescribing folate, vitamin B12, and/or Bcomplex supplement to correct for folate or vitamin B12 deficiency/insufficiency based on clinical signs and symptoms (2B).
Statement on Vitamin C
In adults with CKD 1-5D or posttransplantation who are at risk of vitamin C deficiency, it is reasonable to consider supplementation to meet the recommended intake of at least 90 mg/d for men and 75 mg/d for women (OPINION).
Statements on Vitamin D
In adults with CKD 1-5D (2C) or posttransplantation (OPINION), we suggest prescribing vitamin D supplementation in the form of cholecalciferol or ergocalciferol to correct 25-hydroxyvitamin D (25(OH)D) deficiency/insufficiency.
In adults with CKD 1-5 with nephrotic-range proteinuria, it is reasonable to consider supplementation of cholecalciferol, ergocalciferol, or other safe and effective 25(OH)D precursors (OPINION).
Statement on Vitamins A and E
In adults with CKD 5D on MHD or CKD 5D on PD, it is reasonable to not routinely supplement vitamin A or E because of the potential for vitamin toxicity. However, if supplementation is warranted, care should be taken to avoid excessive doses, and patients should be monitored for toxicity (OPINION).
Statement on Vitamin K
In adults with CKD 1-5D or posttransplantation, it is reasonable that patients receiving anticoagulant medicines known to inhibit vitamin K activity (eg, warfarin compounds) do not receive vitamin K supplements (OPINION).
Statement on Trace Minerals – Selenium and Zinc
In adults with CKD 1-5D, we suggest to not routinely supplement selenium or zinc since there is little evidence that it improves nutritional, inflammatory, or micronutrient status (2C).
Electrolytes
Statements on Acid Load
In adults with CKD 1-4, we suggest reducing net acid production (NEAP) through increased dietary intake of fruits and vegetables (2C) in order to reduce the rate of decline of residual kidney function.
In adults with CKD 3-5D, we recommend reducing net acid production (NEAP) through increased bicarbonate or a citric acid/sodium citrate solution supplementation (1C) in order to reduce the rate of decline of residual kidney function.
In adults with CKD 3-5D, it is reasonable to maintain serum bicarbonate levels at 24-26 mmol/L (OPINION).
Statements on Calcium
In adults with CKD 3-4 not taking active vitamin D analogs, we suggest that a total elemental calcium intake of 800-1,000 mg/d (including dietary calcium, calcium supplementation, and calcium-based phosphate binders) be prescribed to maintain a neutral calcium balance (2B).
In adults with CKD 5D, it is reasonable to adjust calcium intake (dietary calcium, calcium supplements, or calcium-based binders) with consideration of concurrent use of vitamin D analogs and calcimimetics in order to avoid hypercalcemia or calcium overload (OPINION).
Statements on Phosphorus
In adults with CKD 3-5D, we recommend adjusting dietary phosphorus intake to maintain serum phosphate levels in the normal range (1B).
In adults with CKD 1-5D or posttransplantation, it is reasonable when making decisions about phosphorus restriction treatment to consider the bioavailability of phosphorus sources (eg, animal, vegetable, additives) (OPINION).
For adults with CKD posttransplantation with hypophosphatemia, it is reasonable to consider prescribing highphosphorus intake (diet or supplements) in order to replete serum phosphate (OPINION).
Statements on Potassium
In adults with CKD 3-5D or posttransplantation, it is reasonable to adjust dietary potassium intake to maintain serum potassium within the normal range (OPINION).
In adults with CKD 3-5D (2D) or posttransplantation (OPINION) with either hyperkalemia or hypokalemia, we suggest that dietary or supplemental potassium intake be based on a patient’s individual needs and clinician judgment.
Statements on Sodium
In adults with CKD 3-5 (1B), CKD 5D (1C), or posttransplantation (1C), we recommend limiting sodium intake to less than 100 mmol/d (or< 2.3 g/d) to reduce blood pressure and improve volume control.
In adults with CKD 3-5 we suggest limiting sodium intake to less than 100 mmol/d (or< 2.3 g/d) to reduce proteinuria synergistically with available pharmacologic interventions (2A).
In adults with CKD 3-5D, we suggest reduced dietary sodium intake as an adjunctive lifestyle modification strategy to achieve better volume control and a more desirable body weight (2B).