KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update.

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Seasonal changes in phosphorus content of fish tissue as they relate to diets of renal patients.

OBJECTIVE: To investigate seasonal variations in tissue phosphorus (P) levels, P to protein ratio, and P to omega-3 fatty acid (ω3-FA) ratio in 2 species of fish that are commonly consumed in Lebanon. We aim to determine suitability for dietary management of renal patients. DESIGN AND SETTING: Siganus rivulatus (rabbitfish) and Diplodus sargus (white seabream) were caught in traps off the coast of Beirut and transported on ice to the laboratory during various seasons. Fillets of fish were removed, dried to constant weight at 95°C, finely ground, and stored at -20°C. Protein, P, P to protein ratio, and P to ω3-FA ratio were determined. RESULTS: Compared with white seabream (carnivore), rabbitfish (algaevore) had a significantly lower mean P content (±SE) (895 ± 32 mg/100 g vs. 1,132 ± 23 mg/100 g; P < .0001), a significantly lower P to protein ratio (±SE) (10.35 ± 0.39 vs. 13.15 ± 0.34 mg P/g of protein; P < .001), and a significantly lower P to ω3-FA ratio (±SE) (2.81 ± 0.29 vs. 5.93 ± 1.05 g of ω3-FA/g of P; P < .005). P content in flesh of both species varied significantly with season (P < .0001). Rabbitfish P content was least in August and greatest in June (P < .05), whereas white seabream P content was greatest in April and least in June (P < .05). Rabbitfish muscle P to protein ratio and P to ω3-FA ratio was least in August, with a significantly greater P to ω3-FA ratio during the rest of the year. White seabream exhibited wider seasonal variation in P to protein ratio and P to ω3-FA ratio as compared with rabbitfish. CONCLUSION: Because of differences and seasonal variations in P levels that exist among fish species, renal dietitians may need to identify the seasonal proximate composition of individual fish species in various habitats and formulate dietary regimens accordingly. Such advice notwithstanding, oily marine fish remain a healthy food choice for dialysis patients if the fillet is consumed without bones.

Behavioral modeling to guide adherence to fluid control in hemodialysis patients.

OBJECTIVE: This study used the health belief model (HBM) and the transtheoretical model (TTM) to assess hemodialysis (HD) patients' readiness to comply with recommended fluid intake as it relates to their perceptions of therapy and disease. DESIGN: This was a multicenter, cross-sectional study. SETTING: The setting involved 3 hospital-based HD centers in Lebanon. PATIENTS: Patients included 172 consenting HD patients who had been on HD for at least 3 months and were mentally stable. INTERVENTION: Placement of patients into TTM stages was based on their readiness to comply with recommended fluid intake, as confirmed by 4-week interdialytic weight-gain measures, and taking into account their perceptions toward therapy (using HBM constructs). MAIN OUTCOME MEASURES: Mean scores of HBM constructs for each patient were placed in one of the TTM stages of readiness to change. RESULTS: This study included 54.1% males, the average age was 57.8 +/- 14.0 (SD) years, and average number of years on dialysis was 4.6 +/- 4.9. Regarding stages, 18.5% of participants were placed in precontemplation, 40.0% in contemplation, 38.1% in preparation, and 3.4% were in the action/maintenance stages. The HBM constructs were significantly associated with TTM (P < .01). Perceptions of benefits (P = .04) and self-efficacy (P < .01) were significantly associated with TTM. CONCLUSION: Compliance is a multifaceted topic, essential for the survival and quality of life of HD patients. A better understanding of patients' beliefs and level of self-efficacy is a fundamental key to enhancing patients' compliance to therapy and achieving the required behavioral modifications.

Clinical evaluation of heme iron polypeptide: sustaining a response to rHuEPO in hemodialysis patients.

BACKGROUND: Optimizing iron and recombinant human erythropoietin (rHuEPO) therapy is necessary to achieve target hemoglobin levels and minimize costs as the end-stage renal disease (ESRD) population expands. Oral iron products in patients with ESRD have been largely abandoned, and the safety of intravenous (IV) iron preparations has improved with the introduction of new-generation compounds that have little allergenicity. Recent work suggests oral heme iron may be an effective supplement for hemodialysis (HD) patients because it is absorbed by patients with high ferritin levels, has fewer side effects, and its absorption is stimulated by erythropoietin administration. METHODS: We performed an open, 6-month, prospective evaluation of heme iron in HD patients who had been on maintenance IV iron therapy. IV iron was discontinued and replaced with oral heme iron. Serum iron level, hematocrit (Hct), and erythropoietin and IV iron dose were monitored. RESULTS: During 6 months, 4 of 37 patients (11%) dropped out because of insufficient iron supplementation or intolerance and 5 patients (14%) were dropped because of unrelated complications or protocol violation. A slight reduction in average transferrin saturation (TSAT) was seen early, but reversed, and no significant changes were seen in TSAT or Hct. A significant reduction in average serum ferritin level was seen at months 4 through 6 (P < 0.01). CONCLUSION: During the 6-month study period, heme iron polypeptide successfully replaced IV iron therapy in a majority of HD patients and maintained target Hcts with no concomitant use of IV iron. This treatment was associated with a significant increase in rHuEPO efficiency (P = 0.04).

The biological and economic value of oral organic iron in maintenance dialysis.

With the widespread use of recombinant erythropoietin (EPO) for patients with end-stage renal disease (ESRD), management of iron deficiency is an ongoing issue for the renal team. Effective iron replacement and maintenance play a vital role in efficient use of EPO. For hemodialysis patients, intravenous (i.v.) iron has proven convenient and, as an ancillary drug outside of the composite rate, generates profits for dialysis facilities. Improvements in the vehicle with which i.v. iron is administered have led to a reduction in severe or fatal reactions common with iron dextran products. Oral iron has had a spotty track record as an effective therapy for dialysis patients. Compliance has been hindered by patient discomfort when taking oral iron. Patients on peritoneal dialysis and those with chronic kidney disease remain good candidates for oral iron because of convenience, and oral formulas could prove more effective even in the hemodialysis patient population if they were better tolerated and better absorbed, and if using them would not place an economic burden on the patient and/or an economic hardship on the facility. In a capitated/bundled payment environment, oral iron may become a blessing rather than a curse for facilities that need to find more economic ways of providing services. Heme-iron, now undergoing clinical studies, may be a reliable replacement for i.v. iron in that scenario.

Nutritional education for the management of osteodystrophy (nemo) in patients on haemodialysis: a randomised controlled trial.

OBJECTIVE: To examine the effect of self-management dietary counselling (SMDC) on adherence to dietary management of hyperphosphatemia among haemodialysis patients. DESIGN: An eight-week cluster based randomised control trial. PARTICIPANTS: 122 stable adult patients were recruited from an HD unit in Sidon, Lebanon. Study groups were: full intervention (A) (n = 41), partial intervention (B) (n = 41) and control (C) (n = 40). INTERVENTION: Group (A) received SMDC, Group (B) received educational games only and Group (C) did not receive any research intervention. MAIN OUTCOME MEASURES: Serum phosphorus (P), Calcium Phosphate product (Ca × P) and two questionnaires: patient knowledge (PK) and dietary non-adherence (PDnA) to P reduced diet. RESULTS: Group A experienced a significant improvement in mean (± SD) P (6.54 ± 2.05 - 5.4 ± 1.97 mg/dl), Ca × P (58 ± 17 - 49 ± 12), PK scores (50 ± 17 - 69 ± 25%) and PDnA scores (21.4 ± 4.0 - 18.3 ± 2.0). Group B experienced a significant improvement in Ca × P (52 ± 14-45 ± 16). Group C did not experience any significant change post intervention. CONCLUSION: Our findings demonstrate the importance of patient-tailored counselling on serum P management.

Factors affecting the willingness of counselors to integrate preconception care into sexually transmitted disease clinics.

BACKGROUND: The high rate of unintended pregnancy is an immediate barrier to providing preconception care (PCC). Failure to deliver additional PCC messages at sexually transmitted disease (STD) clinics might represent a major missed opportunity to target women at increased risk for unintended pregnancy for behaviors that also put them at risk for adverse pregnancy outcomes. METHODS: Using a survey questionnaire, we assessed perceptions of PCC and factors influencing the willingness of STD counselors to integrate PCC as an intervention service provided by the STD clinics of 140 STD counselors. We used a cross-sectional design and selected survey participants with a minimum of 2 years' experience in providing HIV pretest and posttest counseling and syphilis interviewing using a nonprobability, purposive sample. RESULTS: The level of occupational responsibility and the amount of time available seemed to affect counselor perceptions of the importance of PCC and whether it should be integrated as an intervention service provided by STD clinics. Findings suggested that, although most STD counselors reported that PCC was an important issue, there was significant variation in the perception of whether PCC should be delivered at STD clinics. CONCLUSION: STD counselors perceived PCC to be an important intervention service that can be delivered at STD clinics. Additional study is needed to identify factors that might affect full integration into the STD clinic setting.